Fluid Electrolyte and Acid Base Balance

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Fluid and Electrolyte Balance : 

Fluid and Electrolyte Balance NUR 134 chapter 34 Beginning on p. 1062 And Saunders NCLEX Review p. 74

Basic Terms you need to know : 

Basic Terms you need to know Homeostasis: The tendency of a living organism to maintain constant conditions in the internal environment while attempting to adjust to changes inside or outside the organism. Hyper: above an accepted normal level Hypo: below an accepted normal level (cont)

Basic Terms(cont.) : 

Basic Terms(cont.) Electrolyte: When a substance is dissolved into solution and some of its molecules split or dissociate into electrically charged atoms or ions(carries a positive or negative electrical charge) Fluid volume deficit: condition in which the body’s fluid intake isn’t sufficient enough to meet the body’s fluid needs(dehydration). Fluid volume excess: condition in which fluid intake or retention exceeds the body’s fluid needs( over hydration or fluid overload).

The Electrolytes that we will cover : 

The Electrolytes that we will cover Calcium: ( N= 8.5-10 mg/dL symbol=Ca) Calcium is used for bone formation, blood clotting, maintenance of muscle tone, excitation of cardiac and skeletal muscle, conduction of neuromuscular impulses and the regulation of endocrine and exocrine glands. Magnesium: (N=1.5-2.5 mg/dL symbol=Mg) Located in bones, cartilage, cells. Used for different enzyme actions like: carbohydrate metabolism, protein synthesis, nucleic acid synthesis, contraction of muscle tissue. It regulates clotting and neuromuscular activity.

Electrolytes(cont.) : 

Electrolytes(cont.) Potassium( N= 3.5-5.0 mEq/L symbol=K) A chief electrolyte of intracellular fluid and the primary buffer inside the cell itself, it is necessary for: nerve conduction, muscle function, acid-base balance, and osmotic pressure. K, Ca and Mg control the rate and force of contraction of the heart. Phosphorus (N=2.5-4.5 mg/dL symbol=P) needed for the generation of bony tissues, also functions in glucose in lipid metabolism, acid-base maintenance and the storage and transfer of energy from one site in the body to another. P and Ca are inversely proportional. A high Ca level will cause a low P level and vice versa.

Electrolytes(cont.) : 

Electrolytes(cont.) Sodium( N= 135-145 mEq/L symbol= Na) Sodium is used to maintain acid-base balance, osmotic pressure and transmits nerve impulses.

Body fluid compartments : 

Body fluid compartments Extracellular compartment: all fluid outside of the cells. Interstitial fluids: fluid that is between the cells and the blood vessels Intracellular compartment: all fluid inside the cells. The majority of body fluids are inside the cells. Intravascular compartment: fluid that is within blood vessels.

Explanation of fluid compartments and fluid balance : 

Explanation of fluid compartments and fluid balance All of these compartment fluids have electrolytes in them. Kinds of electrolytes and the amounts are different in each kind of fluid. When everything is working right, the body compartments have the right concentrations of fluids and the right amounts of them. Electrolyte function is a give and take: when one electrolyte moves out, another moves in. Remember in anatomy about potassium and sodium switching in and out of cells to cause movement. This is accomplished by cells having a semi permeable membrane( allowing some things to go in or out of the cell)

Third Spacing : 

Third Spacing This occurs when extracellular fluid is accumulated and trapped in actual( space meant for fluid) or potential( space that wasn’t really meant for fluid storage) space as a result of disease or injury. It is taken out of circulation and represents a volume loss. Some normal spaces for third spacing: pleural(lung), pericardial( around the heart), peritoneal( layer surrounding the abdomen), joint cavities, abdomen or soft tissues

Third Spacing(cont) : 

Third Spacing(cont) Hard to assess, there may not be a change in patient weight or in intake and output.

Edema : 

Edema Excess accumulation of fluid in the interstitial spaces Localized edema( ex. Ankle) usually occurs from trauma, surgery, burns or other local inflammatory process. Generalized edema(anasarca) is located throughout the body’s interstitial spaces and is usually caused by cardiac, renal and/or liver failure.

