med surge power point

NUR 335 Fluid & ElectrolytesSharon Y. Rafalko, MS, RN

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Objectives

Identify clients who are at risk for fluid, electrolyte imbalance.

Asses a client experiencing fluid, electrolyte imbalance.

Formulate nursing diagnoses for a client experiencing fluid, electrolyte imbalance.

State expected outcomes for the client experiencing fluid, electrolyte imbalance.

Review the pathophysiology of and pharmacology use in various types of fluid, electrolyte imbalances.

Discuss the nursing and collaborative management for the client experiencing an imbalance in fluid, sodium, potassium, calcium, magnesium or phosphate levels.

Explain the educational needs for the client, family and/or significant other regarding imbalances in fluid, sodium, potassium, calcium, magnesium or phosphate levels.

Evaluate the nursing and collaborative management for the client experiencing an imbalance in experiencing an imbalance in fluid, sodium, potassium, calcium, magnesium or phosphate levels.

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Inspiration

“The most rewarding things you do in life are often the ones that look like they cannot be done.”

Arnold Palmer

Electrolyte Imbalance Nursing Actions

Hyper and hypokalemia, hypo and hyper Mg, hyper Ca-EKG changes, cardiac monitor

Replace fluids and electrolytes

Treat panic values

Assess lab values

Monitor I & O

Assess for medications that influence electrolytes

Function of Body Water

Needed to maintain homeostasis

Internal equilibrium needed to stay alive

Transport (02, nutrients, electrolytes and waste products, etc)

Body temperature regulation

Lubricant - joints

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Fluid and Electrolyte Balance

Necessary for life, homeostasis

Nursing role: help prevent, treat fluid, electrolyte disturbances

Body Fluid Compartments

Water occupies two main fluid compartments

Intracellular fluid (ICF) – about two thirds by volume, contained in cells

Extracellular fluid (ECF) – consists of two major subdivisionsPlasma – the fluid portion of the blood Interstitial fluid (IF) – fluid in spaces

between cells

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Fluid Compartments

8Figure 26.1

General Rules

Younger people have higher percentage of body fluid than older people

Men have higher percentage of body fluid than women

Obese people have less fluid than thinner people – fat cells contain little water

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The Elderly Increased risk for fluid and electrolyte and

acid-base imbalancesDecreased total body volume Decreased renal blood flow leading to

decreased creatinine clearance Decreased secretion of aldosterone, ADH,

Natriuretic peptides Tend to consume less fluid due to decreased

thirst sensitivity and accessibility to fluidHypernatremia

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Memorize Values

Important to know the ranges

If it is too high, need to remove it

If it is too low, need to give/replace it

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.Sodium Na+ 135-145

Potassium K+ 3.5-5.0

Calcium Ca+ 9.0-11

Magnesium Mg+ 1.5-2.5

Chloride Cl- 96-106

Bicarbonate HCO3-

22-26

Phosphate PO4-

2.8-4.5

Electrolytes

What is an electrolyte?

A substance that, when dissolved in water, dissociates (separates) into electrically charged particles

Table salt or Sodium Chloride when dissolved in water becomes Na+ and Cl-

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Major Electrolytes

Cations (+ charge)

Sodium Na+

Potassium K+

Calcium Ca+

Magnesium Mg+

Anions (- charge)

Chloride Cl-

Bicarbonate HCO3-

Phosphate HPO4-

Sulfate SO4-

Protein14

• Present in body fluids

• Concentrations in intracellular differ from extracellular

Extracellular and Intracellular Fluids

Extracellular fluids are similar (except for the high protein content of plasma)

Sodium is the chief cation

Chloride is the major anion

Intracellular fluids have low sodium and chloride

Potassium is the chief cation

Phosphate is the chief anion

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Osmolarity

Used to describe the number of solute particles in a volume of fluid

Normal osmolarity is contributed to mostly by sodium, chloride, potassium, urea and glucose, as well as other ions and substances in the blood.

Increases with dehydration and decreases with over-hydration

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Osmosis

Net movement of water across a selectively permeable membrane

Driven by a difference in solute concentrations on the two sides of the membrane.

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“Water Follows Solutes”

Blood: Few solutesLots of water Cell:

Many solutesLess water

H2O

Osmosis

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Blood: Many solutesLess of water Cell:

Less solutesMore water

H2O

Osmosis

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Fluid Shifts

Edema Imbalances in hydrostatic and oncotic pressure

Cause fluid to shift into the interstitium (tissue spaces)

Conditions that can cause fluid shifts:Heart failure

Low plasma protein seen in liver and renal diseases and malnutrition

Leakage of protein resulting in loss seen with severe trauma and burns.

