Deck 39: Fluids, Electrolytes, Acid-Base Balance

Question 1

• Identify the major functions of sodium, potassium, calcium, magnesium, chloride, phosphate, and bicarbonate.
• What are the major concerns associated with sodium and potassium intake?
• Identify at least five potassium-rich foods.
• Identify the ideal calcium intakes for each member of the LaGuardia family (MeetYour Patients).

Answer 1

Major functions of electrolytes:
Sodium
• Maintains normal blood pressure
• Maintains normal muscle contraction
• Helps regulate blood volume
• Helps produce electrical nerve impulses.
Potassium
• Helps in muscle contraction
• Regulation of blood pressure.
• Acts in producing electrical impulses for nerve and muscles.
• Regulates heartbeat
• Acid-base balance.
Calcium
• Play a major role in teeth and bone health
• Important for blood clotting
• Assist in nerve impulse conduction
• Blood pressure stability
• Control muscle contractions
• Important for cardiac pacing
• Essential factor in clotting
Magnesium
• Plays a role in energy production
• Involved in maintaining nervous system balance
• Helps keep normal levels of potassium
• Important for DNA synthesis
Chloride
• Maintains osmotic pressure
• Vital for digestive juices
• Acts as a buffer in blood gas exchange.
• Helps in acid-base homeostasis
Phosphate
• Promotes nerve, and muscle function
• Repair of teeth, and bones
• Play a role in acid-base homeostasis
Bicarbonate
• Acts as buffer in renal mechanism for acid-base balance.
Implications of potassium and sodium intake:
Sodium. Increased sodium intake will cause water to be reabsorbed and result in extracellular fluid increase and hypertension.
Potassium. The human body needs potassium to help maintain typical fluid balance and blood pressure.
Potassium-rich foods:
• Oranges
• Bananas
• Apricots
• Carrots
• Figs
• Dates
Recommended calcium intakes for the LaGuardia family:
• 1,200 mg per day for 82 year old Martha, Jackson's mother
• 1,200 mg per day for 58 year old Gemma, Jackson's wife
• 1,000 mg per day for 60 year old Jackson
• 1,000 mg per day for 26 year old Susanna, Jackson's daughter and Jason's mother
• 270 mg per day for 8 month old Jason, Jackson's grandson.

Question 2

• Identify laboratory tests that monitor fluid, electrolyte, and acid-base balance.
• Give at least five strategies to prevent fluid and electrolyte imbalance.

Answer 2

Lab tests for monitoring fluid, acid-base balance, and electrolyte:
• Serum electrolytes. Blood is examined to measure the electrolyte content such as potassium, chloride, sodium, and bicarbonate.
• Urinalysis. Measures urine alkalinity and specific gravity.
• Urine osmolality. Measures the particle concentration in urine
• Complete blood count. Measures fluid status, hematocrit, platelet, white and red blood cells.
• Serum osmolality measures the concentration of particles in the blood
• Arterial blood gas test. This test measures the acidity in the blood.
Strategies to prevent fluid and electrolyte imbalance:
• Instruct client to drink 8 to 12 glasses of water per day. Teach the client about the importance of increasing fluid intake to meet goals.
• Teach the client to use thirst as a guide
• Limit intake of salt and sugar
• Consult a healthcare provider when the client vomits or experiences diarrhea.
• Educate client to drink water before, during, and after
• Encourage clients to drink water before, during, and after a demanding activity.
• Check the client's medical condition and medications for risk of imbalances.
• Warn clients to stay away from long-term use of laxatives.
• Record daily weight if fluid balance is excessive.
• Rapid changes in weight, decreased urine output, swelling, respiratory difficulty should be reported.
• Persuade clients to eat healthy.

Question 3

Differentiate among active and passive transport, osmosis, diffusion, and filtration.

Answer 3

Fluids and electrolytes movement:
Active transport requires energy for the motion of solutes and fluid. This happens when molecules go through cell membranes from a low to an area of high concentration.
Passive transport requires no energy, its transport systems includes:
• Osmosis is the movement of the water across the membrane from a lesser to a higher concentration.
• Diffusion is where the molecules move through cell membranes from higher to lower concentration.
• Filtration is the movement of both smaller particles and water from an area of high pressure to one of low pressure.