Body Fluid : 

Body Fluid It provides the transport of nutrients to the cells and wastes from the cells Made up of water and dissolved substances Total body fluid makes up 60% of body weight A loss of 10% in an adult is serious A loss of 20% in an adult is fatal

Methods of Body Fluid Transport : 

Methods of Body Fluid Transport Diffusion Movement of particles in all directions through a solution. Occurs within fluid compartments and from one compartment to another if that substance can pass through that membrane( semi-permeable membranes allow passage of some solutes but not others. Permeable membranes allow anything to pass) Spreads very concentrated solutes(dissolved stuff) to areas of lower concentration areas. Osmosis Osmotic pressure draws water from a lower concentration solution through a semi permeable membrane to an area of a higher concentration

Methods(cont.) : 

Methods(cont.) filtration Movement of solutes and solvents(stuff that the solute is dissolved in ex. Solvent is water, solute is Kool-Aid) by hydrostatic pressure( force exerted by weight of solution) Moves from an are of greater pressure to lesser pressure Hydrostatic Pressure Capillaries connect arteries and veins. In a capillary at the arterial end, when the hydrostatic pressure is greater than the osmotic pressure, fluids and solutes that can go through the membrane leave the capillary. At the venous end, the osmotic pressure is greater than the hydrostatic pressure and fluids and solutes come into the capillary. Under ideal circumstances, the excess fluid and solutes that are left in the interstitial spaces are returned to the vascular space by the lymph system.

Methods(cont) : 

Methods(cont) Osmolality N= 280-295 mOsm/kg. Refers to the number of active particles per kg of water. Measured in milliosmols. Active Transport Moves electrolytes “ upstream “ or against a gradient, from an area of lower to higher concentration. Energy has to be spent for this to occur. Examples: Na, K, Ca, hydrogen, iron , some sugars and proteins.

Types of IV Solutions : 

Types of IV Solutions Isotonic solutions The concentration of Na solutes into the cells equals the concentration in the fluid. There is little or no fluid exchange. Used to increase extracellular fluid volume. Ex.: NS, LR, D5W Hypotonic solutions The concentration of the Na concentration in the fluid is less than that of the cell, causing fluid to move into the cell. Ex. D5LR, D10W, D5 ½ NS

Types of IV(cont.) : 

Types of IV(cont.) Hypertonic Solutions: The concentration of NA in the IV fluid is greater than the concentration in the cell, forcing fluid out of the cell. Example: ½ NS

Body Fluid Excretion : 

Body Fluid Excretion Fluids leave the body by several routes: skin, lungs, GI tract, kidneys. The largest amount of fluid comes from the kidneys. As long as everything is working okay, the body can maintain fluid balance. The body excretes app. 2400 ml/day. Fluid losses are sensible( can be counted like urine) or insensible( like lost through the lungs or by skin diffusion).

Where does it all leave from? : 

Where does it all leave from? Skin(diffusion) 400 ml/day Skin(perspiration) 100 ml/day Lungs 350 ml/day Feces 150 ml/day Kidneys 1500 ml/day

Fluid loss(cont.) : 

Fluid loss(cont.) Fluid loss by skin is affected by environmental and body temperature( higher= more fluid loss) Lungs: expired air is saturated with water vapor. Amount varies with how fast and how deep the person is breathing( increased rate, depth equals increased loss) GI tract: most of this fluid is reabsorbed. Diarrhea can cause large amounts of fluid and electrolyte loss.

Fluid loss(cont.) : 

Fluid loss(cont.) Kidneys: major part in regulating fluid electrolyte balance. Healthy kidneys can adjust the amount of water and electrolytes leaving the body. The amount of fluid loss is dependent on how much water is ingested and how much waste and solutes need to be disposed of. Ant diuretic hormone(ADH) is secreted from the posterior pituitary gland and causes the distal tubules of the kidneys to reabsorb water. Aldosterone causes Na to be reabsorbed from the renal tubules. The increased Na concentration causes water retention in extracellular fluid, which increases the volume. Renin, which is produced in the kidneys, causes vasoconstriction and the release of Aldosterone, which causes Na retention.

