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Fluids and Electrolytes Lecture

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Leslie Wagner

on 9 January 2016

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Transcript of Fluids and Electrolytes Lecture

Electrolyte Imbalance:
Calcium and Phosphorus have a distinct relationship: when one goes up, the other goes down
Phosphorus is mainly ICF
Calcium regulated by PTH and Calcitonin
PTH: When calcium levels fall, PTH increases
Calcitonin secreted by the thyroid gland when calcium levels are high
Electrolyte Imbalance: Sodium
Electrolyte Imbalance: Potassium
Primary intracellular cation
Vital in cell metabolism, cardiac and neuromuscular function
Maintains nerve impulses, normal cardiac rhythms, and muscle contraction
Fluid and Electrolyte Imbalance
Body Fluid Composition: Water
Primary component of body fluids
Provides a medium for:
Transport and exchange of nutrients and substances to and from cells and metabolic reactions between cells
Assists in regulating body temperature
Body Fluid Movement: Osmosis, Diffusion, Filtration and Active Transport
Controls movement between ICF and ECF
Moves water through semi-permeable membrane
Water will travel from area of low to high concentration
Solutes stay put, water moves
Leslie Wagner, MS-RN
Clemson University
NURS 303

Body Fluid Composition: Electrolytes
Chemical compound of body fluids that dissociate into particles
Become charged:
Water balance
Acid-base balance
Contributes to enzyme reaction
Necessary for neuromuscular function
Body Fluid Distribution
Intracellular: inside the cell
Extracellular: outside the cell and classified by location
Understanding Osmosis
The concentration of the solution
Dependent on sodium, glucose, and urea
Osmotic pressure
The power of a solution to draw water across a membrane
Maintains balance between interstitial (between the cells) and intravascular (in the veins/arteries) spaces and keeps water in vascular system
The effect a solution's osmotic pressure has on water movement across cells within that membrane
Equal in concentration of solutes as the surrounding plasma
Cells will not shrink or swell because there is no gain or loss of water
Example IVF: Normal saline (0.9%Sodium Chloride)
Example use: hemorrhage or GI suctioning
Greater concentration of solutes as surrounding plasma and fluid have
When cells are surrounded by hypertonic solution the cells shrink as water is drawn out of them
Example IVF: 3%Sodium chloride
Example for use: Seizures related to ICP
Have lower concentration of solutes in comparison to surrounding plasma and fluid
Moves water into the cells and causes them to swell
Example IVF: 0.45% Sodium Chloride
Example use: Dehydration
Process of solutes moving across the membrane from an area of high solute concentration into a lower solute concentration through protein channels
Maintains the balance of solutes so they are equal on each side of the membrane
Water and dissolved solutes move from an area with increased hydrostatic pressures to an area of lower hydrostatic pressure
Typically occurs in capillary membranes
Hydrostatic pressure: created when the heart pumps and when gravity pushes against capillary membranes
HP and osmotic pressure are partners in this balance
Active Transport
Allows molecules to move across the membrane even in areas of high concentration
Example: sodium-potassium pump
Body Fluid Regulation
Primary regulator of water intake
Maintains fluid balance and prevents dehyrdration
Thirst center stimulated with drop in volume or serum osmolarity increases
Primary regulator of electrolytes in body
Selectively reabsorb water and electrolytes
Renin Angiotensin Aldosterone System
Maintain intravascular balance and blood pressure
Antidiuretic hormone
Fall in BP or increase in serum osmolarity stimulates ADH
Promotes water reabsortion by increasing permeability of distal tubule
Atrial Natriuretic Peptide
Blocks RAA system
Promotes sodium wasting and increases urine output
Normal Fluid Balance
Intake: Food and Fluid=2500ml/day
Output: 1500ml/day
Insensible losses: 1000ml/day
Non measurable: feces, skin, lungs
Factors that Influence Fluid Balance
Tests and Indicators of Fluid and Electrolyte Imbalance
Elevation in any of these reflect dehydration
Osmolarity: 280-300 mOm
Specific gravity of urine: 1.010-1.030
Hematocrit: 40%
BUN: 5-20
Sodium: 135-145
Other Indicators of Imbalance
Daily weight:increase/decrease reflect gains and losses
I&O: low output can cause fluid volume excess or be due to dehydration
Edema: overload;fluid shifts from intravascular to interstitial
Skin turgor: poor and tenting with dehydration
Mucous membranes: dry with dehydration
Intravenous Access and IV Fluids: Nursing Responsibilities
Part of your head to toe
Insertion date: change every 3
Surrounding area
IV fluids and tubing
Infiltration: site is edematous proximal to insertion, cool, and pale.
