Fluids and Electrolytes Metropolitan Community College Fall 2013

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Fluids and Electrolytes Metropolitan Community College Fall 2013 Jane Miller, RN MSN

Fluids and Electrolytes Metropolitan Community College Fall 2013 Jane Miller, RN MSN

Objectives • Discuss the nurse’s role in understanding fluid and electrolytes as needed for

Objectives • Discuss the nurse’s role in understanding fluid and electrolytes as needed for safe IV therapy. • Examine the importance of maintaining hemostasis. • Review extracellular fluid, intracellular fluid, and interstitial fluid dynamics. • Examine solute and solvent in relation to osmotic pressure and importance of maintaining hemostasis.

 • Identify the major electrolytes, their function, and location. • Describe abnormalities of

• Identify the major electrolytes, their function, and location. • Describe abnormalities of fluid and electrolyte balance, and evaluate how each affects homeostasis. • Discuss the differences between isotonic, hypertonic, and hypotonic IV solutions and their actions in osmosis, indications for and contraindications in various pathophysiological conditions. • Identify normal acid-base balance. • Examine abnormalities in acid-base balance. • Identify the body’s regulatory mechanism for acid-base balance. • Examine hormonal regulation of fluid and electrolyte balance.

Fluid Basics • Water comprises 70% of living cells • Average healthy person needs

Fluid Basics • Water comprises 70% of living cells • Average healthy person needs 2 - 2. 5 liters of water per day to meet fluid requirements • Fluid is lost through – Respirations – Urine – Feces – Perspiration – Vomit – Diarrhea – Wound drainage

Functions of Body Fluid • Transport of nutrients, electrolytes, and oxygen to the cells

Functions of Body Fluid • Transport of nutrients, electrolytes, and oxygen to the cells • Excretion of waste products • Regulation of body temperature • Lubrication of joints and membranes • Medium for food digestion

Fluid Compartments • Intracellular (ICF) – All fluid within the cell wall • Extracellular

Fluid Compartments • Intracellular (ICF) – All fluid within the cell wall • Extracellular (ECF) – All fluid outside of the cell wall • • • Interstitial fluid Plasma CSF Sweat Urine GI secretions

Osmolality • The number of molecules of solute (sodium, urea, and glucose) per kilogram

Osmolality • The number of molecules of solute (sodium, urea, and glucose) per kilogram of water • Osmolality of blood is 275 -295 m. Osm/kg • Isotonic fluids 275 -295 m. Osm/kg – Same solute concentration as plasma • Hypertonic fluids > 295 m. Osm/kg – Higher solute concentration than plasma • Hypotonic fluids < 275 m. Osm/kg – Lower solute concentration than plasma

Body Fluid Regulation • Osmosis – The movement of water from an area of

Body Fluid Regulation • Osmosis – The movement of water from an area of lower particle concentration to one of higher particle concentration

Body Fluid Regulation • Diffusion – The movement of molecules from an area of

Body Fluid Regulation • Diffusion – The movement of molecules from an area of higher concentration to an areas of lower concentration

Body Fluid Regulation • Filtration – The movement of molecules from an area of

Body Fluid Regulation • Filtration – The movement of molecules from an area of higher concentration to one of lower concentration as a result of hydrostatic pressure – Hydrostatic pressure is the pressure exerted on tissue due to the presence of water. It is generated by the pumping action of the heart. – Seen in the capillary system • Arterial pressure is 32 mm. Hg • Venous pressure is 15 mm. Hg

Homeostasis • Serum osmolality is regulated by the osmoreceptors of the hypothalamus • When

Homeostasis • Serum osmolality is regulated by the osmoreceptors of the hypothalamus • When fluid is lost the hypothalamus stimulates the pituitary gland to secrete ADH • ADH signals the kidneys to conserve water • Promotes the sensation of thirst

Isotonic Fluids • 275 -295 m. Osm/kg • Same solute concentration as plasma •

Isotonic Fluids • 275 -295 m. Osm/kg • Same solute concentration as plasma • No net fluid shift • Examples – 0. 9% Na. Cl – Lactated Ringers – D 5 W (can be considered hypotonic due to metabolism of dextrose)

