1. Chamberlain College of Nursing
Fundamentals of Nursing
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2. Homeostasis:
To maintain a stable, relatively constant condition
 Body fluids and
components in constant
motion in an effort to
maintain homeostasis
 Transporting water,
electrolytes, oxygen,
nutrients in and cell
metabolism waste or
unnecessary components
out.
 Many conditions or
diseases can disrupt
 Sweating
 Altered Fluid Intake
 Vomiting
 Diarrhea
 Diabetes
 Organ Failure
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3. Metastatic
Breast
Cancer
Decreased
Sodium
Hypercalcemia
Chemotherapy
Nausea/Vomiting
Fluid Volume
Overload
IV fluids
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4. Intake and output (et al) to be equal
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5. Water
 What it does
 Transportation of
nutrients, electrolytes and
oxygen to the cells
 Excretion of waste
products
 Regulation of body
temperature
 Lubricator, insulator, and
shock absorber of joints
and membranes
 Medium for food digestion
Water composition in
 60% in Adult
 Increased in Child
 Decreased in Older
Adult
 Found in Foods (not
ETOH)
 2000 mL-3000 mL/day
 1 liter H2O=1 kg body
weight
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6. 1 liter Weighs 1 kilogram
 Patient weighs 78
kilograms
 Has vomiting and
diarrhea
 Daily weights are
initiated
 Patient dropped to 75
kilograms
 How much fluid is he
deprived?
 78 kilograms
- 75 kilograms
_______
3 kilograms loss
3 kilogram loss:
3 kg 1 liter
1 kg
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7. Intake and Loss
Intake:
 Fluids: 1500 mL/day
 Solid Foods 800 mL/day
 Metabolism 300 mL/day
Loss:
 Kidneys 1200mL-1500
mL
 Skin 500-600 mL/day
 Lungs 400 mL/day
 GI tract 100-200 mL/day
 Drainage: ???
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8. Intake and output
 Measurable
 Intake
 Oral and tube feedings
 Parental fluids
 Enemas
 Retained irrigant
 Not Measurable:
 Solid foods
 Metabolism
 Measurable
 Urine
 Emesis
 Feces
 Drainage from body
cavity
 Not Measurable:
 Sweating
 Vaporization
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9. Electrolytes
 Chemicals dissolved in body fluid
 Distribution of electrolytes affects fluid balance
 Helps regulates intake, output, acid/base balance,
hormones
 Sodium
 Major Extra cellular electrolyte
 Controls and regulates WATER balance
 Potassium
 Major Intra cellular electrolyte
 Helps maintain intracellular water balance
 Transmits nerve impulses, muscle contraction
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10. Fluid and Electrolyte Labs
Electrolyte Normal Action
Sodium 135-145 mEq/dl Water
Potassium 3.5-4.5 mEq/dl Nerves, muscles, heart
Chloride 98-106 mmol/dl Osmotic pressure, acid
base balance
Calcium 9.0-10.5 mg/dl Nerve, heart, blood
clotting
Phosphate 3.0-4.5 mEq/dl Calcium (inverse
relationship)
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11. .25
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12. Fluid and Electrolyte : Labs
 BUN- nitrogen in the blood from urea
 Creatinine- byproduct of muscle metabolism
 Hematocrit- volume percentage of erythrocytes
 Hemoglobin- the iron containing pigment of the red blood
cells
 Urine Specific Gravity- Urine Concentration
 BMP (“Chem 7)
 (Basic Metabolic Panel)- Na+, K+, Cl-, BUN, Creatinine, CO2, Glucos
 CMP (Chem 14)
 (Comprehensive Metabolic Panel) Na+, K+, Cl-, Ca+, BUN, Creatinine, CO2,
Glucose, Liver Enzymes, (ALT, AST, Bilirubin) Alkaline Phosphatase, Total
Protein, Albumin
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13. Osmolality & Osmolarity
 Both terms refer to concentration of a solution
 Concentration creates osmotic pressure (pulling power)
 Higher concentration = greater pulling power
 Normal value 275 – 295 mOsm/L
 Osmolality
 Concentration of particles per kilogram of water
 Osmolarity
 Concentration of particles per liter of solution (not necessarily
water)
Terms often used interchangeably
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14. Two Compartments of Fluid in the
Body
 Intracellular fluid (ICF)—fluid within cells (70%)
 Extracellular fluid (ECF)—fluid outside cells (30%)
 Includes intravascular and
 interstitial fluids
 transcellular
 Think of it as 3 compartments:
 Inside the cells
 Blood & Blood vessels
 Tissue
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15. Distribution of Fluids
 Intracellular fluid (ICF) – fluid within cells (70%)
 Vital for normal cell function
 Contains oxygen, electrolytes, & glucose
 Extracellular fluid (ECF) – fluid outside cells (30%)
 Interstitial fluids – surround cell
 Intravascular fluids – plasma within vascular system
 Transcellular fluids – cerebrospinal, pericardial, pancreatic,
pleural, intraocular, biliary, peritoneal, & synovial fluid
*** To maintain proper fluid balance, the distribution of fluid
between the two compartments must remain relatively
constant.