Figuring out I/Os : 

Figuring out I/Os Most intakes and outputs are performed for a 12 hour period. First add up how much fluid was consumed orally, IV or by irrigation. Then, add up how much urine was collected, NG tube or Chest tube drainage, or surgical drain accumulation occurred over the same time period. Ideally, there should be very little difference between intake and output.

Example of I/Os for a 12 hour shift : 

Example of I/Os for a 12 hour shift A patient is receiving IV fluids at 150 ml/hr and they consumed 480 ml in oral fluid over a 12 hours shift. There was app. 1500 ml urine noted in the bedside Foley bag for the same time period. There was app. 50 ml of drainage from a surgical drain. First, add up the fluids. 150 ml/hr x 12 hours=1800 ml + 480 ml= 2280 ml. Then add up the urine and the drainage 1500 + 50=1550 ml. Then compare the numbers. This patient took in app. 730 ml more than they excreted. Watch this patient, it could be a sign of fluid overload.

Fluid Volume Deficit vs. Excess : 

Fluid Volume Deficit vs. Excess Fluid volume Deficit Dehydration Goals of tx: to restore fluid volume, replace electrolytes as needed, and to eliminate the cause. Causes: vomiting/diarrhea GI suctioning Continuous GI irrigation Ileostomy or colostomy drainage Draining wounds, burns, fistulas Increased urine output from diuretic use Signs/symptoms: thirst Dry mucous membranes/poor skin turgor Increased heart rate, thready pulses, hypotension Rapid weight loss Flat hand or neck veins dizziness/weakness/confusion Decrease in urine volume/dark, concentrated urine/increased specific gravity of urine(N= 1.005-1.030) Increased hematocrit level(40-55) Treatment: cause is identified and fluids are replaced Monitor VS/ check mucous membranes Daily weights/ I&Os Check spec. gravity/ hemoglobin and hematocrit Fluid Volume Excess Over hydration or fluid overload Goals: restore fluid balance, to correct electrolyte imbalances, and to eliminate or control the underlying cause. s/s: cough/ dyspnea/ lung crackles Increased RR, HR, BP/ pounding pulses Pitting edema Weight gain Decreased hematocrit Confusion Neck and hand vein distention Interventions: monitor VS, I/Os, weight Give diuretics as directed Monitor electrolytes/hematocrit levels Use a low sodium diet as prescribed Check for edema

Potassium (N=3.5-5.0) Imbalances : 

Potassium (N=3.5-5.0) Imbalances Hypokalemia( K below 3.5) Causes: using non-K sparing diuretics( like Lasix) Diarrhea/vomiting Inadequate K intake Excessive gastric suction Excessive fistula drainage Cushing’s syndrome/ chronic use of corticosteroids Renal disease Parenteral nutrition( like TPN) Uncontrolled diabetes Alkalosis Goals: to fix or control cause and to restore normal electrolyte level s/s: leg/abdominal cramps Lethargy/weakness/confusion Shallow respirations/ thready pulses/ postural hypotension( BP drops when sitting up) Decreased or absent reflexes Hypoactive bowel sounds and ileus On EKG: peaked p waves, flat T waves, depressed ST segment and U waves Tx: monitor VS, I/Os, neuromuscular activity Check BUN/ creatinine before giving K Give K supplements as directed( oral or IV) Oral K can cause gastric irritation and shouldn’t be taken on an empty stomach. NEVER, NEVER GIVE A POTASSIUM IV BOLUS. THIS IS FATAL! GIVE IV POTASSIUM AS A DILUTED DRIP. USE AN IV PUMP.ANY PT. RECEIVING OVER 10 MEQ/HR SHOULD BE PLACED ON A MONITOR. Watch your IV sites for irritation. Tell your patient to avoid using potassium containing salt substitutes unless directed by a physician. Hyperkalemia( K above 5.0) Causes: renal failure Intestinal obstruction Cell damage Excessive administration of K supplements/salt substitutes Metabolic acidosis Addison’s disease Transfusion of stored blood( breakdown of red blood cells releases potassium) Goals: To restore normal K level by fixing or controlling cause s/s: muscle weakness Paresthesias Hypotension Diarrhea Hyperactive bowel sounds EKG: flat P waves, widened QRS complex, prolonged PR interval, depressed ST segment, narrow, peaked T waves Tx: monitor VS/ cardiac changes/ renal function/ lab values/ I&Os Decrease K intake/ give non potassium sparing diuretics Emergency tx involves IV dextrose and IV insulin to move K back into the cells Kayexlalate by enema or orally which increases K absorption into the GI tract for excretion