Hypertonic Fluids • • • > 295 m. Osm/kg Higher solute concentration than plasma

Hypertonic Fluids • • • > 295 m. Osm/kg Higher solute concentration than plasma Draw water from the cells and tissues Expands plasma volume Examples – 3% Na. Cl – D 10 W – D 5 NS

Hypotonic Fluids • < 275 m. Osm/kg • Lower solute concentration that plasma •

Hypotonic Fluids • < 275 m. Osm/kg • Lower solute concentration that plasma • Causes water to move out of the plasma to the tissues and cells • Examples – 0. 45% Na. Cl – 0. 33% Na. Cl – D 2. 5 W

Administration of a IV fluid with an osmolality of 288 m. Osm/kg represents what

Administration of a IV fluid with an osmolality of 288 m. Osm/kg represents what kind of fluid? A. Isotonic B. Hypertonic C. Hypotonic

Evaluation of Fluid Status • Specific gravity of urine – Normal 1. 005 -1.

Evaluation of Fluid Status • Specific gravity of urine – Normal 1. 005 -1. 030 – < 1. 005 = overhydration – > 1. 030 = dehydration • Hematocrit – Normal Male 42 -52% – < 42% = overhydration – > 52% = dehydration • Electrolytes – < normal = overhydration – > normal = dehydration

Causes of Overhydration Renal failure Congestive heart failure Liver cirrhosis Syndrome of inappropriate antidiuretic

Causes of Overhydration Renal failure Congestive heart failure Liver cirrhosis Syndrome of inappropriate antidiuretic hormone (SIADH) • Excessive oral or IV intake • •

Clinical Manifestations Overhydration • • • Edema Crackles in the lung bases Dyspnea SOB

Clinical Manifestations Overhydration • • • Edema Crackles in the lung bases Dyspnea SOB Serum p. H <7. 35, respiratory acidosis Ascites Increased blood pressure Bounding pulses Extra heart sound (most common in children) Activity intolerance Increase in body weight

Nursing Management Overhydration • • • I&O Daily weights Vital signs Labs – CBC,

Nursing Management Overhydration • • • I&O Daily weights Vital signs Labs – CBC, BMP, Urinalysis, BUN, Creatinine Prop pt up in bed to reduce dyspnea Allow adequate time for rest Skin assessment and daily care Administer diuretics Stop or slow IV fluids Pt teaching – diet, fluid restriction, diuretics, daily weights, S&S to report

Causes of Dehydration • Decreased oral intake – Elderly – Altered mental status •

Causes of Dehydration • Decreased oral intake – Elderly – Altered mental status • • • Diabetes Insipidus Diabetes Mellitus Vomiting and diarrhea Burns Excessive sweating Overuse of diuretics

Clinical Manifestations Dehydration • • • Severe thirst (may be absent in the elderly)

Clinical Manifestations Dehydration • • • Severe thirst (may be absent in the elderly) Dry mucous membranes Decreased skin turgor Tachycardia Weak pulse Hypotension Decreased urine output Headache Dizziness Mental status changes Mottled extremities

Nursing Management Dehydration • • • I&O Daily weights Vital signs Labs – CBC,

Nursing Management Dehydration • • • I&O Daily weights Vital signs Labs – CBC, BMP, Urinalysis, BUN, Creatinine Monitor neurological status Provide oral care Assess for signs of constipation Administer IV fluids Pt teaching – hydration needs, S&S to report

Electrolyte Overview • Calcium, Chloride, Magnesium, Phosphorus, Potassium, and Sodium • Support normal bodily

Electrolyte Overview • Calcium, Chloride, Magnesium, Phosphorus, Potassium, and Sodium • Support normal bodily functions • Have either a positive or negative charge • Each electrolyte has a normal range where there is optimal body function • When outside of this normal range dysfunction occurs

