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93 Cards in this Set

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What are the electrolyte levels in extracellular fluid (ECF)?
units are mEq (millequivalents) Na - 142 K - 4 Ca - 5 Mg - 3 Cl - 103 Bicarb (HCO3) - 27 Osmolarity 280-310
What are the electrolyte levels of intracellular fluid?
units are mEq (millequivalents) Na - 10 K - 150 Mg - 40 Bicarb (HCO3) - 10 Osmolarity = 350-400
Which IV fluid is most similar to extra cellular fluid?
Lactated Ringer
Which IV fluids are hypotonic?
D5W, ½NS, D5½
Which IV fluids are hypertonic?
- Na Lactate (Sodium Lactate) and 3% saline - hardly ever used
What are some causes of isotonic dehydration?
- vomiting - diarrhea - polyuria - gastric suction (patients with either peg tube or NG tube) - hemmorrhage - fever - third-spacing (fluid in another part of their organ system)
Give some examples of third spacing?
pulmonary edema, pleural effusion, ascites, fluid in the stomach and kidney
What is the presentation of isotonic dehydration?
- dry mucous membrane - weight loss - increased BUN/Creatinine - hypotension - tachypnea - increased Serum protein - AMS - decreased skin turgor - increased hematocrit (HCT) - tachycardia - decreased BP
What is a normal BUN/Serum Creatinine ratio?
< 10
If the BUN/Serum Creatine ratio is greater than 30, what condition may this patient have?
If the BUN/Serum Creatine ratio is less than 30, what condition may this patient have?
renal dysfunction
What type of patient would you not give lactated ringers?
- patients with electrolyte imbalances (elevated potassium) - Lactated ringer has potassium in the solution (can worsen a patient with hyperkalemia)
How would you monitor a patient with isotonic dehydration?
- monitor input/output - skin turgor - level of consciousness - vital signs, BUN, CBC, electrolytes
What is the definition of isotonic overhydration?
- excessive fluid accumulation - fluid/Na+ gain in even amounts in the extracellular fluid; no shift in intracellular fluid
What are some causes of isotonic overhydration?
- patients with CHF, renal failure, or liver disease - excessive ingestion of Na+ - over administration of hypertonic IV fluids - excessive administration of saline solution enemas (given for bowel obstruction) and corticosteroids
How would a patient with isotonic overhydration present?
- polyuria - peripheral edema (specific to isotonic overhydration) - acute weight gain - distended neck veins - pleural effusion - ascities - increased BP - decreased hematocrit (HCT) due to dilution of blood
How do you treat a patient with isotonic overhydration?
- treat underlying cause - restrict fluid intake - give diuretics
How do you monitor a patient with isotonic overhydration?
- input/output - Vital Signs - Chest Xray - BUN - hematocrit (HCT)
What is the urine excretion goal for patients with isotonic overhydration?
1 mg/kg/hr
What is the serum level of potassium in mild hypokalemia? in moderate hypokalemia? in severe hypokalemia?
Mild = 3.0-3.5 mEq/L Moderate = 2.5-3.0 mEq/L Severe = < 2.5 mEq/L
What is hypokalemia?
- excessive ecretion or inadequate intake of K+ - transcellular shift ECF to ICF
What are some causes of hypokalemia?
- stress - excessive GI loss - hepatic disease - increased aldosterone - hypothyroidism - elevated ß-adrenergic activity - laxative abuse - alcoholism, - hypomagnesemia - adrenal tumors - drug induced causes
What are some drugs that can cause hypokalemia?
- diuretics - excessive insulin/glucose therapy (insulin draws potassium into the cell) - ß-adrenergic treatment - corticosteroids - amphotericin B - lithium
How would a patient with hypokalemia present?
- paresthesia (most common) - anorexia - drowsiness - nausea/vomiting - arrhythmias and EKG changes - hypotension - muscle weakness - Digoxin toxicity - leg cramps - lethargy
What labs should you get on a patient on digoxin?
