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Normal Reference Range for Serum Sodium (Na+)
135-145 mEq/L
Normal Reference Range for Serum Potassium (K+)
3.5-5.3 mEq/L
Normal Reference Range for Serum pH
7.35-7.45
Normal Reference Range for Serum pCO2
35-45
Normal Reference Range for Serum HCO3-
22-26
What are the 4 causes of Edema?
1. Increased Blood Hydrostatic Pressure 2. Decreased Plasma Oncotic Pressure 3. Increased Capillary Permeability 4. Obstruction of Lymphatic Vessels
How does increase blood hydrostatic pressure cause edema?
Increased plasma volume leads to an increased hydrostatic pressure which results in increased filtration pressure \"pushing\" more water out of the capillaries at the arteriolar end resulting in edema. This is characterized by ECF excess.
How does decreased plasma oncotic pressure cause edema?
Decreased plasma oncoic pressure results in a decreased \"pull\" pressure at the venous end of the capillaries so less water is \"pulled\" back in and instead remains in the interstitial space resulting in edema
How does increased capillary permeability cause edema?
Plasma proteins \"leak\" into the interstitial spaces usually due to capillary damage or a localized inflammatory or allergic reaction, which results in an interstitial oncotic pressure in the area which \"pulls\" water from the plasma into the interstitial space causing edema. The plasma volume goes down while the interstitial volume goes up.
How does obstruction of lymphatic vessels cause edema?
Blockage or removal of lymphatic vessels prevents lymphatic drainage and causes edema. Edema is distal to the area of interruption of lymphatic drainage.
Describe the etiology of Fluid Volume Excess
Excess fluid intake- increase in free water intake, excessive IV fluids, or excessive Na+ intake Decreased urine output- renal failure, decreased cardiac output, liver disease, inflammation, steroid therapy, low protein diet
Name 5 Risk factors associated with Fluid Volume Excess and Fluid Volume Deficit
Age Acute illness Chronic illness Diet and lifestyle Medications Environmental factors (FVD)
What Acute illnesses are associated with a risk for fluid volume excess?
Surgery initiates the stress response which increases the release of ADH and aldosterone which promotes fluid and Na+ retention Patient receiving IV fluids for medical problems are also at risk
What chronic illnesses are associated with a risk for fluid volume excess?
Cardiovascular disease reduces pumping strength of the heart resulting in decreased flow to the kidneys, leading to Na+ and water retention. Renal disease can lead to abnormal retention of water, Na+, and other electrolytes. SIADH produces excess ADH and can be caused by stress, surgery, lung tumors, or brain tumors Psychogenic polydipsia is compulsive water intake caused by certain psychiatric disorders
What are the Signs and Symptoms of Fluid Volume Excess?
Plasma Excess- rapid bounding pulse, slow venous emptying, neck vein distention, and capillary refill less than 3 seconds Interstitial Excess- sudden weight gain, peripheral edema, pulmonary edema, drowsiness, blurred vision, headache
How is Fluid Volume Excess Managed?
Restrict fluid and sodium intake Promote fluid excretion Monitor during therapy
Explain the therapeutic management for FVE: Restrict Fluid and Sodium Intake
24hr Intake measurements Use IV pump to avoid fluid overload Provide good oral care to decrease thirst Teach patient to read labels for Na+ restriction Suggest alternative seasonings Patients on ACE inhibitors or K+ sparing diuretics should not use salt substitutes
Explain the therapeutic management for FVE: Promote Fluid Excretion
Administer diuretics as ordered usually in the am (Loop diuretics are most commonly used) Administer meds to increase cardiac output may be beneficial in promoting urinary excetion Always monitor for response
Explain the therapeutic management for FVE: Monitor During Therapy
Measure I&O noting color and concentration Weigh daily (2.2lbs or 1kg=1L of water loss) Teach patients to report more than a 2lb gain Monitor for signs of pulmonary edema (anxiety, productive cough, pink frothy sputum, dyspnea, moist crackles in lungs) Monitor VS and watch for signs of hypovolemia Assess for peripheral edema Monitor BUN, HCT, Serum Na+, and ABG\'s
Describe the etiology of Fluid Volume Deficit
Increase loss of body fluids- vomiting, diarrhea, burns, wound drainage, fever, prolonged sweating, or increased urine output Decreased fluid intake- fluid restriction, unavailability of fluids, impaired thirst mechanism, decreased motivation to drink, fasting diets, difficulty swallowing
What acute illnesses are associated with Fluid Volume Deficit?
Surgery (fluid and blood loss) GI illness: nausea, vomiting, diarrhea, NG suction Burns: fluid loss through loss of skin Brain injury: cerebral edema which puts pressure on the hypothalamus altering ADH regulation.
What chronic illnessess are associated with Fluid Volume Deficit?
Liver disease: decreases albumin production Renal disease Diabetes Cancer: may predispose patient to fluid shifts
What environmental factors are associated with Fluid Volume Deficit?
Vigorous exercise Heat injuries
How is diet and lifestyle associated with Fluid Volume Deficit?
