Medical Surgical Nursing
 NURS 127
Megan Rohm, MNc, BSN, RN-BC
 Today:
 Introduce ourselves
 Introduce the course
-Syllabus
• Fluids and Electrolytes
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Medical Surgical Nursing
 NURS 127
 Unit One Topics:
 Fluids and Electrolytes
 Immune System
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Unit 1
Fluid and Electrolytes
MeganRohm, BSN,RN
Acknowledgements to Elsevier
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Unit 1
Fluid and Electrolytes
Objectives:
1) Explain how water balance and electrolyte balance are interdependent
2) List, describe and compare the body fluid compartments
3) Discuss active and passive transport processes and give examples of each
4) Discuss the role of specific electrolytes in maintaining homeostasis
5) Describe the cause and effect of deficits and excesses of sodium, potassium,
chloride, calcium, magnesium, & phosphorus
6) Discuss the role of the nursing process in maintaining fluid and electrolyte
balances.
7) Discuss how the very young, very old, and obese patient are at risk for fluid
volume deficit.
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Homeostasis
 State of equilibrium in body
 Naturally maintained by adaptive
responses
 Body fluids and electrolytes are
maintained within narrow limits
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Water Content of the Body
 60% of body weight in adult
 45% to 55% in older adult
 70% to 80% in infants
 Varies with gender, body mass, and
age
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Fluid Balance
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Compartments
 Intracellular fluid (ICF)
_______ ______ ______cell membrane
 Extracellular fluid (ECF)
 Interstitial = tissue
______________________capillary membrane
 Intravascular (plasma)
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Fluid Compartments of the
Body
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Extracellular Fluid (ECF)
 One third of body fluid
 3 major components
1) Interstitial fluid
2) Intravascular
3) Transcellular fluid
• over or across the cells
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Interstitial Component
 Fluid btwn cells
 Surrounds cells
 Transport medium for nutrients, gases,
waste products and other substances
btwn blood and body cells
 Also acts as a back up fluid reservoir
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Fluid Regulation
 How does movement from space to
space occur?
 Diffusion
 Osmosis
 Filtration
 Active transport
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Fluid Regulation
 Diffusion
 Movement of solutes from an area of higher
concentration to an area of lower concentration in a
solution and or across a permeable membrane
 This movement occurs until near equal state
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Fluid Regulation
 Osmosis
 Now with water.
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Osmosis VS. Diffusion
 Osmosis
 Low to high
 Water potential
 Diffusion
• High to low
• Movement of particles
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Fluid Regulation
 Filtration
 Water pushing against the confining
walls of a space
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Electrolytes
 Substances whose molecules
dissociate into ions (charged
particles) when placed into water
 Cations: positively charged
 Anions: negatively charged
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Electrolyte Composition
 ICF
 Prevalent cation is K+
 Prevalent anion is PO43-
 ECF
 Prevalent cation is Na+
 Prevalent anion is Cl-
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Regulation of Electrolytes
 Active transport
 Allows molecules to move against concentration and
osmotic pressure to areas of higher concentration
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Active Transport:
Sodium–Potassium Pump
Fig. 17-5
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Fluid Movement in Capillaries
 Amount and direction of movement
determined by
 Capillary hydrostatic pressure
 Plasma oncotic pressure
 Interstitial hydrostatic pressure
 Interstitial oncotic pressure
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Fluid Exchange Between Capillary
and Tissue
Fig. 17-8
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Osmolality
 Concentration of body fluids- affects
movement of fluid by osmosis.
