Nursing Sciences Tim Duncan;RN, CCRN, CEN, EMTP · Nursing Sciences Tim Duncan;RN, CCRN, CEN, EMTP 2015 KISSPharm L.L.C + Fluid and Electrolyte Balance

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Nursing Sciences

Tim Duncan; RN, CCRN, CEN, EMTP

2015 KISSPharm L.L.C

+Fluid and Electrolyte Balance

Body fluid compartments

Homeostasis occurs when the number of cations and anions are

the same

Compartments are divided by _____________________________

Intracellular

Fluid

(2/3)

Extracellular

Fluid

(2/3)


Body fluid compartments

Two main compartments

Intracellular (ICF) : fluid inside the cell (2/3 of the cell)

Extracellular (ECF) : fluid outside the cell (1/3 of the cell)

Includes interstitial fluid, blood, connective tissue, water, and

transcellular fluid


Edema

Excess collection of fluid in the interstitial space

Localized edema

Trauma from accidents or surgery

Local inflammatory processes

Burns

Generalized edema

Can occur due to cardiac, renal, or liver failure

Infants and older adults are more susceptible to

fluid-related problems.

+Body fluid transport

Diffusion

Process where a solute from a higher concentration may spread

through a solution to area of lower concentration

Membranes

Permeable

Selectively permeable

Osmosis

Force that pulls the solvent from a less concentrated solute to a

more concentrated solute

+Body fluid transport

Filtration

Hydrostatic pressure

Transfer of solutes and solvents from higher pressure to area of

lower pressure

The hydrostatic pressure is higher than osmotic pressure at the

_____________ end of the capillary

Consequently fluids move out of the capillary

The osmotic pressure is higher than the hydrostatic pressure at

the ______________ end

Therefore the fluids move into the capillary

+Movement of body fluid

Isotonic solutions

Both sides are equal in concentration, very little osmosis occurs

Isotonic solutions have the same osmolality as body fluids

Hypotonic solutions

When a solution has less concentration of solute or salt compared

to another more concentrated solution

Have lower osmolality than body fluids

Hypertonic solutions

When a solution has a more concentration of solutes than other

less concentrated solutions

+

+Movement of body fluid (con’t)

Active transport

In order to have movement from a area of lower concentration to

an area of higher

Need ________

Require active transport

Ions

Sodium

Potassium

Calcium

Iron

Hydrogen

Some sugars

Amino acids

+Movement of body fluid (con’t)

Body fluid

Diarrhea can result in the loss of a lot of water and electrolytes

Most water is reabsorbed in the large colon

Kidneys regulate fluid and electrolyte balance

Adrenal glands

Regulate sodium reabsorption via secreting _________________

ADH also helps to regulate water balance

+Fluid Volume Deficit

Isotonic dehydration

Water and electrolytes are lost equally

Most common type of dehydration as known as hypovolemia

Results in decreased blood volume and therefore insufficient

tissue perfusion


________________ dehydration

Causes

Improper intake of fluids and solutes

Fluid shifts

Dramatic loss of isotonic body fluids

Intracellular

Fluid

(2/3)

Extracellular

Fluid

(2/3)


________________ dehydration

Water loss is greater than electrolyte loss

Cell shrinks

Causes

Extreme perspiration

Hyperventilation

Ketoacidosis

Prolonged fevers

Diarrhea

Early-stage renal failure

Diabetes insipidus

Intracellular

Fluid

(2/3)

Extracellular

Fluid

(2/3)


________________ dehydration

Electrolyte loss is greater than water loss

Cells swell

Causes

Chronic illness

Extreme fluid replacement (hypotonic)

Renal failure

Chronic malnutrition

Intracellular

Fluid

(2/3)

Extracellular

Fluid

(2/3)

+Fluid Volume Deficient Findings

Cardiovascular

Increased pulse

Decreased blood pressure and orthostatic hypotension

Flat neck and hand veins

Diminished peripheral pulses

Decreased CVP

Dysrhythmias

+Fluid Volume Deficient Findings

Respiratory

Increased rate and depth of respirations

Dyspnea

Neuromuscular

Decreased CNS activity

Fever

Skeletal muscle weakness

Renal

Decreased urine output

+Fluid Volume Deficit Findings

Integumentary

Dry skin

Poor turgor

Dry mouth

Gastrointestinal

Decreased motility and bowel sounds

Constipation

Thirst

Decreased body weight

+Fluid Volume Deficit Findings

Laboratory findings

Increased serum osmolality

Increased hematocrit

Increased BUN level

Increased serum sodium level

Increased urinary specific gravity

+Fluid Volume Excess

___________ overhydration (aka hypervolemia)

The extracellular compartment is expanded

Edema

Complications

Cardiac dysfunction

CHF

Pulmonary edema

Causes

Improper IV therapy

Renal failure

Chronic corticosteroid therapy

Intracellular

Fluid

(2/3)

Extracellular

Fluid

(2/3)


_______________ overhydration

The fluid goes from the intracellular compartment to ECF

Causes

Increased sodium ingestion

Rapid infusion

Extreme sodium bicarbonate therapy

Intracellular

Fluid

(2/3)

Extracellular

Fluid

(2/3)


_____________ overhydration (aka water

intoxication)

All body fluid compartments are expanded

Electrolyte imbalance

Causes

Early renal failure

CHF

SIADH

Improper IV therapy

Replacement of isotonic fluid loss with hypotonic fluids

Intracellular

Fluid

(2/3)

Extracellular

Fluid

(2/3)

+Fluid Volume Excess Findings

Cardiovascular

Increased pulse

Increased blood pressure

Distended neck and hand veins

Elevated CVP

Dysrhythmias

Respiratory

Increased respiratory rate (shallow breathing)

