Fluids and Electrolytes Sp 09

8/14/2019 Fluids and Electrolytes Sp 09

1/119

Fluids and Electrolytes

Vesta Fairley RNC, MSN, OCN


2/119

Fluid and Electrolyte Balance

Internal equilibrium

Balanced body systems

Steady state

Fluids, electrolytes

osmolarity are maintainedwithin narrow limits


3/119

We Are in Fluid Balance

Maintain blood volume

Transport nutrients

Medium for chemicalfunction

Cushions, lubricates, gives

structureMaintain body temperature

Eliminates waste


4/119

What Influences the Amount of

Body Fluid?

Body fat / elderly

Age

Gender


5/119

Body Fluid Compartments

Extracellular Intracellula

Interstitial

intravascular


6/119

Body Fluid Compartments

xtracellularIntracellula

Interstitial

intravascular

Third space


7/119

Fluid and Electrolyte Balance

Intracellular

Potassium (k+)

Proteins ( -) Magnesium (mg++)

Phosphates (PSO4

=)

Sulfate (SO4 =)

Extracellular

Sodium(Na+)

Organic Acids Chloride (Cl-)

Bicarbonate

(HCO3-)

Calcium (Ca++)


8/119

Electrolyte Balance

Intracellular Cations Potassium 150 Magnesium 40 Sodium 10

Intracellular Anions Phosphate/ sulfate 150

Bicarbonate10 Proteinate 40

Extracellular Cations

Sodium 142

Potassium 5

Calcium 5

Magnesium 2

Extracellular Anions

Chloride 103

Bicarbonate 26

Phosphate 2, Sulfate 1

Organic acid 5

Proteinate 17


9/119

Electrolyte Functions

Neuromuscular activity

Maintain body fluid volume and

osmolality

Regulates acid base

Distribute body water between

compartments


10/119

Assessment of Imbalance

Change in behavior

LOC, VS

Skin turgor Muscle strength

Condition of mucous membrane

Monitor Intake and output Daily weight


11/119

Evaluation of Fluid Status

Creatinine

Hematocrit

Urine sodium

Blood urea nitrogen

Specific gravity of urine


12/119

Dont Disturb Me Right Now

Routes of Gains

Eating and Drinking Parenteral fluids

Enteral fluids

Total Parenteral Nutrition


13/119

Enteral Feeds

Normal GI motility and absorption arerequired

Pancreatic enzymes and insulinproduction are required

High protein feeds can cause waterdeficit through osmosis. Additional wateris needed


14/119

Routes of Gains and Losses

Output is approximately 1 ml of urine/ kg / hr in

all age groups

300 to 400 ml of water vapor is eliminated bythe lungs every day

100 - 200 ml per day is lost from the GI tract


15/119

Parenteral Fluids

Isotonic - (0.9 %) NS, D5NS, D5 W, LR,

Ringers solution

Hypotonic - Normal saline, Normal

saline

Hypertonic - 3% and 5% sodium solution,

Concentrated dextrose solutions, Whole

blood, albumin, TPN, lipids


16/119

Normal Saline ( 0.9% )

Isotonic, Osmolality of 308 mOsm / L

Used to treat extracellular fluid deficit

Supplies only sodium and chloride Can cause fluid volume excess and

hyperchloremic acidosis if given in

excessive amounts Only solution administered with blood


17/119

5% Dextrose in Water ( D5W )

Isotonic - Osmolality of 252 mOsm / L

Hypotonic when administered

Supplies free water to aid in renalexcretion

Corrects increased serum osmolality

Caloric value about 170 kcal / L


18/119

Ringers Solution

Contains electrolytes (NA, Cl, K, Ca)

Lactated ringers contain lactate which is

bicarbonate precursors

Used in the treatment of hypovolemia(fluid loss,burns,diarrhea)