Sodium: + Na • 135 -145 m. Eq/L • Most numerous cation in the

Sodium: + Na • 135 -145 m. Eq/L • Most numerous cation in the ECF • Maintains ECF volume through osmotic pressure • Regulates acid-base balance by combining with chloride and bicarb • Conducts nerve impulses via sodium channels in cell

Regulation • Aldosterone: Secreted by the adrenal cortex – – Low ECF sodium levels

Regulation • Aldosterone: Secreted by the adrenal cortex – – Low ECF sodium levels Increased ICF potassium Low cardiac output Stress Increases retrieval of sodium from kidney filtrate • ADH: Secreted by the pituitary gland – Increased ECF osmolality • Atrial natriuretic peptide (ANP): Secreted by the atrium of the heart – Excessively stretched atria Antagonist to aldosterone

Hypernatremia • > 145 m. Eq/L • Causes – Cushing’s syndrome – Diabetes insipidus

Hypernatremia • > 145 m. Eq/L • Causes – Cushing’s syndrome – Diabetes insipidus – Excessive sweating – Increased oral intake – Infusion of 3% Na. CL – Severe vomiting – Decreased renal function

Clinical Manifestations • • Thirst Dry mucous membranes Low-grade fever Edema Tachycardia Mental status

Clinical Manifestations • • Thirst Dry mucous membranes Low-grade fever Edema Tachycardia Mental status changes Seizures > 180 m. Eq/L = high mortality

Nursing Management • • • Administer medications to control Cushing’s Syndrome Administer ADH (diabetes

Nursing Management • • • Administer medications to control Cushing’s Syndrome Administer ADH (diabetes insipidus) Use 3% Na. Cl infusions carefully Monitor labs Oral care Skin care and turning Vital signs Monitor neurological status Low sodium diet Encourage oral intake of water

Which of these situations can cause an increased serum sodium level? a. b. c.

Which of these situations can cause an increased serum sodium level? a. b. c. d. e. f. Excessive use of table salt Consuming large quantities of canned soup Increased water intake Use of intravenous 3% Na. Cl Use of diuretics Severe vomiting

Hyponatremia • < 135 m. Eq/L • Causes – Inadequate oral intake – Excessive

Hyponatremia • < 135 m. Eq/L • Causes – Inadequate oral intake – Excessive water intake – Diuretics – Vomiting and diarrhea – Infusion of 5% Dextrose – Burns – Head trauma – Syndrome of inappropriate antidiuretic hormone – Addison’s disease

Clinical Manifestations • • Headache Confusion Seizures Tachycardia Hypotension Muscle weakness Abdominal cramping Possibly

Clinical Manifestations • • Headache Confusion Seizures Tachycardia Hypotension Muscle weakness Abdominal cramping Possibly no manifestations < 115 m. Eq/L = high mortality

Nursing Management • • Monitor VS Monitor labs Monitor neurological status Fluid restriction Administer

Nursing Management • • Monitor VS Monitor labs Monitor neurological status Fluid restriction Administer 0. 9% Na. Cl Administer 3% Na. Cl carefully Allow plenty of time for rest

Potassium: • • + K 3. 5 – 5. 0 m. Eq/L Intracellular cation

Potassium: • • + K 3. 5 – 5. 0 m. Eq/L Intracellular cation 98% is found within the cells Essential for cellular integrity Transmission of neuromuscular impulses Acid-base balance Conversion of carbs to energy Formation of amino acids into proteins

Hyperkalemia • > 5. 0 m. Eq/L • Causes – Increased oral or IV

Hyperkalemia • > 5. 0 m. Eq/L • Causes – Increased oral or IV intake – Decreased urinary excretion – Cellular damage – Severe acidosis – Potassium sparing diuretics – Addison’s disease

Clinical Manifestations • • Muscle cramps Tachycardia Nausea Diarrhea Weakness Numbness Oliguria or anuria

Clinical Manifestations • • Muscle cramps Tachycardia Nausea Diarrhea Weakness Numbness Oliguria or anuria ECG changes – Peaked T waves, shortened QT interval, prolonged PR followed by a disappearance of the P wave, Prolonged QRS. • Cardiac arrest