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16. Distribution and Transport of Fluids
and Particles
Diffusion Osmosis Active Transport Filtration
Definition:
The process
where by solutes
move from an
area of higher
concentration to
an area of lower
concentration.
Molecules are
randomly vibrating
The fluid with
more particles
more concentrated
has more pulling
power.
Fluid will get pulled
across a membrane
from a more dilute
area to a more
concentrated area.
Osmolarity: The
pulling power or
concentration of
a solution.
Particles
“swimming
upstream”
*pushing*
The molecules
need a ”push” to
get across the
membrane.
Energy is required.
(ATP)
Example: Sodium-
potassium pump
Solutes can only
pass through the
capillary walls.
Membranes act as
barriers. We need
pressure to get
across.
Capillary Osmotic
Pressure
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17. Osmolarity of a Solution
Hypotonic Isotonic Hypertonic
# of particles fewer than
plasma.
A hypotonic fluid will
shift and flow into a
more concentrated
solution.
# of particles just like
plasma.
Two isotonic fluids on
different sides of a
barrier stay put!
# of particles greater than
plasma
A hypertonic fluid will
pull a less concentrated
solution into itself.
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18. Regulation of Water Balance:
Other controlsKidneys:
Juxtaglomerular
Apparatus
Kidneys:
Adrenal Cortex
Hypothalamus Heart
Sense low sodium
volume
Release renin
Converts
angiotension I to
Angiotension II
Stimulates release
of aldosterone
(RAAS)
Senses low serum
osmolarity or low
sodium
Releases
aldosterone
Reabsorbs sodium
Increases
K+excretion in to
the urine
Increases serum
osmolarity
Excretes sodium in
the urine
Senses high serum
osmolarity or high
Na+
Stimulates thirst
Triggers release of
ADH: vasopressin
Retains water in
blood
Concentrates urine
Mild constriction of
blood vessels
Decreases serum
osmolarity
Senses increased
volume : stretch
receptors in the
right atrium
Secretes ANP, BNP
Inhibits ADH
Stops RAAS
Increased
Na+excretion
through urine
stops reabsorption
of Na+
Dilates blood
vessels
Decreases serum
osmolarity
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19. Fluid Spacing
 First spacing
 Normal distribution of fluid in ICF and ECF
 Second spacing
 Abnormal accumulation of interstitial fluid (edema)
 Third spacing
 Fluid accumulation in part of body where it is not easily
exchanged with ECF
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20. Gerontologic Considerations
 Decreased body weight 45-50% instead of 60%
 Places them at higher risk for f/e imbalances
 Decreased muscle mass
 Structural changes-
 Kidneys decreased GFR, decreased renin/aldosterone
 Decreased creatinine clearance, decreased ability to
concentrate. Decreased ability to conserve water
 Loss of Subcutaneous tissue, decreased thirst,
musculoskeletal changes, mental status changes,
incontinence- leading to withholding the water to not be
incontinent, then becoming dehydrated.