19/119

Ringers Solution

No calories, dehydration, sodium

depletion, replacement of GI loss

Check urine output before infusing

potassium

Continually assess for electrolyte or

fluid imbalance


20/119

Half Strength Normal Saline

( 0.45% NS )

Hypotonic is used to replace cellularfluid

Provide free water for excretion ofbody waste

Used to treat hypernatremia or otherhyperosmolar conditions


21/119

Half Strength Normal Saline

( 0.45% NS )

Excessive infusion of hypotonic

solutions can lead to intravascular

fluid depletion, decreased blood

pressure, cellular edema and cell

damage


22/119

Dextrose Solutions

(2.5%, 5%, 10%, 20%, 50%)

Hypertonic, Supplies calories as carbs

May cause peripheral circulatory collapse

and anuria in patients with sodiumdeficiency

May aggravate hypokalemia

May irritate veins.

Electrolyte free solution increases body

fluid loss


23/119

Saline Solutions

(0.45%, 0.9%, 3%, 5%)

No calories, fluid replacement,

dehydration, sodium depletion or

hyponatremia

Use chloride solution with caution in

edematous patients with heart, renal or

hepatic disease


24/119

Dextrose Saline Solutions(5% Dextrose in 0.45% or 0.9% NS)

Fluid replacement, calorie feeding, dehydration,

sodium depletion

Use chloride solution with caution in patientswith compromised cardiovascular or pulmonary

status

Continually assess for crackles, edema, and skin

turgor


25/119

I Got the Lytes Knocked Out of Me

Routes of Losses

Kidneys

Skin

Lungs

GI Tract


26/119

He Said Something About a FluidImbalance


27/119

Hypovolemia Sounds Bad

Fluid and electrolytes are lost in the same

proportions

Causes

Vomiting and Diarrhea GI suctioning

Sweating

Decreased intake

Fever, fistulas

Blood loss, burns

Fluid shifts

Diabetes


28/119

Manifestations of Hypovolemia

Acute wt loss and Decr skin turgor

Oliguria / concentrated urine

Postural hypotension and Weak rapid

pulse. Flattened neck veins Increased temp

Cold clammy skin

Thirst and Anorexia

Muscle weakness and Cramps


29/119

Diagnosis of Hypovolemia

Increased

blood urea nitrogen

hematocrit

sodium and potassium level

urine specific gravity


30/119

Management of Hypovolemia

Give oral fluids or IV isotonic fluids

Give hypotonic solution, when

normotensive

Assess I&O, weight, VS, LOC, breath

sounds, skin color


31/119

Nursing Measures of Hypovolemia

Measure I & O every 8 hrs (1 hr)

Daily weight

Vital signs Monitor skin and tongue

Urinary concentration

Mental function


32/119

Hypovolemia Sounds Bad

Fluid Is Lost and Electrolytes Are in

Excess

Osmotic diuresis

Cellular dehydration

Circulation failure

Buildup of waste products

Mental changes. Disruption of brain cells


33/119

Signs of Hypovolemia

Weight loss

Thirst

Increased body temperature due to less

water for temp regulation

Dry mouth and throat

M t f H l i


34/119

Management of Hypovolemia

Give one liter of fluid / kg wt loss plusan additional 1.5 liters of fluid to

supply current daily need.