Peaked t-wave

Peaked t-wave

Nursing Management • • Monitor VS & ECG Monitor labs Diet restriction Slow or

Nursing Management • • Monitor VS & ECG Monitor labs Diet restriction Slow or stop IV fluids with potassium added – Normally no more than 10 m. Eq of KCL per hour • Administer Kayexalate • Administer insulin and glucose (temporary tx) • Administer IV sodium bicarb (temporary tx)

Hypokalemia • < 3. 5 m. Eq/L • Causes – Potassium wasting diuretics –

Hypokalemia • < 3. 5 m. Eq/L • Causes – Potassium wasting diuretics – Decreased oral intake – Alcoholism – Vomiting – Diarrhea – Alkalosis – Steroid use

Clinical Manifestations • • Nausea & Vomiting Diarrhea Abdominal distention Vertigo Malaise Confusion ECG

Clinical Manifestations • • Nausea & Vomiting Diarrhea Abdominal distention Vertigo Malaise Confusion ECG changes – Flat or inverted T waves, depressed ST, may have a U wave

Nursing Management • Monitor VS & ECG • Monitor labs • Encourage diet rich

Nursing Management • Monitor VS & ECG • Monitor labs • Encourage diet rich is potassium – Sweet potatoes, broccoli, bananas, squash • Administer potassium supplement – Irritating to the gastric mucosa, give with 6 -8 ounces of water • Use caution when administering IV • Never give K+ as a bolus

Your patient has this ECG tracing. What do you suspect?

Your patient has this ECG tracing. What do you suspect?

Calcium: 2+ Ca • Normal serum values 8. 5 - 10. 5 mg/d. L

Calcium: 2+ Ca • Normal serum values 8. 5 - 10. 5 mg/d. L • Ionized calcium 4. 0 – 5. 5 mg/d. L • Cation found in both ECF and ICF, but greater concentration in ECF • Maintains cellular membrane stability • Sedative effect on nerves • 98% in bones and teeth, 2% in the serum • Serum p. H greatly affects calcium levels – metabolic acidosis increases levels, alkalosis opposite effect

Functions of Calcium • Neuromuscular – transmission of nerve impulses and contraction of skeletal

Functions of Calcium • Neuromuscular – transmission of nerve impulses and contraction of skeletal muscle • Cardiac – contraction of the myocardium • Cellular and Blood – Maintains cellular permeability - decreased calcium increases cellular permeability – Promotes clotting by converting prothrombin into thrombin • Bone and teeth construction – Calcium along with phosphorous forms bones and teeth

Regulation of Calcium • Vitamin D – Aides in absorption of calcium from the

Regulation of Calcium • Vitamin D – Aides in absorption of calcium from the gut • Calcitonin from the thyroid gland – Increases renal excretion, deposits it in the bones • PTH from the parathyroid gland – Mobilizes calcium from the bone and increases reabsorption by the kidneys

Hypercalcemia • Serum calcium > 10. 5 mg/d. L • Ionized calcium > 5.

Hypercalcemia • Serum calcium > 10. 5 mg/d. L • Ionized calcium > 5. 5 mg/d. L • Causes – Primary hyperparathyroidism – Bone malignancy – Drug toxicity • Thiazide diuretics, lithium carbonate, vitamin A & D – Prolonged bed rest – Rhabdomyolysis – Excessive use of calcium supplements

Clinical Manifestations • • Fatigue Weakness Headache Confusion Polyuria Kidney stones Nausea & vomiting

Clinical Manifestations • • Fatigue Weakness Headache Confusion Polyuria Kidney stones Nausea & vomiting ECG changes – Shortening of the ST segment and QT interval, prolonged PR interval • Soft tissue calcifications • Pathological fractures

Nursing Management • • • Monitor VS & ECG Monitor labs Stop vitamin A,

Nursing Management • • • Monitor VS & ECG Monitor labs Stop vitamin A, D and calcium supplements Low calcium diet Discontinue thiazide diuretics Allow plenty of time for rest Administer antiemetics Turn and reposition carefully Monitor neurological status

Hypocalemia • Serum < 8. 5 mg/d. L • Ionized Ca is < 4.