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21. .50
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22. Fluid and Electrolyte Disorders
 Fluid Volume Deficit
 Fluid Volume Excess
 Hypernatremia/ Hyponatremia
 Hyperkalemia/ Hypokalemia
 Hypercalcemia/ Hypocalcemia
 Hyperphosphatemia/ Hypophosphatemia
 Hypermagnesemia/Hypomagnesemia
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23. Extracellular Fluid Volume
Imbalances
 ECF volume deficit (Hypovolemia)
 Abnormal loss of normal body fluids
 diarrhea, fistula drainage, hemorrhage
 Inadequate intake
 Access, desire, medication influence
 Plasma-to-Interstitial fluid shift
 Edema, 3rd Spacing
 Treatment: replace water and electrolytes with balanced
IV solutions
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24. Fluid Volume Deficit:
Hypovolemia or Dehydration
 Fluid Intake is less than Fluid Output:
 Hypovolemia—water and electrolyte losses about equal
 Clinical Dehydration—more water lost than electrolytes
 Fluid volume deficit + hypernatremia
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25. Causes of Fluid Volume Deficit
• Prolonged fever
• GI Losses: Watery diarrhea, Vomiting, drainage from tubes
• Loss of plasma or whole blood: Burns, Hemorrhage,
Traumas, Surgery
• Excessive sweating
• Renal failure
• Hyperglycemia
• Inability to drink or express thirst (confused)
• Concentrated tube feedings
• Third-space shifts
• Use of diuretics
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26. Fluid Deficit: Signs & Symptoms
Moderate Severe
Thirst
Dizziness
weakness
confusion
anxiety
Postural hypotension
Flushed, dry skin
Possible fever
Dry mucous membranes
Decreased urine output; dark
yellow to amber
Change in skin turgor (?)
Weight loss
HR RR BP
Lethargy progressing to coma
Dry, cracked tongue
Cold, clammy skin
delayed capillary refill
Tenting
Dark or no urine (less than 30
ml/hour)
No tears or sweat
Sunken eyeballs
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27. Lab Values
 Hypovolemia: Loss of fluids and electrolytes.
(Excessive fluid loss like hemorrhage)
 Increased Hematocrit/Hemoglobin
 Increased BUN
 Elevated specific gravity
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28. 1015
 1215
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29. Lab Values
 Dehydration
 Elevated Hematocrit
 Elevated Sodium
 Increased serum osmolality
 Urine specific gravity greater than 1.030
 We’ve lost water, but not electrolytes. More
particles, less fluid.
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30. Fluid Volume Deficit:
The Nursing Process
 Diagnoses:
 Deficient fluid volume
 Risk for imbalanced fluid volume
 Readiness for enhanced fluid balance
 Currently in balance but have many risk factors
 Goals/Outcomes:
 Restore fluid loss
 Identify patients at risk
 Maintain balance between fluid intake and output
 Prevent fluid imbalance
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31. Treatment for Fluid Volume Deficit
Replace missing fluids
 Dehydration: Oral fluids or IV
 Low sodium, hypotonic like 0.45 NS
 Why: Blood is concentrated; Na level is high
 Hypotonic solutions will draw fluid into cells and swell them
if given too quickly
 Administer gradually
 Hypovolemia: Isotonic fluids
 0.9NS or Lactated Ringer’s/blood transfusion PRN
 Why: Restore blood volume and normalize BP
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32. Nursing management: FVD
 VS
 LOC changes
 Safe environment
 I and O
 Daily weights
 Lab values
 Skin turgor and integrity
 IV access
 Urinary catheter
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33. Extracellular Fluid Volume
Imbalances
 Fluid volume excess (Hypervolemia)
 Excessive intake of fluids,
 Abnormal retention of fluids
 Congestive Heart Failure, Renal Disease, Medication
influences
 Interstitial-to-plasma fluid shift
 Treatment: remove fluid without changing electrolyte
composition or osmolality of ECF
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34. Fluid Volume Excess: Over
hydration
 Excessive retention of either just water or water and
sodium.
