Fluid and Electrolyte Imbalance

Fluid and Electrolyte Imbalance
Nurse Refresher Class 2010 by Kim Uddo RN MN CCRN CNE Many Slides borrowed from Arlisha Pratt . Much Thanks.

Objectives Review and define concepts related to fluid movement
Discuss considerations for older adults in relation to fluid imbalance Correctly interpreting laboratory data and diagnostic testing indicating; fluid and electrolyte imbalances Utilizing laboratory data, and signs and symptoms to determine the presence of fluid and electrolyte imbalances

Objectives (cont) Indentify clients at risk for fluid volume imbalances. Indentify specific assessment findings in electrolyte imbalances. Identify priority nursing diagnosis for clients experiencing fluid and electrolyte imbalance. Describe the therapeutic and nursing management of clients exhibiting fluid and electrolyte imbalances

Overview of Fluid Movement
Intracellular Fluid- within the cells Extracellular Fluid- outside the cells (includes the intravascular space) Osmosis-is the movement of water only through a selectively permeable membrane. Osmolality-concentration of particles/kilogram Osmolarity-concentration of particles/liter (does not have to be water)

Overview of Fluid Movement
Filtration-Movement of fluid through a cell or blood vessel membrane Hydrostatic pressure-is the pushing force of fluid against the walls of the space it occupies. Diffusion-particles move from a higher concentration to an area of lower-concentration. Oncotic pressure (colloid osmotic pressure)-the pulling force exerted by colloids in a solution Kidneys filtrate. CHF patients have extra fluid volume in intravascular space and increases the pressure so third spacing occurs in the intravascular space.. Diffusion makes me think of water following sodium. Oncotic pressure is maintained in our blood stream by albumin, which is a big protein that keeps the fluid in the intravascular space. When malnoursihed patients show a loss of protein, they have a drop in albumin. Then the vessels cannot keep the water in the intravascular space, so fluid shift causes edema in the intravascular space.

Types of Fluid Replacements
Isotonic Hypotonic Hypertonic Serum osmolality Colloid Isotonic: normal saline 0.9% NS Hypertonic: D5NS, 3%NS Hypotonic: D5W, 0.5%NS Look on the IV Bag for osmolality Colloid: hetastarch, albumin

0.9%NS: Sodium Chloride 0.9 Grams per 100 ml
9 Grams per 1000ml (liter) 154 mEq sodium 154 mEq chloride

Hormonal/Chemical Fluid Balance
Aldosterone Antidiuretic Hormone (ADH) or Vasopressin Glucocorticoids Atrial Natriuretic Peptides (ANP) Brain Natriuretic Peptides (BNP)

Human serum osmolality
Effected by Na, Glu, and BUN milliosmoles per kilogram of water (mOsm) If glu and Bun is normal you can roughly multiply Na by 2 to get the osmolality Increases in dehydration and decreases in overload Urine measured for osmolality too

Calculated Osmolality
Estimated 2(Na) + BUN/2.8 + Blood Glucose/18 Example 2(135) + 12/ /18 = 280 mOsm Some labs will calculate with the SMA 7 Your calculation my differ from lab

Human urine osmolality
Like specific gravity, it is a measure of urine concentration. Unlike specific gravity, it is NOT concerned with the size or weight of the particles in solution, just the number of them. So big glucose and protein molecules in the urine do not raise the osmolality like they do the specific gravity of urine. More sensitive test than specific gravity, temp is controlled, can be compared to the serum osmolality.

Urine osmolality range
mOsm 800 mOsm = specific gravity If the patient has a 14 hour overnight fast, they should have a urine osmolality at least 3 x greater than the serum osmolality. (No intake = more concentrated urine)

Urine specific gravity
Measures the density of urine compared to density of water Usually, the higher the number, the more concentrated the urine Normal – 1.040 If glucose or protein in urine, false high. If no glucose or protein in urine and specific gravity is high, urine is concentrated due to dehydration or increased output of ADH which causes a decreased urine volume.

Elevated secretion of ADH
Trauma Stress Surgery Drugs Usually means patient needs fluids.

