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Exam 4 Notes
Fluid & Electrolytes
Learning objective Describe variables that influence fluid and electrolyte balance Identify factors related to fluid/electrolyte balance across the lifespan Assess a patient’s nutritional and fluid/electrolyte status Outline specific nursing interventions to promote fluid and electrolyte balance Base decisions on the signs and symptoms of fluid volume excess and fluid volume deficit Base decisions on the interpretation of diagnostic tests and lab values indicative of a disturbance in fluid and electrolyte balance Identify evidence-based practices Fluid & Electrolytes Fluid – water + the substances dissolved and suspended in it (such as glucose, electrolytes, and proteins) Important characteristics of fluid are its volume (amount) and degree of concentration (osmolarity) Electrolytes – substances that are charged particles (ions) when they are placed in H20 (such as sodium, potassium, calcium, and magnesium) Fluid balance – Fluid & electrolyte intake and absorption match the fluid and electrolyte output.
- Fluid volume, osmolarity, and electrolyte concentrations of fluid in the various body fluid compartments are within their normal ranges Location of Water & Electrolytes Intracellular (ICF)
- Fluid within cells
- 2/3 of total body water
- potassium major intracellular ion Extracellular (EFC)
- Fluid outside of cells
- 1/3 of total body water – sodium major extracellular ion
- Three divisions: Interstitial – between cells outside blood vessels Intravascular – within vessels, blood or plasma Transcellular – such as CSF, pleura, synovial, etc. Intracellular fluids (ICFs) are found inside cells and are made up of protein, water, electrolytes, and solutes. The most abundant electrolyte in intracellular fluid is potassium. Intracellular fluids are crucial to the body’s functioning. Extracellular fluids (ECFs) are fluids found outside of cells. The most abundant electrolyte in ECF is sodium. The body regulates sodium levels to control the movement of water into and out of the extracellular space due to osmosis. Body Environment
Body fluids consist of water, electrolytes, blood plasma and component cells, proteins, and other soluble particles called solutes. Body fluids are found in two main areas of the body, called intracellular and extracellular compartments. How do H20 & electrolytes move within the body? Active transport – requires energy (ATP) Diffusion – DOWN the gradient
- Electrolytes & particles move from a higher concentration to a lesser concentration (opposite Osmosis below).
- Passive process that is Seeking equalization. Osmosis – Movement of H20 only across cell membranes.
- Pulls fluid into compartment that has the higher concentration (osmotic pressure) until equalization occurs.
- Isotonic, hypotonic, and hypertonic IV solutions Filtration – hydrostatic pressure
- Movement of fluid between interstitial and vascular compartments – may result in edema Fluid movement occurs inside the body due to osmotic pressure, hydrostatic pressure, and osmosis. Proper fluid movement depends on intact and properly functioning vascular tissue lining, normal levels of protein content within the blood, and adequate hydrostatic pressures inside the blood vessels. Intact vascular tissue lining prevents fluid from leaking out of the blood vessels. Protein content in the blood (in the form of albumin) causes oncotic pressure that holds water inside the vascular compartment. For example, patients with decreased protein levels (i.e., low serum albumin) experience edema due to the leakage of intravascular fluid into interstitial areas because of decreased oncotic pressure. Hydrostatic pressure is defined as pressure that a contained fluid exerts on what is confining it. In the intravascular fluid compartment, hydrostatic pressure is the pressure exerted by blood against the capillaries. Hydrostatic pressure opposes oncotic pressure at the arterial end of capillaries, where it pushes fluid and solutes out into the interstitial compartment. On the venous end of the capillary, hydrostatic pressure is reduced, which allows oncotic pressure to pull fluids and solutes back into the capillary. Filtration occurs when hydrostatic pressure pushes fluids and solutes through a permeable membrane so they can be excreted. Because osmosis causes fluid to travel due to a concentration gradient and no energy is expended during the process, it is referred to as passive transport. Active transport involves moving solutes and ions across a cell membrane from an area of lower concentration to an area of higher concentration. Because active transport moves solutes against a concentration gradient to prevent an overaccumulation of solutes in an area, energy is required for this process to take place. Recall that sodium (Na+) is the primary electrolyte in the extracellular space and potassium (K+) is the primary electrolyte in the intracellular space. Cellular Environment Diffusion
