Fluid Electrolyte Imbalance How to keep things flowing

Fluid & Electrolyte Imbalance How to keep things flowing along! Lisa B. Flatt, RN, MSN, CHPN

Body Fluids • Body mostly composed of: ▫ fluid –water ▫ solutes - electrolytes • Osmolality- the balance between fluid and solutes – This is a delicate balance! Every organ and system reacts differently to an imbalance.

Swollen feet and ankles – water is attracted to sodium! • Semi-permeable membrane – selected particles move by passive diffusion – that’s how sodium follows water. • Osmotic pressure is the strength of the solution to draw the water across the SPM. • Passive diffusion – solutions of greater concentrations moves solutes to solutions of less concentration • Filtration – fluid and solutes move across a membrane from area higher pressure to lower pressure • Active transport – substances are moved from low to high concentration areas (metabolic energy & enzymes are used, ie. Sodium potassium pump)

Let’s see… what are the differences…. • • Osmosis – Diffusion – Filtration – Active transport -

Where you can find Body Fluid Intracellular Fluid Extracellular Fluid • Is 2/3 to ¾ of total body fluid • Found inside the cells • Outside the cells • Divided into compartments ▫ Intravascular fluid Plasma- vascular system ▫ Interstitial fluid Surrounds cells – lymph ▫ Transcellular fluid Epithelial cells (synovial fluid)

Potassium • Potassium (3. 5 – 5. 0 me. Q/l) • Found and for: intracellular- cardiac, skeletal and smooth muscle activity • Hyperkalemia- high K ▫ Causes-renal failure & (drug induced) �S/S – tetany, irritability, parasthesia, GI hyperactivity, cardiac arrhythmias �Nursing interventions: Kayexelate (po and pr), D 50 and Insulin, dietary intake • Hypokalemia- low K ▫ Causes-drug induced, N&V&D, gastric suctioning, exercise (shin splints) �S/S – weak, fatigued, cardiac arrhythmias � Nursing Interventions: IV and PO K, po and iv fluids, dietary intake

Magnesium • Magnesium (1. 5 – 2. 5 m. Eq/l) • Found and For: intracellular metabolism, protein and DNA synthesis • Hypermagnesia – high Mg ▫ Causes-drug induced, �S/S – lethargy, coma, impaired respirations �Nursing Interventions- medication, diet • Hypomagnesia- low Mg ▫ Causes – alcoholism �S/S – confusion, disoriented, tremors, irritability � Nursing Interventions – medications, diet

Sodium -- Salt sucks • Sodium (135 - 145 me. Q/l) • Found and For: intra&extracellular – Na and K balance needed in body – key electrolyte • Hypernatremia – high sodium ▫ Causes – increased dietary intake, body system imbalances (kidney) – dehydration of the cells, water gets sucked from the cells and into the tissue � S/S – edema, thirst, confusion, dry mucus membranes, mental status changes � Nursing Interventions- fluid restrictions, diet restrictions • Hyponatremia – low sodium ▫ Causes- exercise and too much water “water toxicity” – water gets sucked from the cells into the tissue (how most people die in the Grand Canyon – they need to take salt pills **Thank you Wes for the fun fact**) � S/S – muscle cramping, N&V, postural hypotension, mental status changes, hallucinations of oasis! � Nursing Interventions – medications, iv fluids, electrolytes

Calcium • • Calcium (8. 5 – 10. 5 me. Q/l) For: blood coagulation, neuromuscular activity and bone growth Found: Located in Bones Hypercalcemia – high Ca ▫ Causes – cancer with met’s to bone, drugs, parathyroid glandular issue � S/S – kidney stones, lethargy, weakness, decreased muscle tone � Nursing interventions: safety, iv fluid • Hypocalcemia – low Ca ▫ Causes-alcoholism, low serum Mg, parathyroid gland removal � S/S – numbness, tremors, cardiac arrhythmia, osteoporosis � Nursing Interventions: iv fluids, medications, diet **Calcium and Phosphate work together – form bone and teeth --- if one is high the other is lower

Phosphates • Essential for function of: muscles, nerves and RBC • Involved in PRO, Fat and CHO metabolism • Hypophosphatemia - TPN, glucose & insulin cause phosphates to shift into cells ▫ Alcohol withdrawal ▫ Antacid use (acid base imbalance) � S/S – weakness, pain, mental changes, seizures Hyperphosphatemia – Phosphates shift out of cell (trauma, chemo, malignant tumor), at risk – infants fed cow milk ((Fleets phosoda)) S/S – numbness, tingling **Around mouth and fingers** muscle spasm, tetany Nursing interventions: Diet, Medications, IV Fluids, Education

