1
Q
What is tonicity? IV fluids?
A
- measure of the effective osmotic pressure gradient of 2 solns measured by a semipermeable membrane - measured in mOsm/Liter
- fluids are:
isotonic if b/t 240-340 mOsm/L
hypotonic if less than 240
hypertonic if more than 340
2
Q
Fluid compartments in the body?
A
- intracellular:: in osmotic equilibrium in normal circumstances (28 L)
- extracellular:
intravascular: aka plasma 0 fluid contained within circ and lymphatic system (3.5 L) - interstitial: fluid that is found outside the circulatory/lymphatic system that surround tissues (10.5 L)
- 3rd space: spaces where fluid does not normally collect in large acts..CSF, joint spaces, vitreous humor, peritoneal cavity
3
Q
What are colloids?
A
- fluids containing larger MW (greater than 8000) proteins and molecules with plasma oncotic pressures similar to normal plasma proteins
- large molecules that don’t pass through cell membranes
- when infused, they remain in the intravascular compartment and expand the intravascular volume and they draw fluid from extravascular spaces via their higher oncotic pressure
- used as volume expanders:
albumin
plasma protein fraction: plasmanate
synthetic colloids: dextran, hetastarch
4
Q
What are crystalloids?
A
- fluids with molecular wt of less than 8000, and low oncotic pressure: hypotonic, isotonic, and hypertonic
- contain small molecules that flow more easily across the cell membranes, allowing for transfer from the bloodstream into the cells and body tissues
- this will increase fluid volume in both the interstitial and intravascular spaces
5
Q
Diff types of crystalloid groups?
A
- hypotonic: soln of lower osmotic pressure than blood
- isotonic: noting or pertaining to soln containing some salt concentration as blood
- hypertonic: soln higher osmotic pressure than blood
6
Q
What are hypotonic crystalloids and what will they cause? Used for? Types?
A
- soln of lower osmotic pressure than blood, osmolality less than 240 mOsm/L
- will cause fluids to leave vasculature for the interstitial ad intracellular spaces
- used for conditions causing intracellular dehydration when fluid needs to be shifted into cells such as:
hypernatremia
DKA
hyperosmolar hyperglycemic state - IV fluids:
0.45% NS (1/2 NS)
D5W (after infusing) - isotonic until infused and then body metabolizes glucose very quickly - these solns will hydrate cells although their use may deplete fluid within the circulatory system
7
Q
Types of hypotonic fluids?
A
- 0.45% NaCl (0.45% NS), 0.33% NS, 0.2 NS, and 2.5% dextrose in water
8
Q
What are the precautions when using hypotonic fluids?
A
- never give hypotonic fluids to pts with increased ICP b/c it may exacerbate cerebral edema
- don’t use solns in pts with liver disease, trauma, or burns due to potential for depleteion of intravascular fluid volume
- the decrease in vasc bed volume can worsen existing hypovolemia and hypotension and cause CV collapse
- monitor pts for signs and sxs of fluid vol deficit
- in older adult pts confusion may be an indicator of a fluid volume deficit, make sure pts know to tell you when they don’t feel right
9
Q
What are isotonic crystalloids? Types? Purpose?
A
- contain same salt concentration as blood
- doesn’t result in any significant fluid shifts across cellular or vascular membranes
- increases vascular volume
- IV fluids
0.9% NS
LRs - burn protocol
D5W (before infusion)
10
Q
What are hypertonic crystalloids? Types? purpose?
A
- soln of higher osmotic pressure than blood, greater than 340 mOsm/L.
- will draw fluids from the cells and interstitial spaces into vasculature.
- Used as volume expanders!!
- IV fluids:
7.5% NS: used for pts in critical situations of severe hyponatremia, pts with cerebral edema
D5 in 1/2 NS
dextrose 5% in NS - replaces sodium, chloride and some calories
dextrose 10%
D50
11
Q
Precautions in hypertonic solns?