Dyspnea

Moist Crackles


Neuromuscular

Altered consciousness

Headache

Visual disturbances


Paresthesias

Renal

Increased urine output if kidneys are working

Decreased urine output if kidneys are damaged


Integumentary

Pitting edema

Pale, cool skin

Gastrointestinal

Increased motility

Diarrhea

Increased body weight

Enlarged liver

Ascites


Laboratory findings

Decreased serum osmolality

Decreased hematocrit

Decreased BUN

Deceased serum sodium

Decreased urine specific gravity

+Normal Electrolyte values

Sodium: 135-145 mEq/L

Potassium: 3.5-5.1 mEq/L

Chloride: 98-107 mEq/L

Bicarbonate (venous): __________ mEq/L

+Hyponatremia

Serum Na+ level less than ________ mEq/L

Food sources

Bacon

Canned food

Ketchup

Milk

Processed food

Snack food

Soy sauce

Bread

Na+ imbalance are typically related to fluid

imbalances

+Hyponatremia

Causes

Increased sodium excretion

Loss of Fluid

Sweating

Vomiting

Diarrhea

Renal disease

Dilution of serum sodium

Gain of Fluid

SIADH

CHF

Psychogenic polydipsia

DM

+Hyponatremia Findings

Cardiovascular

Normovolemic

Rapid pulse

NL BP

Hypovolemic

Weak rapid pulse

Low BP

Flat neck veins

NL or low CVP

Hypervolemic

Rapid bounding pulse

BP NL or elevated

NL or elevated CVP


Respiratory

Shallow breathing due to skeletal muscle weakness

Neuromuscular

Skeletal muscle weakness (worse in extremities)

Reduced deep tendon reflexes

Renal

Increased urinary output


CNS

Headache

Personality changes

Confusion

Seizures

Coma

Gastrointestinal

Increased motility

Hyperactive bowel sounds

Nausea

Diarrhea

Cramping

+Hyponatremia

Treatment

If there is a fluid volume deficit

Give IV sodium chloride

If due to fluid volume excess

Give osmotic diuretics

If due to SIADH

Give ADH antagonists

Increase sodium intake

Monitor patients taking lithium

Hyponatremia can hinder lithium excretion leading to ___________

+Hypernatremia

Serum Na+ levels exceed 145 mEq/L

Causes

Decreased Na+ excretion

Corticosteroids

Cushing's syndrome

Renal failure

Hyperaldosteronism

Increased Na+ intake

Decreased water intake

+Hypernatremia

Causes

Increased water loss

Increased metabolism

Fever

Hyperventilation

Infection

Extreme diaphoresis

Watery diarrhea

Diabetes insipidus

+Hypernatremia

Treatment

IV therapy

If due to fluid loss

Diuretics

If unable to excrete Na+

+Hypernatremia findings

Cardiovascular

Heart rate and BP depend on vascular volume

Respiratory

Pulmonary edema (hypervolemia)

Neuromuscular

Early manifestation

Spontaneous muscle twitches

Irregular muscle contractions

Late manifestation


deep tendon reflexes are absent


CNS

Most common manifestation

Altered cerebral function

Normo-volemia or hypovolemia

Agitation

Confusion

Seizures

Hypervolemia

Lethargy

Stupor

Coma


Gastrointestinal

Very thirsty

Renal

______________ urinary output

+Hypokalemia

Serum K+ level lower than 3.5 mEq/L

Food sources

Bananas

Avocado

Cantaloupe

Carrots

Meats

Mushrooms

Spinach

Life threatening because it can cause cardiac

arrhythmias!

+Hypokalemia

Causes

Total body K+ loss

Overuse of diuretics or corticosteroids

Increased secretion of aldosterone (Cushing’s syndrome)

Fluid Loss of any kind

Prolonged nasogastric suction

Excessive diaphoresis

Renal disease

Low K+ intake

+Hypokalemia

Pathophysiology

Shift of K+ from ECF to ICF

Alkalosis

_________________________

K+ dilution

Water intoxication

+Hypokalemia Findings

Cardiovascular

Weak irregular pulse

Weak peripheral pulses

Orthostatic hypotension

Respiratory

Shallow respirations

Absent breath sounds


Neuromuscular

Anxiety

Fatigue

Confusion

Coma


Paresthesias and deep tendon hyporeflexia


Gastrointestinal

Decreased motility

Absent bowel sounds

Nausea

Vomiting

Constipation

Paralytic ileus


Laboratory findings

ST depression

Shallow, flat or inverted T wave

Prominent U wave

+Hypokalemia

Treatment

Give K+ supplements

Oral supplements can cause nausea and vomiting

Do not give on an empty stomach

Liquid potassium chloride has a ______________________

So give with juice

+Hypokalemia

Treatment

K+ is never given by IV push

Intramuscular

Subcutaneous routes

IV potassium is diluted and given using an infusion device

+Hypokalemia

Treatment

Recommended infusion rate

5 to 10 mEq/hr

Do not exceed 20 mEq/hr

If patient is getting more than 10 mEq/hr place them on a

cardiac monitor

Check for phlebitis and infiltration

Nurse should also check for renal function

+Hyperkalemia

Potassium level greater than 5.1 mEq/L

Causes

Excessive K+ intake

Decreased K+ excretion

Potassium sparing diuretics

Renal failure

Addison’s disease

Shift of K+ from ICF to ECF

Tissue injury

Acidosis

Hyperuricemia

Hypercatabolism

+Hyperkalemia

Treatment

Restrict K+ diet

If kidney is functioning give K+ excreting diuretics

If kidney is nonfunctional give sodium polystyrene sulfonate

(Kayexalate)

Helps sodium absorption

K+ excretion in the gut

Dialysis

Hypertonic glucose with regular insulin (move K+ into the cells)