Hypocalemia • Serum < 8. 5 mg/d. L • Ionized Ca is < 4. 0 mg/d. L • Causes – – – – – Decreased oral intake (rare) Inadequate vitamin D Hypoalbuminemia Citrated blood transfusions Decreased PTH Alkalosis GI surgery Chronic pancreatitis Small bowel disease Loop diuretics

Clinical Manifestations • • Numbness and tingling of the fingers Muscle cramps Hyperactive reflexes

Clinical Manifestations • • Numbness and tingling of the fingers Muscle cramps Hyperactive reflexes Anxiety Bradycardia Hypotension ECG changes – Prolonged QT intervals

Clinical Tests Chvotsek’s Sign Trousseau’s Sign Tap the facial nerve just below the temple

Clinical Tests Chvotsek’s Sign Trousseau’s Sign Tap the facial nerve just below the temple on the zygomatic arch Inflate BP cuff 20 mm above systolic pressure for 3 minutes

Nursing Management • • Monitor VS & ECG Monitor labs Give oral supplements of

Nursing Management • • Monitor VS & ECG Monitor labs Give oral supplements of calcium and Vit. D Infuse IV calcium supplements slowly – 60 mg/min • Do not give with sodium bicarb because precipitation could result • Encourage dietary consumption – Yogurt, cheese, spinach, sardines

Magnesium: • • • 2+ Mg 1. 4 - 2. 1 mg/d. L Intracellular

Magnesium: • • • 2+ Mg 1. 4 - 2. 1 mg/d. L Intracellular cation Neuromuscular activity transmission Cardiac contraction Cellular – Activates enzymes for carbohydrate and protein metabolism – Responsible for proper transportation of sodium and potassium across cell membranes – Influences utilization of K, Ca, and proteins – Magnesium deficits are FREQUENTLY accompanied by a Potassium and/or Calcium deficit

Hypermagnesemia • > 2. 1 mg/d. L • Causes – Renal failure – IV

Hypermagnesemia • > 2. 1 mg/d. L • Causes – Renal failure – IV infusion (common in OB) – Adrenal insufficiency – Intake of magnesium containing antacids • Maalox, MOM, Mylanta

Clinical Manifestations • • Hypotension Bradycardia Nausea & Vomiting Decreased deep tendon reflexes Drowsiness

Clinical Manifestations • • Hypotension Bradycardia Nausea & Vomiting Decreased deep tendon reflexes Drowsiness Respiratory depression Flushing

Nursing Management • • Stop magnesium-containing products IV push calcium gluconate Monitor VS &

Nursing Management • • Stop magnesium-containing products IV push calcium gluconate Monitor VS & ECG Monitor labs Assess neurological status Administer 0. 45% Na. Cl and diuretics Dialysis

Hypomagnesemia • < 1. 4 mg/d. L • Causes – Malnutrition – Alcoholism –

Hypomagnesemia • < 1. 4 mg/d. L • Causes – Malnutrition – Alcoholism – Loop diuretics – Vomiting – Diarrhea – Increased calcium intake – Diuresis from diabetic ketoacidosis

Clinical Manifestations • • • Confusion Lethargy Seizures Tetany Increased tendon reflexes Hypertension PVCs

Clinical Manifestations • • • Confusion Lethargy Seizures Tetany Increased tendon reflexes Hypertension PVCs V tach V fib

Nursing Management • • • Monitor VS & ECG Monitor labs Assess neurological status

Nursing Management • • • Monitor VS & ECG Monitor labs Assess neurological status Administer magnesium supplements Monitor IV administration closely Encourage dietary intake – Spinach, nuts, fish, beans

Phosphorus • • 2. 5 – 4. 5 mg/d. L Major intracellular anion 85%

Phosphorus • • 2. 5 – 4. 5 mg/d. L Major intracellular anion 85% is in teeth and bones Essential for carb, protein, and fat metabolism Nerve and muscle function Form ATP and ADP Essential for acid-base balance

