 Mental status changes

 Seizures & coma

Fluids & Electrolytes

Potassium (K+)
 Muscular: Low & slow
 Fatigue
 Muscle cramps
 3.5 – 5.0
 Respiratory: Low & slow
 Function
 Respiratory arrest
→ Priority
→ Pumps the heart
 Hyperkalemia (> 5.0)
Chloride (Cl-)
→ Causes
 97 - 107
 Renal failure
 Function
 Low aldosterone
→ Maintains
 Adds sodium
 BP
 Loses potassium
 Blood volume
→ Signs & Symptoms
 pH balance
 Heart: High pumps
 Hyperchloremia (> 107)
 EKG: Peaked T waves & ST elevation
→ Nearly same as hypernatremia
 Severe: VFib & cardiac arrest
→ Signs & Symptoms
 Hypotension & bradycardia: The heart cramps up due to
over pumping  Swollen dry tongue
 NV
 Neuromuscular: High
 Metabolic alkalosis: Due to vomiting
 Increased DTR
 Paralysis & paresthesia / tingling  Hypochloremia (< 97)
 Muscle weakness: General feeling of heaviness → Nearly same as hyponatremia
 GI: High pumps → Signs & Symptoms
 Diarrhea  Fatigue
 Hyperactive bowel sounds  Muscle cramps
→ Treatment  Fever: Only difference
 IV calcium gluconate: Dysrhythmias
 IV 50% dextrose + regular insulin
 Kayexalate (polystyrene sulfonate) Magnesium (Mg+)
 Hypokalemia (< 3.0)  1.3 – 2.1
→ Causes  Function
 Fluid loss → Mellows the muscles
 Diarrhea  Hypermagnesemia (> 2.1)
 Diuretics → Causes
 Diet low in K+  Renal failure
 DKA: Clients have thick sugary blood / high blood osmolality  Alcoholism
 Aldosterone: Adds Na+ & loses K+ in the body  Malnourishment
→ Signs & Symptoms → Signs & Symptoms
 Heart: Low & slow pump  Heart: High mellow
 EKG: Flat T waves, ST depression, & Uwave  Heart block
 Neuromuscular: Low & slow  Hypotension
 Shallow respirations: Most deadly  Bradycardia
 Decreased DTR  DTR: High mellow
 Muscle cramping & flaccid paralysis  Hyporeflexia: Decreased DTRs
 GI: Low & slow  Lungs & GI: High mellow
 Constipation  Depressed respirations
 Hypoactive bowel sounds  Hypoactive bowel sounds
 Paralytic ileus: Priority! Risk for SBO  Hypomagnesemia (< 1.3)
→ Treatment → Causes
 Heart monitor: 1st action  Crohn’s disease
 NEVER push: Instant death  Celiac disease
 IV pump: Only 10 – 20 mEq MAX per hr IV → Signs & Symptoms
 Slow infusion: If arm burns  Heart: Low mellow
 Torsade’s de pointes
 VFib: Due to torsade’s de pointes
Sodium (Na+)  DTR: Low mellow
 135 - 145  Hyperreflexia: Increased DTRs
 Function  Lungs & GI: Low mellow
→ Maintains  Diarrhea
 BP  Hyperactive bowel sounds
 Blood volume
 pH balance
 Hypernatremia (> 145) Calcium (Ca)
→ Causes  9.0 – 10.5
 DI: Low ADH  Function
 Rapid respirations → Contracts & calms the muscles
 Watery diarrhea → Vit D & Mg+ helps it be absorbed
 Loss of thirst → Inverse relationship with phosphate
→ Signs & Symptoms → Keeps the Bs strong
 Body: Big & bloated  Bone & teeth
 Edema  Blood: Clotting
 Flushed red & rosey skin  Beats: Heart
 Increased muscle tone  Hypercalcemia (> 10.5)
 Swollen dry tongue → Causes
 NV  Hyperparathyroidism: Ca is controlled by the PTH
 Hyponatremia (< 135)  Cancer
→ Causes  Immobility
 SIADH: Excess ADH → Signs & Symptoms
 Running in extreme heat: Sweating & excess water intake  High Calm
 Diarrhea  Kidney stones, moans, & groans
 Vomiting  Constipation
 Diuretics  Severe muscle weakness & lethargy
 Diet low in salt  Bone pain: Due to the Ca leaving the bone & going into
 Low aldosterone the blood stream causing high Ca
→ Signs & Symptoms  Hypocalcemia (< 9.0)
 Brain: Low & slow → Causes
 Headache: Cerebral edema  Hypoparathyroidism: Ca is controlled by the PTH
  Renal failure: CKD due to the retention of phosphate, causing → Lab values: High than normal / high & dry
hyperphosphatemia
→ Signs & Symptoms  Hemodilution
 Low Calm → Decreased concentration, like after hemorrhage, of cells & solids