Question 4

Provide nursing interventions for clients with fluid, electrolyte, and acid-base imbalances.

Question 5

Based on the information you have learned about the major electrolytes of the body, which electrolytes are most likely to be out of balance in members of the LaGuardia family (MeetYour Patients)? Explain your answer.

Question 6

• What is the purpose of intravenous fluids?
• Describe the types and functions of three types of IV solutions: isotonic, hypotonic, and hypertonic.
• Under what conditions would a central venous access device be preferable to a peripheral device?

Question 7

PATIENT SITUATION
Darlene Malone, age 42, has been admitted to the emergency department with complaints of fatigue, extreme weakness, and heart palpitations. She says she has not seen a healthcare provider in nearly 10 years. Suddenly, she slumps and falls over. She is not breathing, has no pulse, and does not respond to verbal stimuli. She is resuscitated with CPR and IV epinephrine, and an endotracheal tube is placed. Stat lab results show a potassium level of 7.7 mEq/L, BUN of 102 mg/dL, and creatinine of 5 mg/dL. A physician diagnoses acute renal failure. Among other interventions, an IV is started to administer 10% calcium chloride solution, 1,000 mg, by slow IV push to counteract the toxic effects of hyperkalemia on the cell membranes. The nurse used a 20-gauge over-the-needle catheter in Ms. Malone's right cephalic vein, about 5 cm (2 in.) above her wrist.
DOING
Nursing Process (Planning Goals): Choose the NOC outcome best suited to evaluating Ms. Malone's hyperkalemia. Also choose three outcome indicators you could use to evaluate her goal achievement for that problem.

Question 8

• What factors should you consider when selecting an insertion site for a peripheral IV line?
• What are the preferred locations for peripheral IV lines?
• What equipment is needed when inserting an IV and starting an IV infusion?
• Identify three ways to regulate the flow rate of IV fluid.

Question 9

• Briefly describe the three mechanisms used to maintain pH.
• Rank in order the acid-base balance mechanisms from the most rapidly acting to the slowest acting.

Question 10

• The order reads,"5% dextrose in water/ 0.45% saline solution (D5-I/2 NS) with 20 mEq KCI; infuse I liter in 5 hours." Calculate the hourly rate and the drip rate using (I) a macrodrip administration set with I5 gtts/mL and (2) a microdrip set.
• Describe the difference between infiltration and extravasation as a complication of IV therapy.
• In general, how often are administration sets changed on peripheral IV lines? When TPN is infused?

Question 11

PATIENT SITUATION
Darlene Malone, age 42, has been admitted to the emergency department with complaints of fatigue, extreme weakness, and heart palpitations. She says she has not seen a healthcare provider in nearly 10 years. Suddenly, she slumps and falls over. She is not breathing, has no pulse, and does not respond to verbal stimuli. She is resuscitated with CPR and IV epinephrine, and an endotracheal tube is placed. Stat lab results show a potassium level of 7.7 mEq/L, BUN of 102 mg/dL, and creatinine of 5 mg/dL. A physician diagnoses acute renal failure. Among other interventions, an IV is started to administer 10% calcium chloride solution, 1,000 mg, by slow IV push to counteract the toxic effects of hyperkalemia on the cell membranes. The nurse used a 20-gauge over-the-needle catheter in Ms. Malone's right cephalic vein, about 5 cm (2 in.) above her wrist.
THINKING
Theoretical Knowledge:
a. Which lab results are abnormal? Are they high or low?
b. Which lab results directly reflect her renal failure?
c. What term correctly describes serum potassium of 7.7 mEq/L?

Question 12

Describe the body mechanisms for maintaining fluid and electrolyte balance.

Question 13

• Identify eight potential blood types.
• Describe the types of blood products that are available for transfusion.
• Identify and describe types of transfusion reactions.

Question 14

• Define solute, electrolyte, intracellular fluid, extracelular fluid, cation, and anion.
• Identify the major electrolytes in the ICF and ECF.

Question 15

Martha LaGuardia (MeetYour Patients) is taking the following medications: atenolol (Tenormin) 50 mg daily at bedtime, alendronate sodium (Fosamax) 10 mg daily, furosemide (Lasix) 20 mg every morning, and calcium carbonate 500 mg three times per day. She takes her medications regularly and sees her primary care provider monthly. Using your reference books, look up her prescribed medications. Given that Ms. LaGuardia is now experiencing nausea and vomiting, she may be at risk for developing problems and side effects related to her medications.Which medications may cause problems and what problems might they cause? Explain your rationale.

