Saturday, October 22, 2011

Fluid and Electrolytes Confusion

Three words had me in such turmoil this past week I can only begin to tell you about.
Those three words are FLUID AND ELECTROLYTES.  For any nursing student or nurse for that matter I’m sure we can all agree this is a difficult concept to learn.  This past week every day after class I spent until around 9pm at school studying the topic of fluid and electrolytes, including acid/bases and ABG’s with my strong close-knit study group.  Very few students in our class don’t seem to get concepts easily and I am one of these people.  I tallied up the amount of hours spent on these concepts and in all it came out being 16-18 hours.  That equals less time with my hubby and kids that I spent working through these units.

We were advised by one of our instructors that we should focus a good amount of our study time on the fluid and electrolytes because she would put more of those questions on the test.  So I didn’t spend as much time on tissue, burns, stomas/ostomies, enemas, or PICC lines. 

After finishing the exam for these units the 52 question exam only had two fluid/electrolyte questions.  WHAT???  Holy poop what was my instructor meaning that a good amount should be focused on this area if there were only going to be two questions?  How disappointing after adding up the amount of questions I got wrong.  I still passed the exam but barely.  Not only did she lead us astray in that area but she also made a point to mention to us not to bother bringing our calculators because since our med. Calc. exam was the week prior we weren’t expected to do any of those kinds of problems on this exam.  Sure enough we had two med. Calc. problems on this exam. 

I’m all for the idea of making us well educated on a broad amount of topics but if you, the instructor, tell us, the students, to focus on a certain area there darn well better be more than two measly questions! 

So after collecting myself and writing out a lengthy email to said instructor yesterday after class I asked my hubby to edit it for me so I could send it off as soon as I could.  Unfortunately because I had to work yesterday she probably won’t see my email until Monday, but I hope my complaint isn’t the only one in her inbox.

Does anyone out there have any helpful hints regarding fluid and electrolytes, acid/bases, and ABG’s?  I would take any and all help offered seeing as though these concepts are still foggy for me even after the 16 hours of study.


  1. One of my study techniques was to use a couple of good NCLEX study and question books. They are broken down into systems of the body and they usually gave a good explanation as to the answer was right and the others were wrong.

    You also get to be familiar with how questions are asked and worded in the NCLEX world, which is far different from the real world.

  2. Gah. I hate fluid and electrolytes so much. And I'm afraid you really don't want my help in that area.

    acid/base & ABG's I'm pretty good at. Well, interpreting the values at least. But giving me symptoms and choosing what imbalance the patient has isn't my strongest point. If you have specific questions, feel free to shoot them my way, I'll do what I can to answer them :)

  3. NPO-thanks for the NCLEX suggestion, after posting my blog I went back over my Incredibly Made Easy books and they reinforced what I already learned. It was refreshing.

    Marianne-I think I get the basics for the most part, but just like you, I struggle a little when it comes to matching the symptoms to the right imbalances too. Aww well I'll get there eventually.

  4. I've been a nurse for more than 10 years, and to be honest, I still don't get ABGs. Find a resource that explains them very simply and keep a copy in a little notebook or in your locker, etc. I've saved up tidbits like that; have them laminated and then put on a little binder ring.

  5. pH: 7.35-7.45
    CO2: 35-45
    HCO3-: 22-29

    Remember ROME (Respiratory Opposite, Metabolic Equal)
    I like to write all the values down and then put arrows either up or down indicating if the value is higher or lower than normal. Put an equal sign if it is normal.
    So if the ph is below 7.35 it is acidic. If above 7.45 it is alkalotic.
    Then take a look at the CO2, HCO3 levels. Write arrows next to the values! If it is a respiratory issue the arrows will be opposite.. if it is a metabolic issue the arrows will be equal (both either go up or down).

    pH = 7.60 ^
    CO2 = 30 v
    HCO3- =22 =

    So pH is above 7.45, the patient is alkalotic. Arrows are OPPOSITE (remember ROME!), therefore Resipiratory acidosis is occuring.

    Remember BASE-BUTT. If the patient is having diarrhea they are losing base and will become more acidotic. If the patient is hyperventilating, they are release much more CO2 (acid) and will become alkalotic.

  6. For remembering various electrolyte imbalances (signs/symptoms, causes, treatments), there are some mnemonics in the Memory Notebooks and Memory Notecards. They don't cover everything, but they are helpful. I think all of those mnemonics can be found in this discussion thread on AllNurses:

    For learning the VALUES of the various lab tests, I have a method that works pretty good for me. It's a long description, so I'm going to post it in 2 (or maybe three other comments for Zazzy to decide if it makes any sense, LOL.)

  7. Part 1 - Choose your numerical values

    I don't know if any of this will make sense without seeing me draw it on a board and build up the information, but I'll share some of the things that I do to learn values. (Learning the signs/symptoms and interventions is a whole other ball of wax for which I use a different technique.)