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Fluid Spacing

First spacing normal distribution of fluids in the ICF & ECF compartments

Second spacing abnormal accumulation of interstitial fluid as seen in edema

Third spacing accumulation of fluid in portions of the body which is not

easily exchanged with the rest of the ECF fluid is trapped and unavailable for use

AscitesPeritonitis intestinal obstructionedema associated with severe burns

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Regulation of Water Balance

Hypothalamic and Pituitary

Release of ADH Increase in plasma osmolality or decrease in blood volume will stimulate

thirst and the release of ADH

More ADH: s/p surgery

Opioid analgesics

Increased ADH production: SIADH

Decreased ADH production: DI

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Adrenocortical and Renal Aldosterone: retain Na+ and excrete K+

Cortisol: in large amts- Na+ and H2O retention

Renin Angiotensin Aldosterone (RAA)

Cardiac Atrial Natriuretic Peptides (ANP)

Antagonist to the renin-angiotensin-aldosterone system.

Released in response to ↑blood volume, ↑BP and ↑Na+ levels

Act on the renal tubules to enhance excretion of Na+ & H20, leading to decreased blood volume and pressure.

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Gastrointestinal

Oral intake accounts for most intake

2000 – 3000 mL/day

Usual output 100-200 mL /day

Insensible loss

Fluid loss from skin and lungs due to invisible vaporization

900 ml/day (~600 skin evaporation; ~300 water vapor from lungs)

Diaphoresis not included in insensible loss

Amount Ingested = Amount Eliminated

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Fluid and Electrolyte Disturbances

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Fluid Volume Excess

Causes Increased intake or excessive retention

HF, RF, cirrhosis

Long term steroid use

NA+ retention

Excessive administration of Na+-containing fluids

Clinical Manifestations ↑BP, JVD, edema, crackles, dyspnea…SOB,

wheezing

weight gain (simple most important indicator)

NA+ < 135 -- ↓BUN, ↓Hct

Serum Osmo < 280

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Fluid volume Excess

TreatmentRemove excess fluid without disturbing

electrolyte balance

Main therapy: diuretics and fluid restriction

NA+ restriction

Drainage of fluid in cavities:Third spacing in peritoneal space (ascites)

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Fluid volume Excess

Nursing careAssessmentPt teaching

-Nursing DiagnosesExcess fluid volume r/t compromised regulatory

mechanisms as evidenced by…Impaired gas exchange r/t altered oxygen

supply as evidenced by…

- GoalsClient’s fluid and electrolyte status will return to

normal levels within (timeframe)

Fluid Volume DeficitCauses

Excessive fluid loss (both water & electrolytes): diarrhea, third spacing (burns, ascites), excessive diaphoresis (fever), DI, inadequate fluid intake

Dehydration is loss of water without Na+lossClinical Manifestations

Drowsiness, restlessness, thirst, dry mouth, Decreased skin turgor (elderly= forehead tenting)Postural hypotension Weight loss Decreased UOP with increased BUN NA+ > 150Osmo > 305

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Nursing Interventions: I & O

I&O and… Fluids that cannot be measured can be estimated (scant, small,

medium, large) Urine specific gravity Maintain IV at correct rate (use caution with renal, cardiac, neuro

problems) Add supplemental water to enteral feeds to prevent hyperosmolality

and abnormal fluid shifts Clients with NGT suction should not be given water (increases loss of

electrolytes)

Irrigate NGT with NS only to prevent loss of electrolytes

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Fluid Volume Deficit

Collaborative care

Goal is to correct underlying cause and replace needed fluid and electrolytes

Fluid replacement with isotonic IV fluids

LR or NS

Blood transfusion

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Fluid Volume Deficit

Nursing careAssessment: SOAP

Nursing DiagnosesDeficient fluid volume r/t excessive ECF losses as

evidenced by decreased fluid intake

Decreased cardiac output r/t excessive losses as evidenced by…

GoalsClient’s fluid and electrolytes will return to normal levels

within (time frame)

FVD: Laboratory Data

elevated BUN in relation to serum creatinine,

increased hematocrit

Serum electrolyte changes may occur

Nursing Interventions for Fluid Extracellular Imbalances Intake & Output

Accurate record of I and O Urine Specific gravity

concentrated urine >1.020 Diluted urine

Cardiovascular Excessive: bounding pulse, HTN, JVD, Deficit: postural hypotension, decreased BP, weak -

thready pulse, ↓CVP Respiratory

Excessive: Pulmonary congestion, SOB, crackles, moist cough

Deficit: increased RR r/t hypoxia from decreased circulating volume

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FVD: Manifestations

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Medical management: provide fluids to meet body needs