Surgical Diuresis Surgery is major trauma to the body and activates ADH. Urine Specific Gravity gets high as result As stress decreases, post op day 2, ADH and other hormones like glucocorticosteroids decrease, the fluid that was held in reserve to prevent going into shock is released The increase urine output two days after surgery is to be expected. CABG Patient Coronoary Artery Bypass Patients Normally receive 1-2 liters of fluid in OR to prime the bypass machine. So they receive fluid and they also secrete ADH due to stress….they come back from OR looking puffy…the next day we begin to observe diuresis. While the patient is third spacing, they can be hypovolemic and show a decreased urine output. That is why after surgery, a hypertonic IV will be ordered.

Serum and Urine mOsm Ratio
If urine osmolality goes up and serum is normal or elevated, we know the kidneys are conserving water. Like in dehydration. Bring cups of fluid to represented concentrated, normal and dilute urine.

Dehydration Urine and Serum Osmolality are HIGH.

Ratios If serum osml is low or dilute and urine osmo is high, we know that this is not a normal response. An increased level of ADH can cause this. Think SIADH: syndrome of inappropriate anti diuretic hormone.

Ratio Urine osmo should always be higher than serum osml unless the patient is putting out dilute urine due to diuretics or due to drinking an excess of fluids. Diuretic use can show a lower urine osmolality with a normal serum osmolality.

Diuretic Use Low urine osmolality and normal serum osmolality
What does their urine look like before the diuretic? What does their urine look like after the diuretic?

Something is wrong if The urine osmolality remains dilute while the serum osmolaity starts to climb..remember a dehydrated patient has increased urine and serum levels…. We think that the patient cannot activate their ADH DI: diabetes insipidus….pathologic lack of ADH They look like they are unable to concentrate their urine!

DI vs SIADH DI…. I’m Dry SIADH…. I float Which patient gains weight?
Which patient looses weight? What does the urine look like?

Sensible & Insensible Fluid Loss
INTAKE Measurable Oral intake Parenteral Fluids Enemas Irrigation fluids Not Measurable Solid foods Metabolism OUTPUT Urine Emesis (only if in liquid form) Feces (only if in liquid form) Drainage from body cavities (fistula/wound/ drains) Perspiration Vaporization through lungs Each shift a complete I&O is calculated. Each 24 hours the two shifts are totaled. Weights are done in kilograms and usually recorded next to the 24 hour I&O. Remember 1kg = 1 liter. Remember to measure all those NG tube flushes with meds! Remember the dehydrated patient with amber urine? They will have a I < O. So will the pneumonia patient who is breathing at a rate of 32 breaths per minute. They have a significant insensible fluid loss! The Renal Failure or CHF patient will have a I> 0. Include in your assessment S&S of Fluid Volume Deficit and Fluid Volume Excess.

Hormonal/Chemical Fluid Balance
Thirst Mechanism Stimulated by thirst receptors in the hypothalamus Stimulates ADH and aldosterone release, which promotes reabsorption of water. Depressed in older people (> 60y/o) ADH + Antidiuretic hormone. Helps the patient hold on to their water (antidiurese). The kidneys retain water. Elderly patients loose this ability so they dehydrate easily.

Consideration for Older Clients
Older adults has less total body water than a younger adult. They have decreased thirst sensation Difficulty with walking or other motor skills need for ingesting of fluids They also may take drugs such as diuretics, antihypertensive, and laxatives that increase fluid excretions.

Considerations for Obesity and Females
Females have more fat than males Obese have more fat Less water is stored in fat Dehydrate quickly so beware. High risk for dehydration are Elderly, Obese, and Women.

Evidence Based Nursing
The evidence shows that most hospitalized patients are not offered enough water and become dehydrated. It’s a safety concern Offer water! Teach patient and family to record accurately I& O

Fluid Imbalances Fluid Volume Deficit
Hypovolemia-Circulating blood volume is decreased and leads to inadequate tissue perfusion. Which can quickly lead to shock. Dehydration- Fluid intake is less than what is needed to meet the body’s fluid needs. Can occur with just water loss or with water and electrolyte loss.

Dehydration What do the labs look like? Who is at risk?

Fluid Imbalance Fluid Volume Overload
Fluid overload (overhydration)- is an excess of body fluid; can be either actual excess of total body fluid or a relative fluid excess. Hypervolemia-most common type of fluid overload.

Over hydration What would the labs look like?
One must always associate sodium changes with fluid status changes.

