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Fluid and Electrolyte Imbalances

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Katy Geymont

on 16 April 2014

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Transcript of Fluid and Electrolyte Imbalances

Fluid and Electrolyte Imbalances
Fluid
Electrolytes
References
Fluid and Electrolytes
by
Katy Geymont, RN, BSN

Learning Objectives:

1. Identify normal and abnormal results of electrolyte balances in the adult patient.

2. Identify etiology, signs and symptoms, treatment, nursing interventions and patient education of altered fluid states seen in acute care.

3. Describe the assessment , regulation, imbalances, nursing interventions and patient education of the following electrolytes: sodium; potassium; calcium; magnesium and phosphorous.

4. Compare the use of hypertonic, hypotonic, and isotonic solutions in fluid management.
Water Gains for the Average Adult
Oral Intake:
as water= 1000 ml
in food= 1300 ml
Water of
Oxidation= 200 ml
_________
TOTAL = 2500 ml

Water Losses for the Average Adult
Urine: 1500ml
Insensible Losses:
Lungs 300ml
Skin 500ml
Feces: 200ml
_________
TOTAL = 2500ml

Intracellular and Extracellular
Fluid
Intracellular Fluid (ICF): within the cell.
Extracellular Fluid (ECF): outside the cell.
-Intravascular (IVF) is ECF and is found within blood vessels
-Interstitial (ISF) is ECF and located between the cells in the fluid surrounding the cells.

Interrelations of ICF and ECF
Primary ECF ions are Na+ and Cl-
The amount of Na+ determines ECF volume
Primary ICF ions are K+ and Phosphate
The amount of K+ determines ICF volume

Na+ is the most abundant ECF ion

Na+ is responsible for OSMOTIC balance of ECF space
Third Spacing Leads to Shock
Water Balance
Atrial natriuretic factor (ANF) is a hormone released by heart muscles in response to fluid overload. ANF opposes RAAS by inhibiting renin secretion; promoting sodium waste and diuresis and causing vasodilation.
Edema
Edema is an increase in Hydrostatic Pressure from either venous obstruction or Salt and H20 Retention.
Sodium
Action in the Body & Physiological Response
Sodium (Na+) is the main cation (positive charged ion) in the ECF and helps maintain the concentration and volume.
Na+ is the primary determinant of ECF osmolarity.
Na+ assists in the transmission of nerve impulses and regulation of acid-base balance.
Normal Value
of Sodium
135-145 mEq/L
Hypernatremia
Na+ > 145 mEq/L
A disorder in which there is too much sodium.
Causes:

excessive intake of Na+ from food and drinks
inadequate water consumption
excessive loss of bodily fluids
dehydration
blood pressure medications
Hyponatremia
Na+ < 135 mEq/L
A disorder associated with too little sodium.
Causes:
N/V
Diarrhea
Excessive Hypotonic IV fluids
Water Intoxification
Excessive Sweating
Kidney Disease
Diuretics
Hypernatremia
Patients at risk are:
Impaired Renal Function
Corticosteroid Therapy
High Fever
Heatstroke
Prolonged Hyperventilation
Diabetes Insipidus

Hyponatremia
Patients at risk:
Diuretic Therapy
Excessive Sweating
Heart Failure
Burns
NG Suctioning

Labs & Tests
Blood & Urine
Hyponatremia
:
Serum Sodium = < 135 mEq/L
Serum Osmolarity = < 280 mOsm/kg
Specific Gravity = < 1.008