A
- Should only be admin in high acuity areas with constant nursing surveillance for potentiatl complications
- maintain vigilance when admin hypertonic saline solns because of their potential for causing intravascular fluid volume overload and pulmonary edema
- Shouldn’t be given for an indefinite period of time
- Rxs for their use should state that specific hypertonic fluid to be infused, the total vol to be infused, the total volume to be infused and infusion rate, or length of time to continue the infusion
- it is better to store hypertonic NS solns apart from regular floor stock of IV fluids
12
Q
Where will D5W fluids end up?LR, NS? 7.5% saline? 5% albumin? whole blood?
A
- D5W: majority in intracellular
- NS or LR: take 100 ml out of cells, 825 ml interstitial and then 275 ml into plasma
- 7.5% saline - take out 2950 ml from intracellular, move to interstitial and plasma
- 5% albumin: 500 ml interstitial and 500 plasma
- whole blood: 1000 ml into plasma
13
Q
What is impt to remember when giving fluids?
A
- pick approp IV therapy for pt
- pt’s underlying illness, VS, serum electrolytes and a host of other variable must be considered
- trying to return or keep body in homeostasis
- Must balance all of the fluid compartments
14
Q
2 main categories of IV fluid therapy?
A
- maintenance therapy
- replacement therapy:
mechanical imbalances - hypotension due to hemorrhage, hypotension due to anesthesia, excess fluid loss due to V/D or decreased oral intake
electrolyte imbalances
15
Q
What is the primary manager of body fluid levels?
A
- kidneys
- underlying renal disease complicates things
- poor renal perfusion complicates things
16
Q
What is the most osmotically active electrolyte in the body?
A
- Na+
17
Q
What should you take note of when determining fluid status?
A
- urine output
- serum sodium
- urine osmolality (urine Na)
- edema and BP are impt but don’t replace the above!!!!
- take orthostatic vital signs
18
Q
Maintenance therapy?
A
- replaces normal ongoing losses
- usually undertaken when the individual isn’t expected to eat or drink normally for a longer time (perioperatively, or pt on a ventilator)
19
Q
What does fluid resuscitation do?
A
- corrects any existing water and electrolyte deficits
20
Q
Goal of maintenance therapy? Monitoring?
A
- goal: preserve water and electrolyte balance
- daily wts are easiest way to monitor net gain/loss of fluids
- normal serum Na+ tells you the pt has adequate water balance but not volume balance
- normal adults have obligate fluid loss of 1600 ml/day
21
Q
What is the IV fluid usually used for maintenance therapy?
A
- 0.45% NS + 20 mEq KCl
- think about how water requirement increases 100-150 ml/day for each degree fever greater than 37 C
22
Q
Goals for replacement or resuscitation therapy?
A
- goal: correct existing abnormalities in plasma and volume status
- type of fluid given is determined by type lost and current electrolytes
- generally when hypovolemia occurs - the kidneys conserve Na+ and water:
this will be seen as increased serum Na
will be seen earliest as decreased urine Na (less than 25 mEq/L) - normal BUN/creatinine ratio is 10:1, with hypovolemia this will increase to greater than 20:1
23
Q
Hypovolemia and metabolic situations?
A
- ABGs: tells you if pt is acidodic to alkalotic
- with excessive vomiting or NG suction, the pt loses H+ and may develop metabolic alkalosis and hypovolemia
- with excessive diarrhea, the pt may lose Na bicarb and may develop metabolic acidosis and hypovolemia
24
Q
What is occuring with hemorrhage or trauma?
A
- this results in loss of circulating blood, hypovolemia, and shock
- hypotension with general anesthesia isn’t due to loss of volume, it is due to loss of vascular tone
25
What is good replacement tx of hypovolemia due to decreased intake or excess excretion (sweating or hung-over)?
- 0.45% NS until labs are back
- if Na is greater than 145 change to 0.25 NS
- if Na is less than 138 cahnge to 0.9 NS
- initially run at 125 ml/hr unless hemodynamically unstable
- monitor electrolytes and vitals
- gross est. of renal perfusion is to make 30 ml/hr (minimum) urine
26
Tx for hypovolemia due to vomiting or diarrhea?