Foods rich in K : 

Foods rich in K Avocados Bananas Cantaloupes Carrots Fish Mushrooms Oranges Potatoes Pork, veal, beef Raisins Spinach Strawberries tomatoes

Sodium(N=135-145) imbalances : 

Sodium(N=135-145) imbalances Hyponatremia(<135) Causes: GI suction Inadequate Na intake Excessive H2O intake Irrigation of gastric tubes with plain water Potent diuretics Increased sweating Draining skin lesions Burns Nausea/vomiting Diabetic ketoacidosis(DKA) Syndrome of inappropriate antidiuretic hormone secretion(SIADH) Fluid retention as seen in renal or heart failure Goals: to restore normal electrolyte levels by controlling or fixing cause s/s: rapid, thready pulse Weakness/apprehension Postural BP changes Abdominal cramping Poor skin turgor Muscle twitching/seizures Tx: monitor VS, I&Os, weight, skin turgor and mucous membranes Restrict water intake and avoid tap water enemas Use normal saline solution for irrigation Encourage foods high in Na Replace sodium and if pt. is on Lithium, monitor lithium level. Hyponatremia can cause lithium toxicity. Hypernatremia(>145) Causes: decreased H2O intake Fever Excessive sweating Dehydration Hyperventilation Watery diarrhea Enteral nutrition/parental nutrition Diabetes insipidus Cushing’s syndrome Impaired renal function Use of corticosteroids Excessive sodium bicarbonate administration Goals: restore the electrolyte level by fixing or controlling the cause. s/s: dry mucous membranes Loss of skin turgor Thirst Flushed skin Elevated temperature Oliguria Muscle twitching Fatigue/confusion/seizures Tx: monitor VS, I&Os, lab values Increase water intake orally, encourage 8-10 glasses daily

Food Sources of Sodium : 

Food Sources of Sodium Bacon Butter Canned foods Cheese Hot dogs Ketchup Lunch meats Milk Processed foods Mustard Snack foods Soy sauce Table salt White and whole wheat bread

Calcium (N=8.5-10) Imbalances : 

Calcium (N=8.5-10) Imbalances Hypocalcemia(<8.5) Causes: inadequate dietary intake of Ca/ inhibited absorption from the intestinal tract Inadequate vitamin D absorption Diarrhea Long term immobilization and bone demineralization End stage renal disease(ESRD) Ca secreting medications: diuretics, caffeine, anticonvulsants, heparin, nicotine, laxatives Decreased secretion of parathyroid hormone( this hormone increases the release of calcium from bone, increasing the serum levels) Acute pancreatitis Crohns disease Excessive blood administration Goals: to restore normal electrolyte level and to fix/control the cause. s/s: tachycardia Hypotension Paresthesias Twitching Cramps/tetany Diarrhea/ hyperactive bowel sounds Positive Chvostek’s sign ( contraction of facial muscles in response to a light tap over the facial nerve in front of the ear) and trousseau’s sign( finger spasms started by inflating a blood pressure cuff on the upper arm above the normal site for a few minutes) Tx: monitor VS, seizures, keep pt. quiet, calcium (oral, IV) Hypercalcemia(>10) Causes: excessive Ca/vitamin D intake Increased bone resorption from immobility, tumors, osteoporosis, fractures Renal failure/decreased Ca excretion Use of lithium, glucocorticoids, thiazide diuretics Adrenal insufficiency Goals: to restore the normal electrolyte level and to control/fix cause s/s: increased HR, BP and in the late stages, bradycardia Bounding pulse Nausea, vomiting, constipation, abdominal distention Muscle weakness, diminished deep tendon reflexes Confusion, lethargy, coma Tx: monitor VS, EKG, Labs, neuro status Increase mobility, range of motion, watch for pathological fractures Strain urine and watch for s/s of kidney stones Possible meds: Phosphate, Calcitonin