Blood transfusion patient should receive fresh blood

+Hyperkalemia findings

Cardiovascular

Slow and irregular pulse

Decreased BP

Gastrointestinal

Increased motility


Diarrhea


Respiratory

_____________________________

Neuromuscular

Acute

Muscle twitches

Paresthesias

Chronic


Ascending flaccid paralysis


Laboratory findings

ECG

Tall peaked T waves

Flat P waves

Widened QRS complex

Prolonged PR intervals

+Hypocalcemia

Serum calcium level lower than 8.6 mg/dL

Food sources

Cheese

Collard greens

Milk

Sardines

Spinach

Tofu

Yogurt

+Hypocalcemia

Causes

Decreased calcium absorption in the gut

Not enough oral intake of calcium

Lactose intolerance

Malabsorption

Low vitamin D intake

End-stage renal disease

+Hypocalcemia

Causes

Increased calcium excretion

Renal failure

Diarrhea

Steatorrhea

Wound drainage

+Hypocalcemia

Causes

Decreased ionized fraction of calcium

Hyperproteinemia

Alkalosis

Medications

Acute pancreatitis

Hyperphosphatemia

Immobility

Damaged parathyroid glands

+Hypocalcemia Findings

Cardiovascular

Decreased pulse and ____________________________

Decreased BP

Respiratory

Decreased respiratory movement


Gastrointestinal

Increased gastric motility


Cramping

Diarrhea

Renal

Urinary output depends on the cause


Neuromuscular

Anxiety

Irritability

Hyperactive deep tendon reflexes

Painful muscle spasms

Tetany

Seizures

Positive Trousseau’s and Chvostek’s signs


Laboratory findings

ECG:

Prolonged ST interval

Prolonged QT interval

+Hypocalcemia Treatment

Treatment

Give calcium supplements

Warm the injections and administer slowly

Watch for ECG changes

Medications that increase calcium absorption

Aluminum hydroxide

Vitamin D

10% Calcium gluconate

+Hypercalcemia

Serum level _____________ than 10 mg/dL

Causes

Increased calcium absorption

Decreased calcium excretion (renal failure, use of thiazide

diuetics)

Increased bone reabsorption of calcium (hyperparathyroidism,

hyperthyroidism, malignancy, immobility, glucocorticoids)

Hemoconcentration (dehydration, lithium, adrenal insufficiency)

+Hypercalcemia

Treatment

Discontinue calcium containing substances or drugs

Give medications that get rid of calcium

Phosphorus

Calcitonin

Bisphosphonates

Prostaglandin synthesis inhibitors

Aspirin

Dialysis

Patient with calcium imbalance is at high risk for a fracture, so

move them carefully

Monitor for urinary stones

+Hypercalcemia findings

Cardiovascular

Increased pulse early on, later decreased heart rate can lead to

cardiac arrest

Bounding

Full peripheral pulses

Increased BP

Respiratory

Unsuccessful respiratory movement

Renal

Urinary output depends on cause

Renal calculi

Flank pain


Neuromuscular

Muscle weakness

Absent deep tendon reflexes

Disorientation

Fatigue

Coma

Gastrointestinal

Decreased motility

Hypoactive bowl sounds

Anorexia

Nausea

Constipation

Abdominal distension


Laboratory findings

ECG:

Shortened ST segment

Widened T wave

+Hypomagnesemia

Serum magnesium __________ than 1.6 mg/dL

Food sources

Avocado

Canned white tuna

Cauliflower

Green leafy vegetables

Spinach

Milk

Peanut Butter

Meat

Raisins

+Hypomagnesemia

Causes

Low magnesium

Malnutrition

Vomiting

Diarrhea

Malabsorption syndrome

Increased magnesium secretion

Medications

Chronic alcoholism

Intracellular movement of magnesium

Hyperglycemia

Insulin adminstration

Sepsis

+Hypomagnesemia

Treatment

Hypocalcemia usually occurs with hypomagnesemia

Fix calcium levels

Magnesium sulfate IV

Oral Mg

May cause diarrhea

Increase Mg loss

+Hypomagnesemia Findings

Cardiovascular

Increased HR and BP

Respiratory

Shallow respirations

CNS

Irritability

Confusion


Neuromuscular

Twitches

Hyperreflexia

Tetany

Seizures

Positive Trousseau’s and Chvostek’s signs


Laboratory findings

ECG:

Tall T waves

Depressed ST segments

+Hypermagnesemia

Serum magnesium level __________ than 2.6 ml/dL

Causes

Increased magnesium intake

Decreased excretion of magnesium

Treatment

Diuretics

Calcium chloride IV or calcium gluconate

+Hypermagnesemia Findings

Cardiovascular

Low HR and BP

Neuromuscular

Absent deep tendon reflexes



Respiratory

Respiratory depression

CNS

Drowsiness

Fatigue

Coma


Laboratory findings

ECG:

Prolonged PR interval

Widened QRS complexes

+Hypophosphatemia

Serum phosphorus level ________ than 2.7 mg/dL

Food sources:

Fish

Organ meats

Nuts

Pork

Beef

Chicken

Whole grain breads and cereals

+Hypophosphatemia

Causes

Not enough phosphorus intake

Increased phosphorus excretion (hyperparathyroidism,

malignancy, antacids)

Intracellular shift (hyperglycemia, respiratory alkalosis)