Hypernatremia:
Serum Soduim = > 145 mEq/L
Serum Osmolarity = > 295 mOsm/kg
Specific Gravity = > 1.025
Urine Sodium = < 40 mEq/L
IVF and Medications
Hypernatremia:
IV solution of 5% Dextrose in Water
Hypotonic Saline
Hyponatremia:
IV Hypertonic Saline (3%NaCl)
Vasopressin
Vaprisol
Samsca
Hyponatremia
Assess for:
Decrease in Cognition
Seizure Activity
Muscle Weakness
Dry Skin and Mucous Membranes
Tachycardia
Hypotension
H/A
Hypernatremia
Nursing Assessment
Assess for:
Restlessness
Agitation
Delirium
Twitching
Coma
Hyperflexia
Tachycardia
N/V
Polyuria
Hyponatremia
Nursing Interventions
Fluid Restriction
Provide Safety Measures for Seizure Activity and Falls
Monitor VS
Monitor I&O (Oral and IVF)
Hypernatremia
Restrict Dietary Sodium
Provide Safety Measures for Seizure Activity and Falls
Monitor VS
Monitor I&O Hourly
Hyponatremia
Educate patient based on:
The underlying cause
Manifestations of mild to more severe hyponatremia
Importance of regular serum electrolyte monitoring if taking diuretic or low sodium diet
Types of food and fluids to replace sodium orally
Importance of reporting any s/s to primary provider.
Hypernatremia
Educate based on underlying cause
Importance of responding to thirst and comsuming adequate fluids (make sure caregivers understand importance of providing fluids
Low sodium diet
Use and effects of diuretics
Importance of regular serum monitoring by primary provider
Potassium
Actions in the Body & Physiological Responses
Potassium (K+) is the major ICF cation (positively charged ion)
K+ has crucial role in metabolic, neuromuscular and cardiac function
K+ regulates ICF osmolarity
K+ promotes cell growth
Hyperkalemia
K+ > 5.0 mEq/L
Disorder can be fatal if it is not treated.
Normal Value
Serum Potassium
3.5-5.0 mEq/L
Hypokalemia
K+ < 3.5 mEq/L
IVF & Medications
Treatments for Hyperkalemia:
Diurectics
Dialysis
Ion-Exchange Resins (Kayexalate)
IV Insulin
IV Glucose
IV Calcium Glutonate or Calcium Chloride
Labs & Tests
Blood Test (BMP or CMP)
Hypokalemia = < 3.5 mEq/L

