Fluid and Electrolytes: Balance and Disturbance

Fluid and Electrolytes: Balance and Disturbance

Dr. Ahmad Aqel,

2020

The University of Jordan

School of Nursing

Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 13th ed. Chapter 13. (p 237)

Fluids and Electrolytes

Electrolytes:

– A substance that, on dissolving in solution, ionizes; that is, some of its molecules split or dissociate into electrically charged atoms or ions.

Major cations: sodium, potassium, calcium, magnesium, hydrogen ions Major anions: chloride, bicarbonate, phosphate, sulfate, and proteinate ions.

Dr. Ahmad Aqel 2020 2

Body fluid compartments

Intracellular compartment : fluid inside the cells.

Extracellular compartment: fluid outside the cells.

• Intravascular compartment: fluid inside a blood vessel

• Interstitial fluid: fluid surround the cells 11-12L, lymph, bone, connective tissue, water

– Transcellular: (1L) (eg. cerebrospinal, pericardial, synovial, intraocular, and pleural fluids, digestive secretions, sweat).


Third-spacing:

accumulation and sequestration عزل of trapped extracellular fluid in an actual or potential body space as a result of disease or injury.

The trapped fluid represents a volume loss and is unavailable for normal physiological processes.

Fluids trapped in body spaces such as the pericardial, pleural, peritoneal, or joint cavities; the bowel; or the abdomen, or within soft tissues after trauma or burns


Edema

• Edema :

– excess accumulation of fluid in the interstitial space;

– occurs due to alterations in oncotic pressure, hydrostatic pressure, capillary permeability, and lymphatic obstruction.

1. Localized edema

– occurs as a result of traumatic injury , surgery, local inflammatory processes, or burns.

2. Generalized edema (anasarca),

• accumulation of fluid in the interstitial space occurs as a result of cardiac, renal, or liver failure


Body fluid • Total body fluid: about 60% of body weight in the adult, 55% in the older adult, and 80%

in the infant.



Diffusion الانتشار:

• solutes move from area of higher concentration to one of lower concentration

Osmosis:

• fluids move from area of low solute concentration to area of high solute concentration

Filtration:

• movement of water, solutes occurs from area of high hydrostatic pressure to area of low hydrostatic pressure

Hydrostatic pressure:

– the pressure exerted on walls of vessels

Osmolality

• Osmolality is the concentration of fluid that affects the movement of water between fluid compartments by osmosis.

– Serum osmolality primarily reflects the concentration of sodium (blood urea nitrogen (BUN) and glucose).

– Urine osmolality is determined by urea, creatinine, and uric acid.

– serum osmolality is 280 to 300 mOsm/kg, and normal urine osmolality is 200 to 800 mOsm/kg

– Urine specific gravity measures the kidneys’ ability to excrete or conserve water. (1.010 to 1.025).


Active Transport

Movement against concentration gradient

energy must be expended for the movement to occur.

Sodium-potassium pump: maintains higher concentration of extracellular sodium, intracellular potassium

Requires adenosine (ATP) for energy



Intake Ingested water 1200-1500ml

Ingested food 800-1100

Metabolic oxidation 300 ml

Total 2300-2900ml

Output kidneys 1500ml

Insensible loss (Skin) 600-800

Insensible loss (lungs) 400-600-ml

GI tract 100ml

Total 2600-3000

Sources of fluid Intake and output


Regulation of Fluid (Kidney)

ANP (Atrial Natriuretric Peptide)

الببتيد الاذيني المدر للبول يفرز هذا الهرمون من خلايا الاذين في القلب

ANP: increase fluid and sodium

excretion

decrease blood volume decrease

CVP

decrease CO

decrease pre load


Fluid Volume Deficit

Dehydration

occurs when the fluid intake of the body is not sufficient to meet the fluid needs of the body.

The goal of treatment

• to restore fluid volume, replace electrolytes and treat the cause.



1) Isotonic dehydration:

Water and electrolytes lost in equal, results in decreased blood volume and

inadequate tissue perfusion.

2) Hypertonic dehydration:

Water loss exceeds electrolyte loss. Fluid moves from the intracellular into the

plasma and interstitial spaces, causing cellular dehydration and shrinkage.

