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Fluid and Electrolyte

Disturbances

Isotonic Fluid Imbalance


Sodium and water Increase or
decrease in the same proportion
Hypovolemia

Fluid Volume Deficit

Hypervolemia
Fluid Volume Excess

Isotonic Fluid Imbalance:


Fluid Volume Deficit
Water and sodium decrease in the same
proportions
Causes

Inadequate intake
GI losses
GU losses
Skin losses
Third-space losses

Signs of Fluid Volume Deficit

Body weight decreases

mild deficit - 2% loss


moderate deficit - 4% loss
severe deficit - 6% loss

Urine output :
oliguria
anuria

Urine osmolality increases

Signs of Fluid Volume Deficit


Serum osmolality increases
Poor skin turgor
Dry mucous membranes
Postural hypotension
Tachycardia

Major Complications of Fluid


Volume Deficit
Decreased cardiac output
Shock Hypovolemia
Death

Isotonic Fluid Imbalance:


Hypervolemia
Extracellular fluid volume excess
Sodium and water increase in the same
proportions
Causes

increase in capillary pressure


decrease in capillary oncotic pressure
increases in serum aldosterone

Signs of Hypervolemia
Acute weight gain
Edema
Pulmonary edema

shortness of breath
rales
dyspnea
cough

Venous distention

Major Complications of Fluid


Volume Excess

Pulmonary Edema
Hypoxia
Dyspnea

Hypo-osmolar Imbalance:
Hyponatremia
The serum sodium level falls below 135
mEq/L
Cellular Effect

cells become swollen

Hypo-osmolar Imbalance
Hyponatremia

Causes of Absolute Hyponatremia

Sweating
GI losses
Diuresis
Adrenal insufficiency

Hypo-osmolar Imbalance
Hyponatremia

Causes of Relative Hyponatremia


Excess intake of plain water
Tap water enemas
Absorption of water from irrigating fluids
used in TURP
Long-term intravenous therapy with D5W
Increased ADH levels

Hypo-osmolar Imbalance:
Hyponatremia

SIADH

tuberculosis
pneumonia
oat cell carcinoma
encephalitis
meningitis
pancreatic carcinoma

Major Complications of
Hyponatremia

Neurological Disturbances

cerebral edema
Headache, Lethargy
Depression, Confusion
Convulsions
Coma

Cardiovascular Disturbances
Postural hypotension
Shock

Hypo-osmolar Imbalance:
Hyponatremia

Laboratory Values
Serum sodium is less than 135 mEq/L
Serum osmolarity is decreased
Dilution of chloride, hematocrit, and BUN

Hyperosmolar Imbalance:
Hypernatremia
There is an increase in the serum
sodium level.
Cellular effect

cells shrink

Hyperosmolar Imbalance:
Hypernatremia

Causes of Hypernatremia

Excessive oral intake of sodium


Excessive parenteral intake of sodium
Near-drowning in salt water
Hypertonic tube feedings without free water
Inability to respond to thirst
Increased water losses
Diabetes insipidus

Hyperosmolar Imbalance
Hypernatremia

Manifestations

thirst
dry, sticky mucous membranes
tongue dry and swollen
elevated temperature
agitation
convulsions
tachycardia

Hyperosmolar Imbalance
Hypernatremia

Manifestations
Oliguria or anuria
Increased urine specific gravity

Major Complications of
Hypernatremia
Osmotic Diuresis
Water moves out of the cells into the
circulation
Cellular dehydration
Circulation decreases
Cell function is impaired
Brain cells particularly susceptible

Hypokalemia

Etiology

poor nutrition
diuretic therapy
gastric suctioning
vomiting, diarrhea
burns
alkalosis
hyperaldosteronism

Major Complications of
Hypokalemia

Cardiovascular
dysrhythmias, hypotension, digitalis
toxicity, myocardial damage, cardiac arrest

Neurological
lethargy, confusion, depression

Gastrointestinal
paralytic ileus

Major Complications of
Hypokalemia

Skeletal Muscle
weakness, flaccid paralysis, weakness of
respiratory muscles, respiratory arrest