Causes, Assessment, Clinical Manifestations
Identify who is at risk for fluid and electrolyte disturbances Identify S&S of fluid volume deficit Identify S&S of fluid volume excess Identify S&S of electrolyte disturbances Identify situations that cause disturbances

Laboratory Assessment, Interventions, Patient safety
Protocols set for communication of abnormal labs Use SBAR Conduct Physical Assessment include ECG changes Document your actions including phone calls/ time Critical lab value stickers Get follow up lab orders after intervention and evaluate Teach the patient! Our hospital uses critical lab value communication stickers that go onto the MD Order pages in the patient chart. There is a yellow communication sicker that we place beneath the verbal orders obtained from the MD after we communicate using SBAR Method. The A in SBAR means assessment, so perform a focused physical assessment for that altered lab. This may include running an ECG if they are not already on telemetry. The electrolyed “players” in he heart are sodium (Na) Potassium (K), Calcium (Ca) and Magnesium (Mag). We must document how we responded, who we communicated with, and at what time. If after the first communication attempt fails, the nurse must follow up within 30 minutes. If now communication success follows, the house officer is called and a back up chain of command is followed to communicate with an appropriate MD. This is a safety issue!

Nursing Diagnosis and Case Studies
Use your nursing diagnosis list from clinical manila folder

Case Study #1 A 20 y/o client is admitted to the hospital for c/o nausea, vomiting and diarrhea; and has not had an appetite in 3 days. BP 86/42, pulse 124, resp 30; While in the emergency room, one liter of NS has infused and now D5 1/2NS is infusing at 80 mls/hr. What nursing interventions should the nurse perform and monitor while caring for this client? Evaluate the BP. What is the MAP? Why is the HR so fast? What is a normal HR? What is the normal resp rate? Why is it so fast? What kind of parenteral solution is being delivered? How many mls a day will the client receive? What are crucial assessments the nurse must make? What nursing diagnosis can be made? What are we worried about? What safety issues come to mind? Why do we use weight assessments? Orthostatic assessments? What urine output do we want to achieve?

SBAR the report to the MD
Introduce yourself S B A R Any questions for me? How long did it take?

Case Study # 2 A 55 y/o client with Congestive heart failure is receiving D51/2NS at 150cc/hr after surgery. The client reports trouble breathing, and sits up in bed and coughs up moderate amount of clear mucous. What priority nursing action and follow Up actions are needed and why? What kind of solution is hanging? How many mls is this patient getting per day? What does that solution do to the intravascular shift of fluids? How? Possible fluid overload and impending pulmonary edema. So what is the nursing diagnosis? decrease the IV fluids-notify the physician of finding Auscultate lungs! What other assessments should be made? What findings are you looking for? Pulse oximetry-provide oxygen Vital signs –especially respiratory status Client may need order for IV diuretics, beta-blockers

SBAR the report to the MD
Introduce yourself S B A R Do you have any additional questions for me? How long did it take? What is the situation? What is the background? What are your assessments? What do you want or recommend?

Safety Measures Orient client to the environment (especially the older adult) Monitor for falls Assess the client muscle strengths, gait stability Instruct the client to get up slowly from a lying sitting and standing position Assist the client from the bed to chair Monitor for any skin breakdown Change positions q2 hours What will we do to the environment? What scale will we use to monitor for falls? What meds are they on? Do they make them a higher risk? Why? How will we assess strength and gait? Why get up slow? What may we ask when we dangle the patient?

Electrolytes Electrolyte Reference Range Sodium (Na+) 135-145 mEq/L
Potassium (K+) Calcium (Ca+) Chloride (Cl-) Magnesium (Mg2+) Phosphorus (P) Reference Range mEq/L mEq/L mEq/L mEq/L meq/L mg/dl Electrolytes, or ions are substances in body fluids that carry an electrical charge. Cations- postive charge (sodium major ECF cation) and (Potassium major ICF cation) Anion-negative charge

Electrolyte Balance and Imbalances
Sodium Main cation in the ECF Maintenance of plasma & interstitial osmolarity Maintenance of acid-base balance Generation and transmission of nerve impulses Potassium Main cation in the ICF Regulate intercellular osmolarity Maintenance of electrical membrane excitability Maintenance of plasma acid-base balance