3) Hypotonic dehydration:

Electrolyte loss exceeds water loss. Fluid moves from the plasma and

interstitial fluid spaces into the cells, causing a plasma volume deficit and

causing the cells to swell

Types of fluid volume deficits


Fluid volume deficits

Causes of Isotonic dehydration: Inadequate intake of fluids and solutes

Causes of Hypertonic dehydration: excessive perspiration, hyperventilation, ketoacidosis, prolonged

fevers, diarrhea, early-stage kidney disease, diabetes insipidus

Causes of Hypotonic dehydration: Chronic illness, Excessive hypotonic fluid replacement, Kidney

disease, Chronic malnutrition


Fluid Volume Deficit: Assessment Findings

Tachycardia(weak pulse),

Decreased BP (postural hypotension),

Flat neck vein, diminished peripheral pulses and CVP,

Dysrhythmias.

Increased resp. rate and depth, Dyspnea,

Decreased urine output

Lethargy, coma, Fever, Skeletal muscle weakness

Dry skin, Poor turgor, tenting, Dry mouth

Deceased bowel sounds, Constipation, Thirst, wt loss


Fluid volume deficit

Laboratory findings

Increased (serum osmolality, Na, hematocrit, urea, and urine

specific gravity)

Laboratory tests for evaluating fluid status

1) BUN: the end product of protein metabolism by the liver (normal = 10-20

mg/dl)

2) Creatinine: the end product of muscle metabolism (normal= 0.7-1.4mg/dl)

3) Hematocrit: the volume percentage of RBCs in whole blood. (normal 42%-

52% for males, and 35%-47% for females)

Fluid Volume Deficit: Intervention

1) Provide oral rehydration therapy

2) IV fluid replacement

isotonic dehydration: treated with isotonic fluid solutions

hypertonic dehydration: treated with hypotonic fluid

hypotonic dehydration: treated with hypertonic fluid

3) Monitor I&O

4) Administer medications (antidiarrheal, antimicrobial, antiemetic ) as ordered

5) Monitor electrolytes and treat an imbalance


Fluid Volume Excess

Fluid intake or retention exceeds the fluid needs of the body. Called over-hydration or fluid overload.

TYPES

1) Isotonic over-hydration

hypervolemia, excessive fluid in the extracellular space.

No fluid shifting between the extra & intra-cellular

Causes: circulatory overload and interstitial edema.

in a client with poor cardiac function, heart failure and pulmonary edema can result.


Fluid Volume Excess (Types)

2) Hypertonic over-hydration

Rare condition, caused by an excessive sodium intake.

Fluid is drawn from the intracellular fluid compartment

the extracellular fluid volume expands, the intracellular fluid volume contracts.

3. Hypotonic over hydration

known as water intoxication.

The excessive fluid moves into the intracellular space, and all body fluid compartments expand.

Electrolyte imbalances occur as a result of dilution.



Isotonic over hydration: Inadequately controlled IV therapy Kidney disease, Long-term corticosteroid therapy

Hypertonic over hydration:

Excessive sodium ingestion, Rapid infusion of hypertonic saline , Excessive sodium bicarbonate therapy

Hypotonic over hydration:

Early kidney disease, Heart failure , SIADH Inadequately controlled IV therapy Replacement of isotonic fluid loss with hypotonic fluids Irrigation of wounds and body cavities with hypotonic

Fluid Volume Excess ( Causes)


Bounding, increased pulse rate, elevated BP, distended neck veins, elevated CVP,

dysrhythmias

Increased RR (shallow ), dyspnea, Crackles

Altered LOC, visual disturbances, muscle weakness, parenthesia (pin and needles, tingling)

Increased urine output if kidneys can compensate, decreased urine output if kidney failure

Pitting edema , Pale, cool skin

Increased motility, Diarrhea ,Increased weight, Ascites

Fluid volume excess/assessment findings

Fluid volume excess Laboratory findings

Decreased serum osmolality (normal: 280 to 300 mOsm/kg)

Decreased hematocrit :

Decreased BUN level: (normal 10 to 20 mg/dL)

Decreased serum sodium (normal 135 to 145 mEq/L

Decreased urine specific gravity (normal: 1.010 to 1.025).


Interventions: Fluid Volume Excess

1. Monitor status systems: cardiovascular, respiratory, neuromuscular, renal, integumentary, and gastrointestinal

2. Prevent further fluid overload

3. Administer diuretics: osmotic diuretics may be prescribed initially to

prevent severe electrolyte imbalances.