Thrombophlebitis: irritation of the vein. Red, swollen, and warm
Systemic Complications
Circulatory overload
Bounding pulse
Air embolism
More common in CL
Signs of shock: low BP, tachycardia
Place on left side and in trendelenburg
Allergic reaction
Always confirm before starting IVF and meds
Types of Lines and IV Access
Peripheral line
Central line
PICC line
Triple lumen catheter
Total Parenteral Nutrition (TPN)
Large bag of hyperosmolar (hypertonic) solution
Contains fats, proteins, glucose, vitamins and electrolytes
Patient can eat but is not getting enough
Bowel system is off limits
NOT for those that can be fed enterally and sustain needed amount of calories
If patient's gut works, we try to use it first first
Must be given via central line
One bag hung daily, usually in the evening
Change the entire bag and all tubing with next TPN
Nursing Care of TPN
Hang new bag at exact time ordered
Discard old bag and any fluid left in it
Monitor the patient's BS every 6 hours even if not diabetic
Two RN's must verify before bag is hung
If new bag is not there and old bag is out, hang D10 at same rate until new bag comes
Tubing and TPN have 24 hour hang limit
Complications of TPN
Monitor blood sugar 4x/day at minimum
Easy to happen due to central line entry
Bag and tubing change is important
Fluid overload
Due to increased osmolarity of TPN
Monitor for S/S of overload: LS, respiratory rate, edema
Fluid Volume Deficit
Decrease in intravascular, interstitial, and/or intercellular fluid in the body
Can exist alone or in combination with electrolyte imbalance
Hyper-osmolar (Hypertonic) Volume Deficit
Blood becomes hypertonic and the water moves out of the cells to dilute the extracellular area
Cells shrivel and become dehydrated.
Even though the water is moving from the tissues into the blood vessels it is not enough
If the volume continues to decrease, hypovolemia occurs
Causes of Hyperosmolar Fluid Deficit
Decreased fluid intake
Increased water loss
Hyperosmolar dietary intake
Build-up of solutes due to disease
Sequestration of body fluids
Isotonic Fluid Deficit
Excessive sweating
GI loss:
NGT drainage
Loss of water AND solutes from extracellular
This results in a balanced loss
Balances osmolarity
Signs and Symptoms of Both
Hypotonic solution if patient normotensive
Isotonic solution if patient is hypotensive
Isotonic solution
Electrolyte balance is normal but volume is down
Nursing Care :
Physical assessment
Careful I&O
Deficient fluid volume
Ineffective tissue perfusion
Risk for injury
Fluid Volume Excess
Hypotonic and isotonic
Hypotonic: Causes
Renal failure
Pump failure
SIADH: Syndrome of Inappropriate Antidiuretic Hormone
Isotonic: Causes
Increased venous pressure
Obstruction from DVT
Increased aldosterone
Cushing's disease: salt and water reabsorption
Cirrhosis: decrease in aldosterone metabolism
Decreased capillary oncotic pressure
Loss of protein: burns, liver disease, nephrotic syndrome
Leads to peripheral edema
Increased interstitial oncotic pressure
Blocked lymphocytes
Symptoms of Isotonic and Hypotonic Excess
Skin: dependent edema, tight and cool skin
CNS: lethargy and confusion
Respiratory: shortness of breath, cough, crackles, increased respiration, frothy sputum, decreased oxygen saturation, dyspnea at rest
CV: full bounding pulse, hypertension, distended neck veins, tachycardia
Labs: Normal with isotonic. Hypotonic: decreased sodium, Hct, osmolality, and BUN. UA decreased osmolality and specific gravity
•Pitting edema:
ankle/dependent edema; CHF, pregnancy
•Pulmonary edema:
blood isn't pumping out fast enough and is in lungs
cirrhosis; liver scaring prevents portal blood from going into liver
Types of Edema
Cerebral edema
Fluid shifts from blood into the brain
Causing swelling and increases seizure risk
Low Protein Edema
Non pitting
Caused by low albumin
Often seen with burn victims and malnourished patients
Increase protein in diet
Edema Cause by Electrolyte Imbalance
Edema from Increased Hydrostatic Pressure
Edema Caused by Lymphatic Issues
Lymph nodes have been removed
Congenital defect that impairs one's ability to filter and move fluids appropriately
Diuretics: potassium sparing vs. non potassium sparing
Fluid restriction: divided up throughout the day
Sodium restriction: no added sodium on meal trays plus high sodium foods removed from diet
Elevation of HOB/FOB depending on symptoms
Lymphedema: elevation of extremity, Jobst sleeve, TED hose
Treatment of FVE
Nursing Care
Health assessment:
Recent weight gain
Complaints of SOB, dyspnea at rest, coughing, or edema
Physical assessment:
Weight change
Lung sounds
Urine output
Level of consciousness
Nursing Diagnosis
Fluid volume excess
Risk for impaired skin integrity
Impaired gas exchange
Primary regulator of volume, osmolality, and distribution of extracellular fluid
Helps in maintaining neuromuscular activity
Imbalance effect osmolality of ECF and water distribution between fluid compartments
Low sodium=water drawn into cells, causing them to swell
High sodium=water drawn out of cells, causing them to shrink
Normal Range: 135-145
Kidney disease
Adrenal insufficiency
GI suctioning
Excessive sweating
BP decrease, fluid shifts to intracellular space; shock
Muscle cramps
Brain edema: lethargy, confusion, stupor, coma
If dilution is the cause
Restrict intake and give diuretics
If hypotensive: give normal saline
Patient has CNS symptoms: give 3% saline and/or mannitol
Loop diuretics: use caution for those who are hypotensive
No thiazide diuretics
Nursing Care
High sodium diet if it is a true loss
Monitor neuro status and pad rails
Weigh daily
Accurate I&O
Monitor VS
Monitor electrolytes
Hypertonic dehydration
Water is drawn out of cells leading to cellular dehydration
Serious in brain cells because the cells of the brain shrink and can cause neurological issues
Brain vessels contract and they can tear.