 s/s and treatment will be similar
 Causes:
 kidney, heart, or liver failure
 Too rapid infusion of IV fluids
 Corticosteroids
 Labs: Hemodilution: More water than particles
 Low H and H
 Low or normal Na
 Decreased serum osmolality
 Decreased BUN
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35. 1030
 1230
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36. Fluid Volume Excess:
Signs & Symptoms
 Edema
 Dependent areas first
 Face and whole body later (anasarca)
 Skin: taut, shiny
 Bounding pulse/elevated BP
 JVD: Jugular vein distention
 SOB; crackles; cough
 Weight gain
 LOC: confusion/lethargy
 Muscle cramps/weakness
 Nausea
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37. Fluid Volume Excess: Treatment
 Restrict sodium and water intake
 May give hypertonic fluids
 VS
 Respiratory status
 I and O
 Lab values
 Daily weights
 Raise HOB
 Safety and Comfort
 Meds as needed to help organ function
 Teaching and prevention
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38. Electrolytes: What are they?
 Substances that split when put in water
 Separate into IONS:
 CHARGED PARTICLES: +positive or CATIONS
-negative or ANIONS
 Found in ALL fluid compartments
 Cations are supposed to equal Anions:
 +Sodium, Potassium, Calcium, Magnesium
 -Bicarbonate, Chloride, Phosphorous
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39. Electrolytes
• Measurement:
• International standard is mill moles per liter (mmol/L)
• U.S. uses milliequivalent (mEq)
• Electrolyte Composition:
• ICF
• Prevalent cation is K+
• Prevalent anion is PO4
3
• ECF
• Prevalent cation is Na+
• Prevalent anion is Cl
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40. Major Electrolytes in Brief
 Sodium:135-145mEq/L (fluids; acid-base; nerve and muscle cells)
 Potassium:3.5-5mEq/L (fluids; cell excitability)
 Calcium: Ionized Calcium 4.5-5.5mg/dl (teeth; bones; clotting; nerve/muscle
cells)
 Magnesium: 1.5-2.5 mEq/L (nerve/muscle cells; cellular reactions)
 Chloride: 95-105mEq/L (fluids; pH and acid-base balance)
 Bicarbonate:22-26(arterial)mEq/L,24-30(venous) (acid-base balance)
 Phosphate:2.8-4.5mg/dl acid-base balance; metabolism)
Cations (+) Anions (-)
Na+ Sodium
K+ Potassium
Ca+ Calcium
Mg+ Magnesium
Cl- Chloride
HCO3
- Bicarbonate
HPO4
2- Phosphate
SO4
2- Sulfate
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41. Sodium: Hypernatremia
 NA+= >145 mEq
 (Norm: 135-145 mEq)
 Water loss or excess Na+
 Decreased Na+
excretion- renal failure,
corticosteroids
 Increased NA+ intake-
eating too much salt/
hypertonic IV fluids
 Increased water loss,
fever, infection,
hyperventilation,
sweating, diarrhea
You are “FRIED”
F-Fever
R-Restless
I-Increased fluid retention
E-Edema
D-Decreased urine output
Extreme: Mental status
change, fever, seizures
Treat the etiology-
diuretics, Na+ restriction,
avoid Na+ foods, seizure
precautions
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42. 1045
 1245
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43. Sodium: Hyponatremia
 Na+=<135 mEq
 (Norm: 135-145 mEq)
 Water excess or loss of
Sodium
 Dilution- polydipsia,
diabetes, SIADH, CHF
 Increase excretion of Na+-
sweating, diuretics, GI
wound drainage, renal
disease
 Decreased intake of Na+
NPO, low NA+ diet, severe
vomiting, diarrhea
 Symptoms
 Confusion, headache,
CNS, neurological
(BRAIN)
 Abdominal Cramps,
Nausea, vomiting
 Replace Na+ (usually IV )
 Hypertonic solution (3%
Na+ Solution)
 Fluid Restriction if
caused by fluid excess
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44. Potassium: Hyperkalemia
 >5.0 mEq
 (Norm 3.5-5 mEq)
 Major Intracellular cation
 Na+/K+ Pump- No
hormonal control
 Source: primarily diet
 Avocado, fish, bananas,
OJ, raisins, dried fruit,
meat, milk, fruits,
vegetables
 Oral supplements, IV
supplements
 Route of loss:
Kidneys/urine
Disrupts Cardiac Function-
increased cell excitability