Chloride • Imbalances occur with Na imbalances • Hypochloremia – low Chloride ▫ Causes: sweating, kidney loss, GI tract losses �S/S – twitching, tremors, tetany • Hyperchloremia – high Chloride ▫ Causes: Na retention or high potassium �S/S – tremors, acidosis, weakness, lethargy, arrhythmias, coma �NURSING INTERVENTIONS: Medication, IV Fluids

Electrolyte Imbalances Universality • Nursing Interventions: diet, med’s, iv fluids, education, assessment, labs • Causes: Diet, Medication issues, metabolism (cancers, diseases) • S/S – muscle tremors, twitches, LOC, Mental status, cardiac affects

Look at your patient- be a spy • • • Previous history? Alcoholic = mg or K Malnourished? Objective and Subjective findings? Labs – the blood EKG

Homeostatic Mechanisms • Control the levels of fluids and electrolytes • Found throughout the body ▫ ▫ ▫ _kidneys____ __endocrine_______ __cardiovascular_______ ___GI______Lungs____

Kidneys (not kidney beans!) • Regulate what? ▫ ▫ __water____ __electrolytes____ __acid/base content of blood____ __all body fluids____ • Adjust what? Reabsorption of water • Excrete what? Water and waste == pee

Antidiuretic Hormone ADH • ADH regulates water excretion • Increases in response to increased serum (blood) osmolality • Ducts become more permeable to water and it is reasborbed easier into the blood and urine output will decrease

Renin-angiotensin-aldosterone system • Renin (enzyme) splits Angiotensinogen into angiotensin I and this transforms to angiotensin II (with the help of an ACE inhibitor). • Angiotensin II – stimulates vasoconstriction and secretes aldosterone • Aldosterone – increases Na reabsorption to regulate BP and electrolyte levels

Put it together • Increased osmolality – need more water in blood so: ADH secretion increases and water travels to the blood • R-A-A system – renin excreted to make angiotensin II and secrete aldosterone • Aldosterone causes vasoconstriction increase bp Give ACE inhibitor – stops angiotensin I to II and aldosterone (thereby lowers BP). This may also affect the ability of the body to maintain extracellular fluid (without edema).

Atrial Natriuretic Factor ANF • Secreted from atrial heart tissue • Increases sodium and water elimination (urine) • Lowers the blood volume and decreases cardiac output • Decreases the workload of the heart • OPPOSITE EFFECT OF ADH

p. H acids and bases • Acid = substance that releases Hydrogen ion in a solution • Base = low hydrogen ion concentration • Buffers prevent excessive ph changes by: adjusting the ions • **Major buffer is H 2 CO 3*** ▫ Kidneys and Lungs play a key

Factors that affect fluid and electrolyte balance • • Sex Body size Age Diet NPO General adaption syndrome (GAS) hehe Altered LOC

More factors……. • Body temperature • Renal, cardiac, pulmonary system • Medications ▫ ▫ ▫ Steroids NSAIDs Diuretics Laxatives Electrolyte supplements

More factors…… just when you thought you were done! • • • Dehydration Surgical procedures Vomiting Diarrhea Exercise Culture and traditional foods MSG Religious practices Socioeconomic Emotional

Definitions and conditions • • Fluid volume deficit is__hypovolemia_______ Fluid volume excess is__hypervolemia____ Ascites__fluid in the abdominal cavity______ Edema _fluid in the interstitial space_______

Hypovolemia • Define: low fluid volume • Causes: increased sodium chloride intake (po, iv), dehydration, CHF, Renal failure, Cushing’s, trauma • Nursing ramifications: identify cause and educate, medications, iv’s, etc… • S/S: weak, nausea, low pulse, SOB, low BP

Hypervolemia • • Define: increased volume in vascular system Causes: water toxicity, iv fluids, disease states Nursing ramifications: medication, educate S/S: elevated BP, moist crackles in lungs, bounding pulse, SOB

Ascites • Define: serous fluid in peritoneal cavity (3 rd spaced) • Causes: liver – cardiac dx, sodium retention, some cancers • Nursing ramifications: educate, diet, fluids, albumin (pulls fluid from 3 rd space, interstitially back into the blood stream). Albumin has high osmolality. • S/S: swelling, fluid shift – the wave~~~~~~~ • Treatment: Albumin and Pericentesis