 Trousseau’s sign: Twerking arm when BP cuff on in the blood resulting from gain of fluid
 Tetany: Muscle spasms all over, including the hands, → Lab values: Less than normal / low & liquidly
feet, & voice box → Dilutional hyponatremia: Most serious case of hemodilution
 Chvostek’s sign: Cheeky smile when stroking face
 Diarrhea
 Fractures Fluid Balance
 R/F bleeding
 Pathophysiology of Body Fluids
 Cardiac dysrhythmias
→ Body is made up of 60 – 70 % fluid
→ Skin & blood contain the most fluid in the body
→ Fat cells repels water: Obese clients have less fluid
Phosphate
→ H2O gradually decreases from birth to old age
 3.0 – 4.5
 Due to an increase of muscle mass, which holds water &
 Function
gradually decreases with age
→ Inverse relationship with Ca
 Infants & elderly clients are at most at risk for fluid imbalance
→ Also keeps the bone & teeth strong  Elderly: FVO from HF & renal failure / FVD from dehydration
 Hyperphosphatemia (> 4.5) → Location
→ Causes  Intracellular fluid (ICF)
 Renal failure: CKD due to the retention of phosphate, causing  K+ is the most abundant in the cell
hyperphosphatemia  Extracellular fluid (ECF)
→ Signs & Symptoms  Blood vessels, skin tissues, spinal cord (CSF)
 Hypocalcemia  6 L of blood in the intravascular space
 Trousseau’s sign: Twerking arm when BP cuff on  11 – 12 L of interstitial fluid
 Tetany: Muscle spasms all over  1 L in the transcellular space
 Chvostek’s sign: Cheeky smile when stroking face → Organs
 Diarrhea  Kidneys
 Fractures  High BUN & creatinine: A sign of renal failure problem
 R/F bleeding  High BUN: A sign of dehydration
 Cardiac dysrhythmias  Daily urine output
 Hypophosphatemia (< 3.0)  1–2L
→ Causes  1 mL / kg / hr
 Hyperparathyroidism
 240 mL in 3 hrs
 Genetics
 480 mL in 6 hrs minimum
 Cancer
 960 mL in 12 hrs
→ Signs & Symptoms
 Skin
 Hypercalcemia
 Sensible losses / sensible perspirations
 Kidney stones, moans, & groans
 Sweating solutes: Na+, Cl-, K+
 Constipation
 Bone pain  Burn clients: Most at risk for FVD
 Severe muscle weakness & lethargy  Heat exhaustion
 Fever
 Stress
Foods Rich in Electrolytes  Thyroid crisis
 Lungs
 Electrolytes need to be taken through external sources, except Ca
 Sensible losses: 300 mL per day
& Mg+ in certain cases
 Monitor
 Potassium (K+)
 Clients with respiratory alkalosis
→ Green leafy veggies, spinach
 Hyperventilation: Kussmaul respirations
→ Any fruit: Banana, avocados
 GI Tract
→ Salt substitutes
 Diarrhea & fistulas cause large fluid losses
 Sodium (Na+)
 NGT suctioning
→ Table salt
 Stoma drainage: Colostomy / ileostomy
→ Cheese  Factors
→ Spices & sauces → Muscle: More fluid
→ Salad dressing → Body fat: Less fluid
→ Canned, processed foods → Gender: Men retain more fluid due to muscle mass
 Chloride (Cl-) → Age
→ Salty foods  Terms
→ Salt substitutes → Osmosis
 Magnesium (Mg+)  The movement of fluid from an area of lower solute
→ Green leafy veggies, spinach concertation to an area of higher solute concentration,
→ Almond leading to equalization
→ Yogurt  E.g., Large intestines that absorb high nutrients & balance
 Calcium (Ca) fluids
→ Green leafy veggies, spinach → Diffusion
→ Milk  The movement of solutes from an area of greater
→ Cheese concentration to an area of lesser concentration, leading to
→ Almonds equalization
→ Oranges  E.g., Exchange of O2 & CO2 inside the lungs between the
 Phosphate pulmonary capillaries & alveoli
→ Dairy → Filtration
→ Meats  The movement of both fluid & solutes from an area of high
→ beans hydrostatic pressure to an area of low hydrostatic pressure
 E.g., Kidneys that filter the blood
→ Osmolality
Additional Electrolytes Notes  The concentration of a solution: The number of osmotically
 Electrolytes active particles per kg of water