 Reflects hydration status
 Measured by serum and urine
 Solutes measured-mainly urea,
glucose, & sodium
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Osmolality
 Serum value 280-300 mOsm/kg
 Urine value 250-900 mOsm/kg
 Increases in serum level




Free water loss
Elevated Na
Hyperglycemia
Uremia
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Fluid Volume Shifts
 Normally fluid shifts btwn intracellular
and extracellular compartments to
maintain equilibrium btwn spaces
 Fluid not lost from body, but not
available for use in either compartmentconsidered third-space fluid shift (thirdspacing)
 Enters interstitial compartment
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Causes of Third-Spacing
 Burns
 Peritonitis
 Bowel obstruction
 Massive bleeding into joint or cavity
 Liver or renal failure
 Lowered plasma proteins
 Increased capillary permeability
28
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Assessment of Third-Spacing
 More difficult – fluid sequestered in deeper
structures
 Signs/Symptoms





Decreased urine output with adequate intake
Increased HR
Decreased BP
Increased weight
Pitting edema, ascites
29
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Phases of Third-Spacing
1. Loss phase
 Lasts 48-72 hours
 Symptoms of FVD
2. Reabsorption phase
 Fluid gradually reabsorbed after problem subsides
 FVO possible
 Monitor VS, I&O, Wt, and breath sounds
31
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Treatment
 Treat underlying cause if possible
 Close observation of VS
 Monitor I & O more frequently
 Daily weights
 Measure abdominal girth in ascites
 Measure extremities if necessary
 Monitor lab values
 albumin level important
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32
Treatment Goals
 Stabilized I & O
 Stabilized weight
 VS within normal range
 Resolution of third-spacing
33
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Extracellular Fluid Volume
Imbalances
 ECF volume deficit (hypovolemia)
 Abnormal loss of normal body fluids
(diarrhea, fistula drainage,
hemorrhage), inadequate intake, or
plasma-to-interstitial fluid shift
 Treatment: replace water and
electrolytes with balanced IV solutions
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Fluid Volume Deficit
 Hypovolemia
 Abnormally low volume of body fluid in intravascular
and/or interstitial compartments
 Causes










Vomiting
Diarrhea
Fever
Excess sweating
Burns
Diabetes insipidus
Inadequate intake
Hemorrhage
Overuse of diuretics
Third spacing
35
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Fluid volume deficit
 What happens
 Output > Intake Water extracted
from ECF
• ECF hypertonic (water moves out of cell  cell
dehydration) + osmotic pressure increased
(stimulates thirst preceptor in hypothalamus)
• ICF hypotonic with decreased osmotic pressure
 posterior pituitary secretes more ADH
• Decreased ECF volume adrenal glands secrete
Aldosterone
36
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Signs and Symptoms









Acute weight loss
Decreased skin turgor
Oliguria
Concentrated urine
Weak, rapid pulse
Capillary filling time elongated
Decreased BP
Increased pulse
Sensations of thirst, weakness, dizziness,
muscle cramps
38
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Labs
 Increased HCT
 Increased BUN
 Increased serum osmolality
 Increased urine osmolality
 Increased specific gravity
 Decreased urine volume, dark color
39
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Significant Points
 Dehydration – one of most common
disturbances in infants and children
 Additional S/S
 Sunken eyeballs
 Depressed fontanels
 Significant wt loss
40
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Significant Points
 Older Adult
 Vein filling better indicator than skin
turgor
 Have additional health problems
 Take various medications
 May ↓ intake to prevent incontinence
41
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Nursing Management
Nursing Diagnoses
 Hypovolemia
 Deficient fluid volume
 Decreased cardiac output
 Potential complication: hypovolemic
shock
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Interventions
 Major goal prevent or correct abnormal fluid
volume status before ARF occurs
 Encourage fluids
 IV fluids
 Isotonic solutions (0.9% NS or LR) until BP
back to normal, then hypotonic (0.45% NS)
 Monitor I & O, urine specific gravity, DAILY
WEIGHTS
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43
Interventions
 Monitor skin turgor
 Monitor VS and mental status
 Goal:
 Normal skin turgor, increased UOP with normal
specific gravity, normal VS, clear sensorium, good
oral intake of fluids, labs WNL
44
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Regulation of Water Balance
 Antidieuretic Hormone (ADH)
• Hold on to water
 Aldosterone
• Increases Na+ retention
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Where is a lot of this happening
in the body?