Intake should equal output What ways does the body take in water? What ways does the body lose water? Describe “insensible loss” Hormones involved in fluid balance
- Antidiuretic hormone (ADH)
- Renin-Angiotensin-aldosterone system
- Atrial natriuretic peptides (ANP)
- BNP for heart failure Fluid output occurs mostly through the kidneys in the form of urine. Fluid is also lost via the skin through perspiration, via the gastrointestinal tract in the form of stool, and via the lungs during respiration. Forty percent of daily fluid output occurs due to these “insensible losses” through the skin, gastrointestinal tract, and lungs and cannot be measured. The remaining 60% of daily fluid output is in the form of urine. Normally, the kidneys produce about 1, mL of urine per day when fluid intake is adequate. Decreased urine production is an early sign of dehydration or kidney dysfunction. It is important for nurses to assess urine output in patients at risk. If a patient demonstrates less than 30 mL/hour (or 0.5 mL/kg/hour) of urine output over eight hours, the provider should be notified for prompt intervention. Water Balance Role of Electrolytes
Renin-angiotensin-aldosterone system When there is decreased blood pressure (which can be caused by fluid loss), specialized kidney cells make and secrete renin into the bloodstream. Renin acts on angiotensinogen released by the liver and converts it to angiotensin I, which is then converted to angiotensin II. Angiotensin II does a few important things. First, it causes vasoconstriction to increase blood flow to vital organs. It also stimulates the adrenal cortex to release aldosterone. Aldosterone is a steroid hormone that triggers increased sodium reabsorption by the kidneys and subsequently increased serum osmolality in the bloodstream. Increased serum osmolality causes osmosis to move fluid into the intravascular compartment in an effort to equalize solute particles. The increased fluids in the intravascular compartment increase circulating blood volume and help raise the person’s blood pressure. An easy way to remember this physiological process is “aldosterone saves salt” and “water follows salt.
Excessive fluid volume, also referred to as hypervolemia, occurs when increased fluid is retained in the intravascular compartment. Patients with the following conditions are at risk for developing excessive fluid volume:
- Heart failure
- Kidney failure
- Cirrhosis
- Pregnancy Symptoms of fluid overload include pitting edema, ascites, dyspnea, and crackles from fluid in the lungs. Edema is swelling in dependent tissues due to fluid accumulation in the interstitial spaces. Ascites is fluid retained in the abdomen. Calcium
- Hypercalcemia results from increased intake and absorption shift out of bone decreased excretion of ca++ risk cancer – lethargy
- Hypocalcemia results from lack of intake shift to bound calcium (ionized hypocalcemia) is not available for use by the body pancreatitis – calcium binds with fat and is excreted through the feces – tetany Magnesium
- Hypomagnesemia Assessment done by Trousseau’s sign (hand spasm) Chvostek’s sign (facial twitch) dysrhythmias - torsade’s Deficient fluid volume (also referred to as hypovolemia or dehydration) occurs when fluid loss is greater than fluid input. Common causes of deficient fluid volume are diarrhea, vomiting, excessive sweating, fever, and poor oral fluid intake. Individuals who have a higher risk of dehydration include older adults and individuals who exercise or work outdoors in hot weather. In adults, symptoms of dehydration are as follows:
- Feeling very thirsty or having a dry mouth
- Headache
- Dry skin
- Urinating and sweating less than usual, dark, concentrated urine
- Feeling tired
- Changes in mental status
- Dizziness due to decreased blood pressure
- Elevated heart rate
Electrolytes
Sodium (Na+)
- Increased level Hypernatremia Causes. Excessive salt intake Symptoms. Lethargy, irritability, seizures, and weakness Treatments. Rehydrate w/ D5W and increase water intake
- Decreased level Hyponatremia Causes. Excessive water intake and diuretics Symptoms. Headache, confusion, coma Treatments. 3% NS and fluid restriction Potassium (K+)
- Increased levels Hyperkalemia Causes. Kidney dysfunction, excessive potassium intake, and ACE inhibitors Symptoms. Cardiac arrhythmias, cramping, diarrhea, and irritability Treatments. Limit potassium in diet, loop diuretic, insulin, dialysis, and kayexalate
- Decreased levels Hypokalemia Causes. Loop and thiazide diuretics and IV administration of insulin Symptoms. Weakness, arrhythmias, lethargy, and thready pulse (WALT) Treatments. PO/IV potassium and increase K+ in diet Calcium (Ca++)
- Increased levels Hypercalcemia Causes. Overactive parathyroid glands and cancer Symptoms. Nausea, vomiting, constipation, and thirst Treatments. Decrease calcium in diet, increase mobility, and administer phosphorous