→ Ions that are in body fluids  In the body: Osmotic pressure is measured in milliosmoles
→ They help to conduct electricity & energy that helps to control (m0sm)
body fluids & maintain hemostasis in the body  Equal osmolality
 Isotonic
→ Mainly used in the skeletal muscles
 Normal blood: 270 – 300 m0sm / L
 Hemostasis
 Higher osmolality
→ The state of equilibrium / balance that is maintained by self-
 Higher solutes / heavy
regulating processes
 Hypertonic
 Therapeutic Range
 < 300 m0sm / kg
→ The range of concentrations at which a drug is most effective
 Lower osmolality
with the least toxic effect
 Lower solutes / light & dilute
 Hemoconcentration  Hypotonic
→ Dehydrated clients  > 270 m0sm / kg
  Decreased electrolytes
Fluid Volume Overload (FVO) / Hypervolemia  Hyponatremia
 Clients puff up like a big water balloon manifesting as edema  Hyponatremic encephalopathy: Risk for brain damage
 Edema: The swelling of soft tissues because of excess fluid
accumulation
 Grading Pitting Edema Fluid Volume Deficit (FVD) / Hypovolemia
→ 0+: No pitting edema  FVD is a common manifestation of dehydration, where there is a
→ 1+: 2 mm or less / immediate rebound (mild) deficit / decrease in body fluid
→ 2+: 3 – 4 mm / 15 secs to rebound (moderate)  Clients present sucked in, shriveled up, & very weak like a dried-out
→ 3+: 5 – 6 mm / 30 secs to rebound (moderately severe) raisin in the sun
→ 4+: 8 mm or deeper / 1 – 2 mins to rebound (severe)  Main Causes
 Main Causes of Edema → Vomiting
→ Increased hydrostatic pressure → Diarrhea
 Increased volume → Urination
 Manifestations → Hot body & sweating: Fever, heat stroke, thyroid crisis
 High BP → Severe burns: Most at risk for FVD due to blister formation on
 Pitting edema their skin
 E.g., → DI
 Renal failure: The kidneys fail to filter the blood & let  Clients pee up to 20L per day
excess fluid out of the body & into the potty → DKA
 Heart failure: The heart fails to pump the heart forward &  Hyperglycemia: Increased sugar concentration in the blood
now it backs up in the body & the lungs typically caused by infection
→ Decreased colloid osmotic pressure  Insensible losses: Kaussmaul respiration
 Decreased in fluid retention inside the blood vessels → Diuretics
 Colloid: Serves to hold water in the vascular space normally  Drains the body & into the potty
created by plasma proteins namely albumin that doesn’t  Loss of electrolytes too, namely K+
diffuse across the capillary membrane  Compensations of FVD & dehydration
 Low albumin / low plasma proteins → Increased thirst
 Albumin: Attracts fluid, thus, a low albumin causes for it → Holding on to concentrated urine
to leak into the 3rd space / body cavity → Increased HR & vasoconstriction
 E.g.,  Signs & Symptoms
 Cirrhosis: Liver makes albumin & liver disease results in → Cardiovascular
decreased albumin, allowing fluid to leak out of the  Low BP
vessels & into the 3rd spaces  Priority! Can lead to hypovolemic shock
 Starvation: Since there are no building blocks of protein  Orthostatic hypotension
being consumed to produce albumin  Lightheaded & dizziness upon standing
→ Increased capillary permeability  Decreased CVP
 Typically caused by severe inflammation / tissue destruction  Weak & thready pulses
 E.g.,  Flat neck & hand veins
 Bacteria: Causing infection  Tachycardia: Compensatory mechanism
 Burns: Damages the capillary leading to edema from fluid → Integumentary
leaking out of the vascular space  Sunken eyes
→ Obstruction of the lymphatic system  Dry skin: Poor turgor & tenting
 Lymphatic system: A network of tissues & organs that work  Dry mucous membranes
together to clean the blood, get rid of any waste that cells  Increased body temperature
make, & get rid of plasma 20 L / day with the help of → Neuromuscular
