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Fluid and Electrolytes: Balance and Disturbance:

Fluid and Electrolytes: Balance and Disturbance Karen Larson, MBA/TM, MSN, RN

Fluid and Electrolyte Balance:

Fluid and Electrolyte Balance Necessary for life, homeostasis Nursing role: help prevent and treat fluid, electrolyte disturbances and maintain a safe and effective environment

Fluid :

Fluid Approximately 60% of typical adult is fluid Varies with age, body size, gender Intracellular fluid (ICF)- approximately 2/3 of total body fluid Extracellular fluid (ECF)- approximately 1/3 of total body fluid Intravascular Interstitial Transcellular “Third spacing” (Capillary leak syndrome): loss of ECF into space that does not contribute to equilibrium

Regulation of Fluid:

Regulation of Fluid Filtration: movement of water, solutes occurs from area of high hydrostatic pressure to area of low hydrostatic pressure Diffusion: solutes move from area of higher concentration to one of lower concentration Osmosis: area of low solute concentration to area of high solute concentration Active transport: physiologic pump that moves fluid from area of lower concentration of one of higher concentration Movement against concentration gradient Sodium-potassium pump: maintains higher concentration of extracellular sodium, intracellular potassium Requires adenosine (ATP) for energy

Osmolality/Osmolarity:

Osmolality / Osmolarity Osmolarity is measured in milliosmoles per liter (mOsm/L) of fluid Osmolality is reported as millisomoles per kilogram of water (mOsm/kg) Normal serum osmolality is 270 to 300 mOsm/kg Serum <240 or >320 is critically abnormal Normal urine osmolality is 250 to 900 mOsm/kg

Hormonal Regulation of Fluid Balance:

Hormonal Regulation of Fluid Balance Aldosterone Secreted by adrenal cortex whenever Na level in ECF is decreased Acts on the kidneys to trigger nephrons to reabsorb sodium and water from urine back into blood Antidiuretic hormone (Vasopressin) Made in brain, stored and released from posterior pituitary gland Released in response to blood osmolarity Acts on the kidney tubles and collecting ducts, making them more permeable Natriuretic peptides Secreted by special cells in the lining of the heart Powerful dilator that is released in response to atrial stretch caused high blood pressures/volumes Inhibits the reabsorption of sodium (causing large amounts of sodium in urine)

Routes of Gains and Losses:

Routes of Gains and Losses Gain Dietary intake of fluid, food or enteral feeding Parenteral fluids Loss (sensible, insensible losses) Kidney: urine output Skin loss Lungs GI tract Other

Gerontologic Considerations:

Gerontologic Considerations More prone to dehydration Decreased body fluid percentage Decreased thirst sensation Decrease in motor skills may inhibit their ability to obtain/ingest fluids Medication use Always assess skin turgor of forehead or sternum

Fluid Volume Imbalances:

Fluid Volume Imbalances Fluid volume deficit (FVD): hypovolemia Fluid volume excess (FVE): hypervolemia

Fluid Volume Deficit:

Fluid Volume Deficit Defined as a reduction /shift in body fluids Different types of (FVD)dehydration have different causes. When managing patients with dehydration, the type of water loss must be determined to ensure appropriate treatment. Dehydration types Isotonic Hypertonic Hypotonic Manifestations : rapid weight loss, decreased skin turgor, oliguria, concentrated urine, postural hypotension, rapid weak pulse, increased temperature, cool clammy skin due to vasoconstriction, lassitude, thirst, nausea, muscle weakness, cramps Laboratory Data will vary depending on type of fluid loss/dehydration state

Fluid Volume Deficit Management:

Fluid Volume Deficit Management Medical management: provide fluids to meet body needs Oral fluids IV solutions (Review IV Solution Handout) Nursing Management: I&O, If urine output is below 30 mL / hr. notify the physician VS Monitor vital signs for increase HR, decrease b/p Monitor for symptoms: skin and tongue turgor, mucosa, mental status Measures to minimize fluid loss

NURSING MANAGEMEMT OF FVD (cont.):

NURSING MANAGEMEMT OF FVD (cont.) Administration of oral fluids Administration of parenteral fluids Oral care Weigh patient daily at the same time recognize that a change (loss) of 2.2 lbs represents a loss of 1000 ml Monitor labs urine specific gravity q 8hrs. >1.025 indicates concentrate urine <1.010 indicates dilute urine BUN elevation Elevated hematocrit

Fluid Volume Excess:

