Med Surg Exam 1

B. D5W

B. Hypertonic

B. Pulmonary Edema

A: 3% Saline. A patient with cerebral edema would be ordered a HYPERTONIC solution to decrease brain swelling. The solution would remove water from the brain cells back into the intravascular system to be excreted. 3% Saline is the only hypertonic option.

D. Hypertonic

D. 0.33% saline (1/3 NS)

A. Patient with increased intracranial pressure

C. Hypotonicity

A. Hypotonic

D. 0.9% Normal Saline

C. 0.45% Saline

Sodium

Potassium

Calcium

Magnesium

Chloride

Phosphate

fluid shifting of intracellular and goes into an area where it can't be used, results in decreased fluid in intracellular

Intracranial Pressure*

Diabetics(risk for HYPERglycemia)

Cell presents with the same concentration on the inside and outside with no shifting of fluids (HYDRATION)

0.9% Saline

5% Dextrose *

5% Dextrose in 0.225 saline

Lactated Ringers (LR)

Increase fluid in the extracellular space

Intracellulaer-> extracellular

DEHYDRATION(cell shrinks)

3% saline

5% saline

10% Dextrose (fluid overload w/pulmonary edema)

5% Dextrose in 0.9 saline

5% Dextrose in 0.45 saline

5% Dextrose in LR

Hyponatremia (pulls sodium back into intravascular system)

Cerebral edema w/ swelling by remaining fluid off brain

Loss of extracellular fluid exceeds intake ratio of water (DEHYDRATION)

-Abnormal fluid losses (vomiting,diarrhea,sweating,GI suction)

-Decreased intake(nausea, lack of access, anorexia)

-Third space fluid shifts(due to burns, ascites)

-Diabetes insipidus

-Adrenal insufficiency

-Hemorrhage

-Weight loss

-↓ skin turgor,

-oliguria,

-concentrated urine,

- increased capillary filling time

- low CVP (central venous pressure), ↓ BP,

-flattened neck veins,

-dizziness, weakness, thirst

and confusion,

-↑ pulse,

muscle cramps, sunken

eyes, nausea, increased

temperature; cool, clammy,

pale skin

↑ hemoglobin and hematocrit,

↑ serum and urine osmolality and

specific gravity,

↓ urine sodium,

↑ BUN and creatinine,

↑ urine specific gravity and osmolality

-cognition

-ambulation

-ADLs

-Gag reflex

Oral route prefered

IV for acute or severe losses

Types of solutions

-Lactated Ringer’s solution or 0.9% sodium chloride first line choice for hypotensive pt with fvd

-Normotensive pt a hypotonic electrolyte solution (e.g., 0.45% sodium chloride) is used

-Pt severe FVD-fluid challenge test

•I&O at least every 8 hours, sometimes hourly

•Daily weight

•Vital signs closely monitored

•Skin and tongue turgor, mucosa, urine output, mental status

•Measures to minimize fluid loss

•Administration of oral fluids

•Administration of parenteral fluids

Expansion of the ECF caused by the abnormal retention of water and sodium in approximately the same proportions in which they normally exist in the ecf (secondary to increase total-body sodium content)

•fluid overload or diminished homeostatic mechanisms

•Heart failure, kidney injury, cirrhosis of liver

•Contributing factors: Consumption of excessive amounts of table salt or other sodium salts

•Excessive administration of sodium-containing fluids

-weight gain

•Edema(elevate legs)and ascites

•Distended jugular neck veins

•Crackles

-elevated CVP

-shortness of breath(oxygen), ↑ BP,

-bounding pulse and cough,

-↑ respiratory rate,

-↑ urine

output

↓ hemoglobin and hematocrit, BUN

↓ serum and urine osmolality,

↓urine sodium and specific

gravity

Get chest x-ray

•Diuretics(Loop,Thiaside,Potassium)

•Dialysis (hemodialysis)