Replace fluid over a period of several

days

Give IV glucose and water to replace

water loss and increase urinary flow to

excrete excess electrolytes 2


35/119

Hypervolemia Sounds Bad Too

Sodium and water are retained in thesame proportions

Causes CHF Cirrhosis of the liver

Regulation Problem Renal failure Fluid overload Increased table salt

5


36/119

Manifestations of Hypervolemia

Weight gain

Polyuria

Distended neck

veins

Elevated blood

pressure

Full bounding

pulse

Dyspnea

Tachypnea Ascites

Peripheral edema

Change in mentalstatus

Diagnostic - Decreased BUN and hematocrit


37/119

Nursing Assessment

Hypervolemia

MonitorDaily weight

Intake and output

Blood pressureRespiratory rate

Lab values

Sacral edema in bedriddenpatients

Auscultate lung sounds


38/119

Management of Hypervolemia

Treat causative factors

Restrict fluids and sodium

Diuretics

Dialysis


39/119

Hypervolemia

Water Excess or Water Intoxication

Causes Sodium deficit

Water intake excessive

Intake of electrolyte free fluids Increased secretion of antidiuretic

hormone

Inadequate output of urine


40/119

Signs of Hypervolemia

Change in behavior

Hyperventilation

Sudden weight gain Warm, moist skin

Increased intracranial pressure

Peripheral edema, usually not marked


41/119

Management of Hypervolemia

Water restriction

Lasix and hypertonic saline (5%)

Obtain hourly intake and output Obtain body weight

Auscultate breath sounds

Obtain serum sodium levels

Assess neurological status

Assure patient safety


42/119

Have you lost

your

electrolytes?


43/119

Sodium

Imbalance


44/119

Sodium

(135 - 145 meq/ L)

Extracellular

Regulates fluid balance Essential for glucose to be

transported into the cells

Necessary for muscle and nerveaction

Helps maintain acid base balance


45/119

Causes of Sodium Imbalance

Diuretics

Restricted sodium intake

GI or biliary drainage, draining fistulas

Disease interfering with aldosterone

secretions

Third spacing, heavy perspiration, fever

Chronic renal disease

Manifestations of Sodium


46/119


Imbalance

Hyponatremia Headache

Anorexia and N &V

Muscle cramps Exhaustion

Postural HTN

Weight loss

Hypernatremia Swollen tongue and

thirst

Sticky mucous

membranes

Deep tendon reflexes

Peripheral edema



47/119


Imbalance

Hyponatremia Increased

pressure

Mental

confusion Delirium

Shock

Coma

Hypernatremia Pulmonary edema

Postural hypotension

Increased muscle tone Flushed skin

Neurological changes

related to cellular

dehydration

Di ti f S di I b l


48/119

Diagnostic of Sodium Imbalance

Hyponatremia

Decreased sodium level135 / L

Decreased serumosmolality

Urinary sodium content

changes depending oncause

Hypernatreamia

Serum level greaterthan 145 meq / l

Serum osmolalitygreater than 295mOsm/kg

Increased urinaryspecific gravity


49/119

Management of Sodium ImbalanceHyponatremia Shock rapid infusion of normal saline

Replacement of potassium, calcium

bicarbonate Increase sodium PO, GA, IV

Safety measures

Fluid restriction (treatment of choice)

If neurologic symptoms, administers

hypertonic solution


50/119

Management of Sodium Imbalance

Hypernatremia - Increase fluid, Hydratecautiously, Diuretics, Dialysis


51/119

Potassium

Imbalance


52/119

Potassium Normal value 3.5 - 5.5 meq / l

98% inside cell, 2% outside cell

80 % excreted by kidneys

20% excreted in bowels and sweatglands

Responsible for muscle and cardiacactivity

Potentiates digitalis

6


53/119

Causes of Potassium Imbalance

Hypokalemia Decreased food and

fluids intake

Failure to replace

losses

Alterations in acid

base

Hyperaldosteronism

Hyperkalemia Decreased renal

function

Corticosteroids

deficiency

NSAIDS, captopril, K

sparing diuretics,

aged blood


54/119

Causes of Potassium Imbalance

Hypokalemia

Potassium losing

diuretics

Digitalis toxicity, if

person becomes

hypokalemic Kidney and heart

damage

Hypokalemia

Acidosis

Tissue damage and

trauma, infection


55/119

Clinical Signs of Potassium Imbalance

Deficit Nausea and

Vomiting Excessive urination Cardiac arrest Respiratory arrest Dysrythmias

Excess EKG changes

Cardiac arrest

Skeletal muscle

weakness

Muscle spasms

C S f


56/119

Clinical Signs of Potassium Imbalance

Deficit Fatigue, muscle

weakness Paralytic ileus Abdominal

distention Anorexia

Leg cramps

Excess Paralysis

Nausea

Intestinal colic

Diarrhea

Diagnostics of Potassium


57/119

Diagnostics of Potassium

Imbalance

Hypokalemia Potassium is less than 3.5 meq / L

Sensitivity to digitalis

Alkalotic (metabolic)