EKG

Causes:
Kidney Failure
Massive Tissue Destruction
Heart Attack
Fasting
Intestinal Bleeding
Use of Diuretics
Causes:
Severe Vomiting and/or Diarrhea
Dialysis
Gastrointestinal Disorders
Use of Laxatives
Diuretics
Hyperkalemia
Patients at risk of hyperkalemia include those with:
Addison's Disease
Renal Failure
Massive Tissue Destruction
Use of Potassium-Sparing Diuretics
Use of Potassium Containing Drugs
Hypokalemia
Patients at risk for hypokalemia include those with:
Cushing Syndrome
Diuretic Therapy
Gastrointestional Fistula
Pyloric Obstruction
Starvation
Bulimic
Hyperkalemia
Nursing Interventions
Monitor IV for phlebitis and infiltration
Monitor VS hourly
Monitor I&O hourly
Monitor cardiac rhythms
Monitor muscle weakness
Monitor safety and falls
Hypokalemia
Restrict oral and parenteral Potassium
Monitor for diarrhea from medications
Assess for pain and provide comfort measures
Monitor VS hourly
Monitor I&O hourly
Monitor heart rhythm
Hypokalemia
Nursing Assessment
N/V
Malaise
Muscle Weakness
Hyporeflexia
Leg Cramps
Hyperkalemia
Nursing Assessment
Anxiety
N & V
Diarrhea
Paresthesia
Muscle Cramps and Pain
EKG Change
Cardiac Arrest
Tachycardia
EKG Changes
Hypokalemia
Educate patient and caregivers on the importance of:
Potassium rich foods
Preventing excessive loss of fluid (abuse of laxatives and diuretics)
Importance of potassium supplements
S/S of potassium imbalance
Managing gastrointestinal disorders that cause potassium loss (N/V and ileostomy drainage)
Hyperkalemia
Educate patients and caregivers on importance of:
Diet low in potassium
Medications to avoid (OTC and fitness supplements
Importance of follow-up appointments and lab work
Magnesium
Action in Body & Physiological Responses
Magnesium is the second most abundant cation in the ICF
Mg+ functions as a co-enzyme in the metabolism of carbohydrates, nucleic acid and protein
Mg+ is regulated by the GI absorption and renal excretion
Hypermagnesemia
Mg+ = > 2.5 mEq/L
Disorder where too much magnesium in the body.
Normal Value
Serum Magnesium
1.5-2.5 mEq/L
Hypomagnesmia
Mg+ = < 1.5 mEq/L
Disorder where too little magnesium is in the body.
Labs & Tests
Magnesium Level
Potassium Level
Calcium Level
EKG
Urine
Causes:
End Stage Renal Disease
Addison's Disease
Hypothyroidism
Causes:
Malnutrition
Chronic Alcoholism
Malabsorption Issues
Digestive System Disorders
Excessive Sweating
Chronic Diarrhea
Diuretics
Hypermagnesemia
Treatment
IV Calcium Chloride
Calcium Glutonate
Dialysis if Impaired Renal Funtion
Hypomagnesemia
Treatment
Parenteral IVF
Magnesium IM
Oral Supplements
Dietary Intake of Foods High in Magnesium
Hypomagnesemia
Nursing Assessment
Disorientation
Vertigo
Irritability
Tremors
Increased Tendon Reflexes
Positive Chvostek's Sign
Positive Trousseau's Sign
Increased BP
Tachycardia
EKG changes
Hypermagnesemia
Nursing Assessment
Lethargy
Coma
Paralysis
Decreased Deep Tendon Reflexes
Decreased Respirations
Hypotension
Bradycardia
EKG Changes
Respiratory Arrest
Cardiac Arrest
Hypermagnesemia
Nursing Interventions
Monitor level of consciousness
Monitor patellar reflexes
Monitor VS every 15-20 minutes until stable then every hour
EKG changes
Encourage fluids
Hypomagnesemia
Monitor for seizure activity and provide safety measures
Monitor EKG changes
Monitor for Digitalis Toxicity
Hypermagnesemia
Teach Patients to avoid OTCs with magnesium content
Hypomagnesemia
Teach patients:
Importance of magnesium rich foods
Avoidance of excessive use of Laxatives and Diuretics
Calcium
Action in Body & Physiological Responses
Calcium functions:
Transmission of Nerve Impulses
Myocardial Contractions
Blood Clotting
Formation of Teeth and Bone
Muscle Contractions
Normal Value
Serum Calcium
Ca+ = 8.6-10.1 mg/dL
Hypercalcemia
Ca+ = > 10.1
Hypocalcemia
Ca+ = < 8.6
Hypocalcemia is indicative of too little calcium present in the ECF.
Causes:
Hyperparathyroidism
Fractures
Cancer
Prolonged Immobolization
Causes:
Kidney Failure
Acute Pancreatitis
Hypoparathyroid Disorders
Liver Disease
Malabsorption Syndrome
Heparin Therapy
Hypocalcemia
Patients at risk of Hypocalcemia are those with:
Acute Pancreatitis
Hypoparathyroidism
Liver Disease
Malabsorption Syndrome
Renal Failure
Vitamin D Deficiency
Loop Diuretics
Hypercalcemia
Patients at risk for hypercalcemia are those with:
Acute Osteoporosis
Hyperparathyroidism
Multiple Myeloma
Too much Vitamin D
Prolonged Immoblization
Hypercalcemia
Treatment
Loop Diuretics with Hydration with Isotonic Saline Infusions
Synthetic Calcitonin
Mithracin
Aredia
Hypocalcemia
Treatment
Calcium Lactate
Foods High in Calcium
Vitamin D Supplement
Calcium Gluconate 10% IV Solution
Hypercalcemia
Nursing Assessment
Monitor patient's state of sensorium for safety
Encourage movement and exercise
Assist with movement if pain is present
Monitor VS
Monitor EKG
Monitor for s/s of Digitalis Toxicity

Hypocalcemia
Nursing Assessment
Anxiety
Seizures
Tetany
Positive Trousseau's Sign
Positive Chvostek's Sign
Patholgic fractures
EKG changes