•Dietary restrictions of sodium

•I&O AND DAILY WEIGHTS; ASSESS  LUNG SOUNDS, EDEMA, OTHER SYMPTOMS

•MONITOR RESPONSES TO MEDICATIONS—DIURETICS AND PARENTERAL FLUIDS

•PROMOTE ADHERENCE TO FLUID RESTRICTIONS, PATIENT TEACHING RELATED TO SODIUM AND FLUID RESTRICTIONS

•MONITOR, AVOID SOURCES OF EXCESSIVE SODIUM

•PROMOTE REST

135-145

regulate water in and out the cell

-muscle constriction and nerve impulses

-Loss of sodium, as in use of diuretics(thiazides), loss of GI fluids, renal disease, and adrenal insufficiency.

-Gain of water, as in excessive administration of D5W and

water supplements for patients receiving hypotonic tube feedings; SIADH, such as head trauma and oat-cell lung tumor;

medications associated with water

retention (oxytocin and certain

tranquilizers); and psychogenic

polydipsia. Hyperglycemia and heart

failure cause a loss of sodium.

-hypotonic fluids

anorexia, nausea and vomiting, headache, lethargy, dizziness,

confusion, muscle cramps and weakness, muscular twitching, seizures, papilledema, dry

skin/mucosa, decreased salivation

↑ pulse, ↓ BP,

weight gain, edema

↓ serum and urine sodium,

↓ urine specific gravity and osmolality

•Treat underlying condition

•Sodium replacement

•Water restriction

•Medication (AVP/ADH receptor antagonists)

•Assessment: I&O, daily weight, lab values, CNS changes

•Encourage dietary sodium

•Monitor fluid intake

•Effects of medications (diuretics, lithium)

Fluid deprivation in patients who cannot respond to thirst,

hypertonic tube feedings without adequate water supplements,

diabetes insipidus, heatstroke,

hyperventilation, watery diarrhea, burns, and diaphoresis.

-Excess corticosteroid,

sodium bicarbonate, and sodium chloride administration, and saltwater nonfatal drowning victims.

Thirst, elevated body temperature, swollen dry tongue and sticky mucous membranes, hallucinations,

lethargy, restlessness,

irritability, increased DTR, pulmonary

edema, hyperreflexia,

twitching, nausea,

vomiting, anorexia,

↑pulse, and ↑ BP

↑ serum sodium,

↓ urine sodium,

↑ urine specific gravity and osmolality(exceeds 300), ↓ CVP

•Gradual lowering of serum sodium level via infusion of hypotonic electrolyte solution (0.45% saline) or D5W(rare)

•Diuretics

•Assessment for abnormal loss of water and low water intake

•Assess for over-the-counter sources of sodium

•Monitor for CNS changes

3.5-5

Found mainly in cell...... Na+ out... fluid balance and Na+ - K+ pumps

-opposite relationship with Na+

-Regulates muscle contractions

GI losses

corticosteroid administration,

hyperaldosteronism, recent ileostomy, tumor of intestine, alteration in acid base balance, laxative abuse

loop diuretics, too much insulin (k+ moves into cells) bulimia, osmotic diuresis, alkalosis, starvation, diuretics, and digoxin toxicity

Fatigue, anorexia, nausea and

vomiting, muscle weakness,

polyuria, decreased bowel

motility, ventricular asystole or

fibrillation, paresthesias, leg

cramps, shallow respirations

↓ BP, ileus, abdominal

distention, hypoactive reflexes. (can cause death through cardiac or respiratory arrest)

ECG: flattened T waves,

prominent U waves, ST

depression, prolonged PR

interval

Metabolic alkalosis

•Potassium replacement: Increased dietary potassium, oral potassium supplements or IV potassium for severe deficit (unless oliguria present)

•Monitor ECG for changes

•Monitor ABGs

•Monitor patients receiving digitalis for toxicity

•Monitor for early signs and symptoms

•Administer IV potassium only after adequate urine output has been established/ and after BUN and Creatinine