Calcium food sources : 

Calcium food sources Cheese Collard greens Milk, soy milk Rhubarb Sardines Spinach Tofu yogurt

Magnesium Imbalances(N=1.5-2.5) : 

Magnesium Imbalances(N=1.5-2.5) Hypomagnesemia(<1.5) Causes: malnutrition, Celiac disease Diarrhea Crohns disease Alcoholism, acute pancreatitis Prolonged gastric suctioning, ileostomy, colostomy, intestinal fistulas DKA Eclampsia Chemotherapy Sepsis Goals: to restore normal electrolyte level s/s: twitching, positive chvostek’s /trousseau’s sign, tetany Hyperactive reflexes, seizures Irritability, confusion Shallow respirations, tachycardia EKG: tall T waves, depressed ST segments Tx: monitor VS, Labs, EKG, I&Os, LOC, seizure precautions Give Mg supplements Hypermagnesemia(>2.5) Causes: overuse of antacids or laxatives that contain Mg. Renal insufficiency Treatment of preeclampsia Goals: restoring normal electrolyte levels s/s hypotension, bradycardia, weak pulse Sweating and flushing Respiratory depression Loss of deep tendon reflexes EKG prolonged PR intervals and widened QRS complexes Tx: monitor VS, respiratory status, LOC, muscular activity Remove source of excess Mg. Increase fluid intake and possibly give loop diuretics Tell pt. to avoid antacids and laxatives that contain Mg

Food sources for magnesium : 

Food sources for magnesium Avocados Canned white tuna Cauliflower Oatmeal Spinach, broccoli, dark leafy greens Yogurt Milk Peanut butter Peas Pork, beef, chicken Potatoes raisins

Phosphorus imbalances( 2.5-4.5) : 

Phosphorus imbalances( 2.5-4.5) Hypophosphatemia(<2.5) Causes: decreased nutritional intake, malnutrition Using mg based or aluminum hydroxide based antacids Renal failure Hyperparathyroidism Malignancy Hypercalcemia Alcohol withdrawal DKA Respiratory alkalosis Goals: to restore normal electrolyte levels s/s: confusion, seizures Weakness, decreased deep tendon reflexes Shallow respirations Increased chance of bleeding Immunosuppression Bone pain Tx: monitor VS, EKG, labs Give phosphate, decrease calcium food consumption and promote foods with phosphorus Educate pt. about use of antacids Hyperphosphatemia(>4.5) Causes: excessive dietary intake of phosphorus, phosphate containing enemas, laxatives Vitamin D intoxication Hypoparathyroidism Renal insufficiency Chemotherapy Goals: to restore normal electrolyte level s/s: neuromuscular irritability Muscle weakness, tetany Hyperactive reflexes Positive Chvostek’s/Trousseau’s sign Tx: use aluminum hydroxide to bind phosphate to increase the excretion of P. Prepare for dialysis if needed. Monitor for s/s of hypocalcemia and give calcium if needed. Monitor labs, VS, neuromuscular status.

Foods high in phosphorus : 

Foods high in phosphorus Fish Organ meat Nuts Pork, beef ,chicken Whole grain and white bread

Putting it into practice : 

Putting it into practice Read over your chapter, this presentation and work the questions in your NCLEX review book(p. 83) Look at more than the right answer. The book tells how they got the answer. This is invaluable. Go through the CD included in the book. Look at your ATI fundamentals book under this section.

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