- 0.9% NS until labs are back
- if serum Na is greater than 145 change to 0.45% ns
- initially run at 125 ml/hr unless hemo unstable
- monitor electrolytes and vitals
- gross est of renal perfusion is to make 30 ml/hr urine
27
Replacement therapy for hypovolemia due to hemorrhage?
- pt will be tachycardic, tachypneic, systolic BP less than 90, pale, cool, clammy, confused, may be cyanotic
- bolus 1-2 L 0.9% NS or LR through large bore IVs until labs are back
- continue fluid resuscitation based on vital signs and urine output
- packed RBCs as soon as available: type and cross 2 units of PRBCs
- monitor electrolytes, ABGs and vitals
- gross est of renal perfusion is to make 30 ml/hr min urine
28
Tx of hypovolemia due to burns?
- bolus 1-2 L 0.9 NS or LR through large bore IVs until labs back
- continue fluid resuscitation based on vital signs and urine output
- consider albumin early to maintain pressure and limit edema
- monitor electrolytes, ABGs and vitals
- gross est of renal perfusion is to make 30 ml/hr min urine
29
What are impt parameters used to assess volume deficit?
- 1 blood pressure
- 2 urine output
- 3 JVP
- 4 urine Na concentration
30
Signs and sxs of hypovolemic shock?
- anxiety and agitation
- confusion
- rapid breathing
- low BP
- rapid pulse, often weak and thready
- cool, pale skin
- decreased or no urine output
- disturbed consciousness
- low body temp
31
Tx of severe volume depletion or hypovolemic shock?
- rapid infusion of 1-2 L of isotonic saline (0.9% NS) as rapidly as possible to restore tissue perfusion
32
Tx of mild to moderate hypovolemia?
- choose a rate that is 50-100 mL/h than est fluid losses
- calculating fluid loss as follows:
urine output = 50 ml/hr
insensible losses = 30 ml/hr
additional loss such as vomiting or diarrhea or high fever (add 100-150 ml/day for each degree of temp greater than 37)
33
When can hypervolemia occur during IV fluid admin?
-excessive parenteral infusion
-deficiences in CV or renal fluid volume regulation
- too much fluids in febrile phase
- use of hypotonic crystalloid solns
- inapprop use of FFP or platelets
- cont of IV fluids after critical phase
- comobird conditions: congenital or ischemic heart disease
chronic lung and renal disease
obesity - fluid can't be calculated for IBW
34
Signs and sxs of fluid overload?
- edema: esp in feet and ankles
- difficulty breathing while laying down
- crackles on auscultation
- high BP
- irritated cough
- JVD
- SOB
- strong, rapid pulse
35
Management of fluid overload?
- prevention is best!!
- sodium restriction
- diuretics
- dialysis
36
How do colloid solns work?
- it expands the intravascular volume by drawing fluid from the interstitial spaces into intravascular compartment through their higher oncotic pressure
- has the same effect as hypertonic crystalloids soln but it reqrs admin of less total volume and longer duration of action because the molecules remain within the intravascular space longer
- effect can last for several days if capillary wall linings are intact and working properly
37
Describe 5% albumin?
- most commonly utilized colloid solns
- contains plasma protein fractions obtained from human plasma and works to rapidly expand the plasma volume used for:
vol expansion
mod protein replacement
achievement of hemodynamic stability in shock states
- considered a blood transfusion product and requires all the same nursing precaution useed when admin other blood products
- it can be expensive and its availiability is limited to supply of human donors
38
CIs to albumin?
- severe anemia
- heart failure
- known sensitivity to albumin
- ACEI should be withheld for at least 24 hrs before admin albumin because of risk of atypical reactions such as flushing and hypotension
39
What is hydroxyethalstarches?
- another form of hypertonic synthetic colloids used for vol expansion
- contains sodium and chloride and used for hemodynamic vol replacement following major surgery and to tx major burns
- less expensive than albumin and their effects can last 24-36 hrs
40
Precautions to colloid solns?