- Decreased levels Hypocalcemia Causes. Diuretic use and removal of parathyroid glands Symptoms. Numbness, tingling, Chvotek’s sign, and tetany Treatments. Increase Ca++ in diet and IV/PO calcium Magnesium (Mg+)
- Increased levels Hypermagnesemia Causes. Kidney disease and excessive magnesium intake (e.g., laxatives and antacids) Symptoms. Muscle weakness, bradycardia, asystole, tremors, and slow reflexes Treatments. Dialysis, increased fluid intake, and stopping medications containing Mg+
- Decreased levels Hypomagnesemia Causes. Diuretics, undernutrition, and long-term alcohol use disorder
Nutrition
Leaning Objectives Describe variables that influence nutrition Identify factors related to nutrition across the lifespan Assess a patient’s nutritional status Outline specific nursing interventions to promote nutrition Base your decisions on the action of nutrients, signs of excess and deficiency, and specific foods associated with each nutrient Base your decisions on the interpretation of diagnostic tests and lab values indicative of a disturbance in nutrition Give examples of appropriate vitamin use across the lifespan Identify evidence-based practices related to nutrition Structure and Function The gastrointestinal system (also referred to as the digestive system) is responsible for several functions, including digestion, absorption, and immune response. Digestion begins in the upper gastrointestinal tract at the mouth, where the chewing of food, called mastication, occurs. Mastication results in mechanical digestion when food is broken down into small chunks and swallowed. Masticated food is formed into a bolus as it moves toward the pharynx in the back of the throat and then into the esophagus. Coordinated muscle movements in the esophagus, called peristalsis, move the food bolus into the stomach, where it is mixed with acidic gastric juices and further broken down into chyme through a chemical digestion process. As chyme is moved out of the stomach and into the duodenum of the small intestine, it is mixed with bile from the gallbladder and pancreatic enzymes from the pancreas for further digestion. Absorption
Absorption is a second gastrointestinal function. After chyme enters the small intestine, it comes into contact with tiny fingerlike projections along the inside of the intestine called villi. Villi increase the surface area of the small intestine and allow nutrients, such as protein, carbohydrates, fat, vitamins, and minerals, to absorb through the intestinal wall and into the bloodstream. Absorption of nutrients is essential for metabolism to occur because nutrients fuel bodily functions and create energy. Peristalsis moves leftover liquid from the small intestine into the large intestine, where additional water and minerals are absorbed. Waste products are condensed into feces and excreted from the body through the anus. Nutrients Macronutrients - Carbs, proteins and fats Carbohydrates - sugars and starches (stores sugar)
- Complex carbohydrates - break down more slowly Glycemic index - Measures how quickly glucose levels increase in the bloodstream Protein - peptides and amino acids Fats - Saturated, unsaturated, trans fasts Vitamins - water-soluble and fat-soluble Minerals Grains Critical Thinking What are some factors affecting nutrition and metabolism? Are there nursing considerations for Age? Eating disorders - How do we manage?
- Anorexia nervosa
- Bulimia nervosa
- Bing-eating disorder Obesity What assessment/data collection would you want to get? What are some S/S of poor nutrition? Glucose Regulation Glucose regulation is the process of maintaining optimal blood glucose levels The ultimate end result of glucose metabolism is cellular use of glucose for energy synthesis Categories of Glucose Regulation Hypoglycemia (low blood sugar)
Assess factors that put a patient at risk for alterations in urinary and bowel elimination Identify factors related to alterations in elimination across the lifespan Outline the data that must be collected for identification of alterations in bowel/urine elimination Base decisions on the interpretation of basic diagnostic tests of urinary and bowel elimination: urinalysis and occult blood Detail the nonpharmacologic measures to promote urinary and bowel elimination Identify evidence-based practices Urinary System The urinary system, also referred to as the renal system or urinary tract
- Kidneys
- Ureters
- Bladder