Question 16

Identify the fluid compartments within the body.

Question 17

PATIENT SITUATION
Darlene Malone, age 42, has been admitted to the emergency department with complaints of fatigue, extreme weakness, and heart palpitations. She says she has not seen a healthcare provider in nearly 10 years. Suddenly, she slumps and falls over. She is not breathing, has no pulse, and does not respond to verbal stimuli. She is resuscitated with CPR and IV epinephrine, and an endotracheal tube is placed. Stat lab results show a potassium level of 7.7 mEq/L, BUN of 102 mg/dL, and creatinine of 5 mg/dL. A physician diagnoses acute renal failure. Among other interventions, an IV is started to administer 10% calcium chloride solution, 1,000 mg, by slow IV push to counteract the toxic effects of hyperkalemia on the cell membranes. The nurse used a 20-gauge over-the-needle catheter in Ms. Malone's right cephalic vein, about 5 cm (2 in.) above her wrist.
CARING
Self-Knowledge: Ms. Malone will need dialysis to replace her inadequate renal function and control her serum potassium level. It is likely that her renal failure was brought on by years of illegal drug abuse. She has never held a full-time job and has not worked at all for the last 7 years. Her dialysis treatments will need to be paid for by Medicaid, which is funded by tax dollars. How do you feel about this-specifically, how do you feel about the issues of (a) a person's responsibility for her own health and (b) compassion for people who cannot afford to pay for healthcare? Focus on your own feelings, not on issues of what "should" be done.

Question 18

IHouck, D., Whiteford,J. (2007).Transfusion with infusion pump for peripherally inserted central catheters and other vascular access devices. Journal of Infusion Nursing, 30(6), 341-344.
In a 500-bed community hospital, policy required that blood transfusions be infused by gravity flow.This policy necessitated that a peripheral IV be initiated if the patient had a peripherally inserted central catheter (PICC). Nurses sought to show that using a PICC line with an infusion pump was safe and efficient for transfusing blood.A literature search indicated that one of the main concerns was exceeding the psi (pressure per square inch) tolerance of the catheter. Further literature review showed no increased risk of hemolysis of red blood cells when gjven via pump as compared to gravity. In the study,a total of 169 units of blood products were infused via various types of PICCs and infusion ports, some using a pump and some using gravity flow All PICC lines remained patent during transfusion and no problems with using a pump were identified.The study also revealed that nursing time decreased by 30 minutes when using a pump-the time needed to start and maintain another IV site. Cost was decreased when using a pump because of the savings in nursing time and equipment needed for a new W start. Based on the study, the policy for blood administration via PICC lines was changed.
Based on this study, how do you see nurses can affect institution policy and procedure?

Question 19

• Define deficient fluid volume and excess fluid volume.
• Identify the signs and symptoms of deficient fluid volume and excess fluid volume.
• Describe dehydration and hypervolemia.

Question 20

Based on the information presented in the MeetYour Patients scenario, rank the members of the LaGuardia family based on total body water content.
Does this information help you understand which family members were admitted to the hospital?

Question 21

Summarize the major fluid and electrolyte balance disorders.

Question 22

PATIENT SITUATION
Darlene Malone, age 42, has been admitted to the emergency department with complaints of fatigue, extreme weakness, and heart palpitations. She says she has not seen a healthcare provider in nearly 10 years. Suddenly, she slumps and falls over. She is not breathing, has no pulse, and does not respond to verbal stimuli. She is resuscitated with CPR and IV epinephrine, and an endotracheal tube is placed. Stat lab results show a potassium level of 7.7 mEq/L, BUN of 102 mg/dL, and creatinine of 5 mg/dL. A physician diagnoses acute renal failure. Among other interventions, an IV is started to administer 10% calcium chloride solution, 1,000 mg, by slow IV push to counteract the toxic effects of hyperkalemia on the cell membranes. The nurse used a 20-gauge over-the-needle catheter in Ms. Malone's right cephalic vein, about 5 cm (2 in.) above her wrist.
THINKING
Critical Thinking (Considering Alternatives):
a. What do you think is causing Ms. Malone to have hyperkalemia? You should be able to think this through and make a reasonable guess even if you have not studied pathophysiology.
b. Ms. Malone is to be given 50 mEq of sodium bicarbonate by slow IV push for an acid-base imbalance that is often associated with hyperkalemia. Which imbalance do you think would be treated with sodium bicarbonate: metabolic acidosis or metabolic alkalosis?