K+, Serum Creatinine (because digoxin is excreted by the kidneys), and a Dig level
What is a normal Dig level?
What can happen to a patient with a high dig level and hypokalemia?
they can have arrhythmias or become comatose
What drug is given to patients who are dig toxic?
Why does hypokalemia cause dig toxicity?
- Digoxin works on Na+/K+ pump in the heart - In patients who are hypokalemic, digoxin does not have the K+ to act on, causing digoxin to accumulate
How do you treat hypokalemia?
- treatment of underlying cause - check magnesium levels for hypomagnesemia - give K+ supplements - give potassium sparring diuretics (spironolactone, triametrene), which are weak diuretics
What is the dosage for administering K+ in patients with moderate to severe hypokalemia?
20 mEq/hr or 10 mEq/30 min (as an infusion)
Why should you not give K+ IV push?
- can cause arrhythmia - can sting the skin (can be neutralized with sodium bicarb)
What is hyperkalemia?
- elevated potassium levels due to excessive amounts of K+ intake or decrease in K+ excretion - transcellular shift from intracellular fluid to extracellular fluid
What is the serum K+ level in a patient with mild hyperkalemia? moderate hyperkalemia? severe hyperkalemia?
Mild = 5.5-6.0 mEq/L Moderate = 6.1-6.9 mEq/L Severe = > 7.0 mEq/L
What are causes of hyperkalemia?
- acute or chronic renal failure (most common) - tumor lysis syndrome (TLS) - burns/tissue trauma - metabolic or lactic acidosis - drug-induced causes
What are some drugs that can cause hyperkalemia?
- potassium-sparring diuretics - ACE inhibitors - angiotensis II receptor blockers (ARBs) - NSAIDs - bactrim - heparin - pentamindine - cyclosporine - digoxin toxicity
What drugs can cause lactic acidosis?
metformin/glucophage given to a patient with a SCr > 1.5 can cause lactic acidosis
How would a patient with hyperkalemia present?
- nausea/vomiting/diarrhea - bradycardia - paresthesia - cardiac arrhythmia - EKG changes - confusion
How do you treat a patient with moderate to severe acute hyperkalemia?
- for patient with moderate to severe acute hypercalcemia give Calcium gluconate 10% IV push over 5-10 minutes - to treat acidosis: HCO3 over 5 min, repeat in 15 min, follow with IV infusion - start an insulin drip 1 unit/mL with D10W - Kayexelate (aka sodium polyesterene) 30 gm PO or 50 gm via enema (slow-acting, given for moderate hyperkalemia) - dialysis
Why can you never give calcium to patient who have digoxin toxicity?
can cause the heart to become calcified
When can you give kayexelate to patients with hyperkalemia?
with patient with moderate hyperkalemia
What is the mechanism of kayexelate and what is the dosing?
- kayexelate binds with potassium - dosing is 30 gm PO or 50 gm via enema
What are characteristics of hyponatremia?
- serum sodium less than 135 mEq/L - due excess water in extracellular fluid or decreased sodium intake - fluid shifts from ECF to ICF, causing cellular swelling
What are some signs and symptoms of hyponatremia?
- decreased skin turgor - orthostasis - nausea - malaise/headaches/confusion - cerebral edema - seizures (< 118 mEq/L) - respiratory arrest or coma - pitting edema
What are the 3 types of hyponatremia?
1. Hypovolemic 2. Euvolemic 3. Hypervolemic
What are some characteristics of hypovolemia?
- decrease in sodium and decrease in total body water (TBW) - caused by extra renal losses or renal causes
What are extrarenal causes of hypovolemic hyponatremia?
- vomiting/diarrhea - drainage tubes (peg or NG tubes) - cystic fibrosis - third spacing - pancreatitis - urine Na < 20 mEq/L
What are renal causes of hypovolemic hyponatremia?
- caused by diuretics - metabolic alkalosis - adrenal insufficiency - urine Na > 20 mEq/L
What are some characteristics of euvolemic hyponatremia?