Hyponatremia (< 135mEq/L) Water shift from the ECF to the ICF; resulting in ↓circulating plasma volume & ↑intracellular fluid. Causing cellular swelling Hypernatremia (> 145mEq/L) Water shift from the ICF to the ECF, which result in cellular shrinkage/dehydration Water usually follows sodium. What happens to the fluid shift when the intravascular serum sodium is low? What happens to the brain in hyponatremia? What kind of IV solution would the nurse expect to see hung on this patient? What happens to the fluid shift when the intravascular serum sodium is high? What kind of IV fluids would we expect to hang on a severely dehydrated patient who has been dehydrated for days…who has suffered a three day period of intracellular shift to the extracellular area? Hypertonic, isotonic, or hypotonic, or colloid?

Case Study # 3 The nurse is assigned to a client who is NPO and on prolong intermittent nasogastric suctioning. What will the nurse monitor for and why? # one a client who is NPO and on NG suctioning is at risk for Hyponatremia due to restricted oral replacement and loss of gastric secretion. If on prolong NPO status should have their hydration level maintained via IV adm. Loss of gastric secretions can also lead to electrolyte imbalance, thus labs need to be monitored. Check your potassium! Record intake and output is essential in the care of this client. Indicate the amount, color and consistency of the NG drainage. Gastric suctioning can also lead to acid-based disturbances. Excess acid is removed from the stomach, so the patient can become alkalotic. We will need to larn about serum labs that determine acid base status! (Diarrhea causes a loss of base). List your additional assessments on a piece of paper that you will add to your head to toe assessment. Share your list.

Case Study # 4 In caring for a client with Hypernatremia, what should the nurse do to help ensure client safety? Note: when sodium levels change, think about how the fluid shift has changed. Monitor neurological status, LOC, and observe for potential seizures Monitor s/s of dehydration, edema Keep HOB in low position Assist with ambulation and mobility Monitor for risk for falls.

Causes of Hypernatremia
Dehydration / water loss Too much IV or po saline/salt Many blood bank units of blood Impaired renal function Large increase in sodium intake without proportional water intake (rare cuz this makes you thirsty) Large amount of water loss without salt loss (more common…diarrhea, vomiting) Sometimes one can looses both sodium and water =

Who is at risk for hypernatremia?
Elderly Patients on fluid restrictions Diuretic therapy Receiving hypertonic IV’s or tube feeding Diabetes Mellitus (HHNKD) Dehydration HHNK hyperosmolar hypergylcemic non-ketotic dehydration Classic in large content CHO tube feed without adequate water intake. Look at kangaroo tube feeding sets. Two bags one to house water bolus 30 mls per hour.

Youtube: Dehydration Video

Treat hypernatremia Drink water Change IV to isotonic solution
Give IV fluids Dialysis Strict I&O’s Check Labs

Isotonic dehydration Lose equal parts sodium and water (infants do this with vomiting and diarrhea)

Hypertonic dehydration
Loose more water than sodium: Also called- Hyperosmolar dehydration By the time serum sodium is elevated, the compensory shift of water has left the cells and interstitial spaces has entered the blood stream and dehydrated the cells. The patient is dehydrated at the cellular level when we see elevated serum sodium levels. The water exits via the kidneys and the patient is severely dehydrated intracellularlly and intravascularlly.

Symptoms of hypernatremia
Thirst Dry membranes, tenting Little or no urine output High specific gravity Hematocrit increased Hyperactivity/ seizures Increase 3meq above normal = I liter fluid loss 1 liter fluid loss = 1 kg in body weight Weight Loss: do daily weights!!!!!!

Edema By the time edema is evident, the patient has already gained 3 liters of fluid Weight gain is the best indicator of fluid retention and weight loss is the best indicator of fluid loss.

Hypokalemia (< 3.5 mEq/L) When K+ moves into the ICF, it causes hypokalemia, in turn hydrogen moves out of the cell. Making the ECF more normalized or acidotic. Hyperkalemia ( > 5.0 mEq/L) Hydrogen moves into the cells, causing the ECF to become more normalized or alkalotic, In turn, K+ and Na+ move out of the cell.