Eat foods with potassium-bannans, melons, potatoes, meat, whole grains, apricot

oliguric kidney injury, use of potassium- conserving diuretics in patients with renal insufficiency,

metabolic acidosis, Addison

disease, crush injury, burns,

rapid IV administration of

potassium, and certain

medications such as ACE

inhibitors, NSAIDs, cyclosporine

Muscle weakness, tachycardia →

bradycardia, arrhythmias,

flaccid paralysis, paresthesias,

intestinal colic, cramps,

abdominal distention,

irritability, anxiety, respiratory failure, slurred speech, confusion, metabolic/respiratory acidosis

ECG: tall

tented T waves, prolonged PR

interval and QRS duration,

absent P waves, ST depression

•Monitor ECG, heart rate (apical pulse) and blood pressure, assess labs, monitor I&O

•Limitation of dietary potassium and dietary teaching 

•Administration of cation exchange resins (sodium polystyrene sulfonate)

•Emergent care: IV calcium gluconate, IV sodium bicarbonate, IV regular insulin and hypertonic dextrose IV, beta-2 agonists(albuterol), dialysis

•Administer IV slowly and with an infusion pump

-loop diuretic-furosemide

-for very severe instances doctor may order K-excalate (pulls potassium out of body) anything over 6

8.8-10.4

Health of bones/teeth

-muscle/nerves, clotting

Hypoparathyroidism (may follow

thyroid surgery or radical neck

dissection), malabsorption, osteoporosis, pancreatitis, alkalosis, vitamin D deficiency, massive subcutaneous infection, massive transfusion of citrated

blood, chronic diarrhea, decreased

parathyroid hormone, diuretic

phase of acute kidney injury,

fistulas, burns, alcoholism

Numbness, tingling of fingers,

toes, and circumoral region;

positive Trousseau sign and

Chvostek sign; seizures,

spasms, Tetnay

hyperactive dtr, irritability,

bronchospasm, anxiety,

impaired clotting time, laryngospasm

↓prothrombin, diarrhea, ↓ BP.

ECG: prolonged QT interval

and lengthened ST

Labs indicate: ↓ Mg++

•IV of calcium gluconate for emergent situations (monitor for risk of extravasation)

•Seizure precautions

•Oral calcium and vitamin D supplements

•Exercises to decrease bone calcium loss

•Patient teaching related to diet and medications

Hyperparathyroidism, malignant

neoplastic disease, prolonged

immobilization, overuse of

calcium supplements, vitamin D

excess, oliguric phase of acute

kidney injury acidosis,

corticosteroid therapy, thiazide

diuretic use(lithium), increased parathyroid

hormone, and digoxin toxicity

bone loss related to immobility

CANCER,

Muscular weakness,

constipation, anorexia,

nausea and vomiting,

polyuria and polydipsia,

dehydration, hypoactive dtr, lethargy,

deep bone pain, pathologic

fractures, flank pain, calcium

stones(abdominal distention), hypertension.

ECG:

shortened ST segment and

QT interval, bradycardia,

heart blocks

•Treat underlying cause (Cancer)

•Administer IV fluids, furosemide, phosphates, calcitonin, bisphosphonates

•Increase mobility

•Encourage fluids

•Dietary teaching, fiber for constipation

•Ensure safety 

1.8-2.6

Very important for the heart

Associated with hypokalemia and hypocalcemia

-nerve/muscle/vessels (relaxation BP

-competes with calcium binding site contraction

alcoholism, GI losses,

hyperparathyroidism,

hyperaldosteronism, diuretic phase

of acute kidney injury,

malabsorptive disorders, diabetic

ketoacidosis, refeeding after

starvation, parenteral nutrition,

chronic laxative use, diarrhea, acute

MI,HF,decreased K+ and Ca++ and

certain pharmacologic agents (e.g.,

gentamicin, cisplatin, cyclosporine)