Question 23

What vital sign changes would you expect to find when assessing Jackson LaGuardia (MeetYour Patients)?

Question 24

Identify the appropriate mechanism: osmosis, diffusion, filtration, or active transport:
• Molecules move across a membrane to equalize concentration.
• Fluid moves across a membrane to equalize concentration.
• Molecules move against a concentration gradient.
• Molecules move to equalize pressure.

Question 25

Question 26

Describe the location and function of the major electrolytes of the body.

Question 27

Compare and contrast respiratory and metabolic acidosis and alkalosis.

Question 28

IHouck, D., Whiteford,J. (2007).Transfusion with infusion pump for peripherally inserted central catheters and other vascular access devices. Journal of Infusion Nursing, 30(6), 341-344.
In a 500-bed community hospital, policy required that blood transfusions be infused by gravity flow.This policy necessitated that a peripheral IV be initiated if the patient had a peripherally inserted central catheter (PICC). Nurses sought to show that using a PICC line with an infusion pump was safe and efficient for transfusing blood.A literature search indicated that one of the main concerns was exceeding the psi (pressure per square inch) tolerance of the catheter. Further literature review showed no increased risk of hemolysis of red blood cells when gjven via pump as compared to gravity. In the study,a total of 169 units of blood products were infused via various types of PICCs and infusion ports, some using a pump and some using gravity flow All PICC lines remained patent during transfusion and no problems with using a pump were identified.The study also revealed that nursing time decreased by 30 minutes when using a pump-the time needed to start and maintain another IV site. Cost was decreased when using a pump because of the savings in nursing time and equipment needed for a new W start. Based on the study, the policy for blood administration via PICC lines was changed.
Are there any other concerns related to infusing blood via an infusion pump that you might have,and why?

Question 29

What type of venous access device would you expect Martha LaGuardia (Meet Your Patients) to receive in the hospital? Why?

Question 30

Apply the information on fluid balance to the LaGuardia family (Meet Your Patients).What have you learned that helps you explain why some family members require hospitalization? What additional information do you need to be able to predict each person's fluid balance?

Question 31

• Identify ten physical assessment components that can be used to monitor fluid, electrolyte, and acid-base balance.
• What aspects should be evaluated in a nursing history focused on fluid, electrolyte, and acid-base balance?

Question 32

PATIENT SITUATION
Darlene Malone, age 42, has been admitted to the emergency department with complaints of fatigue, extreme weakness, and heart palpitations. She says she has not seen a healthcare provider in nearly 10 years. Suddenly, she slumps and falls over. She is not breathing, has no pulse, and does not respond to verbal stimuli. She is resuscitated with CPR and IV epinephrine, and an endotracheal tube is placed. Stat lab results show a potassium level of 7.7 mEq/L, BUN of 102 mg/dL, and creatinine of 5 mg/dL. A physician diagnoses acute renal failure. Among other interventions, an IV is started to administer 10% calcium chloride solution, 1,000 mg, by slow IV push to counteract the toxic effects of hyperkalemia on the cell membranes. The nurse used a 20-gauge over-the-needle catheter in Ms. Malone's right cephalic vein, about 5 cm (2 in.) above her wrist.
DOING
Practical Knowledge:
a. When you prepare to administer the sodium bicarbonate (in question 2b), you notice that the IV infusion is barely flowing and that the insertion site is swollen and pale. What is the first thing you should do?
b. You aspirate the catheter and do not obtain a blood return. Ms. Malone absolutely must have this medication. Describe what you would do in the order you would do it.
REFERENCE (QUESTION 2B):. Ms. Malone is to be given 50 mEq of sodium bicarbonate by slow IV push for an acid-base imbalance that is often associated with hyperkalemia. Which imbalance do you think would be treated with sodium bicarbonate: metabolic acidosis or metabolic alkalosis?

Question 33

Describe compensatory mechanisms for acid-base imbalances.