Confusion
Lethargy
Osteoporosis
Pathologic fractures
Hearth Block
Arrest
Anorexia
Flank Pain (Kidney Stone)
Hypercalemia
Nursing Interventions
Hypocalcemia
Nursing Interventions
Monitor patient's state of cognition
Monitor breathing for laryngeal stridor
Monitor EKG changes
Hypercalcemia
Teach patient:
to decrease calcium intake
to increase fiber intake
increase fluid intake
s/s of Digitalis Toxicity if patient is taking
Hypocalcemia
Educate patient on importance of diet high is calcium and Vitamin D
Phosphorus
Action In Body & Physiological Responses
Phosphorus is a primary anion in the ICF that is essential to muscle function, RBCs, and the nervous system
P- is also involved in the acid-base buffering system, production of ATP and cellular use of glucose
P- is involved in the metabolism of carbohydrates, proteins, and fats.
Normal Value
Serum Phosphorus
P- = 2.5-4.5 mg/dL
Hyperphosphatemia
P- > 4.5 mg/dL
Hyperphosphatemia indicates that there is an increase in ECF level of phosphorus.
Hypophosphatemia
P- < 2.4 mg/dL
Causes:
Hypokalemia
Hypomagnesemia
Severe Burns
Chronic Alcoholism
Diabetic Ketoacidosis
Hyperparathyroidism
Respiratory Alkalosis
Malnutrition
Prolong Diuretic Use
Labs & Tests
Serum Phosphate Level
Serum Calcium Level
Platelet Count
Cardiac Enzymes
EKG
Causes:
Kidney Disease
Healing Fractures
Chemotherapeutic Agents
Broken Bones
Intestinal Obstructions
Hypoparathyroidism
Laxatives Containing Phosphorus
Hypophosphatemia
Patients at risk of hypophosphatemia are those with:
Diabetes Mellitus
Hyperparathyroidism
Vitamin D Deficiency
Hyperphosphatemia
Patients at risk of hyperphosphatemia are those with:
Broken Bones
Renal Disease
Too much Vitamin D
Hypoparathyroidism
Hyperphosphatemia
Treatment
IV Calcium Replacement
Oral Calium Replacement
Hypophosphatemia
Treatment
IV Phosphate Replacement (use caution)
IV Sodium Phosphate
IV Potassium Phosphate
Neutra-Phos
OTCs that contain aluminum hydroxide
Hypophosphatemia
Nursing Assessment
Weakness
Paresthesia
Rhabdomyoloysis
Cyanosis
Hypotension
Dysphagia
Hyperphosphatemia
Nursing Assessment
Hypocalemia
Tetany
Tachycardia
EKG changes
N/V
Hyperphosphatemia
Restrict diary products
Monitor for Tetany
Monitor for signs of Hypocalcemia
Monitor HR
Monitor EKG
Encourage hydration
Renal failure patients use Ca+ supplements and phosphate binding agents
Hypophosphatemia
Nursing Interventions
Monitor LOC
Institute safety measures for seizure activity
Comfort measures for pain
Assist with proper body alignment
Monitor for bleeding
Monitor for respiratory failure
Institute precautions to prevent infections
Hyperphosphatemia
Teach patient:
Avoidance of foods high in phosphorus
Excessive use of phosphorus containing laxatives and enemas
Hypophosphatemia
Teach patient:
Phosphorus rich foods
OTCs that contain phosphorus
Fluid Volume
Biolgy24X7. (2012, January 19). Active transport [Video file].

Electrolyte Disorders: Definitions and Patient Education. (2013). Retrieved from: http://www.healthline.com/health/electrolyte-disorders?toptoctests=expand

Lewis, S. M., Heitkemper, M. M., & Dirksen, S. R.(2004). Medical-surgical nursing: assessment and management of clinical problems. St. Louis: Mosby

Munro, J. (2012, September 6). How diffusion works [Video file].


Volume Depletion
Hypovelmia
Volume Overload
Hypervolemia
Edema refers to the presence of excess ECF in the interstitial spaces or fluid compartment
Volume depletion is the loss of water from all fluid compartments of the body.
Fluid is lost first from the ISF, then the IVF and finally from the ICF.