Neuromuscular irritability,

positive Trousseau sign

and Chvostek sign,

insomnia, apathy, anorexia,

vomiting, psychosis, weakness, increase DTR increased

tendon reflexes, and ↑

BP. Ca++ and K+ levels

ECG: PVCs, flat or

inverted T waves,

depressed ST segment,

prolonged PR interval,

and widened QRS

•Magnesium sulfate IV is administered with an infusion pump; monitor vital signs and urine output

•Calcium gluconate or hypocalcemic tetany or hypermagnesemia

•Oral magnesium

•Monitor for dysphagia

•Seizure precautions

•Dietary teaching (green, leafy vegetables; beans, lentils, almonds, peanut butter)

Flushing, hypotension,

muscle weakness,

drowsiness, hypoactive

reflexes, depressed

respirations, cardiac

arrest and coma,

diaphoresis.

ECG:

tachycardia →

bradycardia, prolonged

PR interval and QRS,

peaked T waves

•IV calcium gluconate

•Ventilatory support for respiratory depression

•Hemodialysis

•Administration of loop diuretics, sodium chloride, and LR

•Avoid medications containing magnesium

•Patient teaching regarding magnesium-containing OTC medications

•Observe for DTRs and changes in LOC

2.7-4.5

teeth/bone building, stored in bones

-absorbed in gut and excreted in kidneys

Refeeding after starvation,alcoholism, DKA,respiratory and metabolic alkalosis ,↓magnesium &potassium,hyperparathyroidism, vomiting, diarrhea, hyperventilation, vitamin D

deficiency associated with

malabsorptive disorders, burns, acid–

base disorders, parenteral nutrition and diuretic and antacid use

Paresthesias, muscle weakness, bone pain and tenderness,chest pain,confusion,cardiomyopathy,respiratory failure,seizures, tissue hypoxia, and

increased susceptibility to infection, nystagmus

•Prevention is the goal

•Oral or IV phosphorus replacement (only for patients with serum phosphorus levels less than 1 mg/dL not to exceed 3 mmol/hr), Burosumab, correct underlying cause

•Monitor IV site for extravasation

•Monitor phosphorus, vitamin D and calcium levels

•Encourage foods high in phosphorus (milk, organ meats, beans nuts, fish, poultry), gradually introduce calories for malnourished patients receiving parenteral nutrition

Acute kidney injury and chronic kidney disease, excessive intake of

phosphorus, vitamin D excess,

respiratory and metabolic acidosis,

hypoparathyroidism, volume

depletion, leukemia/lymphoma

treated with cytotoxic agents,

increased tissue breakdown,

rhabdomyolysis, chemotherapy

Tetany, tachycardia, anorexia, nausea and vomiting, muscle

weakness, signs and symptoms of

hypocalcemia; hyperactive reflexes;

soft tissue calcifications in lungs, heart, kidneys, and cornea

-trousseaus and chovesk

-soft tissue calcifications

•TREAT UNDERLYING DISORDER

•VITAMIN D PREPARATIONS, CALCIUM-BINDING ANTACIDS, PHOSPHATE-BINDING GELS OR ANTACIDS, LOOP DIURETICS, IV FLUIDS (NORMAL SALINE), DIALYSIS

•MONITOR PHOSPHORUS AND CALCIUM LEVELS

•AVOID HIGH-PHOSPHORUS FOODS

•PATIENT TEACHING RELATED TO DIET, PHOSPHATE-CONTAINING SUBSTANCES, SIGNS OF HYPOCALCEMIA

96-108

-acid-base balance

-digestion

-balance fluids w/Na+

Loss of sodium, loss of chloride

-Bicard has inverse relationship with chloride

Addison disease, reduced chloride intake, untreated DKA, chronic respiratory acidosis, excessive

sweating, vomiting, gastric suction,

diarrhea, sodium and potassium deficiency, metabolic alkalosis; loop, osmotic, or thiazide diuretic use; overuse of bicarbonate, rapid removal of ascitic fluid with a high sodium content, IV fluids that lack chloride (dextrose and water), draining