    For memorizing normal ranges and critical values for the NCLEX (or your exams), I don't necessarily learn the exact numbers the instructor gave me. Yep, you heard me. I don't always listen to my instructor. The reality is that lab values vary from facility to facility. If you look up normal ranges for any one lab test in two or three sources, the numbers will be similar but not identical.

    I like to look at what my instructor gave us as a range along with two or three other sources. I then choose the set of numbers that seems easiest to memorize (and make a note of my source -- choose alternate sources carefully!!) When I'm choosing, I'm looking for patterns in the numbers. Patterns that I can use as a cue to help me go from one number to the next.

    Questions on the NCLEX will generally be clearly normal or abnormal, rather than being on the border. If your instructor told you a range of 35-40, WebMD says 33-41 and MayoClinic says 34-39, the test is unlikely to use a value near the fringe of any of those ranges. Test questions will often be clearly within range, say 37 (middle of all normal ranges) or it will be 45 (or more) well above/below any of the normal ranges. If the number given in the question is barely normal or barely abnormal (based on the range that you memorized), there are often other clues in the answer options to help you figure out if the question writer intended for you to interpret it as normal or abnormal.

    So because of this, I choose values based on (1) reliable sources (books or internet) and based on (2) ease of memorization. Let me give you an example.

    I need to know MCV, MCH and MCHC values for an exam. For a variety of quirky reasons, I always list these three indices in that order when I talk about them, so I want some numbers that form a pattern in that order. My instructor told us the following numbers: 87+/-5 fL, 29+/-5 pg and 34+/-2%, respectively. I don't see a pattern in these numbers. I found a set of values for them where I see a pattern:

    ** 90 +/- 8
    ** 30 +/- 4
    ** 34 +/- 2

    First, notice that the plus/minus value decreases by a factor of 2 for each. Next, notice that if you divide 90 by 3 you get 30, so those are sorta related. Lastly, if you take the 30 and add 4 you get the "base" number of the last value (i.e. 34). I think this set of numbers is easier to remember than what my instructor gave us and easier than memorizing:

    * 82-98
    * 26-34
    * 32-36

    NOTE: these ranges are what I actually found in my alternate source. I converted it to the +/- values that I prefer to learn. Of course you should also know the UNITS of MEASURE, but I find that clutters my ability to see the number patterns, so while I do know them, I only listed them in the first list of values from my instructor and not on my lists where I'm trying to demonstrate the patterns I see :o)

    Part 2 - making a memory picture...

  8. Part 2a - creating a memory picture...

    Before I even start choosing the numbers to memorize, I like to group tests/values so that they can act as memory tools for me. Some obvious grouping patterns would be ways that you encounter them in the clinical setting, e.g. hematology (CBC w/diff), basic metabolic panel (BMP), complete metabolic panel (CMP), ionic electrolytes (e.g. Na, K, P, Ca, Mg, Cl), liver function test, kidney function tests and so on.

    Once I've settled on a "grouping", I start by memorizing the tests that are in that grouping, usually by creating a memory device that will help me remember the list of tests and THEN I learn the values. It might be a simple acronym menmonic like DDIRRRT that Zazzy mentioned for the patient rights or it might be a more complex picture.

    Here's an example of a complex picture mnemonic (that I also posted on that AllNurses thread that I linked to above). I had a list of lab values from a table in a text book. (Alas, it was NOT a CMP or BMP -- it's a rather random list, but it will still be a good example for how I made it easier for myself to learn the tests/values.)

    My tests I needed to learn were in a random order (that I moved around as I built my mnemonic device, but which I'm going to list now in the same order as my mnemonic device): sodium, chloride, potassium, calcium (total & ionized), albumin, magnesium, protein, BUN, creatinine, and phosphorus.

    I tried to think of a scene that I'd be able to remember very clearly and that would help me to remember all the tests (and even the values for the tests), so first I thought of items that sound like or remind me of the things I need to remember. Sodium - salt, chloride - chlorox bleach, potassium - pot (marijuana), calcium - milk, cows, albumin sounds like albatross and so on. I had probably 3-5 possible words for each item in my list of tests, then I looked for patterns.

    The sodium and chloride immediately had me thinking of the beach which made me think of California. The magazines I had jotted down for a possible magnesium reminder made me think of reading magazines on a plane to or from California. Eventually, I came up with this image:

    I stuck with the "vacation" theme that I have seen in other mnemonics and made my vacation in California where they have ocean, surfers, surfboards, sea birds, pot and happy cows. I pictured really BIG pot plants that were so big that a ton of surfers could "enjoy" just half of a "plant" and that they could provide shade for happy cows frolicking on the beach (with the surfers). Then, I had to fly home. Airplanes always have magazines and I like food and science magazines so there was one of each. On the food magazine, I picture the protein patties each with double buns and on the food magazine and on the science magazine, there's a fossilized, pregnant dinosaur with three fossilized young (so 3.5 "babies" for this creature). At this point, I really wish I could draw. I think this could be a really funny cartoon/picture mnemonic.