Hyperphosphatemia • > 4. 5 mg/d. L • Causes – Excessive oral intake –

Hyperphosphatemia • > 4. 5 mg/d. L • Causes – Excessive oral intake – Decreased levels of PTH – Chemotherapy – Radiation therapy – Rhabdomyolysis – Renal insufficiency – Acidosis

Clinical Manifestations • • • Calcium phosphate deposits in soft tissues Muscle weakness Tachycardia

Clinical Manifestations • • • Calcium phosphate deposits in soft tissues Muscle weakness Tachycardia Nausea Diarrhea Abdominal cramps

Nursing Management • Monitor VS & ECG • Monitor labs • Administer phosphorous binding

Nursing Management • Monitor VS & ECG • Monitor labs • Administer phosphorous binding antacids – Calcium carbonate, calcium acetate • Dietary restriction • Administer insulin and glucose (temp tx)

Hypophosphatemia • < 2. 0 mg/d. L • Causes – Vitamin D deficiency –

Hypophosphatemia • < 2. 0 mg/d. L • Causes – Vitamin D deficiency – Phosphate binding antacids – Alcoholism – Vomiting & diarrhea – Diabetic ketoacidosis – Elevated PTH – Alkalosis – Burns

Clinical Manifestations • • • Confusion Seizures Peripheral neuropathy Tissue hypoxia Dysrhythmias Bleeding from

Clinical Manifestations • • • Confusion Seizures Peripheral neuropathy Tissue hypoxia Dysrhythmias Bleeding from platelet dysfunction Weakness Bone pain Tremors Anorexia

Nursing Management • • • Monitor VS & ECG Monitor labs Watch for signs

Nursing Management • • • Monitor VS & ECG Monitor labs Watch for signs of bleeding Monitor neurological status Administer oral supplements Encourage dietary intake – Dried beans, fish, organ meats, whole grains

Chloride: Cl • 95 -108 m. Eq/L • Primary anion in the ECF •

Chloride: Cl • 95 -108 m. Eq/L • Primary anion in the ECF • Combines with sodium to create electrical neutrality • Assists in reabsorption of sodium from kidneys • Combines with hydrogen to for hydrochloric acid for digestion • Buffers carbonic acid • Used to calculate the anion gap

Hyperchloremia • > 108 m. Eq/L • Causes – Hyperparathyroidism – Dehydration – Metabolic

Hyperchloremia • > 108 m. Eq/L • Causes – Hyperparathyroidism – Dehydration – Metabolic acidosis – Respiratory alkalosis – Excessive dietary intake

Clinical Manifestations • • • Increased depth and rate of respirations Lethargy Stupor Disorientation

Clinical Manifestations • • • Increased depth and rate of respirations Lethargy Stupor Disorientation Coma

Hypochloremia • < 95 m. Eq/L • Causes – Vomiting – Excessive sweating –

Hypochloremia • < 95 m. Eq/L • Causes – Vomiting – Excessive sweating – Diuretics – Diabetic ketoacidosis – It rarely occurs in isolation

Clinical Manifestations • • • Reflects alkalosis Paresthesias of the face and extremities Muscle

Clinical Manifestations • • • Reflects alkalosis Paresthesias of the face and extremities Muscle spasms Slow shallow respirations Hypoxia Tetany Confusion Hypertension Dehydration

Resources • Osborn, Wraa, & Watson chapter 18 • Fluid and Electrolyte Balance http:

Resources • Osborn, Wraa, & Watson chapter 18 • Fluid and Electrolyte Balance http: //www. nlm. nih. gov/medlineplus/fluidandelectrolytebalance. html • I. V. fluids: What nurses need to know. http: //www. nursingcenter. com/lnc/pdf? AID=1156868&an=00152193201105000 -00010&Journal_ID=54016&Issue_ID=1156791 • IV Fluid Basics http: //faculty. weber. edu/kbarton 1/IV%20 Therapy%20 Basics. pdf