Oral fluids

IV solutions

FVD: Medical ManagementFVD: Medical Management

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Nursing Interventions for Fluid Extracellular ImbalancesNeurological

Excessive: cerebral edema

Deficit: decreased cerebral perfusion

Daily Wt.Single most important measurement for fluid

volume statusSame time, same scale, same clothing

1 L (2.2 lbs) = 1 liter of fluid (lost or retained)

Skin assessment & careTurgor in elderly = over sternum or forehead

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Fluid & Electrolyte Replacement

Oral

Preferred route to correct mild imbalances

IV

Common route for acute moderate to severe imbalances and if unable to take PO

Fluid challenge

Isotonic solutions initially

Can change to hypotonic once normotensive

Nursing interventions: Elderly

Access to fluids: assist with fluid intake

Offer drinks at the client’s preferred temperature

Offer the majority of fluids with meals (80%)

Decrease fluids at least 2 hours before bedtime to prevent nocturia and incontinence

Accurate I & O

Tonicity in the RBC

An IV solution’s effect on body fluid movement depends in part on its tonicity, or concentration.

REMEMBER: THERE IS GREATER NA+ CONCENTRATION IN THE ECF VERSUS THE ICF

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IV Types

IsotonicTonicity falls within (or near) the normal range for

blood serum275 to 295 mOsm/kg

No change in the concentration of solute and water in the bloodstream

Osmosis neither moves water into the circulation nor pulls it out.

0.9 NACL ; LR; D5W (functions as hypotonic once glucose is metabolized)

Treatment for ECF deficits – expands ECF volume

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Isotonic

A solution with exactly the same water concentration as the cell

There will be no net movement of water across the cell membrane.

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Blood: Na+ Con. 0.9%

Cell: Na+ Conc. 0.9%H2O

Isotonic

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IV TypesHypotonic

Lower osmolality than blood serumMore water (relative to solute) is being infused than

is already present in the vessel and inside the cells. Therefore, water moves into the cells Indicated for hypernatremia and hyperosmolar

conditions Replaces cellular fluid & provides free water

Can cause cerebral edema and Hypotension from intravascular depletion

Contraindicated in edema and third spacing0.45 NS (1/2 NS) , D5 .45

Hypotonic

A dilute solution, with a higher water concentration than the cell

The cell will gain water through osmosis.

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Blood: Na+ Con. < 0.9%


Hypotonic

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IV Types

Hypertonic

Higher osmolality than blood serum

Osmosis pulls water out of the cells

Cell shrinkage

Increased osmolality of ECF - expands it

Indications: Hyponatremia

3% NACL, D10W, D50W

Hypertonic

A concentrated solution, with a lower water concentration than the cell —

The cell will lose water by osmosis.

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Blood: Na+ Con. > 0.9%


Hypertonic

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Other IVF Types

Plasma Volume Expanders

Stays in the intravascular compartment and increases oncotic pressure

Colloids Protein solutions - albumin (5% or 25%)

Synthetic molecules - Dextran, Hespan (Hetastarch)

Whole blood or packed red blood cells [PRBCs] Indicated for fluid losses from ECF (hemorrhage or

sepsis)

Complications of IV Therapy

Fluid overload

Air embolism

Septicemia, other infections

Infiltration, extravasation

Phlebitis

Thrombophlebitis

Hematoma

Clotting, obstruction

Electrolyte ImbalancesElectrolyte Imbalances

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Sodium Overview

Normal value : 135 – 145 mEq/L

Functions Na determines ECF osmolality

Affects distribution of water between ECF & ICF

Necessary for muscle contraction and nerve impulse transmission

Regulated by ADH, thirst, & RAA system

Gains - taken in via GI tract in food, fluids, medications

Loses - excreted in sweat, urine and feces57

Hypernatremia

Definition [Na > 145 mEq/L] Elevated serum Na level either due to water loss or too

much Na gain. Hyperosmolality causing shift of water out of the cell

and cellular dehydration. Causes

Common in elderly/cognitively impaired Hypertonic enteral feeding w/o water supplementation Excessive Na intake (can be too much Na+ IVF too!!!) Increase insensible water loss such as fever or

heatstroke, osmotic diuretic and diarrhea Disease states such as diabetes insipidus, Cushing

syndrome, uncontrolled DM, hyperaldosteronism 58

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Hypernatremia

Clinical Manifestations

Shifts water out of cell into ECF…cellular dehydration…neurological manifestations!

