NUR 165 Chapter 13 Fluid and Electrolyte Imbalances Fluid and Electrolyte Balance

Necessary for life and homeostasis

Amount of substances balance each other out.

Nursing Role
Help prevent and treat fluid and electrolyte disturbances Know to recognize the signs and symptoms

Fluid
Composes approximately 60% of the typical adult Varies with age, body size, and gender Intracellular fluid (ICF)
Inside the cells

Extracellular fluid (ECF)

Intravascular-within the veins Interstitial-space around Transcellular-spinal fluid, etc in body cavities

Electrolytes
Active chemicals that carry positive and negative electrical
Sodium-Na+: Vascular Normal levels: 135-145 Primary-lot s in the blood Regulates fluid balance Lots of salt causes retention of water Potassium-K+: Cellular Normal levels: 3.5-5 Low levels in the blood Important for cardiac and skeletal muscle Calcium-Ca+ Normal levels 8.5-10 Important for skeletal contractions Low levels can cause twitching, seizures Phosphorus-P Normal Levels: 2.5-4.5 Acid-base Regulates calcium One is up, the other is down Magnesium-Mg Normal Levels: Neuromuscular function When levels are high, acts as sedative Depressed bradycardia, reflexes, respirations When levels are low, everything is increased Elevated BP, respirations

Electrolyte concentrations differ in the fluid compartments

Routes of Gains and Losses

Gains
Dietary intake of fluid and food or enteral feeding Parenteral fluids

Losses
Kidneys: Urine output Skin loss Lungs GI tract

Osmosis
Movement of FLUID from an area of lower solute concentration solute concentration
How fluid shifts with different IV fluids EX: Patient eats a lot of chips. The blood becomes very salty. Sodium 160. Fluid will shift to the vessels (b/c blood is very salty). H2O cells to dilute the blood which causes cells to shrink. This can cause neurologic dysfunction like tetany or seizures.

Isotonic Solutions
Same osmolality as ECF Most common solutions
Normal Saline (0.9%) Lactated Ringer s (LR) No fluid shift

Concentration basically the same as blood (ECF compartment) Example of when used is for dehydration

Hypotonic Solutions
Purpose is to replace cellular fluid
Treat cellular dehydration

Shifts fluid from ECF to ICF Lower osmolarity than blood

0.45% normal saline 0.33% normal saline

With Na of 160 or greater, you want to dilute the blood

The fluid shifts into the cells because of lower concentration from Causes cells to swell

Never give to patient with brain injuries because it could Don t give to patients with low BP because it could further Used for dehydration

Hypertonic Solutions
Draws fluid out of the cells into the ECF Higher osmolality than blood
3% normal saline

5% normal saline Whole blood Albumin

Concentration higher than bloodstream

Fluid shifts out of cells and into bloodstream Causes cells to shrink Will expand blood volume which could cause fluid overload

With hypertonic infusions always assess breath sounds for respiratory rate, and O2 saturation Give to patients with Na level of 115 or less
Typically infuse at a slow rate for critical patients May need to add Lasix (furosimide)

Regulation of Water Balance

Hypothalamic and pituitary regulation
Regulates water Hypothalamus makes ADH which is stored in the pituitary gland ADH regulates water Lots of ADH=lots of fluid ADH is released based on amount of fluid in body Release of ADH stops when have lots of fluid Makes kidneys more permeable to water. Water is reabsorbed to the blood decreasing blood osmolarity by making it more dilute EX: If patient is injured in car accident and bleeding out, with 60/40. ADH will be released to hold in the fluid which amount of salt SIADH-Syndrome of Inappropriate ADH Body has too much ADH Will have signs of edema, swelling, crackles, urine output will decrease and urine specific gravity will increase Normal specific gravity is 1.010 1.025. Higher this equals more concentrated urine. Because is being retained, the urine is more concentrated. Na level will be low because of so much fluid Hct will be low

Adrenal Regulation
Regulates water by secreting aldosterone Aldosterone regulates water by regulating Na Body holds salt which makes it hold water Released whenever sodium levels in the ECF is decreased preventing both water and Na loss The reabsorption of Na and water into the blood from the urine increases blood osmolarity and volume Prevents excessive Na excretion from kidneys Helps prevent blood K+ levels from getting too high Ex: Patient is bleeding out, aldosterone holds onto salt to help body onto water which helps the body maintain fluid