Treatment

Discontinue drugs or sources cause hypophosphatemia

Give phosphorus with a vitamin D supplement

Monitor renal function and for fractures

+Hypophosphatemia Findings

Cardiovascular

Decreased contractility and cardiac output

Low peripheral pulses

Respiratory

Shallow

Neuromuscular

Weakness

Decreased deep tendon reflexes

Decreased bone density

Rhabdomyolysis

+Hypophosphatemia Findings

CNS

Irritability

Confusion

Seizures

Hematological

Decreased platelet aggregation

Increased bleeding time

Immunosuppression

+Hyperphosphatemia

Serum phosphorus level greater than 4.5 mg/dL

Causes

Decreased renal excretion

Tumor lysis syndrome

Increased intake of phosphorus

Hypoparathyroidism

+Hyperphosphatemia

Treatment

Same as hypocalcemia

Phosphate-binding medications

Diet restriction

Drugs containing phosphate restriction

+ECG and electrolyte imbalances

Hypocalcemia

Prolonged ST interval

Prolonged QT interval

Hypercalcemia

Shortened ST segment

Widened T wave


Hypokalemia

ST depression

Shallow, flat or inverted T wave

Prominent U wave

Hyperkalemia

Tall peaked T waves

Flat P waves

Widened QRS complex



Hypomagnesemia

Tall T waves

Depressed ST segment

Hypermagnesemia


Widened QRS complex

+Hydrogen ions, Acids, and Bases

Hydrogen ions

Stated as pH

Has 2 forms in the body:

Volatile hydrogen of carbonic acid

Nonvolatile form of hydrogen and organic acids

+Hydrogen ions, Acids, and Bases

Acids

Contain hydrogen ions and are hydrogen ion donors

Number of hydrogen ions determines the strength of the acid

Bases

No hydrogen ions

Hydrogen ion acceptors

+Regulatory Systems

Buffers

Fastest acting regulatory system

Protect against any changes in hydrogen ions in the ECF

Transport mechanism for hydrogen to the lungs

+Regulatory Systems

Primary buffer systems

Hemoglobin system

Chloride shift

Plasma protein system

Carbonic acid-bicarbonate system

Phosphate buffer system

+Regulatory Systems

Lungs

Second defense of the body with the buffer system to maintain

acid-base balance

Acidosis:

pH decreases

Respiratory rate and depth increase in order to exhale acids

Alkalosis:

pH increases

Respiratory rate and depth decrease

CO2 is retained

Carbonic acid increases

+Regulatory systems (cont’d)

Kidneys

Fundamental correction of acid-base imbalance

Compensation

Acidosis:

Extra hydrogen ions are secreted into the tubules

Hydrogen with a buffer are excreted in the urine

Alkalosis:

Extra bicarbonate ions move into the tubules

Bicarbonate with sodium ions are excreted in the urine

Regulation of bicarbonate

+Regulatory systems (con’t)

____________________

Exchange role

Acidosis:

Hydrogen into the cell

K+ out

Alkalosis:

Hydrogen out to the blood

K+ in the cell

+Respiratory Acidosis

Causes

Primary defect in the function of the lungs or respiratory pattern

Obstruction of airway or depression of respiratory system

Asthma

Atelectasis

Brain trauma

Bronchiectasis

Bronchitis

CNS depressants

Emphysema

Hypoventilation

Pulmonary edema

Pneumonia

Pulmonary emboli

+Clinical Manifestations of

Respiratory Acidosis

Neurological

Drowsiness

Disorientation

Dizziness

Headache

Coma


Respiratory Acidosis

Cardiovascular

Decreased BP

Ventricular fibrillation

Peripheral vasodilation

Neuromuscular

Seizures

Respiratory

Hypoventilation with hypoxia

+Clinical manifestations of

Metabolic Acidosis

Neurological

Drowsiness

Confusion

Headache

Coma

Cardiovascular

Decreased BP

Dysrhythmias

Peripheral vasodilation


Metabolic Acidosis

Gastrointestinal

Nausea

Vomiting

Diarrhea

Abdominal pain

Respiratory

Deep, rapid respirations

+Respiratory Alkalosis

Causes

Overstimulation of the respiratory system

Fever

Hyperventilation

Hypoxia

Hysteria

Over ventilation by mechanical ventilators

Pain


Respiratory Alkalosis

Neurological

Fatigue

Lightheadedness

Confusion

Cardiovascular

Fast HR

Dysrhythmias

Gastrointestinal

Nausea

vomiting

Epigastric pain


Respiratory Alkalosis

Neuromuscular

Tetany

Numbness

Tingling of extremities

Hyperreflexia

___________________

Respiratory

Hyperventilation


Metabolic Alkalosis

Neurological

Drowsiness

Dizziness

Nervousness

Confusion


Metabolic Alkalosis

Cardiovascular

Fast HR

Dysrhythmias

Gastrointestinal

Anorexia

Nausea

Vomiting


Metabolic Alkalosis

Neuromuscular

Tremors

Hypertonic muscles

Muscle cramps

Tetany


Seizures

Respiratory

Hypoventilation


Metabolic Acidosis

Neurological

Drowsiness

Dizziness

Nervousness

Confusion


Metabolic Acidosis

Cardiovascular

Tachycardia

Dysrhythmias

Gastrointestinal

Anorexia

_______________

Vomiting


Metabolic Acidosis

Neuromuscular

Tremors

Hypertonic muscles

Muscle cramps

Tetany


Seizures

Respiratory

Hypoventilation

+Metabolic Alkalosis

Buildup of a ________OR Loss of an _________

Deficit of carbonic acid

Decrease in hydrogen

Causes

Diuretics

Excessive vomiting or GI suctioning

Hyperaldosteronism

Ingestion

Transfusion of whole blood

+Acid-Base Imbalances

Respiratory acidosis

pH: Decreased

HCO3- : Normal

PaO2: Usually decreased

PaCO2: Increased

K+: Increased


Respiratory alkalosis

pH: Increased

HCO3-: Normal

PaO2: Usually normal

PaCO2: Decreased

K+: Decreased


Metabolic acidosis

pH: Decreased

HCO3-: Decreased

PaO2: Usually normal

PaCO2: Normal

K+: Increased


Metabolic alkalosis

pH: Increased

HCO3-: ____________

PaO2: Normal

PaCO2: Normal

K+: Decreased

+Acid-Base Analysis via ABG

1. Know the normal values and how the align in the

acid-base scale

pH (Hydrogen ion concentration)