With decreased ECF volume

Intense thirst, dry, swollen tongue, postural hypotension, decreased CVP, wt loss, oliguria, weakness, ↓DTRs

With normal or increased ECF volume

As above with peripheral and pulmonary edema, increased BP

Hypernatremia


Neurological changes related to cerebral cellular dehydration

Stupor, coma, death

Labs

Serum Na >145 mEq/L

Serum Osmo >300 mmol/L

Urine SG & urine osmo: ↑

Unless…DI= dilute urine

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Hypernatremia

Nursing care Goals

determine underlying cause

prevent further water loss and replace fluids

Interventions Hypotonic IV fluids (D5W or ½ NS reduce Na level)

Promote excretion of excess Na with diuretics

Dietary Na restrictions (foods, fluids, medications, etc).

Reduce Na level no faster than 0.5-1 mEq/L/h

Hyponatremia

Definition [<135 mEq/L] Deficient Na in due to loss of NA+ or excessive fluid

gain or a combination of both. Hypo-osmolality with resultant water shift into the cells

(swelling) Causes

Excessive Na loss (diarrhea, vomiting, fistulas, NGT suctioning, diuretics, adrenal insufficiency, burns, wound drainage);

Inadequate Na intake (fasting diets); Excessive water gain leading to low Na concentration

(excessive hypotonic IV fluids, polydypsia) Disease states (SIADH, heart failure,

hypoaldosteronism from adrenal insufficiency)

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Hyponatremia


With decreased ECF volume

irritability, tremors, seizures, coma

postural hypotension, ↓ CVP, tachycardia, thready pulse

With normal or increased ECF volume

headache, confusion, seizure, coma

wt gain, increased BP and increased CVP

N/V, anorexia, muscle cramps, weakness

Na <115 mEq/L = severe

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Hyponatremia

Nursing care

– usually only fluid restriction is needed to correct the problem.

Unless if hypovolemic hyponatremia from GI losses, diuretics, etc..

– If seizures develops, small amount of IV hypertonic solution (3% NaCl) to restore serum Na level

– Monitor 3% NACL carefully

Can lead to hypernatremia and cerebral dehydration

Potassium Overview Normal value: 3.5 – 5-0 mEq/L Functions – Major ICF cation

Necessary for skeletal and cardiac muscle contraction

Gains – Diet is main source Losses –

Kidneys are major route of K loss (90%) and remainder is loss in sweat and stool

Impaired kidneys will result in toxic level of K in body and potential for cardiac dysrrhythmias

Na and K has an inversed relationship (when one is excreted, the other is retained)

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K+ Movement in the ECF and ICH

K can move from ICF to ECF resulting in high serum K level

Acidosis, Trauma to cells

K can move from ECF to ICF resulting in low serum K level

Insulin, Alkalosis

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Hyperkalemia

Definition [K >5.0 mEq/L]

Causes Massive intake of K (IV administration, K-

containing drugs, salt-substitute) Impaired renal excretion of K (renal disease, K-

sparing diuretics [e.g. Aldactone]) Adrenal insufficiency ACE inhibitors [Vasotec] Shift of K from ICF to ECF (Acidosis, tissue

breakdown or crushed injury) Pseudohyperkalemia

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Hyperkalemia


Irritability, anxiety, abdominal cramps, diarrhea, weakness of lower extremities, paresthesias, flaccid paralysis.

Ventricular dysrhythmias & cardiac arrest if condition is sudden or severe.

EKG Changes

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Lewis al, 2007

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Hyperkalemia

Medical & Nursing care Eliminate intake of K (oral & parenteral)

Increase elimination of K administrate diuretics

Dialysis

Kayexalate

Force K from ECF to ICF IV insulin [including glucose to prevent hypoglycemia]

NaHC03 [to correct acidosis]

IV calcium gluconate to antagonize deleterious effects of hyperkalemia on the heart

Hypokalemia

Definition [K <3.5 mEq/L]

Causes Abnormal K loss

diarrhea, vomiting, fistulas, NGT suction, diuretics

K shift into cells increased insulin, alkalosis,

Lack of K intake

Hyperadldosteronism

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Hypokalemia


Fatigue, muscle weakness, leg cramps, nausea, vomiting

Paralytic ileus, paresthesias, decreased reflexes, decreased bowel motility

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EKG Changes

Lewis et al, 2007

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Hypokalemia

Nursing care

Administrate K supplements orally

IV replacement

Ensure urine output is at lease 0.5 ml/kg

Add no more than 60 mEq/ L KCl in IV fluids (40 mEq/L is normal) and administer slowly

Always on an IV pump!!!!!

