I & O Conversions

1 cup = 240 ml 1 tsp = 5 ml 1 tbs = 15 ml (3 tsp) 1 oz = 30 ml 1 gr = 60 ml 1 kg = 2.2 lbs 1 inch = 2.54 cm

Serum Electrolyte Normal Values

Magnesium Phosphate Potassium Calcium Calcium Chloride Sodium

1.5 - 2.5 2.5 - 4.5 3.5 - 5.0 4.5-5.5 (ionized) 8.5 10.5 (total) 95 108 135 - 154

pH pCO2 Normal Blood Gases

7.35 7.45 35 45

HCO3 22 26 PO2 80 - 100

270 320 Osmolarity <270 = hypotonic (enters cells) >320 = hypertonic (exits cells)

Normal Adult Vital Signs

BP: 110-120/ 60-80 (140/90 = hypertension) HR: 60 -100 RR: 12 20 Temp: (axillary): 97.6 (oral): 98.6 (rectal): 99.6

BP: HR: RR: Normal Newborn Vital Signs

65/41 120 160 (180 when crying) 30 - 60

Normal 1-4 Years Vital Signs

BP: 90-100/ 60-65 HR: 80 140 RR: 20 - 40

Normal 5-12 Years Vital Signs

BP: HR: RR:

100-110/ 55-60 70 115 15 - 25

Symptoms: BP, HR (bounding pulse), Resp, CVP, confusion, muscle weakness, distended neck veins, peripheral edema, lung crackles, DECREASED lab values, low specific gravity. Fluid Volume Excess Causes: CHF, renal failure, burns, excessive Na+, liver cirrhosis. Implementation: Diuretics, fluid restriction, ambulate, high flowlers, breath sounds

Symptoms: BP (orthostatic hypotension), CVP, rapid/weak pulse, Resp, HA, confusion, tachycardia, dizziness, weakness, oliguria, poor turgor (cool & moist), flat neck veins in dependent position, INCREASED lab values, high specific gravity. Fluid Volume Deficit Causes: V/D, suctioning, diuretics, diabetes insipidus, diabetic ketoacidosis, third spacing, hemorrhage. Implementation: Isotonic solution *The higher the hematocrit and specific gravity, the dryer they are high and dry . *Main extracellular ion that regulates fluid balance.

SODIUM

*similar to fluid balance deficit Symptoms: Hypotension, tachycardia, deep tendon reflex, twitching, edema, oliguria, dillusions. Hypernatremia Causes: Fluid loss, increase Na+, renal failure, hypertonic fluids, diabetes insipidus, burns, fever, Cushings syndrome (increased secretion of aldosterone, which increases Na+ reabsorption). Implementation: Hypotonic solution to shift Na+ into cells, decrease sodium in diet. Symptoms: BP, HR (thread pulse), deep tendon reflex, twitching, headache ( ICP), confusion, muscle weakness. Causes: V/D, tap enemas, excessive admin of dextrose and water IVs, excessive water intake, NG suction, diuretics, burns, renal disease, Addison s (decrease secretion of aldosterone, which decreases Na+ reabsorption). Implementation: Oral admin, water restriction. If combined with fluid volume deficit, IV sodium choride is administered. If combined with fluid volume excess, osmotic diuretics given to excrete water rather than

Hyponatremia

sodium. *precipitates LITHIUM toxicity!!!

Symptoms: Excessive UOP (inability to concentrate urine, so it stays in blood), chronic severe dehydration, excessive thirst, weakness, constipation, wt. loss. Diabetes Insipidus (Decrease in ADH posterior pituitary) Causes: head trauma, brain tumor, meningitis, encephalitis (tumors that hypersecrete), high serum sodium, low specific gravity and plasma osmolality (water is not being reabsorbed into the plasma getting lost in urine). Implementation: Administer Vasopressin (Pitressin) causes venous constriction to preserve H2O loss. Acts like hyponatremia: Onconologic Emergency (brain oncology patients suffer from this) Symptoms: N/V, anorexia, tachycardia, HA, lethargy, change in LOC, in DTR, blood volume, UOP, edema not seen (all water reabsorbed into plasma bloodstream) Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) (Increase in ADH posterior pituitary) Causes: tumors that hypersecrete (small cell carcinoma of lung, brain tumors), head trauma, stroke, meningitis, encephalitis, pneumonia, positive pressure ventilation, plasma osmolality (concentration), specific gravity (H2O not lost in urine, all being reabsorbed), serum sodium (115-120). Implementation: FIRST restrict H2O intake (500ml/24hr), hypertonic saline (pull fluid out of cells), administer demeclycline (Declomycin) side effect is to induce diabetes insipidus

Main intracellular ion. Involved in cardiac rhythm and nerve transmission.