Hyperkalemia Elevated potassium level EKG changes

Acidotic (Metabolic)


58/119

Rapid rise in

potassium canbe lethal

Management of Hypokalemia

Oral or IV potassium IV must be on a pump

Schlerose and burns veins

20 meq / hr rate

Concentration < 40 meq/ l

Agitate solution to mix well Must have adequate urine

output

Monitor potassium level

M t f P t i E


59/119

Management of Potassium Excess

EKG and serum potassium level

No oral intake of foods high in

potassium

D 10 with regular insulin Kayexelate

Dialysis

Calcium gluconate IV or sodium

bicarbonate

Bedrest


60/119

Calcium

Imbalance


61/119

Calcium

Serum calcium level 9.0 11.0 mg / dl

Functions

Blood coagulation

Smooth skeletal functions

Cardiac muscle function

Nerve function Bone and teeth formation


62/119

Hypocalcemia

Causes

Inadequate intake or vitamin D deficiency

Hypoparathyroidism

Pancreatic disease

Excess loss through intestinal fistulas

Hyperphosphatemia

Magnesium deficiency

Medications


63/119

Hypocalcemia

Clinical Manifestations

Tetany

Numbness and tingling of the nose, fingers, andtoes

Muscle spasm and muscle pain

Seizures Mental changes such as depression, confusion,

hallucinations


64/119

Trousseaus Sign


65/119

Hypocalcemia

Diagnostics

Decreased corrected calcium

Increased ph

Decreased parathyroid hormone

Decreased magnesium

Decrease phosphorus


66/119

Hypocalcemia

Management

Increase calcium in diet or oral calciumsalts

10 % calcium gluconate IV

Vitamin D or parathyroid hormone

Give aluminum hydrate


67/119

Hypercalcemia

Serum calcium level > 11mg / dl

Causes Malignant neoplastic disease

Hyperthyroid disease

Immobilization

Thiazide diuretics

H l i


68/119

Hypercalcemia

Mild

Polyuria

Severe thirst

Anorexia

Nausea and vomiting Constipation

H l i


69/119

Hypercalcemia

Progressive

Lethargy

ConfusionComatose

Bone pain


70/119

Hypercalcemia


71/119

Hypercalcemia

DiagnosisSerum calcium level > 11 mg / dl

Increased parathyroid hormone

levels

PotassiumSodium

Phosphorus

Urine bun and creatinine Cardiovascular changes

Hypercalcemia


72/119

Hypercalcemia

Treatment Remove the cause

IV saline and diuretics

Calcitonin

Mitramycin, aredia, didronel

Glucocorticoids if cause is cancer

Increase fluid intake to 3 4 L / d to reduce

calculi formation


73/119

Magnesium

Imbalance

Magnesium


74/119

MagnesiumFunctions

Level 1.5 2.5 meq/l

Activates enzyme reaction especially

carbohydrates and proteins

Prevent convulsions in toxemia in pregnancy

Acts as a vasodilator which decreases blood

pressure

Similar to calcium in muscular and nerve

function

Hypomagnesemia


75/119

Hypomagnesemia

Causes Calcium deficit

Loss of intestinal fluids through draining

fistulas, diarrhea, stetorrhea and GI suctioning Alcoholism or prolonged malnutrition Drug therapy with aminoglycosides and loop

diuretics

Endocrine disorders such as increasesecretion of antidiuretic hormone aldosterone