NORMAL is 7.35-7.45

PCO2 (Partial Pressure of Carbon Dioxide)

NORMAL is 35-45

HCO3- (Bicarbonate concentration)

NORMAL is 22-26

2. Plug the values into a tic-tac-toe board…

PCO2 is a breathing parameter so it is associated with a respiratory etiology

HCO3- is a metabolic parameter so it is associated with a metabolic etiology


Acid Alkaline

pH 7.35 Normal 7.45

PaCO2 45 Homeostasis 35

HCO3 22 26

• pH

• NORMAL is 7.35-7.45

• PCO2

• NORMAL is 35-45

• HCO3-

• NORMAL is 22-26

THIS IS THE CONFUSING VALUE

BECAUSE IT IS THE ONLY ONE

THAT A HIGHER VALUE EQUATES

TO ACID INSTEAD OF A BASE –

OPPOSITE OF THE OTHER 2…


7.28 pH

25 PaCO2

19 HCO3

Acid Alkaline

pH 7.35 Normal 7.45


HCO3 22 26


Acid Alkaline

pH 7.35 Normal 7.45


HCO3 22 26

18 HCO3

7.52 pH

32 PaCO2


Acid Alkaline

pH 7.35 Normal 7.45


HCO3 22 26

24 HCO3

7.52 pH

32 PaCO2

+Allen’s Test

Evaluation of collateral blood flow prior to arterial

blood draw

Nursing Intervention:

Explain the procedure

Apply pressure over the ulnar and radial arteries at the same time

Ask patient to open and close hand continually

Release ulnar artery pressure while still compressing the radial

artery

Observe the color of the extremity distal to the pressure point

Record results

Draw arterial blood sampling

+Obtaining a blood sample


Check physician prescription

Identify foods, medications, or other factors that could affect the

procedure

Identify the client

Explain the purpose of the test and procedure

Draw the blood sample

Apply pressure and a Band-Aid or gauze dressing to the

venipuncture

+Coagulation Studies

Activated partial thromboplastin time (________)

Evaluates how well the coagulation sequence is functioning by

measuring the amount of time it takes in seconds for recalcified

citrated plasma to clot after partial thromboplastin is added to it

Test screens for deficiencies and inhibitors of all factors except

VII and XIII

aPTT is used to monitor heparin therapy and screen for

coagulation disorders

Should be between 1.5 and 2.5 times normal when the client is

receiving heparin therapy, if the value is prolonged (longer than

90 seconds), the client is at risk for bleeding.

If the aPTT value is prolonged (>90 sec) in a client receiving IV

heparin therapy, initiate bleeding precautions.

+Coagulation studies

Prothrombin Time PT measures the amount of time (sec) for clot formation

and is used to monitor response to warfarin sodium (Coumadin) therapy or to screen for dysfunction of the extrinsic clotting system resulting from liver disease, vitamin K deficiency, or DIC

PT normal is within 2 seconds of the control

INR is used to test to measure the effects of oral anticoagulants

Values PT: 9.6 to 11.8 seconds (male adult); 9.5 to 11.3 seconds (female

adult)

INR: 2 to 3 for standard warfarin therapy

INR: 3 to 4.5 for high dose warfarin therapy



A baseline PT shown be drawn before anticoagulation therapy is

initiated, note the time on the lab form

Put direct pressure to the venipuncture site for 3-5 mins

Concurrent warfarin therapy with heparin therapy can extend the

PT to 1.5 – 2 times the lab control value

A PT longer than 30 seconds can result in bleeding


Clotting time

Time required for the interaction of all factors involved in the

clotting process

8-15 mins

No heparin therapy for 3hrs before specimen collection

Heparin therapy will affect the results

Anticoagulant therapy can falsely

Prolong the test result

Test tube agitation-?????

Exposure of the specimen to high temperatures


Platelet count

Hemostatic plug formation

Clot retraction

Coagulation factor activation

Produced in the bone marrow

Value: 150,000 to 400,000 cells/mm3

Nurse should monitor venipuncture site for bleeding in

thrombocytopenic patients

Platelet count increased by:

High altitudes

Chronic cold weather

Exercise

+Erythrocyte studies

Erythrocute sedimentation rate

Hemoglobin and hematocrit

Serum iron

RBC count (erythrocytes)

____/_____/_____ rule (normal RBC/HGB/HCT)

+Serum enzymes and cardiac

markers

Creatinine kinase

Nurse roles:

Tell patient to avoid exercising

Troponins

Values usually lower than .6 ng/mL

Value higher than 1.5ng/mL

Could indicate myocardial infarction

Myoglobin

+Serum enzymes and cardiac

markers

Natriuretic peptides

ANP:

22 to 27 pg/mL

BNP:

Less than 100 pg/mL

The higher the BNP level

The more severe the CHF

If the BNP is raised

Dyspnea is due to CHF

If BNP is normal

Dyspnea is due to a pulmonary problem.