lymphocytes  Lethargy to coma
 E.g.,  Weakness
 Cancer: Tumor blockage → Renal & Urinary
 Infection: Big lymph nodes  Increased urine output initially
 Signs & Symptoms
 Decreased urine output at end
→ Weight Gain is Water Gain  “high when dry”
 2 – 3 lbs in 1 day  Increased urine specific gravity
 5 lbs in 7 days  > 1.030
→ Cardiovascular → Respiratory
 High BP  Priority! Airway
 Deadly & priority!  Rapid deep RR
 Hypertension: 140 systolic → GI
 HTN crisis: 180 systolic  Constipation: Decreased motility
 Big distended veins / jugular vein distention (JVD)
 Diminished bowel sounds: Hypoactive bowels
 Increased CVP
→ Lab Values
 Bounding pulses
 Increased osmolality / thickness of blood
→ Integumentary
 Increased Hct
 Periorbital edema
 Increased BUN
 Pitting edema from hydrostatic pressure
 Increased electrolytes
 Pale cool skin
 Hypernatremia
→ Neuromuscular  Risk for brain bleeding due to brain shrinking resulting in
 ALOC vascular rapture & intracranial bleeding
 Headache
 Weakness & paresthesia
→ Renal & Urinary
Solutions
 Increased urine output
 Isotonic Solutions
 “low when liquidy”
→ “I so perfect”
 Decreased urine specific gravity
→ These solutions have perfect balance / equilibrium of solutes
 < 1.005
 Decreased urine output both inside & outside the cell; thus, no fluid shifts are made
 If the client cannot compensate, like if they have renal → Very little osmosis: Blood is isotonic; thus, very little osmosis
issues occurs since isotonic solutions have the same osmolality as body
 E.g., Kidney damage fluids
→ Respiratory → Caution
 Priority! Airway  Too much will cause FVO
 Rapid shallow respiratory rate  Monitor: Blood pressure
 Pulmonary edema  HTN Crisis
 Rales / moist crackles: Fluid in lungs  BP > 180 systolic
→ GI  Risk for CVA stroke
 Diarrhea: Increased motility → List of Fluids
 Hepatomegaly  0.9 Sodium Chloride (Normal Saline)
 Ascites  Lactated Ringer’s (LR)
→ Lab Values → Uses
 Decreased osmolality / thickness of blood  Hypotension: To increase BP
 Decreased HcT  Blood transfusions: To add volume during blood
 Decreased BUN administration
 Hemorrhaging: To rehydrate the body
  DKA & HHNS  HcT & possible other electrolytes will appear falsely elevated
 Body gets overload with high blood sugar, making the because of hemoconcentration due to decreased circulating
blood thick & body dry volume
 Initially started on isotonic, then hypotonic  Serum osmolality is also increased due to
 Hypotonic Solutions hemoconcentration
→ “Hippo tonic”  Mr. W is a 50-year-old client with a history of congestive HF who is
→ These solutions have a lower osmolarity & concentration of salts being seen in the clinic today due to a weight gain of 4 lbs over the
/ solutes than the intracellular fluids (ICF) / body fluids last 24 hours. Upon assessment, 2+ pitting edema is noted in both
→ Osmosis: The movement of water into cells, swelling the cells, & ankles
therefore should be administered slowly to prevent cellular → Given the scenario, which assessment data will be the nurse’s
edema priority to collect first?
→ Caution  BP
 Give slowly: To prevent cellular edema & cerebral swelling  Hypertension is deadly
 Contraindicated: Clients with ICP  140 systolic can lead to HTN crisis of 180 systolic, stroke
 Cerebral Edema Manifestations risk
 Headache → The BP is currently at 158 / 98. What does the nurse suspect as
 Altered LOC the underlying cause for the client’s abnormal assessment data
 Seizures & coma including the edema, weight gain, & increased BP
→ List of Fluids  FVO: Secondary to exacerbation of congestive HF
 0.45% Sodium Chloride (1/2 NS) → Which pathophysiological process is responsible for the client’s
 0.225% Sodium Chloride (1/4 NS) pitting edema?