Encourage high K diet

Teach client how to prevent low K level

NURSE ALERT!!!

K+ is NEVER given IV push or ________!!!!!!

Calcium Overview Normal value

4.5 – 5.5 mEq/L or 9 – 11 mg/dl Functions

Transmission of nerve impulses, myocardial contractibility, blood clotting, formation of teeth and bone, and muscle contractions

Gains Foods (only 30% is absorbed via GI tract) 99% combines with phosphorus and stored in bones inverse relationship with phosphorus PTH increases serum CA++

Loses Low albumin results in low calcium level in serum Calcitonin decreases serum CA++ Decreased Vit D leads to decreased Ca++ absorption

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Hypercalcemia

Definition

[Ca > 10.2 mg/dL]

Causes

multiple myeloma, prolonged immobilization, hyperparathyroidism, vitamin D overdose

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Hypercalcemia


Lethargy, weakness, depressed reflexes, decreased memory, confusion, personality changes, psychosis, anorexia, nausea & vomiting

Increased urine output and dehydration

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Hypercalcemia

Nursing care

Treat underlying cause

Promote excretion

loop diuretic

Phosphate administration

Hydrate with isotonic saline

Promote Ca loss in urine

Prevent ca stone formation

Synthetic Calcitonin

Increased bone reabsorption, increases urinary Ca excretion

Hypocalcemia Definition

[Ca < 8.6 mg/dL]

Causes

– Decreased total CA++: hypoparathyroidism

chronic renal failure

Administration of Lg. amts of citrated blood

vitamin D deficiency

Pancreatitis

low serum albumin level

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Hypocalcemia Assessment

Primarily affects nerve transmission and muscle (cardiac) functionNeuromuscular

Numbness, tingling

Muscle crampstwitching

Tetany

the involuntary contraction of muscles

Convulsions

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Trousseau’s Sign

Apply BP Cuff Inflate to over 20mm

HG above BP Adducted thumb Flexed wrist Extended fingers May take 1 to 4

minutes to see the response

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Chvostek’s sign

Tap facial nerve by earBrief

contraction of upper lip, nose, side of face

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Hypocalcemia

Nursing careAdminister oral or IV calcium gluconate as

prescribed (never give CA++ IM necrosis and tissue sloughing)

IV CA++ given in severe cases encourage diet high in calcium and vitamin D supplement

Suspect precipitated hypocalcemia in any client with neck surgery

radical neck dissection thyroidectomy [especial total]observe for manifestations of hypothyroidism in the

immediate post-operative period r/t decreased PTH production

Phosphate Overview

Normal value2.5 – 4.5 mg/dL

Functionsessential for proper functioning of muscle,

RBC, and nervous system Gains

low calcium level results in high phosphorus level and vice versa

Loseskidneys (major route) and feces

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Hyperphosphatemia

Definition

[ P04 > 4.5 mg/dl]

Causes

Renal failure- most common

Chemotherapeutic agents

Excessive ingestion

TPN administration

Hypoparathyroidism

Decreased PTH leads to decreased CA++

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Hyperphosphatemia


Hypocalcemia, tetany, deposition of Ca-P04 precipitates in skin, soft tissue, corneas, viscera and blood vessels

Nursing care

Restrict P04 in diet [dairy product]

Encourage fluids to increase P04 loss in urine

Give calcium supplements and P04-binding agents or gels

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Hypophosphatemia

Definition[ P04 < 2.5 mg/dl]

Causesmalabsorption syndrome, P04-binding antacids,

recovery from DKA, respiratory alkalosis

Clinical Manifestationsconfusion, coma, muscle weakness

Nursing careadminister oral supplement or administer IV P04 for

severe cases;

Magnesium Overview

Normal value 1.5 – 2.5 mEq/L

Functions Important for neuromuscular function

Gains GI tract

Loses Kidney [conserves or excretes in response

to level]

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Hypermagnesemia

Definition [Mg > 2.5 mEq/L]

Causes renal failure, excessive administration or intake

Clinical Manifestations lethargy, drowsiness, nausea, vomiting,

somnolence, loss of deep tendon reflexesloss of deep tendon reflexes respiratory and cardiac arrest

Nursing care promote renal excretion by pushing fluids

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Hypomagnesemia Definition

[Mg < 1.5 mEq/L] Causes

diarrhea, vomiting, chronic alcoholism, impaired GI absorption

Clinical Manifestations confusion, hyperactive deep tendon reflexes,

tremors and seizures Nursing care

IV administration needed for severe cases Respiratory and cardiac arrest from rapid

administration

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