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NURS 127
Megan Rohm, MNc, BSN, RN-BC
Today:
Introduce ourselves
Introduce the course
-Syllabus
• Fluids and Electrolytes
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Medical Surgical Nursing
NURS 127
Unit One Topics:
Fluids and Electrolytes
Immune System
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Unit 1
Fluid and Electrolytes
MeganRohm, BSN,RN
Acknowledgements to Elsevier
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Unit 1
Fluid and Electrolytes Objectives:
1) Explain how water balance and electrolyte balance are interdependent
2) List, describe and compare the body fluid compartments
3) Discuss active and passive transport processes and give examples of each
4) Discuss the role of specific electrolytes in maintaining homeostasis
5) Describe the cause and effect of deficits and excesses of sodium, potassium,
chloride, calcium, magnesium, & phosphorus
6) Discuss the role of the nursing process in maintaining fluid and electrolyte
balances.
7) Discuss how the very young, very old, and obese patient are at risk for fluid
volume deficit.
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Homeostasis
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Water Content of the Body
60% of body weight in adult
45% to 55% in older adult
70% to 80% in infants
Varies with gender, body mass, and
age
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Fluid Balance
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Compartments
Intracellular fluid (ICF)
_______ ______ ______cell membrane
Extracellular fluid (ECF)
Interstitial = tissue
______________________capillary membrane
Intravascular (plasma)
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Fluid Compartments of the
Body
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Extracellular Fluid (ECF)
One third of body fluid
3 major components
1) Interstitial fluid
2) Intravascular
3) Transcellular fluid
• over or across the cells
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Interstitial Component
Fluid btwn cells
Surrounds cells
Transport medium for nutrients, gases,
waste products and other substances
btwn blood and body cells
Also acts as a back up fluid reservoir
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Fluid Regulation
How does movement from space to
space occur?
Diffusion
Osmosis
Filtration
Active transport
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Fluid Regulation
Diffusion
Movement of solutes from an area of higher
concentration to an area of lower concentration in a
solution and or across a permeable membrane
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Fluid Regulation
Osmosis
Now with water.
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Osmosis VS. Diffusion
Osmosis
Low to high
Water potential
Diffusion
• High to low
• Movement of particles
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Fluid Regulation
Filtration
Water pushing against the confining
walls of a space
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Electrolytes
Substances whose molecules
dissociate into ions (charged
particles) when placed into water
Cations: positively charged
Anions: negatively charged
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Electrolyte Composition
ICF
Prevalent cation is K+
Prevalent anion is PO43-
ECF
Prevalent cation is Na+
Prevalent anion is Cl-
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Regulation of Electrolytes
Active transport
Allows molecules to move against concentration and
osmotic pressure to areas of higher concentration
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Active Transport:
Sodium–Potassium Pump
Fig. 17-5
Copyright
Copyright
© 2007,
© 2007,
2004,
2004,
2000,
2000,
Mosby,
Mosby,
Inc.,Inc.,
an affiliate
an affiliate
of Elsevier
of Elsevier
Inc. Inc.
All Rights
All Rights
Reserved.
Reserved.
Fluid Movement in Capillaries
Amount and direction of movement
determined by
Capillary hydrostatic pressure
Plasma oncotic pressure
Interstitial hydrostatic pressure
Interstitial oncotic pressure
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Fluid Exchange Between Capillary
and Tissue
Fig. 17-8
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Osmolality
Concentration of body fluids- affects
movement of fluid by osmosis.