POTASSIUM

Symptoms: BP, HR (weak, irregular), resp. depression, twitches, weakness, parathesias, diarrhea, increased GI motility. Causes: Renal failure, cellular destruction (burns, trauma) diabetic ketoacidosis, hyperglycemia, Addisons. Hyperkalemia Implementation: Administer loop diuretics, Kayexalate (diarrhea inducer), dialysis. In emergency: Calcium gluconate, sodium bicarbonate, regular insulin & dextrose (shifts K+ into cells). ECG: Tall, peaked T waves; Flat P waves; widened QRS; prolonged PR interval. Symptoms: BP, HR (thready, irregular), shallow respirations (failure), muscle weakness, confusion, polyuria, GI mobility, dysrhythmias, DT hyporeflexia. Causes: D/V, NG suction, diuretics or corticosteroids, diaphoresis, wounds, metabolic alkalosis, Cushings. Hypokalemia Implementation: Increase dietary intake, supplements IV (can t give >40mEq/L into periph IV or without cardiac monitor) ECG: ST depression, inverted/flat T wave, prominent U wave. *Hypokalemia may precipitate Digitalis toxicity.

Potassium Administration

CALCIUM

Oral K+- (can cause nausea or vomiting, shouldn t be taken on empty stomach). IV K+ - infusion must be controlled. Liquid form K+ has unpleasant taste. Points about administering K+: Never given by IV push or IM or SQ route. Dilution of no more than 1 mEq/L of K+ to 10 ml of IV solution is recommended. Recommended infusion rate = 5-10 mEq/Hr. Should NEVER exceed >20 mEq/Hr. K+ infusion can cause phlebitis. Assess site frequently. *Functions in bone formation, blood clotting, nerve impulse transmission and contraction of myocardial and skeletal muscle. *Regulated by the parathyroid hormone (parathyroid gland) & Vitamin D (also activated by the PTH). *When serum phosphorus levels decrease, serum calcium levels increase and vice versa. So hypocalcemia acts like hyperphosphatemia. *Sedative effect on NS Symptoms: Confusion, Muscle weakness, lack of coordination, Depressed deep tendon reflexes, Constipation, ECG Changes dysrhythmias, GI Motility.

Hypercalcemia

Causes: Hyperparathyroidism, Malignant neoplastic disease, Immobility, Excessive intake of calcium carbonate antacids. Implementation: Foods low in calcium, high in phosphorus. Fluids, Lasix, Calcitonin (to decrease Ca+ level), Mobilize patient, Maintain acidic urine ECG: Shortened ST segment, Widened T wave. *NS becomes excitable Symptoms: BP, HR, Confusion, Tetany, dysrhythmias, Seizures, Positive Trousseau and Chvostek signs, Parathesia (tingling, numbness), hyperactive DTR, anxiety, irritable, GI motility.

Hypocalcemia Causes: Hypoparathyroidism, Pancreatitis, Renal Failure, Steroids & Loop diuretics, Post-thyroid surgery, Malabsorption (Crohn s), Immobility Implementation: Foods high in calcium and low in phosphorus. Calcium gluconate or calcium chloride

(administer with OJ to maximize absorption). USE CAUSIOUSLY with digitalis patients (b/c both are cardiac depressants). Administer phosphate-binding antacids = calcitrol, Vitamin D. ECG: Prolonged ST and QT intervals.

*Used as an index to determine metabolic activity and renal function. MAGNESIUM *Needed in blood clotting, regulates neuromuscular activity, effects metabolism of calcium. *Magnesium acts as a depressant. Think Deep Tendon Reflexes. It is a smooth muscle relaxant (diaphragm & bladder) Symptoms: Depresses the CNS, hypotension, depresses cardiac impulse transmission, shallow respirations, muscle weakness, absent DTR, drowsiness, lethargy. Hypermagnesemia Causes: Renal failure, antacids or cathartics (excellerates defication mag citrate, mag sulfate, maalox). Implementation: Administer calcium gluconate ECG: Prolonged PR, widened QRS. Symptoms: Tremors, tetany, (positive trousseaus and chvostek) seizures, dysthythmias, confusion, dysphagia, irritable, confusion. Causes: V/D, alcoholism, GI suction, abuse of laxatives. Hypomagnesemia Implementation: Dietary, IV mag sulfate ECG: Tall T waves, depressed ST *Low mag potentiates Digitalis toxicity.