Conditions Leading to Volume Depletion
Inadequate Fluid Intake:
inability to swallow
unavailability of water
extreme debilitation and illness
mechanical devices and intubation
Excessive Fluid Loss:
chronic vomiting
severe diarrhea
Diabetes Insipidus
kidney failure
fever
hemorrhage
hyperventilation
drainage from wounds
GI suctioning
burns
Signs & Symptoms
Thirst
Dry Skin and Mucous Membranes
Sunken Eyes
Low Grade Fever
Increased Pulse Rate
Decreased Blood Pressure (hypotension)
Altered Mental Status
Body Fluid Regulation
Homeostasis requires several regulatory mechanisms and processes to maintain the balance between fluid intake and excretion. These include:
Thirst
Kidneys
Renin-Angiotensin-Aldosterone System
Atrial Natriuretic Factor (ANF)
Thirst
Primary regulator of Water intake
Important for fluid balance
Important for preventing dehydration
Thirst Center, located in the brain, is stimulated when the blood volume drops due to water losses or when serum osmolarity (solute concentration) increases
Effective in regulating extracellular Na+ levels
Inhibition occurs when serum Na+ is lowered and low serum osmolarity
Kidneys
Responsible for regulating fluid volume and electrolyte balance in the body
Control the excretion of water and electrolytes with volume and osmolarity of body fluids
170 Liters of plasma is filter in a day
99% of glomerular filtrate is reabsorbed
Diagnostic Tests
Serum Electrolytes
Serum Osmolality
Serum H+H
Urine Specific Gravity
Urine Osmolality
Central Venous Pressure
Treatment
Fluid Challenge
Isotonic Electrolyte Solutions
Hypotonic Solutions
Nursing Interventions
Monitor LOC
Monitor VS
Monitor I&O
Monitor Labs
Monitor IV sites with IVF infusions
Weigh Daily
Monitor Safety d/t Orthostatic Hypotension
Patient Education
Teach Patient and Caregivers on:
The importance of hydration
Monitoring skin and urine for s/s of dehydration
Avoiding excessive sweating in high heat
How to replace fluid loss form diarrhea with juices or bouillon
Fluid volume excess results when both water and sodium are retained in the body.
Fluid volume overload- excess water and sodium intake or by impaired mechanisms that maintain homeostasis
Hypervolemia-excess intravascular fluid
Conditions Leading to Fluid Volume Excess
Malnutrition
Heart Disease
CHF
Kidney Disease
Pregnancy
Anti-Diuretic Medications
Severe Burns
Liver Disease
Nursing Assessment
Bounding pulse
Distended neck and peripheral veins
Increased CVP
Dyspnea
Orthopnea
Crackles
Polyuria
Ascites
Anasarca
Edema
Anasarca
Diagnostic Tests
Serum Electrolytes
Serum Osmolality
H+H
Renal Function
Liver Function
Urine Osmolality
ABG
Treatment
Diuretics (Loop, Thiazide, and Potassium Sparing)
Fluid Restriction
Dietary Modifications
Nursing Interventions
Monitor I&O
Monitor VS
Restrict Fluid
Monitor Tissue Integrity
Monitor Cardiac Rhythm
Monitor Labs
Monitor Oxygenation
Patient Education
Instruct patient on:
the importance of daily weights
Sodium restrictions
Monitoring s/s of overload
Loose clothing
Proper use of diuretics
Proper fluid intake

IVF & Medications
Lab Tests
Blood & Urine
Hyperkalemia
Diagnostic Tests
Serum Blood level
-CMP or BMP
EKG
Hypokalemia
IVF & Medications
Potassium (oral & IV)
CHS Guidelines for Replacement
IV Solutions
Isotonic
Hypertonic
Hypotonic
Normal Saline
D5 in Water
Lactated Ringers
D5NS
3% NaCL
10% D5 in NS

0.45% NS
Scenarios
Scenario #1
Your patient arrives in the ED with decreased urine output, swelling in his feet and ankles, hypertension, and mild shortness of breath. He reports that he did not go to dialysis yesterday.
Labs:
Na = 135
K = 6.2
Mag= 1.7
Ca = 8.2
Phos = 4.9
Creat = 2.9
BUN = 35
Scenario #2
Herman is a 42 year old man with Type 1 DM and renal insufficiency. He is homebound b/c of an infected ankle ulcer and osteomyelitis of the femur. The home health nurse provides daily dressing changes and IV Vancomycin. Medications include Enalapril and Insulin. He presents to the ED with weakness, muscle weakness in legs, extreme thirst, and dizziness when standing. He has diarrhea and frequent urination.
VS:
Temp 99.3
HR = 95
BP = 107/71
Resp = 22
O2 = 96%
BS = 350
Based on his clinical manifestations, what fluid imbalance does Herman have?
You draw blood for a serum chemistry evaluation. What main potentially dangerous electrolyte imbalance does his history and symptoms suggest?
Scenario #3
You are caring for an 87 y/o female who presents to the ED speaking very little English. You are able to find out that she has a 3 day history of intermittent abdominal pain, bloating, and n/v. She has just moved here from Puerto Rico 2 months ago and is living with her grandson. PMH includes hysterectomy 12 years ago and hernia repair 2 years ago. All other systems are negative.
Labs:
Hgb = 10.3
Mag = 2.0
Na = 132
K = 2.8
BUN = 31
Creat = 1.6

What are some risk factors in this patient for developing fluid and electrolyte imbalances?
What lab values are of concern to you and what are the reasons for these abnormal levels?
If left untreated, what signs and symptoms might the client experience bc of these lab values?
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