Case Study # 5 A 55 year old client is admitted to the hospital with complaint of diarrhea for three days. The client reports being weak and feels like his/her heart is racing What questions should the nurse ask about the clients medical hx? What other s/s maybe present What labs maybe ordered What orders would the nurse expect this client to receive? Loose bicarbonate from GI and expect to see chloride and Bun increase…if holding onto salt will see increase in Na. Give isotonic IV solution if mildly dehydrated…give hypotonic solution to rehydrate depleted cells.

Nursing Diagnosis Decreased cardiac output r/t dysrhythmia 2ndary to electrolyte imbalance (K, Mag, Cal) Impaired physical mobility r/t skeletal muscle Imbalance nutrition r/t decreased renal function or poor dietary intake 2ndary to renal failure anorexia or NPO status or Risk for injury r/t muscle weakness and seizures 2ndary to electrolyte imbalance Impaired safety r/t confusion or altered LOC 2ndary to hyponatremia

Calcium Maintain strong bone and teeth Transmission of nerve impulses Allow blood clotting Regulate BP Control by the PTH, Vit D and calcitronin Phosphorus Activate vitamins and enzymes Forming ATP Assisting in cellular growth and metabolism. Acid-base balance Calcium homeostasis

Hypocalcemia (< 9.0 mg/dl) Abnormally low calcium level or decreased availablity of ionized calcium; any condition that cause a decrease in PTH production. Hypercalcemia (> 11.0 mg/dl) An Anbormally elevated serum calcium level; symptoms may not appear until the serum calcium is >12mg/dl

Case Study # 6 A 54y/o client with a diagnosis of multiple myeloma has been admitted to your unit. The client has a c/o of increasing fatigue, muscle weakness, and bone pain. What do you think is the cause of these symptoms What is the nurse priority nursing intervention How will you evaluate if therapy has been effective. What exactly is multiple myeloma? Multiple myeloma is a cancer that begins in plasma cells, a type of white blood cell. These cells are part of your immune system, which helps protect the body from germs and other harmful substances. In time, myeloma cells collect in the bone marrow and in the solid parts of bone.

What is it? Lets check the web.
Excellent resource Awesome movie explaining X-plain.com

Hypophosphatemia (< 2.5 mEq/L) An abnormal decrease in serum phosphorus level. Hyperphosphatemia (> 4.5 mEq/L) An abnormal increase in serum phosphorus level. Phosphorus shifts from the ICF to the ECF which causes serum level to increase

Case Study # 7 Mr. G is a 56 y/o client with newly diagnosed chronic renal failure as a complication of diabetes mellitus. He is receiving hemodialysis 3 times a week and will continue this therapy when discharged. Which electrolyte imbalance the nurse would expect (hypo/hyperphosphatemia) Why? What dietary modifications would be necessary? What role will dialysis play in managing the imbalance? In chronic kidney failure, blood levels of urea and creatinine, metabolic waste products that are normally filtered out by the kidneys, are increased. Typically, the blood becomes moderately acidic. The level of potassium in the blood is often normal or only slightly increased but can become dangerously high when kidney failure reaches an advanced stage or if people ingest large amounts of potassium or take a drug that prevents the kidneys from excreting the potassium. Usually, people have some degree of anemia. The levels of calcium and calcitriol in the blood decrease, and the phosphate and parathyroid hormone levels increase. Analysis of the urine may detect many abnormalities, including protein and abnormal cells.

Magnesium Powers the sodium-potassium pump Activates enzymes Important for skeletal muscle relaxation Aids in converting ATP for energy release Chloride Aids in cellular integrity by maintaining balance. Serves as a buffer in exchange of O2/CO2 Regulates the pH of the stomach

Hypomagnesemia ( < 1.5 mEq/L) Abnormal secretion of magnesium in the blood. Can cause lethal torsades dysrhythmias Hypermagnesmia ( > 2.5mEq/L) Rare electrolyte imbalance, occur to excessive intake of magnesium and decreased renal excretion.

Case Study # 8 A 25y/o client during a clinic visit reports to the nurse that she has been experiencing; chest pains and frequent cramps in her legs and hands for the past week . Her vital signs are BP 110/72, P 98, resp 18. What other data is necessary to gather? What imbalance may this client be experiencing according to the above data? What collaborate measures should be considered?