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Renal Regulation
 regulating fluid and electrolyte
balance
 Adjusting urine volume
• Selective reabsorption of water and
electrolytes
• Renal tubules are sites of action of ADH
and aldosterone
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Effects of Stress on
F&E Balance
Fig. 17-10
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Gastrointestinal Regulation
 Oral intake accounts for most water
 Small amounts of water are
eliminated by gastrointestinal tract
in feces
 Diarrhea and vomiting can lead to
significant fluid and electrolyte loss
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Extracellular Fluid Volume
Imbalances
 Fluid volume excess (hypervolemia)
 Excessive intake of fluids, abnormal
retention of fluids (CHF), or
interstitial-to-plasma fluid shift
 Treatment: remove fluid without
changing electrolyte composition or
osmolality of ECF
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Causes
 Excessive isotonic or hypotonic IV
fluids
 Heart failure
 Renal failure- urinary
 Liver failure, cirrhosis
 Long-term use corticosteroids
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Signs/Symptoms








Headache, confusion, lethargy
Edema
Distended neck veins
Bounding pulse,
Polyuria
Dyspnea, crackles, pulmonary edema
Wt. Gain
Seizures, coma
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Nursing Management
Nursing Diagnoses
 Hypervolemia
 Excess fluid volume
 Ineffective airway clearance
 Risk for impaired skin integrity
 Disturbed body image
 Potential complications: pulmonary
edema, ascites
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Nursing Management
Nursing Implementation
 I&O
 Monitor cardiovascular changes
 Assess respiratory status and
monitor changes
 Daily weights
 Skin assessment
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Nursing Management
Nursing Implementation
 Neurologic function
 LOC
 PERLA
 Voluntary movement of extremities
 Muscle strength
 Reflexes
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Electrolyte
Imbalances
 Refer to charts available on Angel
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Electrolyte Disorders
Signs and Symptoms
Electrolyte
Excess
Deficit
Sodium (Na)
Hypernatremia
Thirst
CNS deterioration
Increased interstitial fluid
Hyponatremia
CNS deterioration
Potassium (K)
Hyperkalemia
Ventricular fibrillation
ECG changes
CNS changes
Hypokalemia
Bradycardia
ECG changes
CNS changes
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Electrolyte Disorders
Signs and Symptoms
Electrolyte
Excess
Deficit
Calcium (Ca)
Hypercalcemia
Thirst
CNS deterioration
Increased interstitial fluid
Hypocalcemia
Tetany
Chvostek’s, Trousseau’s
signs
Muscle twitching
CNS changes
ECG changes
Magnesium (Mg)
Hypermagnesemia
Loss of deep tendon reflexes
(DTRs)
Depression of CNS
Depression of
neuromuscular function
Hypomagnesemia
Hyperactive DTRs
CNS changes
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Sodium
 Normal 135-145 mEq/L

Plays a major role in



ECF volume and concentration
Generation and transmission of nerve impulses
Acid–base balance
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Differential Assessment of
ECF Volume
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Hypernatremia
 Elevated serum sodium occurring
with water loss or sodium gain
 Causes hyperosmolality leading to
cellular dehydration
 Primary protection is thirst from
hypothalamus
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Signs/Symptoms
 Early: Generalized muscle weakness,
faintness, muscle fatigue, HA
 Moderate: Confusion, thirst
 Late: Edema, restlessness, thirst,
hyperreflexia, muscle twitching,
irritability, seizures, possible coma
 Severe: Permanent brain damage,
hypertension, tachycardia, N & V
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65
Nursing Management
Nursing Diagnoses
 Risk for injury
 Potential complication: seizures and
coma leading to irreversible brain
damage
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Nursing Management
Nursing Implementation
 Treat underlying cause
 Free water to replace ECF volume
 If oral fluids cannot be ingested, IV
solution of 5% dextrose in water or
hypotonic saline (gradual)
 Diuretics
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Hyponatremia
 Results from excess loss of Na containing fluids
or from water excess:
 GI losses, diuretic therapy, severe renal dysfunction,
severe diaphoreses, narcotic use
 Manifestations, S/S
 Confusion, nausea, vomiting, seizures,
decreased BP, headache, muscle twitching,
cramps
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Nursing Management
Nursing Diagnoses
 Risk for injury
 Potential complication: severe
neurologic changes
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Nursing Management
Nursing Implementation
 Caused by water excess
 Fluid restriction is needed
 Severe symptoms (seizures)