Reflects hydration status
Measured by serum and urine
Solutes measured-mainly urea,
glucose, & sodium
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Osmolality
Serum value 280-300 mOsm/kg
Urine value 250-900 mOsm/kg
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Fluid Volume Shifts
Normally fluid shifts btwn intracellular
and extracellular compartments to
maintain equilibrium btwn spaces
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Causes of Third-Spacing
Burns
Peritonitis
Bowel obstruction
Massive bleeding into joint or cavity
Liver or renal failure
Lowered plasma proteins
Increased capillary permeability
28
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Assessment of Third-Spacing
More difficult – fluid sequestered in deeper
structures
Signs/Symptoms
Decreased urine output with adequate intake
Increased HR
Decreased BP
Increased weight
Pitting edema, ascites
29
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Phases of Third-Spacing
1. Loss phase
Lasts 48-72 hours
Symptoms of FVD
2. Reabsorption phase
Fluid gradually reabsorbed after problem subsides
FVO possible
Monitor VS, I&O, Wt, and breath sounds
31
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Treatment
Treat underlying cause if possible
Close observation of VS
Monitor I & O more frequently
Daily weights
Measure abdominal girth in ascites
Measure extremities if necessary
Monitor lab values
albumin level important 32
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Treatment Goals
Stabilized I & O
Stabilized weight
VS within normal range
Resolution of third-spacing
33
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Extracellular Fluid Volume
Imbalances
ECF volume deficit (hypovolemia)
Abnormal loss of normal body fluids
(diarrhea, fistula drainage,
hemorrhage), inadequate intake, or
plasma-to-interstitial fluid shift
Treatment: replace water and
electrolytes with balanced IV solutions
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Fluid Volume Deficit
Hypovolemia
Abnormally low volume of body fluid in intravascular
and/or interstitial compartments
Causes
Vomiting
Diarrhea
Fever
Excess sweating
Burns
Diabetes insipidus
Inadequate intake
Hemorrhage
Overuse of diuretics
Third spacing
35
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Fluid volume deficit
What happens
Output > Intake Water extracted
from ECF
• ECF hypertonic (water moves out of cell cell
dehydration) + osmotic pressure increased
(stimulates thirst preceptor in hypothalamus)
• ICF hypotonic with decreased osmotic pressure
posterior pituitary secretes more ADH
• Decreased ECF volume adrenal glands secrete
Aldosterone
36
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Signs and Symptoms
Acute weight loss
Decreased skin turgor
Oliguria
Concentrated urine
Weak, rapid pulse
Capillary filling time elongated
Decreased BP
Increased pulse
Sensations of thirst, weakness, dizziness,
muscle cramps
38
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Labs
Increased HCT
Increased BUN
Increased serum osmolality
Increased urine osmolality
Increased specific gravity
Decreased urine volume, dark color
39
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Significant Points
Dehydration – one of most common
disturbances in infants and children
Additional S/S
Sunken eyeballs
Depressed fontanels
Significant wt loss
40
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Significant Points
Older Adult
Vein filling better indicator than skin
turgor
Have additional health problems
Take various medications
May ↓ intake to prevent incontinence
41
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Nursing Management
Nursing Diagnoses
Hypovolemia
Deficient fluid volume
Decreased cardiac output
Potential complication: hypovolemic
shock
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Interventions
Major goal prevent or correct abnormal fluid
volume status before ARF occurs
Encourage fluids
IV fluids
Isotonic solutions (0.9% NS or LR) until BP
back to normal, then hypotonic (0.45% NS)
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Interventions
Monitor skin turgor
Goal:
Normal skin turgor, increased UOP with normal
specific gravity, normal VS, clear sensorium, good
oral intake of fluids, labs WNL
44
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Regulation of Water Balance
Antidieuretic Hormone (ADH)
• Hold on to water
Aldosterone
• Increases Na+ retention
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Where is a lot of this happening
in the body?
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Renal Regulation
regulating fluid and electrolyte
balance
Adjusting urine volume
• Selective reabsorption of water and
electrolytes
• Renal tubules are sites of action of ADH
and aldosterone
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Effects of Stress on
F&E Balance
Fig. 17-10
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Gastrointestinal Regulation
Oral intake accounts for most water
Small amounts of water are
eliminated by gastrointestinal tract
in feces
Diarrhea and vomiting can lead to
significant fluid and electrolyte loss
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Extracellular Fluid Volume
Imbalances
Fluid volume excess (hypervolemia)
Excessive intake of fluids, abnormal
retention of fluids (CHF), or
interstitial-to-plasma fluid shift
Treatment: remove fluid without
changing electrolyte composition or
osmolality of ECF
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Causes
Excessive isotonic or hypotonic IV
fluids
Heart failure
Renal failure- urinary
Liver failure, cirrhosis
Long-term use corticosteroids
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Signs/Symptoms
Headache, confusion, lethargy
Edema
Distended neck veins
Bounding pulse,
Polyuria
Dyspnea, crackles, pulmonary edema
Wt. Gain
Seizures, coma
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Nursing Management
Nursing Diagnoses
Hypervolemia
Excess fluid volume
Ineffective airway clearance
Risk for impaired skin integrity
Disturbed body image
Potential complications: pulmonary
edema, ascites