and thyroid hormone

Hypomagnesemia


76/119

yp gClinical Manifestations

Confusion

Hallucinations

Weakness

Convulsions

Depression

Increased reflexes

Tremors

Muscle spasms

Trousseau's sign andchvostek's sign

Hypomagnesemia


77/119

Hypomagnesemia

Diagnostics

Serum albumin < 1.5 meq / l

Decreased potassium and calcium level

Management

Correction of the underlying problem

Mild cases can be corrected by diet alone

Oral magnesium salts

IV magnesium sulfate (calcium gluconate must be

readily available


78/119

Hypermagnesemia

Causes

Can result from frequent use ofmagnesium containing antacids

Can be caused by renal failure

Can be caused by a adrenocortical

insufficiency

Hypermagnesemia


79/119


Mild

Decreased blood pressure

Facial flushing Sense of heat

Thirst

Nausea and vomiting

Hypermagnesemia


80/119

Hypermagnesemia


ModerateLethargy

Difficulty speakingDrowsinessLoss of deep tendon reflexes

Muscle weaknessParalysisRespiratory depression


81/119

HypermagnesemiaDiagnostic

Level > 2.5 mg / dl

Management

Calcium gluconate (temporary treatment)

Hemodialysis with a magnesium free

dialysate Duretics and 0.45% NACL to enhance

excretion


82/119

Phosphorus

Imbalance

Ph h


83/119

PhosphorusNormal serum level 2.5 - 4.5 meq / dl

Functions

RBC formation (ATP)

