1、UNIT IIINursing Sciences,UNIT III Nursing Sciences,Fluids and Electrolytes,Chapter 9,CRITICAL THINKING,What Should You Do?The nurse notes the presence of U waves on a clients cardiac monitor screen. What action(s) should the nurse take?,Pyramid terms,Fluid volume deficit/excess 体液不足/体液过多Homeostasis
2、内稳态Hyper- 过高Hypo- 过低E.g. Hypertension高血压Hypotension 低血压,Pyramid terms,Sodium 钠 135-145 mEq/LHypernatremia Hyponatremia Calcium 钙 8.6-10 mg/dLHypercalcemiaHypocalcemiaPotassium 钾 3.5-5.1 mEq/LHyperkalemiaHypokalemia,Pyramid terms,Magnesium 镁 1.6-2.6 mg/dLHypermagnesemiaHypomagnesemia Phosphorus 磷 2.7
3、-4.5 mg/DlHyperphosphatemiaHypophosphatemia,Properties of Electrolytes and Their Components(BOX 9-1),Atom 原子Molecule 分子Ion 离子Cation阳离子ktanAnion 阴离子,Body Fluid Compartments,Intracellular(ICF): all fluid inside the cells (70%)细胞内液Extracellular(ECF): fluid outside the cells(30%)细胞外液Interstitial细胞间液Intr
4、avascular: fluid inside a blood vessel血管内液,Third-spacing第三间隙液Disease or injuryFluid may be trapped in body spaces such as the pericardial, pleural, peritoneal, or joint cavities; the bowel; or the abdomen; or within soft tissues after trauma or burnsEdemaidim 水肿,Body Fluid,Infants and older adults n
5、eed to be monitored closely for fluid imbalances！,ICF is mostly water and is rich in K+，Mg2+，, SO4，HPO4，and protein atoms.ECF contains more Na+, Cl-, HCO3-, and Ca2+.,Blood fluid transport,Diffusion扩散 spread the molecules from an higher concentration to an area of Lower concentration.,Osmosis渗透 from
6、 a Less concentrated solute into a More concentrated solute.,Filtration过滤 from Higher hydrostatic pressure to a Lower one. Regarding to the weight.,Body fluid transport,Hydrostatic pressure静水压Osmolality渗透压,Body fluid intake and output,Homeostasis,Fluid Volume Deficit体液不足,Dehydration 脱水TypesIsotonic
7、dehydration等渗性脱水：水、钠成比例丢失Hypertonic dehydration高渗性脱水：失水为主Hypotonic dehydration低渗性脱水：失钠为主,Fluid Volume Deficit体液不足,Diminished peripheral pulseDeep respirationFeverDecrease urine outputDry skin，dry mouthThirst,TABLE 9-1 Assessment Findings: Fluid Volume Deficit and Fluid Volume,Interventions,In genera
8、l, isotonic dehydration is treated with isotonic fluid solutions, hypertonic dehydration with hypotonic fluid solutions, and hypotonic dehydration with hypertonic fluid solutions.,Fluid Volume Excess体液过多,Overhydration or fluid overload水中毒TypesIsotonic OverhydrationHypertonic OverhydrationHypotonic O
9、verhydration,Fluid Volume Excess体液过多,Overhydration or fluid overloadElevated blood pressure CVC(central venous pressure中心静脉压） Shallow respiration浅呼吸Increase or decrease urine outputPale，Cool skin,TABLE 9-1 Assessment Findings: Fluid Volume Deficit and Fluid Volume,Interventions,Administer diuretics;
10、 osmotic diuretics typically are prescribed first to prevent severe electrolyte imbalances.Monitor electrolyte values, and prepare to administer medication to treat an imbalance if present.,A client with acute kidney injury or chronic kidney disease is at high risk for fluid volume excess.,Practical
11、 questions,The nurse is assigned to care for a group of clients. On review of the clients medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?1. A client with an ileostomy2. A client with heart failure3. A client on long-term corticosteroid thera
12、py4. A client receiving frequent wound irrigations,1,The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?1. Lung congestion2. Dec
13、reased hematocrit3. Increased blood pressure4. Decreased central venous pressure (CVP),4,The nurse is assigned to care for a group of clients. On review of the clients medical records, the nurse determines that which client is at risk for fluid volume excess?1. The client taking diuretics2. The clie