Hyperaldosteronism-body has too much salt, fluid level will decrease, BP will increase Ex: Patient eats lots of chips, comes to ER with Na level of 160 Aldosterone level will decrease

Natriuretic Peptide

Released through special cells in cardiac muscle Atrial natriuretic peptide (ANP)-line atria Brain natriuretic peptide (BNP)-ventricles of the heart Secreted in response to increased blood volume and BP, which heart tissue Creates effects opposite of aldosterone Kidney absorption of Na is inhibited while urine output is increased Causes decreased circulating blood volume and blood osmolarity

Renal Regulation
The kidneys respond to either release fluid or hold onto fluid

Dehydration
Fluid intake is less than what is needed to meet the body s fluid
Results in fluid volume deficit

Causes
Too little intake, fluid loss from vomiting, diarrhea, GI suctioning, decreased intake

Signs
Decreased BP, increased HR

Manifestations

Rapid weight loss, decreased skin turgor, oilguria,concentrated (increased SG), postural hypotension, rapid and weak pulse, thirst, confusion Elevated BUN (byproduct of protein metabolism), increased Not enough circulating volume

Lab Data Medical Management

Oral Fluids IV Fluids Give isotonic fluids to expand volume (NS) Need to treat the root cause

Fluid Overload
Excess of body fluid Risk Factors
Heart failure, renal failure, and cirrhosis of the liver

Manifestations

Edema, distended neck veins, abnormal lung sounds, (crackles), tachycardia, increased BP, increased weight, shortness of breath, UO

Lab Data

Decreased hgb/hct and protein More fluid dilutes everything (also Na)

Medical Management

Restrict fluids and sodium Admin diuretics Pay attention to what kind: Loop and Thiazide watch for decrease in K+ Others cause K+ increase Sit patient up with shortness of breath or crackles Give O2

Interventions

Hyponatremia
Serum sodium less than 135 mEq/L
Osmolarity of ECF is lower than ICF Water moves into cell causing it to swell

Causes
Adrenal insufficiency, (Addison s Disease), SIADH (a lot of ADH), intoxication (weight gain), and losses by vomiting, diarrhea, diuretics (especially thiazide)

Manifestations

Muscle weakness, abdominal cramping, hyperactive bowel sounds, symptoms based on hypo/hypervolemia (salt level may go down much fluid or because of meds like Lasix which deplete salt), and changes/seizures (pay attn to safety precautions) Sodium replacement (hypertonic solution like 3% saline at 30 restriction, osmotic diuretic, hypertonic saline (severe cases Try water restriction first. If use IV give at slow rate and monitor overload

Medical Management

Hypernatremia
Serum sodium level greater than 145 mEq/L
Fluid shifts out of the cell into vasculature and cell shrinks

Causes
Excess water loss, excess sodium administration (overload would increased BP and HR-lungs would hear crackles), tube feedings water, diabetes insipidus (opposite of SIADH; deficiency of ADH. water-large amounts of diluted urine and decreased SG), hyperaldosteronism (increased Na, decreased K+, decreased BP), dehydration, and hypertonic IV solutions

Manifestations

Neurologic symptoms, muscle weakness, symptoms based on hypo/hypervolumia

Medical Management Interventions

Hypotonic electrolyte solution; 0.45% saline Want to dilute the salt

Encourage patient to avoid foods high in salt like processed foods, foods, condiments, cheese, milk

Hypokalemia
Below normal serum K+ (<3.5 mEq/L) Causes
Gi losses, medications, , poor dietary intake, hyperaldosteronism insulin drip, acute pancreatitis (heavy vomiting), alkalosis (low K+)

Manifestations

Fatigue, anorexia, nausea, vomiting, ECG changes (low K+ shows T-wave (atrial relaxation) could go low, flat, or depressed. High K+ wave), dysrhythmias, decreased muscle strength, decreased deep reflexes (DTR s)

Medical Management

Increased dietary potassium (bananas, oranges, whole grains, salt supplement (pill or liquid-check stool for blood), IV for severe give IV push or IM or SubQ Be aware that low K+ puts patient at risk for digtoxicity if on Patients need adequate K+ on digoxin Side note: Alkalosis is decreased hydrogen ions. Hydrogen ions the cells to the blood. K+ leaces the blood and comes into the cell

Interventions

Example
Why would a patient with an NG tube need an IV with NS and K+? Because of suctioning