Metabolism of carbohydrates, fats and

proteins

Maintenance of acid base balance

Nerve and muscle function

Support of bones and teeth

H h h i


84/119

Hypophosphoremia

Causes Overzealous intake of carbohydrates

Anorexia nervosa

Alcoholism or alcohol withdrawal

Poor dietary intake

Thermal burns

Vitamin D deficiency

Diabetic ketoacidiosis

Diagnostics -Level < 2.5 mg / dl

Hypophosphoremia


85/119

Hypophosphoremia

Irritability

Apprehension

Weakness

Numbness

Confusion

Seizures

Coma

Tissue anoxia

Bruising

Bleeding

Clinical manifestations

ManagementOral phosphorus replacement

IV phosphorus

H h h i


86/119

Hyperphosphoremia

Causes Decreased excretion of phosphorus

Increase phosphorus intake of absorption Muscle necrosis

Diagnostics Level > 4.5 mg / dl

Abnormal bone development


87/119

Hyperphosphoremia

Clinical manifestations

Complication of joint calcification

Tetany - tingling of fingers and toes Anorexia

Nausea

Vomiting Muscle weakness


88/119

Hyperphosphoremia

Management

Treat underlying disorder

Allopurinol Restrict dietary phosphorus

Dialysis

Phosphate binding gels


89/119


90/119


T t l P t l N t iti


91/119


Method of giving highly concentrated solutions

Intravenously to maintain a patients nutritional

Balance when oral or enteral nutrition is not

Possible

12

Total Parenteral N trition


92/119


Indications Major GI diseases

Fistulas and inflammatory disease

Severe trauma or burns Severe GI side effects from radiation or

chemotherapy

Congenital malformations of the GI tract

Severe malnutrition

12

Contents of All TPN


93/119

Contents of All TPN

Water

Proteins

Carbohydrates

Fat Vitamins

Trace elements

Dextrose 25% 35%

Amino acids 3% 5%

Electrolytes Minerals

Vitamins

Fat emulsions 10% 20%

12



94/119

Administration

Must be on a pump

If TPN is stopped for any reason, hang D10 or D5

as ordered Only lipids can be hung with TPN

Lipids are unfiltered, TPN is filtered

12



95/119

Administration

Must be on a pump

If TPN is stopped for any reason, hang D10 or D5

as ordered Only lipids can be hung with TPN

Lipids are unfiltered, TPN is filtered

12



96/119

Administration

12

Must be through a central line

D 10 or less can be administered

through a peripheral IV



97/119

Administration

12

Maintain strict aseptic technique

May be unrefrigerated < 30 minutes

prior to admin

Use within 24 hours after mixing



98/119

Administration

12

Dressing change every 72 hours if

central line or every 48 hours if

peripheral line



99/119

Administration

12

Although the bags are

numbered, pay attention to the

expiration date



100/119

Administration

Start administration slowly about 25 cc / hr

Gradually increase rate about every 4 hrs in

25 cc increments until ordered rate is reached

When discontinuing, gradually taper off over

about 6 hours

Monitor blood glucose levels every 4 hours

12

T t l P t l N t iti


101/119


Mechanical complications

Pneumothorax

Hemothorax Air embolism

Catheter misplacement

Thromboembolism

13

Mechanical Complications


102/119


Pneumothorax, hemothorax

Needle tip penetrated the pleura of the lung which

usually occurs in thin malnourished patients

Pneumothorax is characterized by a sudden sharp

pain around the area where the needle was

inserted, coughing, chest pain, cyanosis or

becomes hypotensive

13



103/119


Air Embolism

Occurs when changing the

tubing or when the tubing isseparated

100 - 200 cc of air is fatal

12


104/119


105/119

Management of Air Embolism

Place in trendelenburg

Lay on left side

Perform the valsava maneuver, while

disconnecting the tubing

13



106/119


Thromboembolism

Predisposition Venous stasis

Hypercoagulable state

Local trauma

13

Prevention of


107/119

Prevention of

Thromboembolism Heparin added to the solution

Thrombosis may be asymptomatic

Signs of pulmonary embolism may

be the first sign of thrombosis

13

Catheter Related Sepsis


108/119

Catheter contamination is the major sourceof TPN sepsis

Catheter sepsis can be minimized by aseptic

technique in the maintenance as well as

insertion and restricted use of catheter for

nutrition use only

13

Metabolic Complications


109/119


Glucose intolerance

Hypoglycemia can result from sudden

withdrawal of a prolonged infusion

Symptoms include diaphoresis, confusion

and agitation

Treatment include frequently monitoring ofglucose levels and reinstitution an infusion

of 10% dextrose in water

13



110/119


Glucose intolerance Hyperglycemia infusion rate too fast for

the patient's insulin response

Treatment for a patient with

hyperglycemia is to increase the

percentage of calories provided by fat,infusing glucose infusions slowly, and

providing insulin when necessary

13

Metabolic Compensation


111/119

Metabolic Compensation

Hypomagnesemia

Symptoms include apathy, weakness,

seizures, arrhythmia hallucinations,hyperreflexia

Symptoms resolve rapidly withmagnesium replacement

13



112/119

Hypophosphatemia Signs and symptoms include tremor,paresthesias. Ataxia, decreased platelet

and erythrocyte survival, impaired

leukocyte function and weakness

Treated with 10 - 15 mmol of phosphate per

liter of solution

13


113/119

Complication Fluid Imbalance

Volume infused is excessive

Treatment consist of decreasing the

rate of fluid and optimizing cardiac andrenal function

13

Complications Acidosis


114/119

Complications Acidosis

Acidosis occurs when carbohydrates arebroken down

The increased production of carbondioxide can induce respiratory distress

Abnormal neurological symptoms includedisorientation, lethargy , stupor, and

convulsions which can lead to coma and

death

13

Administration of Lipid


115/119


Emulsions

Lipids can be piggybacked in the

TPN but it has to be below the

filter preferably close to the

insertion site

13



116/119

Emulsions

The rate is usually 30 - 60 ml/hr

10% emulsion - 30 ml / hr for 30

min 20% emulsion - 15 ml / hour for 30

min

Gradually increased to prescribeddose if no reaction



117/119


Emulsions

Lipids can be given peripherally

Lipids can be given to a patient who

is glucose intolerant


118/119


119/119

Fluids and Electrolytes Sp 09

Documents

Transcript of Fluids and Electrolytes Sp 09