 Give small amount of IV hypertonic
saline solution (3% NaCl)
 Abnormal fluid loss
 Fluid replacement with sodiumcontaining solution
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Potassium
 Normal 3.5-5.5 mEq/L
 Major ICF cation
 Necessary for
 Transmission and conduction of nerve
and muscle impulses
 Maintenance of cardiac rhythms
 Acid–base balance
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Potassium
 Sources
 Fruits and vegetables (bananas and
oranges)
 Salt substitutes
 Potassium medications (PO, IV)
 Stored blood
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Hyperkalemia
 High serum potassium caused by
 Massive intake of K
 Impaired renal excretion
 Shift from ICF to ECF
 Common in massive cell destruction
 Burn, crush injury, or tumor lysis
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Hyperkalemia
 Manifestations, S/S
 Weak or paralyzed skeletal muscles
 ECG changes; Ventricular fibrillation
or cardiac standstill
 Abdominal cramping or diarrhea
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Nursing Management
Nursing Diagnoses
 Risk for injury
 Potential complication:
dysrhythmias
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Nursing Management
Nursing Implementation
 Eliminate oral and parenteral K
intake
 Increase elimination of K (diuretics,
dialysis, Kayexalate)
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Nursing Management
Nursing Implementation
 Force K from ECF to ICF by IV
insulin or sodium bicarbonate
 Reverse membrane effects of
elevated ECF potassium by
administering calcium gluconate IV
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Hypokalemia
 Low serum potassium caused by
 Abnormal losses of K+ via the kidneys
or gastrointestinal tract
 Magnesium deficiency
 Metabolic alkalosis
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Hypokalemia
 Manifestations
 Most serious are cardiac
 Skeletal muscle weakness
 Weakness of respiratory muscles
 Decreased gastrointestinal motility
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Nursing Management
Nursing Diagnoses
 Risk for injury
 Potential complication:
dysrhythmias
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Nursing Management
Nursing Implementation
 KCl supplements orally or IV
 Slowly
 K is an irritant
 Should not exceed 40 mEq/hr
 To prevent hyperkalemia and cardiac
arrest
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Nursing Management
Nursing Implementation
 Hypertonic glucose solution
 Monitor
 I&Os
 VS, cardiac rhythm
 Muscle strength
 Bowel sounds
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Calcium
 Normal 4.5-5.5 mEq/L
 Obtained from ingested foods
 More than 99% combined with
phosphorus and concentrated in
skeletal system
• the other 1% is in ECF and soft tissues
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Calcium
 Bones are readily available store
 Blocks sodium transport and
stabilizes cell membrane
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Calcium
 Functions
 Transmission of nerve impulses
 Myocardial contractions
 Blood clotting
 Formation of teeth and bone
 Muscle contractions
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Calcium
 Balance controlled by
 Parathyroid hormone
 Calcitonin
 Vitamin D
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Hypercalcemia
 High serum calcium levels caused by
 Hyperparathyroidism (two thirds of
cases)
 Malignancy
 Vitamin D overdose
 Prolonged immobilization
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Hypercalcemia
 Manifestations, S/S
 Decreased memory
 Confusion, fatigue, coma
 Anorexia, constipation
 Muscle weakness, loss of muscle tone
 Polyuria & predisposes to renal calculi
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Nursing Management
Nursing Diagnoses
 Risk for injury
 Potential complication:
dysrhythmias
 death
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Nursing Management
Nursing Implementation
 Excretion of Ca with loop diuretic
 Hydration with isotonic saline
infusion
 Synthetic calcitonin
 Mobilization
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Hypocalcemia
 Low serum Ca levels caused by
 Decreased production of PTH
 Acute pancreatitis
 Multiple blood transfusions
 Alkalosis
 Decreased intake
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Hypocalcemia
 Manifestations
 Positive Trousseau’s or Chvostek’s
sign
 Laryngeal stridor
 Dysphagia
 Tingling around the mouth or in the
extremities
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Tests for Hypocalcemia
Fig. 17-15
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Nursing Management
Nursing Diagnoses
 Risk for injury
 Potential complication: fracture or
respiratory arrest
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Nursing Management
Nursing Implementation
 Treat cause
 Oral or IV calcium supplements
 Not IM to avoid local reactions
 Treat pain and anxiety to prevent