- normal sodium, elevated total body water - overhydration if urine Na < 20 mEq/L - tumor, hypothyroidism, or SIADH (syndrome of inadequate anti-diuretic hormone) if urine Na > 20 mEq/L
What are characteristics of hypervolemic hyponatremia?
- increased Na and increased total body water (TBW) - CHF, cirrhosis, nephrosis if urine Na < 20 mEq/L - acute or chronic renal failure if urine Na > 20 mEq/L
What drugs can cause drug-induced hyponatremia?
- cisplatin (chemotherapy agent) - cyclophosphamide - morphine - vasopressin - NSAIDS - SSRIs - carbamazepine - clonidine - tricyclic antidepressants (TCAs)
What is the treatment for hypovolemic, euvolemic, and drug-induced hyponatremia?
- isotonic saline 1.5-2 mEq/L/hr until symptoms resolve - Na+ goal is 120 mEq/L - also can treat severe hyponatremia (Na < 118) can treat with 3% hypertonic saline
What precautions should you take when giving 3% hypertonic saline?
- if given too quickly, can cause central pontine demylinating disorder and can cause paralysis by damaging the cerebellum
What is the treatment of hypervolemic hyponatremia?
- 3% hypertonic saline, diuretic and fluid restriction
What are some characteristic of hypernatremia?
- serum Na > 145 mEq/L - decreased water in ECF or increased Na intake - fluid shift from ICF to ECF causing cellular shrinkage
What are signs and symptoms of hypernatremia?
- restlessness - weakness - tackycardia - flushed skin - delirium - decreased salivation - tears
What are the 3 types of hypernatremia?
1. hypovolemia - decreased Na and total body water (TBW) 2. euvolemic - normal Na and decreased TBW 3. hypervolemic - increased Na and normal TBW
What are characteristics of hypovolemic hypernatremia?
- urine Na < 20 mEq/L - can be caused by extrarenal losses in the GI tract, adrenal glands, lungs, and perspiration - can be caused by renal losses due to renal obstruction and osmotic diuresis
What types of patients are given osmotic diuresis?
- patients with increased intercranial pressure or cerebral edema
What is the treatment for hypovolemic hypernatremia?
- if extrarenal, treat with normal saline (NS), once the patient is stable, switch to ½ NS - if renal, give hypotonic saline (either ½ NS, D5W, or ½D5W), monitor Q 2-3 hrs until Na < 148 mEq/L
Give causes of entrarenal and renal losses in euvolemic hypernatremia?
- extrarenal cause would be through the skin, as in excess perspiration - renal causes include DM insipidus, head trauma, CNS malignancy, and encephalopathy
What are causes of hypervolemic hypernatremia?
- improper diet formula - hyperaldosteronism
What is the treatment of hypervolemic hypernatremia?
- loop diuretics - D5W - dialysis
What is hypocalcemia?
- serum Ca < 8 mEq/L - due to inadequate dietary intake, excessive loss of unbound and bound Ca, or abnormal PTH
What is corrected Ca formula?
Ca + [(4-alb) x 0.8] - used to correct calcium level when the albumin level is low (< 4.0) alb = measured albumin level
What are the causes of hypocalcemia?
- hypo/hypermagnessemia - chronic malabsorption syndrome - inadequate light exposure - thyroidectomy - vitamin D deficiency - acute/chronic renal failure - drug induced (furosemide, bisphosphonates, anticonvulsants (such as valproic acid or lithium)
What is a common side effect of Calcium?
severe constipation
What are some signs or symptoms of hypocalcemia?
- paresthesias - seizures - tetany - anxiety - confusion - hallucinations - EKG changes - bradycardia
What is the treatment for hypocalcemia?
1. Calcium gluconate 100-300 mg Bolus (one time shot) 2. Infusion: 0.5-2.0 mg Calcium/kg/hr 3. Ca with vitamin D (suc as Oscal) with chronic or mild-moderate hypocalcemia
Why should you give Calcium by itself when giving it IV?