Renal function BUN BUN : Creatinine Ratio UUN BUN:Creatinine Ratio
Serum Creatinine Creatinine clearance

Blood Urea Nitrogen BUN
Urea is a waste product from protein metabolism. It is formed in the liver and travels to the kidneys for elimination from the body. Since the kidneys excrete this, it is a good lab to determine kidney function. Normal 8 – 25 mg/dL Dehydration, malnutrion with protein wasting, liver failure, and over hydration can mask the renal function on this test.

Elevated BUN Kidney failure
Poor perfusion to kidneys due to shock or CHF High protein tube feedings Dehydration Bleeding in the GI tract (blood is protein)

Decreased BUN Over hydration

UUN 1 gram of nitrogen in each 6 grams of protein
We loose 4 grams of Nitrogen each day in stool Nitrogen balance= g of pro intake/6.25 – (24 hour UUN +4) If the number is less than 0 the patient is not wasting or loosing protein. A patient with a negative protein balance needs extra protein in diet.

Serum Creatinine Waste product of creatinine phosphate from skeletal muscle Normal men mg/dL Normal women mg/dL Elevated in nephron damage

Bun to Creatinine Ratio
About 10: 1 is normal 15:1 dehydration or protein breakdown (ratio goes up) Look at together. Kidney failure both will be elevated. If BUN elevated and not creatinine, look for dehydration or protein stores

Uric Acid Proteins and muscle breaks down into purines and are excreted by kidneys as uric acid waste. Feel joint pain. Hyperuricemia: due to renal impairment, drugs, pre-eclampsia, Allopurinol is the medication to correct this.

ALBUMIN Albumin (3.5-5 g/dl) Long half life…only get ever two weeks
Prealbumin ( mg/dl) Shorter half life….more sensitive indicator in changes in nutrition. Hypoalbuminemia= think leaking capillaries in blood vessels and lungs! Loss of colloid pressure.

CBC RBC Count (4.7-6 males/ 4.2-5.4 females)
Hematocrit (42-52% males/ %) Hemoglobin (14-18 g/dl males / g/dl females) WBC Count with differential (5-10 x 10 to the 9th ) The CBC can help detect blood diseases and disorders, such as anemia, infections, clotting problems, blood cancers, and immune system disorders Red blood cells carry oxygen from your lungs to the rest of your body. Abnormal red blood cell levels may be a sign of anemia, dehydration (too little fluid in the body), bleeding, or another disorder Hematocrit (hee-MAT-oh-crit) is a measure of how much space red blood cells take up in your blood. A high hematocrit level might mean you're dehydrated. A low hematocrit level might mean you have anemia. Abnormal hematocrit levels also may be a sign of a blood or bone marrow disorder. Hemoglobin (HEE-muh-glow-bin) is an iron-rich protein in red blood cells that carries oxygen. Abnormal hemoglobin levels may be a sign of anemia White blood cells are part of your immune system, which fights infections and diseases. Abnormal white blood cell levels may be a sign of infection, blood cancer, or an immune system disorder. A CBC measures the overall number of white blood cells in your blood. A CBC with differential looks at the amounts of different types of white blood cells in your blood. p. 25

WBC Neutrophils and bands :neutrophilia (bact. Infec)
Nomal bands less than 3% decreased neutrophil count: neutropenia (viral infec) Increased eosinophil count: eosinophilia (asthma) Decreased eosinophil count: (steroid use) Basophil count changes (infec and steriods) Increased lumphocyte count: lymphocytosis (CD numbers)(infections lymphocytic leukemia) Decreased lymphocyte count: lymphopenia (HIV) CD numbers: clusters of differentiation

Coagulation Tests Activated clotting time (180-570 sec)
D-dimer Screen (less than 500 ng/ml)(high w clot) Fibrinogen( mg/dl) (2-4 g/liter)(low in DIC) Fibrinogen Degradation Products(fsp)(high in DIC) Partial Thromboplastin time (PTT)(therapy 1.5-2x) Activated PTT (30-40 sec) Platelet count ( x 10 9th per liter) (20 severe) Prothrombin time (PT)(10-14sec)(therapy x) International Normalized Ratio (INR) Platelets (PLATE-lets) are blood cell fragments that help your blood clot. They stick together to seal cuts or breaks on blood vessel walls and stop bleeding. Abnormal platelet levels may be a sign of a bleeding disorder (not enough clotting) or a thrombotic disorder (too much clotting). Hemoglobin (HEE-muh-glow-bin) is an iron-rich protein in red blood cells that carries oxygen. Abnormal hemoglobin levels may be a sign of anemia p. 303