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Nursing Management
Nursing Implementation
I&O
Monitor cardiovascular changes
Assess respiratory status and
monitor changes
Daily weights
Skin assessment
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Nursing Management
Nursing Implementation
Neurologic function
LOC
PERLA
Voluntary movement of extremities
Muscle strength
Reflexes
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Electrolyte
Imbalances
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Electrolyte Disorders
Signs and Symptoms
Electrolyte Excess Deficit
Calcium (Ca) Hypercalcemia Hypocalcemia
Thirst Tetany
CNS deterioration Chvostek’s, Trousseau’s
Increased interstitial fluid signs
Muscle twitching
CNS changes
ECG changes
Magnesium (Mg) Hypermagnesemia Hypomagnesemia
Loss of deep tendon reflexes Hyperactive DTRs
(DTRs) CNS changes
Depression of CNS
Depression of
neuromuscular function
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Sodium
Normal 135-145 mEq/L
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Differential Assessment of
ECF Volume
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Hypernatremia
Elevated serum sodium occurring
with water loss or sodium gain
Causes hyperosmolality leading to
cellular dehydration
Primary protection is thirst from
hypothalamus
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Signs/Symptoms
Early: Generalized muscle weakness,
faintness, muscle fatigue, HA
Moderate: Confusion, thirst
Late: Edema, restlessness, thirst,
hyperreflexia, muscle twitching,
irritability, seizures, possible coma
Severe: Permanent brain damage,
hypertension, tachycardia, N & V 65
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Nursing Management
Nursing Diagnoses
Risk for injury
Potential complication: seizures and
coma leading to irreversible brain
damage
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Nursing Management
Nursing Implementation
Treat underlying cause
Free water to replace ECF volume
If oral fluids cannot be ingested, IV
solution of 5% dextrose in water or
hypotonic saline (gradual)
Diuretics
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Hyponatremia
Results from excess loss of Na containing fluids
or from water excess:
GI losses, diuretic therapy, severe renal dysfunction,
severe diaphoreses, narcotic use
Manifestations, S/S
Confusion, nausea, vomiting, seizures,
decreased BP, headache, muscle twitching,
cramps
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Nursing Management
Nursing Diagnoses
Risk for injury
Potential complication: severe
neurologic changes
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Nursing Management
Nursing Implementation
Caused by water excess
Fluid restriction is needed
Severe symptoms (seizures)
Give small amount of IV hypertonic
saline solution (3% NaCl)
Abnormal fluid loss
Fluid replacement with sodium-
containing solution
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Potassium
Normal 3.5-5.5 mEq/L
Major ICF cation
Necessary for
Transmission and conduction of nerve
and muscle impulses
Maintenance of cardiac rhythms
Acid–base balance
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Potassium
Sources
Fruits and vegetables (bananas and
oranges)
Salt substitutes
Potassium medications (PO, IV)
Stored blood
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Hyperkalemia
High serum potassium caused by
Massive intake of K
Impaired renal excretion
Shift from ICF to ECF
Common in massive cell destruction
Burn, crush injury, or tumor lysis
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Hyperkalemia
Manifestations, S/S
Weak or paralyzed skeletal muscles
ECG changes; Ventricular fibrillation
or cardiac standstill
Abdominal cramping or diarrhea
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Nursing Management
Nursing Diagnoses
Risk for injury
Potential complication:
dysrhythmias
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Nursing Management
Nursing Implementation
Eliminate oral and parenteral K
intake
Increase elimination of K (diuretics,
dialysis, Kayexalate)
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Nursing Management
Nursing Implementation
Force K from ECF to ICF by IV
insulin or sodium bicarbonate
Reverse membrane effects of
elevated ECF potassium by
administering calcium gluconate IV
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Hypokalemia
Low serum potassium caused by
Abnormal losses of K+ via the kidneys
or gastrointestinal tract
Magnesium deficiency
Metabolic alkalosis
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Hypokalemia
Manifestations
Most serious are cardiac
Skeletal muscle weakness
Weakness of respiratory muscles
Decreased gastrointestinal motility
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Nursing Management
Nursing Diagnoses
Risk for injury
Potential complication:
dysrhythmias
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Nursing Management
Nursing Implementation
KCl supplements orally or IV
Slowly
K is an irritant
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Nursing Management
Nursing Implementation
Hypertonic glucose solution
Monitor
I&Os
VS, cardiac rhythm
Muscle strength
Bowel sounds
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Calcium
Normal 4.5-5.5 mEq/L
Obtained from ingested foods
More than 99% combined with
phosphorus and concentrated in
skeletal system
• the other 1% is in ECF and soft tissues
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Calcium
Bones are readily available store
Blocks sodium transport and
stabilizes cell membrane
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Calcium
Functions
Transmission of nerve impulses
Myocardial contractions
Blood clotting
Formation of teeth and bone
Muscle contractions
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Calcium
Balance controlled by
Parathyroid hormone
Calcitonin
Vitamin D
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Hypercalcemia
High serum calcium levels caused by
Hyperparathyroidism (two thirds of
cases)
Malignancy
Vitamin D overdose
Prolonged immobilization
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Hypercalcemia