+Serum Gastrointestinal studies

Albumin

Alkaline phosphatase

Ammonia

Alanine aminotransferase (ALT)

Aspartate aminotransferase (AST)

Amylase

Lipase

Bilirubin

Lipids

Uric acid

+Glucose studies

Fasting glucose: 70-110 mg/dL

Glucose monitoring (capillary blood): 60-110 mg/dL

Glucose tolerance test (oral): Baseline fasting: 70-110 mg/dL

30-min fasting: 110-170 mg/dL




+Glucose studies

Glucose tolerance test

Tell patient to eat a high-carbohydrate (200-300g) diet for 3 days

before the test

Avoid

36 hours before test:

Alcohol

Coffee

Smoking

8 hours before the test:

Exercise

Fast 10 to 16 hours before test

+Glucose studies

Glucose tolerance test

Patients with diabetes mellitus

Do not take morning insulin or oral hypoglycemic drugs

Tell patient that the test may

Take ____________________

Require IV or oral administration of glucose

Require many blood samples

+Glucose studies

Glycosylated hemoglobin

Blood glucose bound to Hb

Hb A1c tells how well blood glucose levels have been controlled

for the past 3 to 4 months

Hyperglycemia

Cause of increase HbA1c in diabetic patients

Fasting is _____________________

+Glucose studies

Glycosylated serum albumin (fructosamine)

Reproduces avg. serum glucose levels over a period of 2 to 3 weeks

More sensitive to recent changes than HbA1c (hemoglobin A1c)

Values

Not diabetic:

2.5 to 2.7 mmol/L

Diabetic:

2 to 5 mmol/L

Fast for 12 hours before the test

+Glucose studies

Diabetes mellitus autoantibody panel

Assess insulin resistance

Recognize type 1 diabetes and patients with allergies to insulin

Value:

Less than 1:4 titer with no antibody detected

Avoid radioactive scans within 7 days of the test

No fasting required

+Real function studies

Serum creatinine

Avoid:

Exercise for 8 hours before the test

Extreme red meat intake for 24 hours before the test

Value:

0.6 to 1.3 mg/dL

+Real function studies

Urea

Normally freely filtered through the renal glomeruli

Some amount reabsorbed in the tubules and

The rest excreted in the urine

High levels shows a slowing of the GFR

Value:

8 to 25 mg/dL

BUN/CREAT ratio 10:1

+Elements

Calcium

Functions in bone formation

Nerve impulse transmission

Contraction of myocardial and skeletal muscles

Helps in blood clotting by converting prothrombin to thrombin

Value:

8.6 to 10 mg/dL

Nurse roles

Tell patient to eat a diet with normal calcium levels (800

mg/day) for 3 days before the test

+Elements

Magnesium

Indicative of metabolic activity and renal function

Needed for blood-clotting mechanism

Regulates neuromuscular activity

Acts as a cofactor

+Elements

Phosphorus

Functions in bone formation

Energy storage and release

Urinary acid-base buffering

Carbohydrate metabolism

Value:

2.7 to 4.5 mg/dL

Tell patient to fast before the test

+Thyroid studies

Values

TSH: 0.2 to 5.4 microunits/mL

T4: 5 to 12 mcg/dL

Free T4: .8 to 2.4 ng/dL

T3: 80 to 230 ng/dL

Avoid radionuclide scan within 7 days before the test

+White Blood Cell Count

Value 4,500 to 11,000 cells/mm3

___________________

Neutrophils: 1,800 – 7,800 cells/mm3

Bands – 0-700 cells/mm3

Eosinophils -0-450 cells/mm3

Basophils – 0-200 cells/mm3

Lymphocytes- 1000 – 48000 cells/mm3

Monocytes – 0-800 cells/mm3


Nurse Roles

A low total WBC count with a left shift could indicate

A recovery from bone marrow depression

An infection of such intensity that the demand for neutrophils in

the tissue is higher than the capacity

High total WBC count with a left shift could be due to

Increased release of neutrophils by the BM in response to an

infection or inflammation


Nurse Roles

A “shift to the _________” means that

An increased number of immature neutrophils

A “shift to the _________” means that

Cells have more than usual number of nuclear segments

Found in liver disease

Down syndrome

Megaloblastic and pernicious anemia

+Hepatitis testing

Radioimmunoassay

ELISA

Microparticle enzyme immunoassay

Serological tests for specific hepatitis virus

markers

Help in determining what specific type of hepatitis the patient has

+Hepatitis testing

Values

Hepatitis A

IgM antibody

Total antibody to hepatitis A

Hepatitis B

HBcAg

HBeAg

HBsAg

+Hepatitis testing

Values

Hepatitis C

Confirmed with antibodies against Hepatitis C

Hepatitis D antigen (HDAg)

Seen in Hepatitis A virus

Hepatitis E

IgM and IgG antibodies to Hepatitis E

+Hepatitis testing

Nurse role:

If the radioimmunoessay tecnique is being used

Within 1 week before blood test

Injection of radionuclides may result in false positive levels

+HIV and AIDS testing

Common tests include

ELISA

Western blot

IFA

ELISA

Used for screening

Western blot or IFA

Must be performed after as a confirmatory test

Repeat test _______________ later


CD4+ T cell count

Monitor progression of HIV

CD4+ count will go down as the disease gets worse

Immune system remains healthy with CD4+ T-cell counts higher

than 500 cells/L

Problems start occurring with CD4+ count is 200-499 cells/L

Severe immune system problems occur with CD4+ count is lower

than 200 cells/L


CD4-CD8 ratio

Monitors progression of disease

Normal ratio is 2:1

Viral load testing

Measures the occurrence of HIV viral genetic material (RNA) in

client’s blood

P24 antigen assay

counts the quantity of HIV viral core protein in the patient’s serum

+Urine Tests

Color: pale yellow

Odor: specific aromatic odor, similar to ammonia

Turbidity: clear

pH: 4.5-7.8

Specific gravity: 1.016 to 1.022

Glucose: <0.5 g/day

Ketones, protein, bilirubin, casts, crystals, bacteria: none

Red blood cells: <3 cells/HPF

White blood cells: < 4 cells/H

Chloride: 110-250 mEq/ 24 hr

Magnesium: 7.3 – 12.2 mg/dL

Potassium 25 – 125 mEq/ 24 hr

Sodium 40 – 220 mEq/ 24 hr

Uric acid: 250 – 750 mg/ 24 hr

+Serum medication levels

Acetaminophen (Tylenol) : 10-20 mcg/mL

Amikacin (Amikin) : 25-30 mcg/mL

Amitriptyline: 120-140 ng/mL

Carbamazepine (Tegretol): 5-12 mcg/mL

Chloramphenicol (Chloromycetin): 10-20 mcg/mL

Desipramine (Norpramin) : 150-300 ng/mL

Digoxin (Lanoxin): 0.5-2 ng/mL

Disopyramide (Norpace): 2-5 mcg/m

Ethosuximide (Zarontin): 40-100 mcg/mL

+Serum medication levels

Gentamicin: 5-10 mcg/mL

Imipramine (Tofranil): 150-300 ng/mL

Lidocaine (Xylocaine): 1.5-5 mcg/mL

Lithium (Lithobid): 0.5-1.2 mEq/L

Magnesium sulfate: 4-7 mg/dL

Phenobarbital (luminal) : 10-30 mcg/mL

Phenytoin (Dilantin): 10-20

Propranolol (Inderal): 50-100 ng/mL

Salicylate: 100-250 mcg/mL

Theophylline: 10-20 mcg/mL

+Nutrition

Carbohydrates

Sugars, starches, and cellulose provide ______ cal/g of energy

Advance normal fat metabolism

Spare protein

Increase lower GI function

+Nutrition

Carbohydrates

Food sources

Milk

Grains/ Starch

Fruits/ Fructose

Vegetables/ Cellulose

Glucose, lactose, sucrose

+Nutrition

Fats

Cholesterol, monounsaturated fats, polyunsaturated fats, saturated

fats provide _____ cal/g of energy

Protects

Internal organs

Maintain body temperature

Part of the plasma membrane

+Nutrition

Fats

Inadequate intake

Feeling cold

Skin lesions

Risk of infection

Amenorrhea

Increased intake

Obesity

Increase risk of cardiac diseases and some cancers

+Nutrition

Proteins

Amino acids are the building blocks of protein

Provide ______ cal/g of energy

Functions

Build and repair body tissues

Control fluid balance

Uphold acid-base balance

Make antibodies

Provide energy

Produce enzymes and hormones

+Nutrition

Proteins

Essential amino acids must be obtained through diet

Food sources:

Eggs

Diary products

Meat

Fish

Poultry

Insufficient protein intake can lead to malnutrition and extreme

wasting of fat and muscle tissue

+Nutrition

Vitamins

Good for life and growth processes

Maintain and regulate body functions

Fat-soluble vitamins are A,D,E, and K

They can be stored in body so have there is a risk of toxicity

The B and C vitamins are water-soluble

Excreted in the urine

+Nutrition

Vitamins

Vitamin K

Catalyst for enabling blood-clotting factors

Especially ___________________

Vitamin C

Helps in the production of collagen

Important in wound healing

Vitamin A

Helps with eyesight and epithelial linings

+Nutrition

Minerals

Part of hormones, cells, tissues, and bones

Catalysts for chemical reactions and enhancers of cell function

Deficiency can occur in chronically ill or in the hospitalized

+Therapeutic diets

Clear liquid diet

Fluids and some electrolytes to prevent dehydration

Initial feeding after complete bowel rest

Use to feed a malnourished person

Use for preparation of bowel surgery

Postoperatively in clients with fever, vomiting or diarrhea

Gastroenteritis or pancreatitis

+Therapeutic diets

Full liquid diet

Used after clear liquid diet after surgery

Clients who have trouble chewing, swallowing, or solid foods.

+Therapeutic diets

Mechanically altered diet

Texture is altered to require minimal chewing

For those who have dental problems, surgery of head and neck, or

dysphagia

Soft diet

For those who have difficulty chewing or swallowing

Clients with mouth sores should be served food at colder temp

Sour candy can increase salivary flow for those with dry mouth

+Therapeutic diets

Low-residue, _______________ diet

Least likely to form an obstruction when intestinal tract is

narrowed by inflammation or scarring or when GI motility is slow

Use in inflammatory bowel disease, partial obstructions of the

intestinal tract, gastroenteritis, diarrhea and other GI problems

+Therapeutic diets

High-residue, high-fiber diet

Used for constipation, irritable bowel syndrome, and

asymptomatic diverticular disease

Give 20 to 35 g of dietary fiber daily

Fruits, vegetables, and whole grain products are high-residue

foods

Increase fiber slowly and give adequate fluids so to avoid

abdominal discomfort

+Therapeutic diets

Cardiac diet

Atherosclerosis, DM, hyperlipidemia, hypertension, MI, nephrotic

syndrome, and renal failure

Restrict fat amount, cholesterol and salt

+Therapeutic diets

Fat-restricted diet

Use to reduce abdominal pain, steatorrhea, flatulence, and

diarrhea

Used for patients with malabsorption disorder, pancreatitis,

gallbladder disease, and GI reflux

High-calorie, _________________ diet

Used for severe stress, burns, wound healing, cancer, HIV, AIDS,

COPD, respiratory failure, or any other debilitating disease

Encourage snacks between meals

+Therapeutic diets

Carbohydrate-consistent diet

Used for patients with diabetes mellitus, hypoglycemia,

hyperglycemia, and obesity

Sodium-restricted diet

Used for hypertension, heart failure, renal disease, cardiac

disease, and liver disease

+Therapeutic diets

Protein-restricted diet

Used for renal disease and liver disease

Renal diet

Patient with acute or chronic renal failure, hemodialysis, or

peritoneal dialysis patients

+Therapeutic diets

Potassium-modified diet

Low- potassium diet

Hyperkalemia

Impaired renal function

Hypoaldosteronism

Addison’s disease

ACE inhibitor medications

Immunosuppressive meds

K+ sparing diuretics

Chronic hyperkalemia

+Therapeutic diets

Potassium-modified diet

High- potassium diet

Hypokalemia

Renal tubular acidosis

GI losses

Intracellular shifts

K+ wasting diuretics

Antibotics

Glucocorticoid excess from primary or secondary aldosteronism

Cushing’s syndrome or exogenous corticosteroid use

+Therapeutic diets

High- calcium diet Needed during bone growth and in adulthood to avoid

osteoporosis and to enable vascular contraction, vasodilation, muscle contraction, and nerve transmission

