Peripheral arterial disease

• Intermittent claudication or leg pain with walking or exercise that improves with rest is a hallmark symptom of peripheral artery disease.
• Causes of fluid imbalance:

  • Vomiting, diarrhea, NG tube suction
  • Diaphoresis
  • Burns
  • Altered intake
  • Long term NPO status
  • Impaired swallowing or impaired thirst
  • Anorexia
  • Confusion
  • Diuretic therapy
  • Hemorrhage, blood loss, hypovolemia
  • Third spacing
  • Respiratory losses
  • Transcutaneous evaporation
• Aging consideration:

  • Reduced organ function (e.g. decrease GFR, loss of elastin in the skin, muscle atrophy, reduced thirst reflex) puts them at higher risk of fluid imbalance
• Symptoms of fluid imbalance:

  • Early symptoms: thirst, cramps, weakness, dizziness, fatigue
  • Late symptoms: abdominal pain, agitation, lethargy, confusion
• Lab tests for fluid imbalance:

  • CBC
  • Basic Metabolic Panel
  • Potassium
  • Sodium
  • Calcium
  • CO2
  • Chloride
  • Glucose
  • Blood urea nitrogen (BUN) and Creatinine
  • Urine specific gravity
• Treatment and management:

  • Identify causation
  • Restore fluid and electrolyte imbalance
  • Prevent hypovolemic shock
  • Provide oral or IV rehydration
  • Monitor I&Os, vital signs, weight, A&O + GCS
  • Implement fall risk precautions
  • Maintain skin integrity
• Excess of body fluid (overhydration) can lead to:

  • Heart failure
  • Pulmonary edema
  • Dilution of sodium and potassium leading to seizures, cardiac arrhythmias, coma, death
• Types of fluid replacements:

  • Crystalloids: first line treatment to maintain fluid balance and/or electrolyte balance, small molecules, cost less, better tolerated
  • Colloids: large molecules, quicker volume expansion but higher risk of adverse reactions (allergy, clotting disorders, kidney failure)
• Electrolyte normal levels and associated foods:

  • Sodium: 136-145 mEq/L, controls ECF osmolarity, found in condiments, canned, processed, preserved, smoked, and pickled foods
  • Potassium: 3.5-5.0 mEq/L, key player in acid-base balance, found in fruits, avocadoes, green leafy veggies
  • Magnesium: 1.8-2.6 mg/dL, important for muscle contraction and blood coagulation, found in nuts, seeds, spinach, beans
  • Calcium: 9.0-10.5 mg/dL, essential for bone and teeth health, found in dairy products, fish, green leafy veggies
• • Phosphorous: 3.0-4.5 mg/dL, vital for cellular and energy metabolism, found in protein-rich foods
• Causes of specific electrolyte imbalances:

  • Hyponatremia: primarily due to intake of water that cannot be excreted
  • Hypernatremia: primarily due to loss of water that has not been replaced
  • Hypovolemia: primarily due to loss of water and sodium
  • Edema: primarily due to sodium and water retention
• Monitoring and management of fluid imbalance:

  • Monitor I&O, vital signs, daily weight
  • Call provider if weight changes exceed specified limits
  • Assess breath sounds and peripheral edema
  • Maintain Na restriction diet and fluid restrictions if ordered
  • Implement pressure reducing mattress, assess bony prominences, and falls risk precautions
  • Monitor labs and implement appropriate interventions
• Types of fluid solutions:

  • Crystalloids: most similar to ECF, include hypertonic, isotonic, and hypotonic solutions
  • Examples of crystalloid solutions: 5% saline, lactated ringers, 0.9% sodium chloride
  • Function of crystalloid solutions: to maintain fluid balance and electrolyte balance
• Reminder for crystalloid solutions:

  • Hypertonic: water leaves the cell to meet salt in the vessel
  • Isotonic: stays where it is placed
  • Hypotonic: fluid moves into the cell, hydrating the cell
• Examples of crystalloid solutions:

  • 5% saline
  • 3% saline
  • 5% dextrose in 0.9% saline (D5NS)
  • 5% dextrose in 0.45% saline (D5 1/2NS)
  • 5% dextrose in LR (D5LR)
  • 10% dextrose in Water (D10W)
  • 0.9% sodium chloride (NS)
  • 5% dextrose in water (D5W)
  • Lactated Ringers (LR)
  • 0.45% saline (1/2 NS)
  • 0.33% saline (1/3 NS)
  • 0.225% saline (1/4 NS)
• Function of crystalloid solutions:

  • Water leaves the cell to meet salt in the vessel (dehydrates cell shifting fluid back into circulation)
  • No fluid shift; expands vascular volume
  • Fluid moves into the cell, hydrating the cell
• Calcium and Phosphorus have an inverse relationship with protein-rich foods such as meats, nuts, beans, and dairy products
• Hypovolemic hyponatremia (dehydration) is characterized by the loss of fluid and sodium together
• Causes of hypovolemic hyponatremia include fluid loss, body fluids, diuretics, NG tube suction, and third spacing
• Hypervolemic hyponatremia is due to an increase in body water and sodium, but water is greater than sodium
• Euvolemic hyponatremia occurs when body water increases and dilutes normal sodium levels, often seen in conditions like SIADH and water toxicity
• Symptoms of hypovolemic hyponatremia include increased heart rate, decreased blood pressure, and increased respiratory rate
• Symptoms of hypervolemic hyponatremia include increased heart rate, increased blood pressure, and increased respiratory rate
• Signs common to all types of hyponatremia include arrhythmia (ST elevation), dyspnea, abdominal cramping, nausea/vomiting, restlessness, and confusion
• Low sodium levels can lead to symptoms such as seizures, stupor, abdominal cramping, confusion, lethargy, and muscle weakness
• Treatment priorities for hyponatremia include administering IV salty solutions for hypovolemic hyponatremia, monitoring urine output, and ensuring safety to prevent falls
• Water loss can lead to hyponatremia, with causes including diarrhea, renal loss, excess sodium intake, excess hypertonic IV fluids, and seawater near-drowning
• Potassium plays a role in heart and muscle contraction, with high levels posing a risk of MI and low levels leading to symptoms like irregular heart rhythm and muscle weakness
• Metabolic acidosis can result from potassium imbalances, with symptoms including irregular heart rhythm, neuro irritability, confusion, and respiratory failure
• Treatment for hyperkalemia includes monitoring EKG, I&O, and administering medications like polystyrene sulfonate or IV calcium gluconate
• Hypokalemia can be caused by GI loss, medications, thiazide and loop diuretics, alkalosis, and kidney disease, with symptoms like lethargy, confusion, and cardiac changes
• Calcium is essential for bones, blood clotting, and muscle contractions, with hypercalcemia and hypocalcemia presenting different symptoms and complications
• Magnesium imbalances can lead to symptoms like muscle weakness, arrhythmias, and neuro irritability, with treatment aimed at restoring electrolyte balance
• Phosphorus imbalances can cause symptoms like muscle spasms, confusion, and weakness, with treatment focusing on identifying the cause and restoring balance