Manifestations, S/S
Decreased memory
Confusion, fatigue, coma
Anorexia, constipation
Muscle weakness, loss of muscle tone
Polyuria & predisposes to renal calculi
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Nursing Management
Nursing Diagnoses
Risk for injury
Potential complication:
dysrhythmias
death
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Nursing Management
Nursing Implementation
Excretion of Ca with loop diuretic
Hydration with isotonic saline
infusion
Synthetic calcitonin
Mobilization
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Hypocalcemia
Low serum Ca levels caused by
Decreased production of PTH
Acute pancreatitis
Multiple blood transfusions
Alkalosis
Decreased intake
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Hypocalcemia
Manifestations
Positive Trousseau’s or Chvostek’s
sign
Laryngeal stridor
Dysphagia
Tingling around the mouth or in the
extremities
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Tests for Hypocalcemia
Fig. 17-15
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Nursing Management
Nursing Diagnoses
Risk for injury
Potential complication: fracture or
respiratory arrest
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Nursing Management
Nursing Implementation
Treat cause
Oral or IV calcium supplements
Not IM to avoid local reactions
Treat pain and anxiety to prevent
hyperventilation-induced
respiratory alkalosis
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Phosphate
Primary anion in ICF
Essential to function of muscle, red
blood cells, and nervous system
Deposited with calcium for bone and
tooth structure
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Phosphate
Involved in acid–base buffering
system, ATP production, and
cellular uptake of glucose
Maintenance requires adequate
renal functioning
Essential to muscle, RBCs, and
nervous system function
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Hyperphosphatemia
High serum PO43- caused by
Acute or chronic renal failure
Chemotherapy
Excessive ingestion of phosphate or
vitamin D
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Hyperphosphatemia
Manifestations
Calcified deposition in soft tissue such
as joints, arteries, skin, kidneys, and
corneas
Neuromuscular irritability and tetany
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Hyperphosphatemia
Management
Identify and treat underlying cause
Restrict foods and fluids containing
PO43-
Adequate hydration and correction of
hypocalcemic conditions
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Hypophosphatemia
Low serum PO43- caused by
Malnourishment/malabsorption
Alcohol withdrawal
Use of phosphate-binding antacids
During parenteral nutrition with
inadequate replacement
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Hypophosphatemia
Manifestations
CNS depression
Confusion
Muscle weakness and pain
Dysrhythmias
Cardiomyopathy
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Hypophosphatemia
Management
Oral supplementation
Ingestion of foods high in PO43-
IV administration of sodium or
potassium phosphate
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Magnesium
50% to 60% contained in bone
Coenzyme in metabolism of protein
and carbohydrates
Factors that regulate calcium
balance appear to influence
magnesium balance
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Magnesium
Acts directly on myoneural junction
Important for normal cardiac
function
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Hypermagnesemia
High serum Mg caused by
Increased intake or ingestion of
products containing magnesium when
renal insufficiency or failure is present
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Hypermagnesemia
Manifestations
Lethargy or drowsiness
Nausea/vomiting
Impaired reflexes
Respiratory and cardiac arrest
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Hypermagnesemia
Management
Prevention
Emergency treatment
• IV CaCl or calcium gluconate
Fluids to promote urinary excretion
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Hypomagnesemia
Low serum Mg caused by
Prolonged fasting or starvation
Chronic alcoholism
Fluid loss from gastrointestinal tract
Prolonged parenteral nutrition without
supplementation
Diuretics
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Hypomagnesemia
Manifestations
Confusion
Hyperactive deep tendon reflexes
Tremors
Seizures
Cardiac dysrhythmias
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Hypomagnesemia
Management
Oral supplements
Increase dietary intake
Parenteral IV or IM magnesium when
severe
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IV Fluid Replacement
Purposes
1. Maintenance
• When oral intake is not adequate
2. Replacement
• When losses have occurred
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IV Fluid Reference
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IV Fluids
Hypotonic
More water than electrolytes
• Pure water lyses RBCs
Water moves from ECF to ICF by
osmosis
Usually maintenance fluids
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IV Fluids
Isotonic
Expands only ECF
No net loss or gain from ICF
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IV Fluids
Hypertonic
Initially expands and raises the osmolality of ECF
when it shifts fluids from ICF & ECF into vascular
component- expands blood volume
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Normal Saline (NS)
Isotonic
No calories
30% stays in intravascular space
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Normal Saline (NS)
Expands IV volume
Preferred fluid for immediate response
Risk for fluid overload higher
Does not change ICF volume
Blood products
Compatible with most medications
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Lactated Ringer’s
Isotonic
More similar to plasma than NS
Has less NaCl
Has K, Ca, PO43-, lactate (metabolized
to HCO3-)
Expands ECF
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Plasma Expanders
Stay in vascular space and increase
osmotic pressure
Colloids (protein solutions)
Packed RBCs
Albumin
Plasma
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.