hyperventilation-induced
respiratory alkalosis
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Phosphate
 Primary anion in ICF
 Essential to function of muscle, red
blood cells, and nervous system
 Deposited with calcium for bone and
tooth structure
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Phosphate
 Involved in acid–base buffering
system, ATP production, and
cellular uptake of glucose
 Maintenance requires adequate
renal functioning
 Essential to muscle, RBCs, and
nervous system function
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Hyperphosphatemia
 High serum PO43- caused by
 Acute or chronic renal failure
 Chemotherapy
 Excessive ingestion of phosphate or
vitamin D
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Hyperphosphatemia
 Manifestations
 Calcified deposition in soft tissue such
as joints, arteries, skin, kidneys, and
corneas
 Neuromuscular irritability and tetany
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Hyperphosphatemia
 Management
 Identify and treat underlying cause
 Restrict foods and fluids containing
PO43 Adequate hydration and correction of
hypocalcemic conditions
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Hypophosphatemia
 Low serum PO43- caused by
 Malnourishment/malabsorption
 Alcohol withdrawal
 Use of phosphate-binding antacids
 During parenteral nutrition with
inadequate replacement
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Hypophosphatemia
 Manifestations
 CNS depression
 Confusion
 Muscle weakness and pain
 Dysrhythmias
 Cardiomyopathy
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Hypophosphatemia
 Management
 Oral supplementation
 Ingestion of foods high in PO43 IV administration of sodium or
potassium phosphate
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Magnesium
 50% to 60% contained in bone
 Coenzyme in metabolism of protein
and carbohydrates
 Factors that regulate calcium
balance appear to influence
magnesium balance
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Magnesium
 Acts directly on myoneural junction
 Important for normal cardiac
function
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Hypermagnesemia
 High serum Mg caused by
 Increased intake or ingestion of
products containing magnesium when
renal insufficiency or failure is present
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Hypermagnesemia
 Manifestations
 Lethargy or drowsiness
 Nausea/vomiting
 Impaired reflexes
 Respiratory and cardiac arrest
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Hypermagnesemia
 Management
 Prevention
 Emergency treatment
• IV CaCl or calcium gluconate
 Fluids to promote urinary excretion
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Hypomagnesemia
 Low serum Mg caused by
 Prolonged fasting or starvation
 Chronic alcoholism
 Fluid loss from gastrointestinal tract
 Prolonged parenteral nutrition without
supplementation
 Diuretics
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Hypomagnesemia
 Manifestations
 Confusion
 Hyperactive deep tendon reflexes
 Tremors
 Seizures
 Cardiac dysrhythmias
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Hypomagnesemia
 Management
 Oral supplements
 Increase dietary intake
 Parenteral IV or IM magnesium when
severe
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IV Fluid Replacement
 Purposes
1. Maintenance
•
When oral intake is not adequate
2. Replacement
•
When losses have occurred
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IV Fluid Reference
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IV Fluids
 Hypotonic
 More water than electrolytes
• Pure water lyses RBCs
 Water moves from ECF to ICF by
osmosis
 Usually maintenance fluids
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IV Fluids
 Isotonic
 Expands only ECF
 No net loss or gain from ICF
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IV Fluids
 Hypertonic
 Initially expands and raises the osmolality of ECF
when it shifts fluids from ICF & ECF into vascular
component-
expands blood volume
 Require frequent monitoring of
• Blood pressure
• Lung sounds
• Serum sodium levels
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Normal Saline (NS)
 Isotonic
 No calories
 30% stays in intravascular space
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Normal Saline (NS)
 Expands IV volume
 Preferred fluid for immediate response
 Risk for fluid overload higher
 Does not change ICF volume
 Blood products
 Compatible with most medications
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Lactated Ringer’s
 Isotonic
 More similar to plasma than NS
 Has less NaCl
 Has K, Ca, PO43-, lactate (metabolized
to HCO3-)
 Expands ECF
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Plasma Expanders
 Stay in vascular space and increase
osmotic pressure
 Colloids (protein solutions)
 Packed RBCs
 Albumin
 Plasma
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