DIC Disseminated intravascular clotting in microcirculation…use up all the clotting factors….bleed…see a drop in platelets Ddimer positive = clot somewhere Abruptio placentae D dimer negative = r/o pulmonary embolus

Therapeutic Levels On heparin drip post op MVR (PTT 1.5 – 2x normal)
On Coumadin by mouth for chronic afib ( normal) so 10 x 2.5 = 25 sec INR: 2-3 for chronic afib INR: for mechanical heart valve replacement

Acid Base Balance ABG’s Anion gap Serum CO2 Electrolytes shift
Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

ABG’s Great online tutorials pH 7.35 – 7.45

Anion Gap (8-16 +/- 4) Acid base lab
Think of conditions that create acid DKA Lactate lactic acidosis from shock and sepsis Gap = higher number Differentiates the types of acidosis Lactic acid = gap High chloride no gap

Serum Co2 High levels think high base binding ability
Carbon dioxide binding power or total CO2 is an indirect measurement of serum bicarbonate. If anion gap is high, this will be low And vice versa

CO2 Base Excess Extra buffering base on board to compensate for losses of H ions, K, and Cl Common cause: GI suctioning induced loss of gastic contents. COPD compensation

CO2 Base Deficit Less buffer binding availability
Compensation to acidosis buffers used up Or due to Chloride elevated Or due to kidneys loosing bicarbonate

Electrolyte Shift What happens to K during acidosis event?
What happens to K during alkalosis event? Chloride Elevated acidosis (no anion gap)

Relationships We rarely ever just look at one lab value.
We look at relationships between the labs. Inverse relationships Proportional relationships.

Inverse Relationship Acidic Environment Alkaline Environment
Serum co2 decreases Potassium increases Serum co2 increases Potassium decreases

Proportional Relationship
Calcium Albumin Calcium travels on albumin If albumin levels are low calcium will be low. Expect this finding Indicates nutritional status If you want to improve the calcium level, think about feeding the patient protein. Normal 3.5 – 5.2 g/dl

Corrected Calcium For every gram decrease in albumin calcium will decrease 0.8. This is our coeffiencient. Mid normal Albumin is 4.0 0.8 (4.0 – current albumin) = x X + calcium level= corrected calcium level

Example Lab report shows calcium level to be 7.5
The nurse knows that if albumin is low, calcium will also probably be low. But how low? Albumin is 3.0 0.8 ( )= 0.8 = 8.3 The corrected calcium is low. If the patient is showing physical symptoms, they probably will be given IV calcium gluconate Trousseau’s and Chvostecks sign classic & tremors

Example Calcium is 7.5 Albumin is 2.8

Patient Populations Pancreatitis Diabetes/ DKA/ DI
Hemorrhage/ thrombocytopenia Post op CABG Liver Failure/ ETOH Abuse Malnutrition Homework: Post on Wiki

Each population What labs should you follow?
What do the labs look like in this condition? What is the goal (expected outcomes) for our labs? What interventions do we do?

Questions

Lipoprotein panel A lipoprotein panel gives information about your:
Total cholesterol. LDL ("bad") cholesterol. This is the main source of cholesterol buildup and blockages in the arteries. (For more information about blockages in the arteries, go to the Diseases and Conditions Index Atherosclerosis article.) HDL ("good") cholesterol. This type of cholesterol helps decrease blockages in the arteries. Triglycerides. Triglycerides are a type of fat in your blood. A lipoprotein panel measures the levels of LDL and HDL cholesterol and triglycerides in your blood. Abnormal cholesterol and triglyceride levels may be signs of increased risk for CHD. Most people will need to fast for 9 to 12 hours before a lipoprotein panel

Fluid and Electrolyte Imbalance

Similar presentations

Presentation on theme: "Fluid and Electrolyte Imbalance"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Fluid and Electrolyte Imbalance

Similar presentations

Presentation on theme: "Fluid and Electrolyte Imbalance"— Presentation transcript:

Similar presentations

About project

Feedback