Hyperosmotic tube feeding
Fluid loss without electrolyte loss
Certain diuretics
Medication related sodium retention: cortisone, PCN
Increased intake of salt
Excessive thirst
Lethargy, weakness, irritability
Coma, seizures, death
Weight gain
Dry mucous membranes
Hypotonic fluids: 0.45%NS
OR: D5W (iso when given, hypo when glucose metabolizes)
Diuretics (thiazide)
Nursing Care
Fluid replacement
Assessment of neurological function
Safety precautions
Hypokalemia: Causes
Inadequate intakes
Excessive renal, intestinal, or skin losses
Redistribution between the ICF and ECF: diabetic ketoacidosis
Secondary loss from medications: diuretics, corticosteroids, certain antibiotics
GI/GU losses
Confusion, lethargy
Dysrhythmias, irregular pulse, ECG abnormalities, cardiac arrest
Nausea/vomiting, diarrhea
Fatigue, muscle cramps, muscle weakness, parasthesia
Paralytic ileus due to decreased muscle activity in smooth muscle
Medications: IVF with potassium added, oral and/or parenteral supplements
Potassium rich foods: bananas, oranges, avocados, spinach, potatoes, tomatoes, meat, seafood, milk, yogurt
Nursing Care
Urine output: monitor for decreasing/normalizing output
Digoxin: hypokalemia potentiates the digoxin
Evaluate serum labs
Dilute potassium given intravenously
Hyperkalemia: Causes
ICF to ECF redistribution: burns, acidosis, chemotherapy
Total body excess from increased intake
Renal retention from failure (ARF or CRF)
Oliguria (if related to renal failure)
Intestinal colic, diarrhea
EKG changes: peaked T waves and wide QRS
Muscle twitching, weakness, irritability
Insulin with D50: shifts potassium back into the cells
Low potassium diet
Nursing Care
High serum levels need to be called ASAP
Assess heart sounds and pulse irregularity
Monitor heart via ECG monitor; ask if potassium is above 6 and not ordered
Monitor muscle tone and deep tendon reflexes
Hypocalcemia: Causes
Decreased intake from poor nutrition; decreased vitamin D
Decreased absorption from loss of parathyroid gland
Risk Factors
Older adults, especially women
Lactose intolerance
Numbness and tingling, especially around the mouth
Tetany: spasms and cramping of the hands and feet
Deep tendon reflex hyperactivity
Trousseau’s sign: increase BP cuff 2-3 minutes and hand flexes
Chvosteks sign: tap facial nerve, lip contracts
Laryngeal spasms
Oral or IV calcium
Calcium gluconate if tetany
Calcium rich diet: dairy products, canned salmon, broccoli, spinach, tofu.
Nursing Care
Health history: current manifestations
Physical assessment: musculoskeletal and respiratory status
Monitor airway and respiratory status, report stridor (high pitched, harsh inspiratory sound in the upper airway)
Tetany: provide safe, quiet environement with raised bedrails and keeping an oral airway at bedside
Hypercalcemia: Causes
High dietary intake of calcium or vitamin D
Diseases that cause calcium to be released
Fractures or long term immobility cause calcium to be released
Thiazide diuretics increase calcium reabsorption in renal tubules and cause calcium to be released
GI: nausea, vomiting, diarrhea, anorexia
MS: weakness, fatigue
CNS: lethargy, confusion, personality changes
CV: dysrhythmia, ECG changes
IVF: normal saline to enhance calcium excretion
Loop diuretics flush out calcium
Calcitonin when immediately needed; quickly absorbs calcium into the bones
Nursing Care
Physical assessment: bowel sounds, muscle strength, level of consciousness
Increase mobilization to drive calcium back into bones
Encourage fluids
Nursing Diagnosis:
LR: Lactated Ringers
Balanced electrolyte formula
Common for surgical patients
Caution in use with renal patients
Lactated: helps reverse acidosis after surgery
0.9% Normal Saline: NS
Used for vascular volume expansion and fluid resuscitation.