4. Restrict fluid and sodium intake.

5. Monitor: I&O; weight, electrolytes


Hypokalemia

Serum potassium <3.5 mEq/L, life-threatening

Causes:

1. Actual total body potassium loss. Excessive use of medications (diuretics, corticosteroids)

Increased secretion of aldosterone,

Vomiting, diarrhea , Wound drainage, Prolonged nasogastric suction , Excessive diaphoresis

Kidney disease impairing reabsorption of potassium


Hypokalemia

Causes …. continued

2. Inadequate potassium intake: Fasting; NPO status

3. Movement of K from extracellular to intracellular

In case of a. Alkalosis b. Hyperinsulinism

4. Dilution of serum potassium

a. Water intoxication

b. Iv therapy with potassium-deficient solution


Manifestations: Fatigue, muscle weakness and cramps anorexiaفقدان الشهية, nausea, vomiting, Dysrhythmias Paresthesia تنميل, decreased muscle strength and DTRs Glucose intolerance


Hypokalemia

Hypokalemia (ECG changes)

ST depression Flat, or inverted T wave Prominent U wave

Hypokalemia (Intervention)

1) Cardiac monitoring & check electrolyte values.

2) Administer potassium orally.

Do not give on empty stomach, may cause N & V

Take liquid K with juice (unpleasant taste )

Discontinue if C/O abd. pain, N, V, D or GI bleeding.

3) Safety measures for patients experiencing muscle weakness

4) Change K-losing diuretic with K-retaining diuretic if indicated

5) Avoid food high in potassium (Avocado, banana, cantaloupe الشمام ,oranges, strawberries فراوله, tomatoes, carrots, spinach, fish, beef, potatoes, raisins زبيب.



IV potassium Never administer K by IV push, IM, or subcutaneous

A dilution of no more than 1mEq/10ml of solution

Before administering rotate and invert the bag.

Properly labeled

Maximum rate is 5-10mEq/h, never to exceed 20/hour

If more than 10mEq/h is ordered, cardiac monitoring and use infusion device

Assess the IV site frequently for phlebitis and infiltration, if occurs, stop the infusion immediately

Assess renal function before administering K, monitor I&O

Hypokalemia (Intervention)

Hyperkalemia

Hyperkalemia: serum K level >5.0 mEq/L

Causes: 1) Excessive potassium intake (food, k supplements)

2) Decreased potassium excretion Potassium-retaining diuretics, Kidney disease, Adrenal insufficiency, such as in Addison’s disease

3) Movement of potassium from the intracellular to the extracellular (Tissue damage, Acidosis)

• Pseudohyperkalemia: occur due to methods of blood specimen collection and cell lysis


Manifestations:

dysrhythmias, muscle weakness with potential respiratory impairment, paresthesias, anxiety, GI manifestations


Management:

1. Cardiac monitoring, Discontinue K, Potassium-restricted diet.

2. administer potassium-excreting diuretics, If renal is not impaired:

3. administer sodium polystyrene sulfonate (Kayexalate), (oral or rectal route) if renal is

impaired ( to promotes gastrointestinal sodium absorption and potassium excretion.

Hyperkalemia

Hyperkalemia (Management)

4) Dialysis

5) IV calcium if hyperkalemia is severe, to avoid myocardial excitability.

6) Hypertonic glucose with regular insulin to move excess potassium into the

cells.

7) When blood transfusions are prescribed, the client should receive fresh blood,

if possible;

transfusions of stored blood (elevate the potassium because the breakdown of older blood

cells releases potassium.


Hyperkalemia

• A potassium imbalance can cause cardiac dysrhythmias that can be life-threatening


Hyponatremia

• Normal level of sodium (Na) 135-145mmole/L

• Hyponatremia: a serum sodium <135 mEq/L

• Manifestations: Poor skin turgor, dry mucosa, headache, decreased salivation, decreased BP, nausea, abdominal cramping, neurologic changes

• Common food sources:

– Bacon لحم الخنزير, Frankfurters السجق , milk, butter, cheese, canned food, Table salt, ketchup, mustard الخردل


Hyponatremia (Causes)

1) Increased sodium excretion

Excessive diaphoresis , Diuretics , Vomiting , Diarrhea and Wound drainage, Kidney disease , Decreased secretion of aldosterone

2) Inadequate sodium intake (Fasting (NPO); Low-salt diet )

3) Dilution of serum sodium

Excessive hypotonic fluids or irrigation with hypotonic fluids

Kidney disease , SIADH, HF, Hyperglycemia, Freshwater drowning


Hyponatremia (Intervention)

1) If Hyponatremia with fluid volume deficit:

Administer sodium chloride infusions to restore sodium & fluid

2) If Hyponatremia with fluid volume excess

Administer Osmotic diuretics to promote the excretion of water

3) If caused by excessive secretion of ADH (vasopressin):

Administer Vasopressin antagonists

4) Increase oral sodium intake

5) If the client is taking lithium:

monitor lithium level, hypornatremia can cause diminished lithium excretion, resulting in toxicity.