Hyperkalemia- cause is
primarily from kidney
dysfunction
False high results:
lab inaccuracies
 Poor lab collection
practices/improper specimen
handling
 Prolonged tourniquet
 Old blood, cell destruction,
acidosis, hypoxia, exercise,
catabolic state, K+ sparing
diuretics (spironolactone)
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45. Hyperkalemia
 Symptoms
 MURDER
 M- muscle weakness
 U-Urine-oliguria, anuria
 R-Respiratory distress
 D-Decreased cardiac
contractility
 E-ECG changes
 R-Reflexes: hyperreflexia
or anreflexia
 Treatment:
 Cardiac Monitoring
 Kayexelate (oral or
rectal)
 Calcium gluconate, Lasix
 Stop K+ in IV fluids
 Avoid foods high in
potassium
 Dialysis if severe
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46. Potassium: Hypokalemia
 >3.5 mEq
 (Norm 3.5-5.0 mEq)
 Cardiac Function
(decreased excitability of
cells)
 Causes: vomiting, NG
suction, diarrhea,
diuretics, laxatives,
insulin, metabolic
alkalosis, rapid cell
building, B12 or
erythropoietin to
increase RBC
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47. Hypokalemia
 Signs/Symptoms
 Dysrhythmia, weakness,
nausea/vomiting,
paralytic ileus,
constipation, decreased
blood pressure, weak
pulse, increase digoxin,
muscle weakness,
paralysis, diuresis
 Treatment
 Cardiac Monitor
 Foods high in potassium
 Watch for digoxin
toxicity
 Potassium IV only if
good output
 Spironolactone
 Treat constipation
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48. Potassium Intravenous
Supplements
 Must have adequate
urine output (at least
600 mL/Day)
 Never IV push- cardiac
arrest potential
 Cardiac Monitor
 Assess IV site often- Very
irritating- prefer CVC
 Always dilute- no more
than 20 mEq/hr; no
more than 40 mEq in IV
bag
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49. 1100
 100
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50. Hypercalcemia
 >10.5 mg
 (Norm 9.0-10.5 mg)
 Bones- primary source
 Affects transmission of
nerve impulses, heart
and muscle contractions,
blood clotting, formation
of teeth and bones
 Must have Vitamin D to
absorb
 Dietary intake GI
absorption
 Parathyroid hormone-
 causes Ca+ to increase
Ca+ to release from
bones and increase
Vitamin D
 Decrease kidney
excretion of Ca+
Calcitonin decreases
calcium absorption,
inhibits bone
reabsorption
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51. Hypercalcemia
 Hypercalcemia
 Nausea, constipation
 Cardiac Arrest
 Decreased excitability,
tetany, increased heart,
interrupts muscle cell
 Prolonged
immobilization, renal
failure
 Lethargy, confusion,
sever muscle weakness,
fractures, kidney stones,
increased clotting time
 Treatment:
 Get rid of calcium, Lasix,
 Hydration 3-
4000mL/day,
 weight bearing activity
 NO antacids
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52. Hypocalcemia
 <9.0 mg
 (Norm 9.0-10.5 mg)
 Removal of parathyroid,
immobility,
malabsorption, renal
failure post menopausal
 Treatment:
 Calcium supplements,
diet increase Calcium
with Vitamin D
supplement
 Biggest risk: Thyroid
surgery
 Signs/Symptoms: CATS
 C- Convulsion
 A-Arrhythmias
 T- Tetany
 S- Spasms/Stridor
 Trousseaus-
Carpal/pedal spasms
 Chvostec’s sign- facial
nerve
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53. fe66; IV 96 53

54. Phosphate 3.0-4.5 mEq
 Hyperphosphatemia
 Cause: renal failure,
tumors, lysis syndrome,
 s/s- Calcium deposits in
joints, skin, kidneys, eyes,
hypocalcemia, tetany,
neuromuscular irritability
 Treatment: Correct
Hypocalcemia (inverse
relationship)
 Hypophosphatemia
 Cause: malnutrition,
malabsorption, alcohol
abuse, too many antacids
 s/s- CNS depression,
confusion, muscle
weakness, dysrhythmias,
fractures
 Treatment: oral
supplements, decrease
calcium intake, IV
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55. Magnesium 1.3-2.1 mEq
 Hypermagnesemia
 Cause: increased intake,
MOM, Maalox, Chronic