- calcium can precipitate with other substances such as potassium or phosphate
What is hypercalcemia?
- elevated calcium - serum Ca > 10.5 mEq/L (critical > 15 mEq/L) - rate of Ca entry into ECF is greater than rate of renal excretion or bone resorption - usually seen with renal failure and cancer
What are some causes of hypercalcemia?
- fractures - bone metastasis (most common cause) - immobilization - drug-induced (ie thiazides, lithium , Ca supplement overuse, estrogen)
What are some signs or symptoms of hypercalcemia?
- anorexia - constipation - nausea/vomiting - polyurea - muscle weakness and cramps - bone changes (accumulation of bone/calcium in the joints) - decreased QT interval - death (usually occurs with serum Ca > 15) - acute renal failure
What is the treatment for hypercalcemia ?
- Symptomatic or life-threatening: dialysis, NS 200-300 mL/hr, lasix 80 mg IV Q 1-4 hrs. (monitor Ca drop 2-3 mg/dL/24 hr) - Calcitonin: 4 units/kg Q 12 hr - Prednisone: 40 mg/day - Bisphsphonates: Pamidronate 90 mg over 2 hr - Zolindronate (or Zometa): 4 mg/30 min.
What treatment would you give to a patient with tumor lysis syndrome or has an oncologic emergency?
pamidronate 90 mg over 2 hr
What is hypomagnesemia?
- serum Mg < 1.5 mEq/L - excessive renal excretion, GI loss of Mg, or insufficient dietary Mg)
What are signs and symptoms of hypomagnesemia?
- tachycardia - hypotension - arrhythmias - tetany - confusion - flattened T waves - slightly widened QRS complex
What are some causes of hypomagnesemia?
- malabsorption syndrome - GI loss - laxative use - hypercalcemia - chronic alcoholism - burns - DKA (tend to be acidotic) - acute pancreatitis - sepsis (can be caused by antibiotics like amphotericin B) - drug induced (cisplatin, cyclosporine, high dose steroids in immunosupressed patient or with rheumatoid arthritis)
What is the treatment for hypomagnesemia?
- Magnesium sulfate (MgSo4) 1 gm over 1 hr - MOM QID - Maalox TID - Mg Oxide QID
What do you need to treat first before trying to normalize Ca or K?
- if the patient has hypomagnesemia, treat Mg first before normalizing Ca or K
What is hypermagnesemia?
- serum Mg > 3.0 mEq/L - caused by renal failure and excessive Mg intake
What are signs and symptoms of hypermagnesemia?
- lethargy - depressed respiration - EKG changes (widen QRS, prolonged PR intervals, elevated T waves)
What is the treaetment for patients with hypermagnesemia?
- calcium chloride IV push (to antagonize effects of Mg) - CaCl 5-10 mEq IV drip
What is the serum phosphate level in hypophosphatemia?
< 3 mg/dl
What are causes of hypophsphatemia?
- decreased intestinal absorption - refeeding syndrome (reinstitution of nutrition to patients who are starved or severly malnourished) - diuretics - phosphate binders - peptic ulcer disease
What are signs and symptoms of hypophosphatemia?
- anorexia - seizures - arrhythmias - bone pain
What is the treatment of hypophosphatemia?
0.5 mmols of phosphorus/kg over 4 hr
Why should you be cautious about giving phosphorus too quickly?
- phosphorus given too quickly can cause seizures
What is the serum phosphate level in hyperphosphatemia?
> 4.5 mg/dL
What are causes of hyperphosphatemia?
- hypocalcemia - acute/chronic renal failure - hyperthyroidism - rhabdomyolysis - lactic acidosis
What are signs and symptoms of hyperphosphatemia?
- tetany - seizures - paresthesias - muscle spasm
What is the treatment of hyperphosphatemia?
antacids and phosphate binders
What drugs can cause lactic acidosis?
metformin, glucophage