    Next, part 2B.. what the heck is this crazy IndyElmer person talking about??

  9. Part 2c... the image further develops (and maybe starts to make sense)

    So with that general image in mind, I added some more details, including NUMBERS:

    While on vacation in California, I met 140 salty surfers sharing 100 bleached boards and 4.5 pot plants (they smoked half of one) protected by 4 albatrosses and sheltering 5 (happy) milk cows and a 2-headed radioactive cow (apparently they are VERY big pot plants if they are sheltering cows and just half of one can satisfy 140 surfers).

    On the plane home, I saw 2 magazine covers –(cooking and science, of course!) One cover featuring 15 BUNS and 7 PROTEIN patties (I guess they’re making double-bunned burgers) and the other about dinosaurs with 1 (pregnant?) creature with 3.5 fossilized babies (3 born, 0.5 = pregnant?? not hatched??)

    "what?!" you may be asking yourself? For me, this kind of vivid (but admittedly strange) picture helps me remember. After just a couple times of saying it to myself, I could easily remember all of my "props" the salty surfers, the bleached boards, the creature and her fossil babies because it was a very vivid picture in my mind. Within just a couple of times of matching up the numbers, I could remember them too.

    For each of the numbers in the mnemonic, I actually needed to know a range (just like the MCV, MCH, MCHC above). And learning JUST the middle number was easier because nearly all of these particular tests have one of three plus/minus numbers -- either 0.5, 1 or 5. It was just a matter of remembering which test had which plus/minus and then I could easily recall the actual ranges. (There are a few exceptions, e.g. BUN is a rare +/- 10, potassium isn't a +/- anything as it's particularly unusual.) So here's how the memory picture breaks down:

    140 (+/-5) salty surfers > salty > sodium: 135-145 mEq/L

    100 (+/-5) bleached boards > bleach > Clorox bleach > chloride: 95-105 mEq/L

    4.5 (weird) pot plants > pot... > potassium: 3.5-5.3 mEq/L

    4 (weird) albatrosses > alb... > albumin: 3.5-5 g/dL

    5 (+/-0.5) milk cows > milk > calcium (this it TOTAL calcium since the next one is ionized calcium): 4.5-5.5 mEq/L (also 9-11 mg/dL)

    2 (weird)-headed cow > two heads due to ionizing radiation, cow is still milk > ionized calcium: 2.2-2.5 mEq/L (also 4.4-5 mg/dL)

    2 (+/-0.5) magazines > mag... > magnesium: 1.5-2.5 mEq/L (also 1.8-3.0 mg/dL)

    15 (+/-10) buns > BUN (blood urea nitrogen): 5-25 mg/dL

    7 (+/-1) protein patties > Protein (total): 6-8 g/dL

    1 (+/-0.5) creature > crea... > creatinine: 0.5-1.5 mg/dL

    3.5 (+/-1) fossil(ized baby creatures) > foss... > phos... > phosphorus: 2.5-4.5 mg/dL

    Obviously this is still missing some other things that can be measured, including ABG values and quite a few other relevant lab values. I wish the list that I used to make this mnemonic had been CMP or BMP, but I still find it useful.

    Lastly, part 3... a few more tricks to using this mnemonic or making your own

  10. Part 3 ... A few more tips for using that mnemonic or making your own...

    Once I could remember the "middle values" I wanted to learn the ranges and the units. To help myself remember the units (not sure it truly matters), I associate mg/dL with magenta pink and I associate g/dL with green. So I tweaked the memory picture so that the protective albatrosses are now "Irish mob enforcers" (so they're green) and I made the cooking magazine the December issue with green pistachio-encrusted protein patties with red (pink) buns and then since I already had a potentially pregnant creature, I made her and all her offspring "pink" too. (Keep in mind that some of these can be measured in more than one kind of units. For example, calcium can be measured in mEq/L, mg/dL and mmol/L -- each with a DIFFERNT set of numbers - gah!)

    To help myself remember the ranges that aren't a perfect +/-0.5 or +/-1, I think that "pot makes you wacky/weird" and that albatrosses are a "weird" seabird for me to have put in my mnemonic (In a round of Family Feud, I'm sure that seagulls are number one seabird) and of course, 2-head cows are weird. All the rest of the ranges are a nice +/- and it's just a matter of practice to learn which are 0.5, 1 or 5 for the plus/minus.

    **Keep in mind when choosing the source for your numbers, that you want to have some degree of consistency. Since all of the hematology indices are calculated in a similar manner, I wanted all of their values to come from the same source. So if you're making a list of liver function test values, you might want to use the same source for all of those, but you could use a different source for your cardiac biomarker values.

    I hope this helps some readers down the road. Apologies if I completely messed this up by trying to use the HTML tags. If it's difficult to read, I did get the tags right on the AllNurese thread, LOL.

  11. Holy Moly IndyElmer you are such a fountain of knowledge. Thank you so much for your tips and tricks on keeping these things straight. I love the visual pictures including the "pot makes you wacky/weird" haha.