Fluid Volume Excess Due to fluid overload or diminished homeostatic mechanisms Risk factors: heart failure, renal failure, cirrhosis of liver Contributing factors: excessive dietary sodium or sodium-containing IV solutions Manifestations: edema, distended neck veins, abnormal lung sounds (crackles), tachycardia, increased BP, pulse pressure and CVP, increased weight, increased UO, shortness of breath and wheezing

Fluid Volume Excess Management :

Fluid Volume Excess Management Medical Management directed at cause, restriction of fluids and sodium, administration of diuretics Nursing Management I&O and daily weights; assess lung sounds, edema, other symptoms; monitor responses to medications- diuretics Promote adherence to fluid restrictions, patient teaching related to sodium and fluid restrictions Monitor, avoid sources of excessive sodium, including medications Promote rest Semi-Fowler’s position for orthopnea Skin care, positioning/turning

Electrolytes:

Electrolytes Active chemicals that carry positive (cations), negative (anions) electrical charges Major cations: sodium, potassium, calcium, magnesium, hydrogen ions Major anions: chloride, bicarbonate, phosphate, sulfate, and proteinate ions Electrolyte concentrations differ in fluid compartments Movement of fluid through capillary walls depends on Hydrostatic pressure: exerted on walls of blood vessels Osmotic pressure: exerted by protein in plasma Direction of fluid movement depends on differences of hydrostatic, osmotic pressure

Electrolyte Imbalances:

Electrolyte Imbalances Sodium: hyponatremia, hypernatremia Potassium: hypokalemia, hyperkalemia Calcium: hypocalcemia, hypercalcemia Magnesium: hypomagnesemia, hypermagnesemia Phosphorus: hypophosphatemia, hyperphosphatemia

Hyponatremia :

Hyponatremia Serum sodium less than 135 mEq/L Causes: adrenal insufficiency, water intoxication, SIADH or losses by vomiting, diarrhea, sweating, diuretics Euvolemic Hypervolemic Hypovolemic Manifestations: poor skin turgor, dry mucosa, headache, decreased salivation, decreased BP, nausea, abdominal cramping, neurologic changes Medical management: water restriction, sodium replacement Nursing management: assessment and prevention, dietary sodium and fluid intake, identify and monitor at-risk patients, effects of medications (diuretics, lithium)

Caution: Lithium:

Caution: Lithium Patients on Lithium must include adequate intake of both sodium and fluids. A low sodium level causes lithium retention and can lead to toxicity within hours.

Hypernatremia:

Hypernatremia Serum sodium greater than 145mEq/L Causes: excess water loss, excess sodium administration, diabetes insipidus, heat stroke, hypertonic IV solutions Manifestations: thirst; elevated temperature; dry, swollen tongue; sticky mucosa; neurologic symptoms; restlessness; weakness Note: thirst may be impaired in elderly or the ill Medical management: hypotonic electrolyte solution or D5W Nursing management: assessment and prevention, assess for OTC sources of sodium, offer and encourage fluids to meet patient needs, provide sufficient water with tube feedings

Hypokalemia:

Hypokalemia Below-normal serum potassium (<3.5 mEq/L), may occur with normal potassium levels with alkalosis due to shift of serum potassium into cells Causes: GI losses, medications, alterations of acid-base balance, hyperaldosterism, poor dietary intake Manifestations: fatigue, anorexia, nausea, vomiting, dysrhythmias, muscle weakness and cramps, paresthesias, glucose intolerance, decreased muscle strength, DTRs Medical management: increased dietary potassium, potassium replacement, IV for severe deficit Nursing management : assessment, severe hypokalemia is life-threatening, monitor ECG and ABGs, dietary potassium, nursing care related to IV potassium administration

Hyperkalemia:

Hyperkalemia Serum potassium greater than 5.0 mEq/L Causes: usually treatment related, impaired renal function, hypoaldosteronism, tissue trauma, acidosis Manifestations: cardiac changes and dysrhythmias, muscle weakness with potential respiratory impairment, paresthesias, anxiety, GI manifestations Medical management: monitor ECG, limitation of dietary potassium, cation-exchange resin (Kayexalate), IV sodium bicarbonate , IV calcium gluconate, regular insulin and hypertonic dextrose IV, -2 agonists, dialysis Nursing management: assessment of serum potassium levels, mix IVs containing K+ well, monitor medication affects, dietary potassium restriction/dietary teaching for patients at risk Hemolysis of blood specimen or drawing of blood above IV site may result in false laboratory result Salt substitutes, medications may contain potassium Potassium-sparing diuretics may cause elevation of potassium Should not be used in patients with renal dysfunction