SKINNY (hypoglycemic) = add hormones Hyperkalemia, Hyponatremia Addison s Disease (Adrenal insufficiency = hyposecretion of adrenal hormones (mineralcorticods: Aldosterone -regulates the amounts of Na+ absorbed by the kidneys; glucocorticoids, androgens) Symptoms: BP, wt. loss, weakness, orthostatic hypotension, hyperpigmentation, alopecia. Diagnosis: Na+ = dehydration, Blood volume = shock, blood sugar = insulin shock, K+ = metabolic acidosis & arrhythmias. Implementation: High protein, carb, sodium and low potassium diet. Hormone replacement. Symptoms: N/V, fever, abdominal pain, muscular weakness, fatigue, severe hypoglycemia, hyperkalemia and dehydration. BP drops, leading to shock and coma. Interventions: Administer Hydrocortisone Isotonic fluids, IV glucose, Kayexalate.

Addisoninan Crisis

FAT (hyperglycemic) Hypokalemia, Hypernatremia Symptoms: BP, muscle wasting, cramps, edema, purple skin striations, hirtuism, moon face, buffalo hump, retain Na+ and fluid, immunosuppressed, obesity (trunk), thin extremities with bruising, mood swings, female masculinization. Diagnosis: Na+, blood volume ( BP), blood sugar = ketoacidosis, K+ = metabolic alkalosis. Implementation: Hypophysectomy (removal of the pituitary gland), adrenalectomy (removal of the adrenal gland). High protein, potassium and Low sodium diet. Low calaries, fluid restriction. Administer aminoglutethimide and metyrapone to decrease cortisol production.

Cushings Disease (Adrenal insufficiency (hypersecretion) = Aldosterone (regulates the amounts of Na+ absorbed by the kidneys)

Male: Female: Child: Red Blood Cells

4.5 6.2 million/mm3 4.0 5.5 million/ mm3 3.2 5.2 million/mm3

Normal: 150,000 400,000 Platelets Low = thrombocytopenia (bleeding precautions)

Normal: 4,500 11,0000 WBC Low = immune compromised High = infection

Hemoglobin

Male: 14 18 g/dL Female: 12 16 g/dL Child: 11 12.5 g/dL *Vehicle for transporting O2 and CO2. Determines anemia s.

Hematocrit

Male: 42 52% Female: 35 47% Child: 35 45% *Represents RBC mass, identifies anemia or polycythemia.

Normal: 8 15 minutes Clotting Time

Bleeding Time

Normal: 1.5 9.5 minutes

Used to monitor response to Warfarin (Coumadin) Control: 9.5 12 seconds Prothrombin Time (PT) Warfarin should maintain the PT at 1.5 2 times the control (14 24). *If PT time > 30 seconds, initiate bleeding precautions. *Diets high in green leafy veggies can increase Vitamin K, which shortens the PT.

Used to monitor response to Warfarin (Coumadin) Control: International Normalized Ratio (INR) Warfarin should maintain the PT at 1.5 2 times the control (2 - 4). 1-3 for standard Warfarin therapy 2.5 4 for high-dose therapy (heart valves)

Used to monitor response to Heparin therapy Lower Limit: 20 25 seconds Upper Limit: 32- 40 seconds Partial Thromboplastin Time (PTT) Heparin should maintain the PTT 1.5 2.5 times the control (30 90). *If PTT> 90 seconds, initiate bleeding precautions.

Male = < 15 mm /hr Female < 50 yrs = < 25 mm/hr Female > 50 yrs = < 30 mm/hr *Tests acut/chronic infection, inflammation, neplasms, tissue necrosis, infarction.

Erythrocyte Sedimentation Rate (ESR)

Male: 65 175 mg/L Female: 50 170 mg/L Iron *Iron found in Hg, acts as a carrier of O2 from lungs to tissue.

