CARDIOVASCULAR
assessment findings for
FLUID VOLUME DEFICIT
Thready, increased pulse rate
Decreased BP
Orthostatic hypotension
FLAT Neck & hand veins (in dependent pos.)
Diminished PERIPHERAL pulses
DECREASED Central Venous Pressure (CVP)
Dysrhythmias
CARDIOVASCULAR
assessment findings for
FLUID VOLUME EXCESS
BOUNDING, INCREASED PULSE rate
ELEVATED BP
DISTENDED neck and hand veins
ELEVATED Central Venous Pressure (CVP)
Dysrhythmias
RESPIRATORY
assessment findings for
Fluid Volume DEFICIT
Increased RATE & DEPTH
of respirations
Dyspnea
RESPIRATORY
assessment findings for
Fluid Volume EXCESS
Increased RESPIRATORY RATE....
SHALLOW RESPIRATIONS
Dyspnea
Moist CRACKLES on auscultation
NEUROMUSCULAR
assessment findings for
Fluid Volume DEFICIT
Decreased central nervous system activity
-from LETHARGY to COMA
Fever
Skeletal Muscle WEAKNESS
NEUROMUSCULAR
assessment findings for
Fluid Volume EXCESS
Altered LOC
Headache
Visual disturbances
Skeletal Muscle weakness
Paresthesias
RENAL
assessment findings for
Fluid Volume Deficit
Decreased Urine output
RENAL
assessment findings for
Fluid Volume Deficit
Increased urine output if kidnes can compensate;
Decreased urine output if kidney damage is cause
INTEGUMENTARY
assessment findings for
FLUID VOLUME DEFICIT
Dry skin
Poor turgor, tenting
Dry mouth
INTEGUMENTARY
assessment findings for
FLUID VOLUME EXCESS
Pitting EDEMA in dependent areas
PALE, COOL skin
GI assessment findings for
FLUID VOLUME DEFICIT
DECREASED MOTILITY
DIMINISHED BOWEL SOUNDS
CONSTIPATION
THIRST
DECREASED BODY WEIGHT
GI assessment findings for
FLUID VOLUME EXCESS
INCREASED MOTILITY in GI tract
Diarrhea
INCREASED Body Weight
LIVER enlargement
Ascites (accumulation of fluid in peritoneal cavity)
LAB findings for Fluid Volume DEFICIT
INCREASE in
HCT (hematocrit)
BUN
serum SODIUM
URINE Specific Gravity
LAB findings for Fluid Volume EXCESS
DECREASE in
HCT
BUN
serum SODIUM
URINE specific Gravity
Causes of
ISOTONIC overhydration (HYPERVOLEMIA)
Inadequately controlled IV therapy
Renal Failure
Long term CORTICOSTEROID therapy
Causes of HYPERTONIC dehydration
(water loss exceeds electrolyte loss)
conditions that increase fluid loss, such as excessive perspiration
hyperventilation
ketoacidosis
prolonged fevers
diarrhea
early-stage renal failure
diabetes insipidus
Chronic Illness
Excessive hypotonic fluid replacement
Renal failure
Chronic malnutriti
Causes of HYPERTONIC overhydration
Excessive SODIUM ingestion
Rapid infusion of hypertonic saline
Early renal failure
Congestive Heart failure
inadequately controlled IV therapy
Irrigation of wounds & body cavities with hypotonic fluids
Normal SODIUM value (Na)
135-145
Serum SODIUM level of hyponatremia
< 135
Causes of HYPONATREMIA
Excessive diaphoresis
Diuretics
Vomiting
Diarrhea
Wound drainage (esp. GI)
Renal disease
Decreased secretion of aldosterone
Freshwater drowning
Hyperglycemia
Congestive Heart failure
Tx. of HYPONATREMIA
with fluid volume DEFICIT (HypOvolemia)
IV Sodium Chloride
Tx. of HYPONATREMIA
with fluid volume EXCESS (hypervolemia)