14、nt with kidney disease3. The client with an ileostomy4. The client who requires gastrointestinal suctioning,2,Sodium,钠 135-145 mEq/LHypernatremia低钠血症 Hyponatremia 高钠血症,Na+,Hyponatremia and hypernatremia,Normal serum sodium level Na+ : 135-145 mEq/LCommon food sources: Box 9-2,p88Causes Assessment: T
15、able9-2.p89Intervention,Na+,Common food sources: Box 9-2,p88,Bacon熏肉Butter黄油Canned food罐头食品Cheese奶酪Frankfurters灌肠Ketchup番茄酱Lunch meat午餐肉,Milk牛奶Mustard芥菜Processed food加工食品Snack food休闲食品Soy sauce酱油Table salt食盐White and whole-wheat bread白面包和全麦面包,Na+,Hyponatremia135 mEq/L低钠血症,Causes: Diuretics利尿剂Wound d
16、rainage, especially gastrointestinalRenal disease/failureAldosterone(醛固酮）Low-salt dietExcessive ingestion of hypotonic fluids or irrigation with hypotonic fluids过度摄入低渗的液体或冲洗低渗的液体Freshwater drowning淡水淹溺Syndrome of inappropriate antidiuretic hormone(抗利尿激素)secretionHyperglycemia高血糖症Congestive heart fai
17、lure充血性心力衰竭,Na+,Hypernatremia 145mEq/L,Causes: Corticosteroids皮质类固醇Cushings syndromeRenal failureHyperaldosteronism高醛甾酮症Oral sodium ingestion/sodium-containing IV fluidsDecreased Water intake: Nothing by mouthIncreased water loss: metabolism， fever, hyperventilation换气过度, infection, excessive diaphor
18、esis, watery diarrhea, diabetes insipidus（尿崩症）,Na+,Assessment,Hyponatremia,hypernatremia,Shallow, ineffective respiratory movement浅的，无效的呼吸运动Generalized skeletal muscle weakness全身骨骼肌肉无力Headache, seizures头痛，癫痫发作Hyperactive bowel sounds肠鸣音亢进Dry mucous membranes粘膜干燥,Hypervolemia pulmonary edema肺水肿Extrem
19、e thirst极度口渴Decreased urinary output尿量减少,Na+,Intervention,Monitor cardio, renalstatusIf the client is taking lithium, hyponatremia can cause diminished lithium(锂） excretion, resulting in toxicity! monitor the lithium level!,The nurse is reviewing laboratory results and notes that a clients serum sod
20、ium level is 150 mEq/L. The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid?1. Peas2. Nuts3. Cauliflower4. Processed oat cereals,4,The nurse carin
21、g for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one clients laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level?1. The client who is taking diuretics2. The clien
22、t with hyperaldosteronism3. The client with Cushings syndrome4. The client who is taking corticosteroids,1,The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, a
23、nd diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?1. Muscle twitches2. Decreased urinary output3. Hyperactive bowel sounds4. Increased specific gravity of the urine,3,Potassium K+ 3.5-5.0 mEq/L,Comm
24、on food sources Avocado鳄梨BananasCantaloupe哈密瓜Carrots胡萝卜FishMushroomsOrangesPotatoesPork, beef, vealRaisins葡萄干Spinach菠菜StrawberriesTomatoes,Hypokalemia - 5.1mEq/L 高钾血症 Major cause : Renal failure；Addisons disease,K+,Potassium is never administered by IV push, intramuscular, or subcutaneous routes.严禁通
25、过静脉推注、肌肉注射或皮下补钾。IV potassium is always diluted and administered using and infusion device.通过静脉补钾时必须稀释！,K+,ECT Changes in Electrolyte Imbalances,The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which food
26、s? Select all that apply.1. Peas2. Raisins3. Potatoes4. Cantaloupe5. Cauliflower6. Strawberries,2/3/4/6,The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the clients record and determines that the client was at risk for developing the potassium deficit because o
27、f which situation?1. Sustained tissue damage2. Requires nasogastric suction3. Has a history of Addisons disease4. Is taking a potassium-retaining diuretic,2,The nurse reviews a clients electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L. Which pattern would the nurse note o