Low-Purine diet Used for gout, kidney stones, and elevated uric acid levels

Food restrictions include anchovies, herring, mackerel, sardines, scallops, and glandular meats

High- Iron diet Anemia

Organ meats, meat, egg yolks, whole wheat, dark green leafy vegetables, dried fruit, and legumes

+Therapeutic diets

___________________ diets

Lacto-Ovo

Lacto

Vegan

Pesco

Enternal Nutrition

Liquefied foods into the GI tract via a tube

Used for patients with swallowing problems, burns, major trauma,

liver or other organ failure, or severe malnutrition

+Parenteral Nutrition (PN)

Supplies nutrients thru the veins

Supplies carbohydrates in form of dextrose, fats in

an emulsified form, proteins in the form of amino

acids, vitamins, minerals, electrolytes, and water

Prevents subcutaneous fat and muscle protein from

being catabolized by the body for energy

PN is least desirable form of nutrition and used

when there is no alternative.

+Administration and discontinuation

Types of administration

Continuously over 24 hours

Most commonly used in a hospital setting

Less risk of complications when administered continuously

Intermittent PN

Generally 12-hour infusions that are usually given at night

Discontinuing PN therapy

Gradually decrease the flow rate for 1 to 2 hours while increasing

oral (this assists in preventing hypoglycemia)

+Complications

Air embolism Associated with tubing changes and central line placement

Pneumothorax Associated with central line placement

Hyperglycemia

Hypervolemia

Hypoglycemia

Infection

+Intravenous therapy

Used to sustain clients who are unable to take

substances orally

Replaces water, electrolytes, and nutrients more

rapidly than oral administration

Types of solutions

Isotonic

Hypotonic

Hypertonic

Colloids

+Intravenous devices

IV cannulas

Steel needles or butterfly sets

Plastic cannulas

The needle is .5 to 1.5 inches in length, with needle gauge sizes

from 16 to 26

IV containers


IV gauges

For rapid emergency fluid administration, blood products, or

anesthetics

Large-diameter lumen needles or cannulas are used

14,16,18, or 19 gauge

Peripheral fat infusions (lipids)

20 or 21 gauge lumen or cannula is used

For standard IV fluid and clear liquid IV medications

22 or 24 gauge lumen or cannula

If client has small veins

24 to 25 gauge lumen or cannula is used


IV tubing

Drip chambers Macrodrip chamber

Microdrip chamber

Filters

Needleless infusion devices

Intermittent infusion devices

Electronic IV infusion devices


Complications

Air embolism

Catheter embolism

Circulatory overload

Electrolyte overload

Hematoma

Infection

Infiltration

Phlebitis and thrombophlebitis

Tissue damage

+Central venous catheters

Used to deliver hyperosmolar solutions, measure

central venous pressure, infuse parenteral

nutrition, or infuse multiple IV solutions or

medications

Tunneled central venous catheters

Vascular access ports

PICC line

+Epidural Catheter

Catheter is placed in the epidural space for the

administration of analgesics, this method of

administration reduces the amount needed to

control pain, therefore the client experiences

fewer side effects

Get client’s vital signs, level of consciousness, and

motor and sensory function

+Types of blood components

Packed RBC

_________________

Used to treat thrombocytopenia and platelet coagulation studies

and fibrinogen levels

White blood cells (WBCs)

Types of blood donations

Autologous

Blood salvage

Designated donor

+Compatibility

ABO type and Rh type

An antibody screen is done to determine the

presence of antibodies other than anti-A and anti-B

Crossmatching

Universal RBC donor is O negative, the universal

recipient is AB positive

+Compatibility

Complications

Transfusion reactions

Signs of an immediate transfusion reaction:

Chills and diaphoresis

Muscle aches

Back or chest pain

Allergic reactions

Hives

Itching

Swelling

Rapid, thready pulse

+Compatibility

Complications

Signs of an immediate transfusion reaction:

Dyspnea

Cough or wheezing

Pallow and cyanosis

Apprehension

Tingling and numbness

Headache

Nausea/ Vomiting/ Diarrhea

Abdominal cramping

+Compatibility complications

Signs of a transfusion reaction in an unconscious client

Weak pulse, fever, tachycardia or bradycardia, hypotension, visible

hemoglobinuria, oliguria or anuria

Delayed transfusion reactions

Signs include fever, mild jaundice, and a decreased hematocrit level

Circulatory overload

Caused by the infusion of blood at a rate too rapid for the client to tolerate

Assessment: cough, dyspnea, chest pain, and wheezing on auscultation of

the lungs, headache, hypertension, tachycardia and a bounding pulse,

distended neck veins


Septicemia

Occurs with the transfusion of blood that is contaminated with

microorganisms

Rapid onset of chills, high fever, vomiting, diarrhea, hypotension,

shock

Iron overload

After receiving multiple blood transfusions

Vomiting, diarrhea, hypotension, altered hematological values

Tx: ___________________ (Desferal)


Disease transmission

Hypocalcemia

Hyperkalemia

Nursing Sciences Tim Duncan;RN, CCRN, CEN, EMTP · Nursing Sciences Tim Duncan;RN, CCRN, CEN, EMTP 2015 KISSPharm L.L.C + Fluid and Electrolyte Balance

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