- pt is at risk for developing fluid overload
- as for blood products use an 18 gauge or larger needle to infuse colloids
- monitor pt for signs and sxs of hypervolemia including:
increased BP
dyspnea or crackles in the lungs
edema
- closely monitor I & O
- colloid solns can interfere with platelet fxn and increase bleeding times so monitor pts coag indexes
- elevate the head of the bed unless CI
- anaphylactoid rxns are rare but potentially lethal adverse reactions to colloids. Take a careful allergy hx from pts receiving colloids (or any other drug or fluid), asking if they have ever had a rxn to an IV infusion
41
Usual IV fluid of choice?
- NS (0.9%) - isotonic
42
Only use for D5W as stand alone fluid?
- when Na is greater than 145 and pt is sx with hypernatremia
- rarely used b/c isotonic then hypotonic
43
when is LR indicated?
- isotonic, FOC for volume depletion due to trauma, burns, etc
44
When is 0.45% NS useful?
- hypotonic, useful until serum Na comes down and in maintenance
45
When is 0.25% NS used?
- hypotonic, used when serum Na is very high
46
Manifestation of pt being dehydrated?
- tachycardia, weak pulses, postural hypotension
- flushed, dry skin
- dry mucous membranes
- decreased urine output
- increased hematocrit
- increased serum sodium level
47
When is pt considered to be tilt positive?
- if he/she has change of 15 bpm with pulse AND decrease of 10 in systolic BP
48
Pt presents with fluid imbalance - first steps?
- get CBC, CMP and UA (may not get one initially)
- then start 1 L NS or RL IV over approx 1 hr
- adjust the fluid when you get the lab values
- don't stop IV until the pt can urinate
49
What is the best marker for volume status?
- urine Na+, greater than25
- pt is probably not hypovolemic if they have baseline normal renal fxn
- hypertonic salt soln may be lifesaving in pts with severe dilutional hyponatremia and in trauma pts when blood isn't readily available - rarely used
- monitor labs frequently and do daily weights/PE/ urine prod
50
When should 0.9% NS be given?
to tx low ECF, as in fluid volume deficit from:
- hemorrhage, severe vomiting, or diarrhea, heavy draining from GI suctions, fistulas, or wounds
- shock
- mild hyponatremia
- metabolic acidois (DKA)
- fluid of choice for resuscitation efforts
- Only fluid used with admin of blood products
- use cautiousy in pts with cardiac or renal disease - don't want to volume overload them
51
When should LRs be used?
- most physiologically adaptable fluid b/c electrolyte content is most closely related to composition of body's blood serum and plasma
- Another choice for first line resuscitation for certain pts, such as those with burn injuries
- used to replace GI tract fluid losses (D/V)
- fistula drainage
- fluid losses from burns or trauma
- pts experiencing acute blood loss or hypovolemia due to 3rd space fluid shifts
- LR: for metabolic acidosis
52
What patients would benefit getting the LRs instead of NS?
- pts requiring electrolye repacement (surgical or burn pts)
-
53
Cautions with LR use?
- LR metabolized in liver, converted lactate to bicarb
- don't give to pts with liver disease as they can't metabolize lactate
- use cautiously in pts with severe renal impairment b/c it contains some K+
- Shouldn't be give to pt whose pH is greater than 7.5
54
Who should you avoid IV fluids in?
- pts with ECF volume excess
55
What needs to be documented at beginning of infusion?
- baseline vital signs
- edema status
- lung sounds
- heart sounds
- monitor during and after
Nephrology
flashcards
Decks in class (15)
# Cards
-
physiology68
-
Renal Lab Eval102
-
Fluids- electrolytes60
-
Renal imaging22
-
IV fluids55
-
CKD60
-
Cystic diseases of the kidneys33
-
Renal Pharm29
-
Glomerulonephropathies44
-
Renal Neoplastic Disease52
-
Renal Health maintenance24
-
Renal ID41
-
nephrotic syndrome45
-
Acid-base disorders44
-
Acut kidney injury50