Hypernatremia

Hypernatremia: a serum sodium level >145mEq/L

Causes:

1. Decreased sodium excretion

Corticosteroids, Cushing’s s, Kidney disease ,Hyper-aldosteronism

2. Increased sodium intake:

Excessive oral sodium or excessive sodium-containing IV fluid

3. Decreased water intake:

Fasting; nothing by mouth status

4. Increased water loss:

fever, hyperventilation, infection, diaphoresis, watery diarrhea, DI


Manifestations • Thirst; elevated temperature; dry, swollen tongue; sticky mucosa; neurologic

symptoms; restlessness; weakness

Interventions

1. If the cause is fluid loss, administer IV infusions.

2. If the cause is inadequate renal excretion of sodium, administer diuretics that promote sodium loss.

3. Restrict sodium

Hypernatremia


Hypocalcemia

• Calcium normal value: 9.0-10.5

• Hypocalcemia: serum calcium <9.0 mg/dL

• Common food sources: milk, cheese, yogurt, kale كرنب, Sardines

Collard green

الكرنب الاخضر


Hypocalcemia (Causes)

1. Inhibition of calcium absorption from the GIT

Inadequate oral intake of calcium & vitamin D , ESKD, Lactose intolerance, Malabsorption

2. Increased calcium excretion

Kidney disease (polyuria phase), Diarrhea, Steatorrhea, Wound drainage, especially gastrointestinal

3. Conditions that decrease the ionized fraction of ca

Hyper-proteinemia , Alkalosis , Medications, Acute pancreatitis , Hypophosphatemia , Immobility , Removal or destruction of the parathyroid glands


Hypocalcemia

Tests for hypocalcemia.

1) Chvostek’s sign is contraction of facial muscles in response to alight tap over the

facial nerve in front of the ear 2) Trousseau’s sign is a carpal spasm induced by inflating a blood pressure cuff

above the systolic pressure for a few minutes.


Hypocalcemia (Intervention )

1. cardiac monitoring.

2. Administer calcium orally or intravenously.

When administering calcium intravenously:

warm the injection solution to body temperature, administer slowly, monitor for ECG changes, observe for infiltration, monitor for hypercalcemia

3. Administer medications that increase calcium absorption

a. Aluminum hydroxide reduces phosphorus levels, causing the counter effect of increasing calcium levels.

b. Vitamin D aids in the absorption of calcium from GIT


Hypocalcaemia (Intervention )

4. Provide a quiet environment

5. Initiate seizure precautions.

6. Move the client carefully, and monitor for signs of a pathological fracture.

7. Keep 10% calcium gluconate available for treatment of acute calcium deficit

8. Instruct the client to consume foods high in Ca


Hypercalcemia

Hypercalcemia: serum calcium level >10.5 mg/dL

Causes:

1. Increased calcium absorption

Excessive oral intake of calcium, vitamin D

2. Decreased calcium excretion

Kidney disease, Use of thiazide diuretics

3. Increased bone resorption of calcium

Hyperparathyroidism , Hyperthyroidism, Malignancy , Immobility, Use of glucocorticoids

4. Hemo-concentration

Dehydration, Use of lithium, Adrenal insufficiency


Hypercalcemia

Manifestations: • muscle weakness, incoordination, anorexia, constipation, nausea and vomiting,

abdominal and bone pain, polyuria, thirst, ECG changes, dysrhythmias

Interventions

1) Place the client on a cardiac monitor.

2) Discontinue IV infusions containing calcium and oral medications containing calcium or vitamin D.

3) Thiazide diuretics may be discontinued and replaced with diuretics that enhance the excretion of calcium.


Hypercalcemia (Interventions)

4) Administer medications that inhibit calcium resorption from the bone, such as phosphorus, calcitonin.

5) dialysis if medications fail to reduce the serum calcium

6) Monitor for signs of a pathological fracture.

7) Strain the urine to check for the presence of urinary stones.

8) Instruct the client to avoid foods high in calcium


Hypercalcemia

• A client with a calcium imbalance is at risk for a pathological fracture.

• Move the client carefully and slowly; assist the client with ambulation.


Fluid and Electrolytes: Balance and Disturbance

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