kidney disease
 s/s lethargy,
nausea/vomiting, loss of
deep tendon reflexes,
respiratory/cardiac
arrest
 Treatment: avoid
magnesium containing
foods/drugs, dialysis if
severe
 Hypomagnesemia
 Cause: prolonged
fasting, starvation,
alcohol abuse,
 s/s increased deep
tendon reflexes,
confusion, tremors,
seizures, cardiac changes
 Treatment oral
supplements, increased
green vegetables, nuts,
bananas oranges, peanut
butter, chocolate
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56. 1115
 115
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57. Electrolytes: Food sources
 Sodium
 Table salt/processed and canned foods/deli
 Potassium
 Bananas/citrus/melon/apricots/broccoli/potatoes
 Magnesium
 Grains/beans/green leafy veg/seafood/meat/chocolate
 Calcium
 dairy
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58. Administering Medications
 Mineral-electrolyte preparations
 often powders dissolved in water or juice
 diluted so they don’t taste so bad and don’t irritate the
stomach
 Sudden hyperkalemia can cause cardiac arrest
 POTASSIUM GIVEN IV PUSH IS LETHAL
(Never, never, never do this !!!)
 Diuretics
 Rid body of excess fluid (and electrolytes!)
 Must be monitored closely to prevent further imbalances.
 Intravenous therapy
 Use appropriate solutions
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59. Acid-Base Balance
 Chemical balance in the body is regulated by acidity or
alkalinity, which is measured by the pH value
 Arterial Blood Gas (ABG) analysis is the best way to
evaluate acid-base balance and oxygenation
 Our body must maintain a delicate balance between
acidity and alkalinity in order for life to be maintained
 Common Health problems which lead to imbalance
 Diabetes mellitus
 Vomiting and diarrhea
 Respiratory conditions
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60. Acid–Base Balance: Where’s the hydrogen?
 Our acidity defines us. It’s a delicate balance,
without which life cannot be supported. All our
internal chemical reactions can only take place
within the right acid-base environment.
 Acid
 substance that releases H+ ion when dissolved in water
 Base
 substance that will bind with H+ ion when dissolved in
water
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61. pH
 Normal values 7.35-7.45
 Compatible with life 6.8 - 8.0
 Body fluids maintained normal values by:
 Buffers, Respiratory system, Renal system
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62. ABG’s: Measuring acid-base
 pH 7.35-7.45
 Hydrogen ion concentration
 PaCO2: 35-45mmHG
 Arterial carbon dioxide- Carbonic Acid
 HCO3: 22-26mEq/L
 Bicarbonate
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63. 1130
 130
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64. Causes of Acid-Base Balance
Metabolic Acidosis
Diabetic ketoacidosis
Diarrhea
Renal failure
Shock
Aspirin overdose
Sepsis
Metabolic Alkalosis
Loss of gastric secretions
Overuse of antacids
K+ wasting diuretics
Respiratory Acidosis
Hypoventilation
COPD
Airway obstruction
Drug overdose
Chest trauma
Pulmonary edema
Neuromuscular disease
Respiratory Alkalosis
Hyperventilation
Hypoxia
Anxiety
High altitude
Pregnancy
Fever
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65. Acid/Base Compensation
 Lungs
 eliminates or retains
carbonic acid
 Very fast/efficient to
respond to change
 Alters rate/depth of
respirations
 Faster rate/more
depth - eliminates
CO2 and pH rises
 Slower rate/less depth
retains CO2 and pH
lowers
 Kidneys
 Regulate by selectively
excreting or conserving
bicarbonate and hydrogen
ions
 Slower to respond to
change
 Takes hours to days to
restore H+ ion
concentration.
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66. Let’s Practice …
Mr. Lowery, 54, suffered an acute anterior wall MI and
is now in cardiogenic shock. ABGs show:
pH: 7.27
PaCO2: 38
HCO3
- : 14
What is his acid/base status ???