Difficulty swallowing Malnutrition Excess alcohol consumption
Which medications place patients at risk for Fluid Volume Deficits?
Diuretics Lazatives Chemotherapy
Why are infants and young children at risk for Fluid Volume Deficits?
High % of body water ECF is more easily lost Kidneys are immature up to age 2 and cannot conserve or excrete in order to keep normal balance Body surface area is relatively larger and more fluid is lost through the skin Higher metabolic rate Fevers tend to be higher and last longer in acute illnesses
Why are the elderly at risk for Fluid Volume Deficits?
Only 45-50% body weight is water Muscle mass declines and % of fat rises with age (muscle holds more water than fat) Kidneys lose function Diminished thirst mechanism Decreased pancreatic function and glucose intolerance increases the risk of hyperglycemia and results in osmotic diuresis
Why are the elderly at risk for Fluid Volume Excess?
Decreased heart and kidney function cannot compensate for excesses easily
Why are infants and children at risk for Fluid Volume Excess?
Infants have immature kidneys and cannot dilute or excrete as well as adults Children 2-12 have less regulatory responses to fluid balances
What medications are risk factors for Fluid Volume Excesses?
Long term use of glucocorticoid steroid use predisposes people to Na+ and fluid retention.
What are the clinical manifestations of mild dehydration?
Thirst except in infants and elderly
What are the clinical manifestations of marked dehydration?
Marked thirst Dry mucous membranes- furrowed tongue Slow hand vein filling, delayed cap refill Cool extremities, low grade temp Tachycardia, weak and thready pulse Postural hypotension (late sign in children) Weight loss, low urine volume Elevated Hct, Hgb, BUN Weakness, fatigue, and dizziness Flat neck veins, sunken eyeballs, fontanels<18mo Poor skin turgor, tenting Elders check on sternum, forehead, top of hipbone Rely on VS for children
What are the clinical manifestations of severe dehydration?
All symptoms associated with mild and marked Flushed skin Very low B/P Behavioral changes: restlessness, irritability, disorientation, and delirium (this is often the first sign seen in elderly and children)
How is Fluid Volume Deficit Managed?
Safety Prevent further loss(medications) Replace fluid (oral, parenteral replacement)
Explain the Therapeutic management of FVD: Oral Rehydration
Only if defict is mild, thirst is intact, and patient can drink Commercial oral rehydration solutions provide glucose, and electrolytes in a concentration that is easily absorbed Avoid soda, juice, and sports drinks due to hypertonic effects that promote fluid loss
Explain the Therapeutic management of FVD: Parenteral Replacement Therapy
Initially expand ECF with isotonic fluids to get adequate circulating volume May need to give fluid bolus Infusion of blood for lost RBC\'s (hypovolemia) Give the type of fluids needed for type of dehydration present
Give isotonic IV fluid to treat ? dehydration
Isotonic fluids treat Isotonic dehydration
Give hypertonic IV fluid to treat ? dehydration
Hypertonic fluids treat Hypotonic dehydration
Give hypotonic IV fluid to treat ? dehydration
Hypotonic fluids treat Hypertonic dehydration
Explain the Therapeutic management of FVD: Medication Therapy
Minimizes further losses Antiemetic controls vomiting Antidiarrheals to prevent GI loss Antipyretics to contro fever if present
What should the nurse be monitoring during therapy of FVD?
VS to return to normal Mucous membranes, fontanels in infants Mental status for alertness, improvement in mentation Urine concentration I&O and daily weights Lung sounds-monitor for FVE due to fluid therapy Monitor IV infusion rates
What are the two main types of hypertonic solutions?
Crystalloids Colloids
Describe crystalloid hypertonic solutions
3% or 5% electrolyte solutions that raise the osmolality of the ECF and draws water out of the cells. Used to expand the ECF **Monitor for fluid volume excess and cellular dehydration
Describe colloid hypertonic solutions
Protein molecules which include, plasma, albumin, and commercial plasmas. Helpful in ER situations where patients need an increase in intravascular volume to increase their B/P
How does the body respond to an increase in osmolality?
By stimulating the release of ADH, which causes the kidneys to retain water
Solutes dissolved in fluid exert a pressure on membranes that pulls fluid toward it. What is this \"pulling\" pressure called?
Oncotic pressure
How does aldosterone help control fluid and electrolyte balance?
Aldosterone is released by the adrenal cortex in response to a decrease in plasma osmolality It acts on the kidney nephrons, triggering them to retain sodium and water to increase blood osmolarity and blood volume It also prevents K+ levels from becoming too high
How does the atrial natriuretic peptide (ANP) mechanism respond to changes in fluid volume?
When an increase in fluid volume is sensed in the atrium of the heart, ANP is secreted This stimulates the kidneys to get rid of sodium and water through the urine
Which fluids have a lower concentration of solutes than inside the cells , which cause fluid to flow into the cells causing them to swell?
Hypotonic
Which fluids have a higher concentration of solutes than is found inside the cells, which cause fluid to flow out of the cells causing them to shrink?
Hypertonic
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