Edema • Define: fluid in the tissues • Causes: increased sodium, electrolyte imbalances, poor cardiac output, kidney failure, hypervolemia, diseases • Nursing ramifications: fluid restrictions, educate & elevate body parts, sodium restrictions, medications • S/S: swelling (LOL), weeping skin, pain, numbness, cool skin, bruised/discolored

Edema • Pitting – leaves a small depression or pit • Areas of edema: body parts, periorbital edema, axillary, groin, generalized ▫ Note how many seconds it takes for pit to disappear (normally 10 -30 seconds)

What’s the Difference? Dehydration Overhydration • Define: loss body fluid, normal electrolytes • Causes: decreased fluid intake • Nursing ramifications: IVF, educate, diet, assessment • S/S: jugular vein distention, tachycardia, mental status changes, confusion, weight loss, dry skin, poor skin turgor, dry mucus membranes, increased thirst • Define: water intake is greater than electrolyte intake • Causes: increased fluid intake • Nursing ramifications: education, diet, medications, assessment • S/S: altered mental status, edema, SIADH (water toxicity), possible decreased urine output

Acid-Base Balance • • • Normal p. H of blood: _7. 35 -7. 45____ Acidic p. H of blood: __<7. 35_____ Alkaline p. H of blood (basic): _>7. 45___ Blood is acidotic if the p. H is __low__ Blood is alkalitic if the p. H is __high__

Metabolic condition Metabolic Alkalosis Metabolic Acidosis • HCO 3 – high • Causes: excess intake of baking soda (antacid) or alkalitic substances; lots of puking • The body compensates: ▫ CO 2 is retained and carbonic acid levels increase to help balance the excess HCO 3 • HCO 3 – low • Causes: starvation, renal impaired, DM • The body compensates: ▫ Stimulates respiratory system and eliminates CO 2

Respiratory condition Respiratory alkalosis Respiratory acidosis • HCO 3 – high • Causes: hyperventilation, fever, anxiety, pulmonary infections • The body compensates: kidneys excrete HCO 3 (or stop hyperventilation ASAP) • HCO 3 – low • Causes: hypoventilation, lung dx, asthma, COPD • The body compensates: ▫ Kidneys retain NAHCO 3 **may take hours or days to restore p. H

Intrepretation practice!

Nursing Interventions Include: • Dietary education ▫ Menus ▫ Special diets • Oral fluid/food intake ▫ Restrictions • Administering medications as ordered ▫ IVF ▫ Diuretics ▫ Electrolyte supplements • Education on medication uses/side effects and complications

Educating on Diuretics • Loop diuretic – Lasix/Furosemide • Thiazide sparing – HCTZ • Potassium sparing - Aldactone

Educating on Electrolyte supplements • • • Potassium Magnesium Sodium Bicarbonate Others? Gatorade, Power waters, Coconut water What do we recommend if you are exercising in the heat? Water and Power/Gatorade, etc… • Babies who have diarrhea need? Pedialyte • We use __kayexelate, D 50 and Insulin_to reduce Potassium

Intravenous Fluids - Types • Hypotonic solutions: . 45%NS, . 33%NS, 2. 5%Dextrose – lower osmotic pressure than plasma –DO not give if at risk for IICP • Hypertonic solutions: D 5 NS, D 51/2 NS, D 5 LR D 5 W – higher osmotic pressure than plasma – kidney, cardiac and dehydration • Isotonic solutions: 0. 9 NS, LR – expand vascular volume – LR has extra ingredients, treats metabolic acidosis • Electrolyte replacement: Potassium, KCL, MG, Banana bags!

Ethical consideration with IVF • • Life sustaining? Religious and/or cultural issues? Comfort measure? Emotional?

Calculations (oh no…. not math!)

Assessing the patient • • • Urine Skin Mental state MS Bowel status

Further Assessment • Labs ▫ BUN 7 -18 mg/dl �Increased indicates- renal failure �Decreased indicates - malnutrition, over hydration, liver damage ▫ Creatinine 0. 6 – 1. 5 mg/dl �Increased indicates – renal failure, CHF, shock �Decreased indicates – fluid status, dehydration

Let’s do a care plan! CHF Patient See pg 98 -100