Hyperkalemia
Serum K greater than 5.0 mEq/L Causes
Excessive intake (foods), blood transfusions, impaired renal K is excreted by the kidneys. If not working, K builds up. Gets too requires emergency dialysis), aldosterone deficiency (body won t enough salt so K level increases), acidosis (H leaves vessel and K creating high level in blood), burns (cells destroyed so K is medications (K sparing diuretics-speradactone, ACE inhibitors)

Manifestations

ECG changes (T-wave peaks), dysrhythmias, muscle twitching weakness, numbness, tingling, anxiety, increased motility

Medical Management

Lasix (loop or thiazide diuretics), kayexalate (drink or enema binds excretes through GI tract), insulin and dextrose IV (decreases K shifts it into the cells), limit dietary K, perform dialysis

Hypocalcemia
Serum level less than 8.5 mg/dL Causes
Hypoparathyroidism (para secretes hormone that travels to bone level is low to tell it to excrete more Ca. If not working can t send

excrete), inadequate vitamin D (needed for Ca absorption), renal (hard time excreting P. Ca goes down P goes up and vice versa. In high, Ca low), acute pancreatitis (secretes too much amylase and which binds to Ca causing levels to go down)

Manifestations

Tetany (involuntary muscle spasms), hyperactive DTR s, positive sign, positive Chevstek s sign, seizures Trousseau s Sign-apply BP cuff to arm and inflate. Will have involuntary muscle spasm due to decrease in oxygen Chovstek s Sign-tapping facial muscle, will twitch or have

Medical Management Side Note

IV of calcium glutonate, calcium and vitamin D supplements, diet

Parathyroid gland is beside the thyroid and can accidently be during thyroidectomy. If this happens patient may exhibit signs of hypocalcemia because it cand send signals to tell bone to secrete Nurse should always have calcium and trach tube at bedsidecontractions could occur and patient could have airway obstruction

Hypercalcemia
Serum level above 10.0 mg/dL Causes
Hyperthyroidism (secreting too much, bone releasing too much Ca become weak. Pt at risk for pathological fractures), bone loss immobility (Ca released from bone), increased vitamin D

Manifestations

Muscle weakness, incoordination, anorexia, constipation, nausea vomiting, abdominal and bone pain, confusion. Patient also at risk kidney stones, be sure to give lots of fluids also lowers Ca.

Medical Management

Treat underlying cause (tumor, immobile), administer fluids, excrete), phosphate (as P increases, Ca decreases), calcitonin from secreting Ca and increased secretion of Ca) If patient immobile, have them sit up and do weight bearing shift Ca back into the bone.

Hypophosphatemia
Serum level below 2.5 mg/dL Causes
Alcoholism, vitamin D deficiency, hyperventilation (resp into the cells because blowing off CO2), hyperparathyroidism (high secreting lots of Ca causing P to do down), diarrhea, use of diuretics to P to and excretes it) and phosphate binders, low dietary intake & whole grains are rich in P)

Manifestations

Muscle weakness, muscle pain, decreased bone density Oral or IV P replacement (give very slow)

Medical Management

Hyperphosphatemia
Serum level above 4.5 mg/dL Causes
Renal failure (cannot excrete P), excess P, excess vitamin D, hypoparathyroidism.

Manifestations

Symptoms occur due to associated hypocalcemia (Ca level down, P goes up)

Medical Treatment Side note

Treat underlying disorder, low P diet, phosphate-binding gels or dialysis

When P levels are too high, it binds to Ca and forms salts which can organ damage. Teach patient importance of medication compliance

Hypomagnesia
Serum levels less than 1.8 mg/dL Causes
Alcoholism, GI losses, low intake of magnesium

Manifestations

Neuromuscular irritability (sedates neuromuscular function so all increase), tremors, ECG changes and dysrhythmias, alterations in level of consciousness, increased reflexes and BP, tachycardia

Medical Management

Diet, oral magnesium, and magnesium sulfate IV

Hypermagnesia
Serum levels above 2.7 mg/dL Causes
Renal failure (most common cause. Never give mg in patient with failure because they cannot excrete it), dehydration, excessive magnesium

Manifestations

Lowered BP, nausea, vomiting, hypoactive reflexes, drowsiness, weakness, depressed respirations, bradycardia, and dysrhythmias decrease) IV calcium glutonate (antidote for toxicity), increase fluids, loop hemodialysis

Medical Management