< 160 mg/dL (No CAD, less than 2 risk factors) < 130 mg/dL (No CAD, greater than 2 risk factors) Total Cholesterol < 100 mg/dL (CAD present)

Normal: 100 200 mg/dL Triglycerides

Optimal <140 mg/dl Borderline 140-160 Low Density Lipoproteins (LDL) High > 160 *you want to be LOW

Males: 35 70 mg/dL High Density Lipoproteins (HDL) Females: 35 85 mg/dL *you want your HDL to be HIGH

Fasting = 60-110 mg/dL 1 hr = 190 2 hr = 140 3 hr = 125 *140 200 = impaired *>200 = diagnostic of diabetes *A reflection of how well BG levels have been controlled for the past 3-4 months. Glycosylated Hemoglobin (HbA1c) Poor control of diabetes = >8%

Glucose Tolerance Test (GTT)

Creatinine Kinase (CK)

Males: 50 235 U/L Females: 50 250 Child: 0 - 70

*used to diagnose acute MI, can detect in 3 5 hours.

When > 90 = Diagnostic of an MI Myoglobin

Troponin I if > 1.5 = Diagnostic of an MI Tropinin Troponin T if > 0.2 = Diagnostic of an MI

When LDH 1 > LDH 2 = diagnostic of an MI Lactase Dehydrogenase (LDH)

Adult: 0.7 1.4 Serum Creatinine Child: 0.4 1.2 Infant: 0.3 0.6

24 hour collection Creatinine Clearance Normal: 1.67 2.5 ml/s *tests how well creatinine is removed from your blood by your kidneys. *Decreases with nephrotoxicity

Normal = 8-20 mg/dL Blood Urea Nitrogen (BUN) *Tests renal function. Is affected by protein intake, tissue breakdown and change in fluid volume. *BUN/Creatinine ratio = 10:1 or 20:1

Specific Gravity

Normal: 1.010 1.030 *Increased levels indicate slowing of GFR.

Normal: 6-8 g/dL Protein *Regulates osmotic pressure and is major building material for blood, skin, hair, nails and organs. *Increased in Addisons, chronic infection, crohn s disease. *Decreased in liver disease, burns, edema.

Normal: 3.5 5.5 g/dL Albumin *detects protein malnutrition *presence in urine = abnormal renal fucntion

Normal: 50 150 U/L Alkaline Phosphatase *level rises during periods of bone growth, liver disease, and bile duct abstruction.

Normal 10 40 mcg/dL Serum Ammonia Elevated = liver dysfunction

Normal: 4 6 Alanine Aminotransferase (ALT) Liver function test

Asparatate Aminotransferase (AST)

Normal: 5 35 Liver function test

Normal: 25 160 U/dL Amylase *Diagnostic of pancreatitis and acute cholecystitis

Normal 10 140 units >200 - BAD Lipase *Diagnostic of acute and chronic pancreatitis, biliary abstruction, hepatitis and cirrhosis.

Total: 0.3 1.0 mg/dL *Want is <1.5 Billirubin Direct (conj): 0.1 0.4 Indirect (unconj): 0.1 1.0

Normal: 3 -8 mg/dL Uric Acid *accumulation leads to gout

Diagnoses Vitamin B12 deficiency (pernicious anemia) Schilling Test Normal > 10% of dose excreted in 24 hours

Normal < 100,000 colonies/mL Urine Culture

Gastric Aspirate

Normal is < 4.0

TSH, T3,T4, basal metabolic rate. FAT, COLD, DRY, SLOW Symptoms: Decreased activity and HR, cold intolerance, wt gain, constipation, alopecia, dry ( sweating), slowed physical and mental function, sensitivity to narcotics (risk for resp depression). Causes: inflammation of thyroid, thyroidectomy, pituitary deficiencies, iodine deficiency. Implementation: Hormone replacement (Synthroid, Levothyroid). Low calorie, high protein, high fiber diet. *Myexedema coma causes: acute illness, surgery, chemo, DC of meds *Destruction of thyroid can be caused from Hashimoto s Disease where cells of immune system attack T-cells and destroy tissue. TSH, T3,T4, basal metabolic rate. SKINNY, HOT, HYPER Symptoms: Heat intolerance, tachycardia, wt loss, diarrhea, bulging eye, accelerated physical and mental functions (hyperactive, diff. sleeping), fine/soft hair. Hyperthyroidism (Grave s Disease) Implementation: antithyroid drugs (SSKI methimazole, proplthiouracil), surgery, irradiation. *Thyroid Storm (post thyroidectomy): increased temp and pulse, hypertension, abdominal pain, seizures. Treatment = hypothermia blanket, O2, PTU (slows down body).

Hypothyroidism (Myxedema puffy face)