- Urethra The purpose: to eliminate waste from the body, regulate blood volume and blood pressure, control levels of electrolytes and metabolites, and regulate blood pH. The kidneys filter blood in the nephrons and remove waste in the form of urine. Urinary System Terminology Anuria. Absence of urine output, typically found during kidney failure, defined as less than 50 mL of urine over a 24-hour period. Dysuria. Painful or difficult urination. Frequency. The need to urinate several times during the day or at night (nocturia) in normal or less-than- normal volumes. It may be accompanied by a feeling of urgency. Hematuria. Blood in the urine, either visualized or found during microscopic analysis. Oliguria. Decreased urine output, defined as less than 500 mL of urine in adults in a 24-hour period. Nocturia. The need to get up at night on a regular basis to urinate. Nocturia often causes sleep deprivation that affects a person’s quality of life. Polyuria. Greater than 2.5 liters of urine output over 24 hours, also referred to as diuresis. Urine is typically clear with no color. New polyuria should be reported to the health care provider because it can be a sign of many medical conditions. Pyuria. At least ten white blood cells in each cubic millimeter of urine in a urine sample, typically indicating infection. In severe infections, pus may be visible in the urine Urgency. A sensation of an urgent need to void. Urgency can cause urge incontinence if the patient is not able to reach the bathroom quickly. The gastrointestinal (GI) system The gastrointestinal (GI) system
- Mouth
- Esophagus
- Stomach
- Small intestine
- Large intestine
- Anus Ingested food and liquid are pushed through the GI tract by peristalsis The stomach mixes food and liquid with digestive enzymes and then empties into the small intestine. The muscles of the small intestine mix food with enzymes and bile from the pancreas, liver, and intestine and push the mixture forward for further digestion. Bowel Elimination Terminology Black Stools. Black-colored stools can be side effects of iron supplements or bismuth subsalicylate (Pepto- Bismol). Rectal Bleeding. Rectal bleeding refers to bright red blood in the stools, also referred to as hematochezia. It is a sign of bleeding in the lower GI tract. Rectal bleeding can range in severity from minimal drops of blood on the toilet tissue, caused by hemorrhoids, to large amounts of severe bleeding, which are life- threatening and require emergency care. Tarry Stools. Stools that are black, sticky, and appear like tar are referred to as melena. Melena. Melena is typically caused by bleeding in the upper part of the gastrointestinal tract, such as the esophagus, stomach, or the first part of the small intestine, or due to the patient swallowing blood. The blood appears darker and tarry-looking because it undergoes digestion on its way through the GI tract. Bleeding from the upper part of the GI tract can also range from mild to life-threatening, depending upon the cause, and should always be reported to the health care provider. UTIs A UTI is a common infection that occurs when bacteria, typically from the rectum, enter the urethra and infect the urinary tract. Who is at higher risk of getting a UTI? Symptoms of UTI include
- Pain or burning while urinating (dysuria)
- Frequent urination (frequency)
- Urgency with small amounts of urine
- Bloody urine
- Pressure or cramping in the groin or lower abdomen
- Confusion or altered mental status (in older adults) Symptoms of a more serious kidney infection (pyelonephritis) include fever above 101 degrees F (38. degrees C), shaking chills, lower back or flank pain (i.e., on the sides of the back), and nausea or vomiting. Types of Urinary Incontinence Continence is achieved through an interplay of the physiology of the bladder, urethra, sphincter, pelvic floor, and the nervous system coordinating these organs.
- Stress urinary incontinence
- Urge urinary incontinence (also referred to as “overactive bladder”)
- Stage 3. The deep sleep or slow-wave sleep stage based on a pattern that appears during measurements of brain activity. Individuals spend the most sleep time in this stage during the early part of the night. When sleeping, individuals cycle through two phases of sleep: rapid eye movement (REM) sleep and non- REM sleep. A full sleep cycle takes 80 to 100 minutes to complete, and most people typically cycle through four to six cycles per night. It is common to wake up briefly between cycles. Restoration takes place mostly during slow-wave non-REM sleep, during which the body’s temperature, heart rate, and brain oxygen consumption decrease. Brain activity decreases, so this stage is also referred to as slow-wave sleep, and it is observed during sleep studies. Non-REM sleep has three stages: During REM sleep, the heart and respiratory rates increase. The brain is active and eyes twitch as they rapidly move back and forth. Brain activity measured during REM sleep is similar to activity during waking hours. Dreaming occurs during REM sleep, and muscles normally become limp to prevent acting out dreams. People typically experience more REM sleep as the night progresses.
- However, hot and cold environments can affect REM sleep because the body does not regulate temperature well during REM sleep. Factors that Influence Sleep What are some factors that influence sleep and wakefulness?