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67. fe66; IV 96 67

68. fe66; IV 96 68

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70. Rationales and objectives of
parenteral therapy
 Maintenance therapy for daily body requirements
 Replacement therapy for present losses
 Restoration therapy for concurrent or continuing
losses:
 Hemorrhage
 Low Platelets
 Vomiting
 Diarrhea
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71. Intravenous Therapy
 Delivery method considerations
 Purpose of therapy
 Length of time the infusion is to run
 Diagnosis, age, and health history
 Type of solution used or what drugs are being
administered
 Condition of veins
 Peripheral lines vs. Central lines vs. Ports
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72. General Guidelines/Short
Peripheral Catheters
 Short Peripheral Catheter:
 Use the smallest size catheter to accommodate therapy
Size of Catheter Use
14-16 gauge Trauma, large volume at a rapid rate
18 gauge Surgical patient, rapid administration of
fluids and blood products
20-24 gauge Most medical/surgical patients, daily
use
22-24 gauge Older adults, small vein access
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73. General Guidelines:
Peripherally inserted central
catheter
 Major factors:
 Therapy will continue for 1 month or more
 Therapy includes administration of a vesicant infusion
or long-term antibiotic therapy
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74. Placement of Peripherally Inserted
Central Catheter (PICC)
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75. Central Lines
 Large Lumen Catheter surgically placed into a central
vein (subclavian or internal jugular)
 Used for:
 Long Term Therapy
 All IV Therapies
 Blood Draws
 Bad peripheral veins
 Large fluid volumes
 Total parenteral nutrition
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76. 1015
 1215
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77. Central Line Considerations
 Surgically placed (not PICC)
 Placement verified by x-ray (Superior Vena Cava)
 Sterile dressings and technique
 Flushing and Locking per facility policy
 Complications include: Central Line Infection,
pneumothorax, hemothorax, cardiac perforation,
 Watch for: SOB, chest pain, cough, hypotension,
tachycardia, anxiety after or during insertion
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78. Implanted Ports
 Fluid reservoir is surgically inserted in a subcutaneous
pocket(usually upper chest) with catheter via the
internal jugular or subclavian vein with the tip resting
in the superior vena cava
 All IV Therapies can be administered through the port
 Have a low infection rate
 Has cosmetic advantages
 Must use non-coring needle to access
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79. IV Solutions
Isotonic Hypotonic Hypertonic
Isotonic fluid stays
inside the bloodstream
or intravascular
compartment.
Ex:
0.9% NS
LR (contains Na+, Cl+, K+, &
Ca+ )
A hypotonic fluid will
shift and flow into a
more concentrated
solution.
Draw fluid from
vessels and move fluid
into the cells.
Ex:
D5W
0.45% NS
A hypertonic fluid will
pull a less concentrated
solution into itself.
Draw fluid out of the
cells and into the
blood
Used for panic low Na
levels (115)
Ex:
3% NS
5% NS
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80. Skills:
Administering Parenteral Fluids
 The nurse should observe for the following guidelines:
 Monitor the solution infusion rate
 Infuse the amount of prescribed solution.
 Maintain the patency of the IV catheter.
 Monitor site every 1 to 2 hours or as per policy
 During parenteral therapy, the patient’s I&O should be
recorded.
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81. Skills:
Administering Parenteral Fluids
 Intravenous Therapy/Venipuncture
 Before the procedure, assemble and make ready the
equipment.
 Assess the patient’s veins (start distally)
 Select and clean a puncture site. Follow strict aseptic
principles
 Perform venipuncture.
 Begin infusion.
 Teach the patient about the signs and symptoms of
problems and ways to perform activities while on IV
therapy. fe66; IV 96 81

82. Skills:
Administering Parenteral Fluids
 Intravenous Therapy/Venipuncture
 Intravenous Monitoring
 Patency
 A condition of being opened and unblocked
 Flow rate is ordered by the physician.
 Assess tubing for kinks or obstructions.
 Inspect and palpate the site for complications
 Assess for signs and symptoms of fluid overload.
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83. 1030
 1230
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84. Skills:
Administering Parenteral Fluids-
complications
 Intravenous Therapy/Venipuncture
 Phlebitis
 This results from mechanical irritation (the needle moving in
the vein), the low pH of some IV solutions, and highly
concentrated additives.