28、n the electrocardiogram as a result of the laboratory value?1. U waves2. Absent P waves3. Elevated T waves4. Elevated ST segment,1,The nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student i
29、s unprepared for this procedure if the student states that which action is part of the plan for preparation and administration of the potassium?1. Obtaining an intravenous (IV) infusion pump2. Monitoring urine output during administration3. Preparing the medication for bolus administration4. Ensurin
30、g that the medication is diluted in the appropriate amount of normal saline,3,Hypocalcium - 10mg/dLAssessment findings: Absent deep tendon reflex,Ca2+,Hypocalcemia and hypercalcemia,Serum calcium level: 8.6-10 mg/dLCommon food sources: box 9-5,p92Causes Assessment: Table 9-5,p93Intervention,Ca2+,Cau
31、ses of hypocalcemia,Lactose intolerance乳糖不耐症Malabsorption吸收不良syndromes: celiac sprue乳糜泻or Crohns disease克罗恩病End-stage renal diseaseRenal failure, polyuric phaseDiarrheaSteatorrhea脂肪痢Wound drainage, especially gastrointestinal,Ca2+,Causes of hypocalcemia Cont.,Hyperproteinemia高蛋白血症Alkalosis碱中毒Medicat
32、ions such as calcium chelators螯合剂or binders粘结剂Acute pancreatitis急性胰腺炎Hyperphosphatemia高磷酸盐血症ImmobilityRemoval or destruction of the parathyroid glands甲状旁腺,Ca2+,Causes of hypercalcemia,Oral intake of calcium/vitamin DRenal failureUse of thiazide diuretics噻嗪利尿剂 Hyperparathyroidism甲状旁腺机能亢进Hyperthyroidi
33、sm甲状腺机能亢进Malignancy恶性（肿瘤等）Glucocorticoids糖皮质激素Adrenal insufficiency肾上腺机能不全,Ca2+,Interventions,Vitamin DHypo: initiate seizure precautionsMonitor for hypercalcemiaPathological fractureMove the client carefully and slowly Assist the client with ambulation,Ca2+,The nurse is assessing a client with a su
34、spected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?1. Twitching2. Hypoactive bowel sounds3. Negative Trousseaus sign4. Hypoactive deep tendon reflexes,.The nurse caring for a client with hypocalcemia would expect to note which change on the e
35、lectrocardiogram (ECG)?1. Widened T wave2. Prominent U wave3. Prolonged QT interval4. Shortened ST segment,Hypomagnesemia - 2.6mg/dL,Mg2+,Hypophosphatemia - 4.5 mg/dL,Hypophosphatemia and hyperphosphatemia,Serum phosphorus level: 2.7-4.5 mg/dLCommon food sources: box 9-7,p95Causes AssessmentInterven
36、tion,Causes of hypophosphatemia,Intake :malnutrition and starvationExcretion :hyperparathyroidism（甲状旁腺功能亢进）, malignancy（恶性肿瘤）, magnesium-based antacids（抗酸剂）Hyperglycemia（高血糖）Respiratory alkalosis（呼吸性碱中毒）,Causes of hyperphosphatemia,Renal failureTumor lysis syndrome肿瘤溶解综合征Intake :dietary, phosphorus-
37、containing laxatives（泻剂） or enemas（灌肠）Hypoparathyroidism 甲状旁腺功能减退,The nurse reviews a clients laboratory report and notes that the clients serum phosphorus level is 2 mg/dL. Which condition most likely caused this serum phosphorus level?1. Alcoholism2. Renal insufficiency3. Hypoparathyroidism4. Tumo
38、r lysis syndrome,CRITICAL THINKING,What Should You Do?The nurse notes the presence of U waves on a clients cardiac monitor screen. What action(s) should the nurse take?,AnswerCardiac changes in hypokalemia include impaired repolarization, resulting in a flattening of the T wave and eventually the em
39、ergence of a U wave. Therefore, the nurse should suspect hypokalemia. The incidence of potentially lethal ventricular dysrhythmias is increased in hypokalemia. The nurse should immediately assess the clients vital signs and cardiac status and for signs of hypokalemia. The nurse should also check the clients most recent serum potassium level and then contact the health care provider to report the findings and obtain prescriptions to treat the hypokalemic state.,