 0.33 Sodium Chloride (1/3 NS)  Increased hydrostatic pressure
 5% Dextrose in 0.225% Saline (D51 / 4NS) → What additional assessment data does the nurse anticipate for
 5% Dextrose in Water (D5W): Isotonic in bag, hypotonic in this client?
body  Bounding pulses
→ Uses  Decreased Hct
 Cellular Dehydration: Hypernatremia  Decreased serum Na+
 Hypertonic Solutions  Decrease urine specific gravity
→ “hypertonic high & dry” → What is the underlying pathophysiology for decreased. Urine
→ These solutions have a higher osmolarity & concentration of salts specific gravity in clients with fluid volume excess?
/ solutes than the intracellular fluids (ICF) / body fluids  In clients with excessive fluid volume, there is an excess of
→ Very thick salty solutions having more solutes & less water, very dilute urine with a decreased specific gravity
causing water to be moved outside the cells & making the cells  The nurse is caring for a client with a primary medical diagnosis of
skinny acute renal failure secondary to treatment of a urinary tract
→ Caution infection with a nephrotoxic antibiotic. The client’s morning BMP
 Give slowly: To prevent massive fluid shifts inside the cell reveals the following abnormal data
into the bloodstream causing cellular dehydration & FVO → Na+ 135 mEq/L
 Monitor: Blood pressure → K+ 6.5 mEq/L
 HTN Crisis → Ca+ 7.1 mg/dL
 BP > 180 systolic → Phos+ 5.3 mmol/L
 Risk for CVA stroke → Which electrolyte levels are out of normal range according to the
→ List of Fluids client’s BMP?
 3% Sodium Chloride (3% NS)  Hyperkalemia, hypocalcemia, hyperphosphatemia
 5% Sodium Chloride (5% NS) → Which assessment data will be the nurse’s priority to collect first
 10% Dextrose in Water (D10W) according to the above electrolyte abnormalities?
 5% Dextrose in 0.9% Sodium Chloride (D5NS)  HR & rhythm
 5% Dextrose in 0.45% Sodium Chloride (D51 / 2NS)  The client is at high risk for dysrhythmias due to
 5% Dextrose in Lactated Ringer’s (D5LR) hyperkalemia
→ Uses → Which additional assessment data does the nurse anticipate in
 Hypovolemia clients with hyperkalemia?
 Heat related / heat exhaustion  Paresthesia
 Peritonitis  Muscle weakness
 Peritoneal dialysis: To draw all the fluids out of the body &  Hypotension
into the potty  Increased DTR
→ What assessment data does the nurse anticipate in clients with
hyperphosphatemia?
Case Studies  Tetany
 Ms. J is an 80-year-old client admitted to the emergency department  Chvostek’s sign
with reports of dizziness & episodes of lightheadedness when she  Trousseau’s sign
stands up too quickly. She reports flu like symptoms with vomiting & → What is the underlying pathophysiology behind this client’s
diarrhea for the past 3 days hypocalcemia?
→ Given the current scenario, which assessment data will be the  Due to the client’s acute renal failure, the client is unable to
nurse’s priority to collect first? excrete phosphorus readily, leading to a state of
 HR & BP hyperphosphatemia. Calcium & phosphorus have an inverse
 Orthostatic hypotension relationship leading to hypocalcemia in these clients
 Low BP & dizziness upon standing
 Priority! Because it can kill the client from hypovolemic
shock making the heart unable to pump enough blood
supply to the body
 FVD: Due to vomiting & diarrhea for the past 3 days
resulting in severe dehydration
→ Upon assessment, the HR is 110 BPM & BP is 82 / 48. What does
the nurse suspect as the underlying cause for the client’s
abnormal VS?
 FVD: Due to vomiting & diarrhea for the past 3 days resulting
in severe dehydration
→ What additional assessment data does the nurse expect based
on the client’s underlying problem?
 Weight loss
 Dry mucous membranes
 Weak pulses
 Increased body temperature
 Increased Hct
→ What is the underlying pathophysiology for the client’s
hypotension & increased HR?
 The client is hypotensive due to decreased circulating
volume & the HR is increased as a compensatory mechanism
for the decreased volume & tissue / organ perfusion
→ What is the underlying pathophysiology for increased Hct in
clients with FVD?