Hypocalcemia:

Hypocalcemia Serum level less than 8.5 mg/dL, must be considered in conjunction with serum albumin level Causes: hypoparathyroidism, malabsorption, pancreatitis, alkalosis, massive transfusion of citrated blood, renal failure, medications, other Manifestations: tetany, circumoral numbness, paresthesias, hyperactive DTRs, Trousseau’s sign, Chovstek's sign, seizures, respiratory symptoms of dyspnea and laryngospasm, abnormal clotting, anxiety Medical management: IV of calcium gluconate, calcium and vitamin D supplements; diet Nursing management: assessment, severe hypocalcemia is life-threatening, weight-bearing exercises to decrease bone calcium loss, patient teaching related to diet and medications, and nursing care related to IV calcium administration

PowerPoint Presentation:

Trousseau’s sign Chvostek’s sign

Caution: Renal Patients:

Caution: Renal Patients Renal patients have high phosphorus levels. Calcium and phosphorus have a reciprocal relationship. (If one is up, the other is down)

Hypercalcemia:

Hypercalcemia Serum level above 10.5 mg/dL Causes: malignancy and hyperparathyroidism, bone loss related to immobility Manifestations: muscle weakness, incoordination, anorexia, constipation, nausea and vomiting, abdominal and bone pain, polyuria, thirst, ECG changes, dysrhythmias Medical management: treat underlying cause, fluids, furosemide, calcitonin, biphosphonates Nursing management: assessment, hypercalcemic crisis has high mortality, encourage ambulation, fluids of 3 to 4 L/d, provide fluids containing sodium unless contraindicated, fiber for constipation, ensure safety

Hypomagnesemia:

Hypomagnesemia Serum level less than 1.5 mg/dL, evaluate in conjunction with serum albumin Causes: alcoholism, GI losses, enteral or parenteral feeding deficient in magnesium, medications, rapid administration of citrated blood; contributing causes include diabetic ketoacidosis, sepsis, burns, hypothermia Manifestations: neuromuscular irritability, muscle weakness, tremors, athetoid movements, ECG changes and dysrhythmias, alterations in mood and level of consciousness Medical management: diet, oral magnesium, magnesium sulfate IV Nursing management: assessment, ensure safety, patient teaching related to diet, medications, alcohol use, and nursing care related to IV magnesium sulfate Hypomagnesemia often accompanied by hypocalcemia Need to monitor, treat potential hypocalcemia Dysphasia common in magnesium-depleted patients Assess ability to swallow with water before administering food or medications

Hypermagnesemia:

Hypermagnesemia Serum level more than 2.5 mg/dL Causes: renal failure, diabetic ketoacidosis, excessive administration of magnesium Manifestations: flushing, lowered BP, nausea, vomiting, hypoactive reflexes, drowsiness, muscle weakness, depressed respirations, ECG changes, dysrhythmias Medical management: IV calcium gluconate, loop diuretics, IV NS of RL, hemodialysis Nursing management: assessment, do not administer medications containing magnesium, patient teaching regarding magnesium containing OTC medications

Hypophosphatemia :

Hypophosphatemia Serum level below 2.5 mg/dL Causes: alcoholism, refeeding of patients after starvation, pain, heat stroke, respiratory alkalosis, hyperventilation, diabetic ketoacidosis, hepatic encephalopathy, major burns, hyperparathyroidism, low magnesium, low potassium, diarrhea, vitamin D deficiency, use of diuretic and antacids Manifestations: neurologic symptoms, confusion, muscle weakness, tissue hypoxia, muscle and bone pain, increased susceptibility to infection Medical management: oral or IV phosphorus replacement Nursing management : assessment, encourage foods high in phosphorus, gradually introduce calories for malnourished patients receiving parenteral nutrition

Hyperphosphatemia:

Hyperphosphatemia Serum level above 4.5 mg/dL Causes: renal failure, excess phosphorus, excess vitamin D, acidosis, hypoparathyroidism, chemotherapy Manifestations: few symptoms; soft-tissue calcifications, symptoms occur due to associated hypocalcemia Medical management: treat underlying disorder, vitamin-D preparations, calcium-binding antacids, phosphate-binding gels or antacids, loop diuretics, NS IV, dialysis Nursing management: assessment, avoid high-phosphorus foods; patient teaching related to diet, phosphate-containing substances, signs of hypocalcemia

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