Osmotic Diuretics
S&S of HYPONATREMIA
LATE: shallow, ineffective respiratory movement r/t skeletal muscle weakness
muscle weakness in extremities
Diminished DEEP TENDON REFLEX
Headache, personality change, confusion
Increased motility & hyperactive bowel sounds
Nausea
Abdominal cramping & dia
S&S of HYPERNATREMIA
EARLY: spontaneous muscle twitches
irregular muscle contractions
LATE: skeletal muscle weakness, deep tendon
reflexes diminished
ALTERED CEREBRAL FUNCTION
(most common)
extreme thirst
Dry & STICKY tongue & mucous membranes
Serum SODIUM level of Hypernatremia
> 145
Causes of HYPERNATREMIA
Corticosteroids
Cushing's Syndrome
Renal Failure
Hyperaldosteronism
Increased sodium intake
Decreased water intake
Normal Lab value for Potassium (K)
3.5 - 5.1
Causes of HypoKalemia
Excessive use of diuretics or corticosteroids
Increased secretion of aldosterone (like in Cushing's syndrome)
Vomiting, diarrhea
Wound drainage (esp. GI)
Prolonged NOSOGASTRIC SUCTIONING
Excessive diaphoresis (sweating)
Renal disease impairing reabsorptio
Common food sources of Potassium (K)
Avacado
Banana
Cantaloupe
Carrots
Fish
Mushrooms
Oranges
Potatoes
Pork, Beef, Veal
Raisins
Spinach
Strawberries
Tomatoes
Administration of Potassium (K)
ALWAYS DILUTED & INFUSION PUMP
NEVER IV push, IM, or Sub Q
dilution of no more than 1 mEq / 10ml of solution is recommended
Infusion rate of 5 - 10 mEq / hr (never > 20)
Place on cardiac monitor
Continually assess for PHLEBITIS
Assessment findings for HypoKalemia
Thready, weak, irregular PULSE
Weak peripheral pulses
Shallow, ineffective RESPIRATIONS
Diminished BREATH sounds
Anxiety, lethargy, confusion, coma
Loss of tactile discrimination
Deep tendon HYPOreflexia
DECREASED / ABSENT bowel sounds
Assessment findings for HyperKalemia (K)
Slow, weak, irregular HEART RATE
DECREASED BP
Respiratory failure
EARLY:
MUSCLE TWITCHES, CRAMPS, paresthesias
(tingling & burning followed by numbness in the hands & feet and around the mouth)
HYPERactive BOWEL SOUNDS
ECG changes in HypOCalcemia
PROLONGED ST interval
PROLONGED QT interval
ECG changes in HYPERCalcemia
SHORTENED ST segment
WIDENED Twave
ECG changes in HypOKalemia
ST DEPRESSION
SHALLOW, FLAT, or INVERTED T wave
PROMINENT U wave
ECG changes in HYPERKalemia
TALL PEAKED T waves
FLAT P waves
WIDENED QRS complex
PROLONGED PR interval
ECG changes in HypOmagnesemia
TALL T waves
DEPRESSED ST segment
ECG changes in HYPERmagnesemia
PROLONGED PR interval
WIDENED QRS complex
Normal CALCIUM value
8.6 - 10
Contraction of facial muscles in response to a light tap over the facial nerve in front of the ear.
May indicate
HYPOCALCEMIA or HYPOMAGNESEMIA
positive CHVOSTEK'S sign
Carpal spasm induced by inflating a BP cuff
May indicate HYPOCALCEMIA or
HYPOMAGNESEMIA
TROUSSEAU'S sign
Normal Lab values for Magnesium
1.6 - 2.6
Normal Lab values for Phosphorus
2.7 - 4.5
A DECREASE in the PHOSPHORUS level is accompanied by...
an INCREASE in the CALCIUM level
An INCREASE in the PHOSPHORUS level is accompanied by...
a DECREASE in the CALCIUM level