Stays in the blood and is used for shock.
Common in ER and for BP elevation.
5% Dextrose: D5W
Becomes free water when dextrose metabolizes
Expands intracellularly and interstially
Used for short term only
Isotonic Solutions
0.45% Normal Saline: 1/2NS
Treats cellular dehydration
Promotes waste elimination by kidneys
For dehydration if the BP is adequate.
Monitor older adults for confusion with administration
5%Dextrose and 0.45%Normal Saline:D51/2NS
Draws fluid into the vasculature from interstitial and intracellular compartments
Hypertonic when infusing but becomes hypo when dextrose is metabolized.
3% Normal Saline: 3%NS
Prevents seizures from severe hyponatremia
Only used when at risk of seizures from brain edema.
5%Dextrose and Lactated Ringers: D5LR
Electrolyte formula used for patients with draining wounds
5% Dextrose in Normal Saline: D5 NS
Provides calories to prevent catabolism when NPO
Electrolyte Imbalance: Phosphorus
85% of phosphorus is in a structural combination with calcium and collagen forming teeth and bones
Essential to carb, lipid, and protein metabolism
Needed for nerve and muscle function
Regulated primarily by the kidneys
Hyperphosphatemia: Causes
Renal disease
Over use of phosphate based enemas
Phosphorus increase=calcium decrease
Cell destruction: malignancy, chemotherapy, radiation therapy
Because of the close calcium relationship, deposits of calcium in soft tissue
Occurs when the product of serum calcium and phosphate levels exceed 70mg/dl
Calcium phosphate deposits in the heart cause dysrhythmias
Most symptoms are related to low calcium
Low BP
Phosphorus binding antacids: calcium carbonate or calcium acetate
Phosphorus excretion is increased via feces
Treat the low calcium that will come with high phosphorus
Hypophosphatemia: Causes
Vitamin D deficiency
Bowel disorders that interfere with absorption
Excessive phosphate binding antacids: Maalox, Mylanta
Diabetic ketoacidosis
Confusion, seizures, coma
Motor paralysis: similar to Guillian-Barre'
Hemolytic anemia: due to inabilities of erythrocytes to maintain integrity of the cell membranes
Increase phosphorus in diet
Organ meats
Dried beans
Seeds and nuts
Avoid phosphate binding antacids
Oral supplements: neutra-phos
IV route when extremely severe and only when bowel is not functioning
We don't want to run the risk of causing hypocalcemia followed by tetany
Electrolyte Imbalance: Magnesium
Over 50% of the bodies magnesium is stored in the muscle and the bone
Absorbed from diet and excreted through kidneys
In magnesium depleted states, absorption of magnesium competes with calcium absorption
When calcium absorption goes up, magnesium absorption goes down
Alcohol ingestion decreases renal absorption
Hypermagnesemia: Causes
Renal failure: acute or chronic
Adrenal insufficiency and hypothyroidism (in very rare cases)
Obstetrical settings
Women receive IV magnesium to decrease symptoms of pregnancy induced hypertension
Similar to hyperkalemia in terms of neuromuscular activity
CV: postural hypotension, bradycardia, flushed and warm skin, potential respiratory or cardiac arrest
Neuro: drowsiness, mental status changes
Respiratory depression when >10
Deep tendon reflexes lost after >8
Decreasing PO magnesium intake
Leafy veggies, whole grains, seafood, bananas, oranges, chocolate
IV push calcium gluconate
Actions of magnesium in CV and neuro function are antagonized by calcium
1/2 NS: if kidneys are intact to promote excretion
Hypomagnesemia: Causes
Increased urinary excretion
Osmotic diuresis in diabetes
Loop diuretics
GI loss
Vomiting, diarrhea, malabsorption disorders
Confusion, lethargy, seizures, hallucinations
Cardiac dysrhythmias
Parenteral or oral magnesium supplements
Severe depletion is treated with IV magnesium bolus
Chronic but less severe: oral magnesium salts, magnesium containing acids, high magnesium foods
We are not reviewing magnesium and phosphorus for this exam. You do not need the information on slides 92-106.
Please disregard.
Lab Work
Isotonic: Normal
Hyperosmolar: Everything increases
Urine: osmolality and specific gravity
Full transcript