fistulas and ileostomies, heart failure, cystic fibrosis

Agitation, irritability,

tremors, muscle

cramps,

hyperactive deep

tendon reflexes,

hypertonicity,

tetany, slow

shallow

respirations,

seizures,

arrhythmias, coma

↓serum chloride, ↓

serum sodium, ↑ pH, ↑ serum

bicarbonate, ↑ total carbon

dioxide content, ↓urine chloride

level, ↓ serum potassium

•Replace chloride-IV NS or 0.45% NS

•Ammonium chloride

•Monitor I&O, ABG values and electrolyte levels

•Assess for changes in LOC

Educate about foods high in chloride (tomato juice, bananas, eggs, cheese, milk) and avoid drinking free water (water without electrolytes)

Excessive sodium chloride infusions with water loss, head injury (sodium retention), hypernatremia, kidney injury, corticosteroid use, dehydration, severe diarrhea (loss of bicarbonate), respiratory alkalosis, administration of diuretics, overdose of salicylates and ammonium chloride use, hyperparathyroidism, metabolic acidosis

Tachypnea, lethargy, weakness, deep

rapid respirations, decline in cognitive status, ↓cardiac output, dyspnea,

tachycardia, pitting edema, arrhythmias, coma

•Correct the underlying cause and restore electrolyte and fluid balance

•Hypertonic IV solutions

•Lactated Ringers

•Sodium bicarbonate, diuretics

•Monitor I&O, ABG

•Focused assessments of respiratory, neurologic, and cardiac systems

•Patient teaching related to diet and hydration

pH 7.35-7.45

PO2 (oxygen) 80-100%

PCO2(carbon dioxide) 35-45

HCO3(bicarb) 22-26

Low pH (less than 7.35)

PCO2 normal

Bicarb low

-Hyperkalemia may occur

-Salicylate poisoning

-renal failure

-propylene glycol toxicity

-DKA

-starvation

Headache, confusion, drowsiness, increased respiratory rate/depth

-low BP

-Low cardiac output/dysrhythmias

-shock

•Correct underlying problem, correct metabolic imbalance

•Bicarbonate may be administered

•Monitor serum electrolytes

•Monitor potassium levels

•Hemodialysis

•Peritoneal dialysis

Increased pH and Bicarb

normal PCO2

Gi losses

-meds-longterm diuretic use

-hyperaldosteronism

-cushings syndrome

-hypokalemia

symptoms related to decreased calcium, respiratory depression, tachycardia, symptoms of hypokalemia including tingling of toes, fingers, dizziness and tetany, ECG changes, decreased GI motility

•Correct the underlying acid–base disorder

•Restore fluid volume with sodium chloride solutions

•Monitor I&O

•Monitor for ECG and neurologic changes

Low pH

High CO2

Normal bicarb

Pulmonary edema, overdose, atelectasis(collapsed lung), pneumothorax(trapped air in lung), severe obesity, pneumonia,  COPD, muscular dystrophy, multiple sclerosis, myasthenia gravis

With chronic respiratory acidosis, , may be asymptomatic. With acute respiratory acidosis may see sudden increased pulse, respiratory rate, and BP; mental changes; feeling of fullness in head (intracranial pressure) and increased conjunctival vessels.

•Improve ventilation

•Bronchodilators(albuterol), antibiotics, anticoagulants(heparin, warfarin)

•Pulmonary physiotherapy

•Adequate hydration

•Mechanical ventilation if necessary

•Monitor respiratory status, I&O

Increased pH

Decreased CO2

Bicarb normal

HYPERVENTILATION

Extreme anxiety, panic disorder, hypoxemia, salicylate intoxication, gram-negative sepsis, inappropriate ventilator settings

Lightheadedness, inability to concentrate, numbness and tingling in extremities, tachycardia, and ventricular and atrial arrhythmias

•Treat the underlying cause

•Antianxiety agent

•Have patient breathe into a bag

•Monitor anxiety and respiratory status

•Educate patient on techniques to decrease anxiety

Nephron