 Classic Signs
 Erythema, warmth, edema, and discomfort
 Applying warm compresses to the inflamed area lessens
discomfort.
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85. 2011 Recommendations of the
Infusion Nurses Society
Phlebitis Scale
Grade Clinical Criteria
0
1
2
3
4
No symptoms
Erythema at access site with or without edema
Pain at access site with erythema or edema
Pain at access site with erythema or edema plus streak
formation and palpable cord
Pain at access site with erythema and edema, streak,
palpable cord>1 inch in length & purulent drainage
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86. Infiltration Scale
Symptoms 0 1 2 3 4
Blanching    
Edema < 1 inch 1-6 inches > 6 inches >6 inches,
pitting
Cool to touch    
Pain +/- +/- 
Mild to
moderate;
numbness

Moderate to
severe;
Circulatory
impairment
Blood or
vesicant
therapy

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87. Extravasation
 Definition: seepage of IV medication into tissue
 Cause: vein has ruptured allowing vesicant to seep
into surrounding tissues
 Symptoms: swelling, redness, pain, blisters
 Extravasation kit may be used to neutralize the
damage
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88. Severed Catheter
 Catheter “broke” off an tip entered the circulatory
system
 Rare but deadly.
 Pain at site, decreased BP, weak rapid pulse, cyanosis
 Apply tourniquet above site of pain
 Notify MD stat
 Monitor and support patient
 Avoid causing by:
 Never reinserting a needle through a catheter after
withdrawing it.
 Remove catheter slow & parallel to skin
 Inspect catheter after removal
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89. Complications of IV therapy
Infection: redness, warmth, pain, hardness, fever,
purulent drainage
If infection is suspected, determine whether
culture of catheter is needed PRIOR to discontinuing
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90. 1045
 1245
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91. Skills for Administering Parenteral
Fluids
 Intravenous Therapy/Venipuncture
 Septicemia
 A systemic infection occurs from pathogens introduced into
the circulating bloodstream.
 Signs and Symptoms
 Fever, chills, prostration, pain, headache, nausea, and
vomiting
 Antibiotic therapy is vigorously initiated if blood cultures
verify a septicemia condition.
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92. Nursing care of the IV patient
 Check IV order for completeness, accuracy
 I and O and Weights
 Monitor rate of infusion (IV fluids can kill!)
 Remember the size and age of your patient (don’t overload
them!)
 Change site, dressing, tubing and solution per agency
policy (usually every 24 hours)
 Documentation:
 Date, time, site, type of catheter inserted
 Type and amount of fluid infused
 Patient’s response to therapy and teaching
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93. Blood Transfusions : Process
 Verify physician order; Obtain Consent
 Patient must have a type and cross-match blood sample performed
 Large bore catheter: 18 gauge
 Administer with 0.9% Normal Saline
 Baseline vital signs, hold and notify if abnormal
 Pre-medication may be ordered: Diphenhydramine, Acetaminophen
Double check with two RNs at patient’s bedside:
Everything must match!
 Begin transfusion slowly- watch for reactions
 Observe closely for first 15 min- Stop immediately if any sign of
reaction
 Blood may not hang longer than 4 hours
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94. Blood Transfusion Reactions
 Caused by:
 Blood incompatibility
 Allergic sensitivity
 Signs and Symptoms:
 Change in Vital Signs, fever, chills, rash, hypotension, shock
STOP TRANSFUSION
 Treatment: give Normal Saline, prepare for emergency
drugs; save tubing
 Anaphylactic Reaction is promptly treated with
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95. Skills:
Blood Transfusion Reactions
 Blood Transfusion Reactions
 If the infused blood is not compatible with the patient’s blood
type, an acute hemolytic reaction will occur.
 A transfusion reaction is an emergency. Transfusion is
stopped immediately and the reaction must be treated
intensively to reduce complications and death of patient.
 Signs and symptoms
 Statement of “not feeling right”
 Chills, fever, low back pain, pruritus, Hives/Rash,
hypotension, nausea and vomiting, decreased urine output,
hematuria, chest pain, dyspnea, shock
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96. fe66; IV 96 96