- medical conditions
- medications
- stress
- sleep environment
- foods and fluids consumed
- exposure to light; specialized cells in the retina process light and send messages to the brain to align the body clock with periods of day or night. Exposure to bright artificial light in the late evening can disrupt this process, making it hard to fall asleep. Factors Affecting Sleep Physical illness
- Hypertension,
- Respiratory
- Musculoskeletal
- Chronic illness
• GI
- Nausea Drugs and Substances
- Hypnotics
- Diuretics
- Narcotics
- Antidepressants
- Alcohol
- Caffeine
- Beta-blockers
- Anticonvulsants Lifestyle
- Work schedule
- Social activities
- Routines Usual Sleep Patterns
- May be disrupted by social activity or work schedule Emotional Stress
- Worries
- Physical health
- Death
- Losses Environment
- Noise
- Routines Exercise and Fatigue
- Moderate exercise and fatigue cause a restful sleep Food and Calorie Intake
- Time of day
- Caffeine
- Nicotine
- Alcohol A number of factors affect the quality and quantity of sleep. Often, several factors contribute to a sleep disorder. Physiological, psychological, and environmental factors inhibit sleep. [Box 42-4 on p. 946 presents drugs and their effects on sleep.] Sleep and Rest Rest contributes to:
- Mental relaxation
- Freedom from anxiety
- State of mental, physical, and spiritual activity Bed rest does not guarantee that a patient will feel rested.
Sleeping for only short periods due to waking up often during the night or being awake for most of the night; this is the most common symptom and typically affects older adults Waking up too early in the morning and not being able to get back to sleep Having poor-quality sleep that causes one to wake up feeling unrested, feel sleepy during the day, and have difficulty focusing on tasks. Insomnia can also cause irritability, anxiousness, and depression.
- Sleep apnea is a common sleep condition that occurs when the upper airway becomes repeatedly blocked during sleep, reducing or completely stopping airflow. If the brain does not send the signals needed to breathe, the condition may be called central sleep apnea. Sleep apnea can be caused by a person’s physical structure or other medical conditions. Risk factors include obesity (causing fat deposits in the neck), large tonsils (which narrow the airway), thyroid disorders, neuromuscular disorders, heart or kidney failure (causing fluid buildup in the neck, which narrows the airway), genetic syndromes (such as cleft lip or Down’s syndrome), and premature birth (before 37 weeks gestation).
- Common signs and symptoms of sleep apnea include the following: Reduced or absent breathing, known as apnea events Frequent loud snoring Gasping for air during sleep Excessive daytime sleepiness and fatigue Decreases in attention, vigilance, concentration, motor skills, and verbal and visuospatial memory Dry mouth or headaches when waking Sexual dysfunction or decreased libido Waking up often during the night to urinate
- Narcolepsy is an uncommon sleep disorder that causes periods of extreme daytime sleepiness and sudden, brief episodes of deep sleep during the day.
- Signs and symptoms of narcolepsy include the following: Extreme daytime sleepiness Falling asleep without warning, called sleep attacks Difficulty focusing or staying awake Waking frequently at night
- Individuals may experience hallucinations while falling asleep or waking up or sleep paralysis, a feeling of being awake but being unable to move for several minutes. Narcolepsy is diagnosed based on medical history, family history, a physical exam, and a sleep study. The sleep study looks at daytime naps to identify disturbed sleep or a quick onset of rapid eye movement (REM) sleep. Activity and Exercise Factors that influence Activity and Exercise include:
- Developmental changes across the lifespan Examples: ◦ newborn has to learn to control neck muscles ◦ a toddler’s wide stance ◦ an adolescent’s growth spurt
◦ a young adult pregnancy related changes ◦ older adult and osteoporosis or kyphosis
- Behavioral – motivation to be active?
- Environment – work, school, community opportunities
- Cultural influences
- Family and social support Design and exercise program for you! Nurse’s need to model self-care and wellness to be an effective teacher of self-care. Normal Sleep Requirements & Patterns Neonates
- 16 hours a day Infants
- 8-10 hours at night for a total of 15 hours per day Toddlers
- Total of 12 hours per day Preschoolers
- 12 hours per night School Age
- 9-10 hours Adolescents
- Get 7 ½ hours Young Adults
- 6-8 ½ hours Middle and Older Adults
- Total number of hours declines Sleep duration and quality will differ across the life span. In adolescents, shortened sleep time often results in excessive daytime sleepiness, which frequently leads to reduced performance in school, vulnerability to accidents, behavior and mood problems, and increased use of alcohol. In middle age, the amount of stage 4 sleep begins to fall—a decline that continues with advancing age.
Specimen Collection
Blood Glucose Monitoring Blood glucose monitoring is performed on patients with diabetes mellitus and other conditions that cause elevated blood sugar levels. Diabetic patients require frequent blood glucose monitoring to administer customized medication therapy to prevent long-term complications from occurring. Nasal/Oropharyngeal