Renal System
decreased ability to concentrate urine, water
loss, kidney damage

Acid-Base Balance
metabolic alkalosis

Hyperkalemia

Etiologies
retention of potassium
renal failure, potassium sparing diuretics,
adrenocortical insufficiency

major release of potassium from the cell


trauma, burns, transfusions of old blood,
acidosis

rapid intravenous administration of


potassium

Major Complications of
Hyperkalemia

Nervous System
Paraesthesia

Neuromuscular
Muscle twitching, muscle weakness,
paralysis

Cardiovascular
Bradycardia
Cardiac arrest

Hypocalcemia

Etiologies
Hormone
Hypoparathryoidism
Elevated calcitonin
Vitamin D Deficiency

Renal
Renal failure
Hyperphosphatemia
Loop diuretics

Hypocalcemia

Etiologies
Acid Base Imbalance
Alkalosis

Nutritional
Malnourishment
Malabsorption syndromes

Multiple Blood Transfusions


Neonatal hypocalcemia

Major Complications of
Hypocalcemia

Nervous System
Paraesthesia

Muscular System
Tetany, Laryngeal spasms

Cardiovascular System

congestive heart failure


decreased cardiac output
cardiac dysrhythmias

Hypercalcemia

Etiologies
Hormone Imbalance
Hyperparathyroidism
Vitamin D excess

Thiazide diuretic use


Resorption of bone
Prolonged immobilization
Multiple fractures
Bone tumors
Multiple myeloma

Major Complications of
Hypercalcemia

Neurological Manifestation
lethargy, confusion, coma

Skeletal Manifestations
deep bone pain
pathological fractures

Renal Manifestations
kidney stones

Hypercalcemia

Gastrointestinal Manifestations
Constipation
Anorexia
Nausea and Vomiting

Cardiovascular Manifestations

Shortened QT interval
Bradycardia
Cardiac arrest

Hypercalcemia

Treatment

Dilute the calcium


Loop diuretics
Oral phosphate preparations
IV phosphate preparations
Plicamycin (slows bone resorption)
Calcitonin (slows bone resorption)

Hypomagnesemia

Etiologies

malnutrition
chronic alcoholism
loop diuretics
diarrhea
severe dehydration

Hypomagnesemia

Manifestations

Severe respiratory muscle depression


Apathy, depression, confusion
Muscle weakness, tremors, tetany
Life-threatening cardiac arrhythmias

Hypomagnesemia

Treatment
IV Magnesium Sulfate
2 Grams over 2 minutes
12 Grams over 12 hours

Hypermagnesemia

Etiologies
Chronic renal failure
Laxatives that contain magnesium
Antacids that contain magnesium

Hypermagnesemia

Manifestations

severe muscle weakness


depression of respirations
inability to swallow
hyporeflexia
hypotension
cardiac dysrhythmias

Hypermagnesemia
Discontinue all magnesium containing
drugs
Fluid therapy
Calcium gluconate to counteract the
effects of magnesium
Mechanical ventilation

Hypophosphatemia

Causes
alcoholism
malnutrition
diabetic ketoacidosis

Hypophosphatemia

Manifestations

Hemolytic anemias
Muscular weakness
Paraesthesias
GI distress from reduced energy and
oxygen stores to cells

Hyperphosphatemia

Etiologies
Chronic renal failure
Rapid cell catabolism
Excessive intake of phosphates

Hyperphosphatemia

Treatment

Dietary restriction of phosphates


Aluminum containing antacids
Hydration
Correct hypocalcemia

Edema
Expansion or accumulation of interstitial
fluid volume
Third-spacing is the movement of fluid
to areas where it becomes unavailable
for use by the body

Causes of Edema
Increased hydrostatic force
Decreased colloid osmotic pressure
Increased capillary permeability
Obstruction of a lymphatic vessel
Sodium and water excess

Distribution of Edema

Localized
Venous or lymphatic obstruction

Generalized
hypoproteinemia

Dependent
heart failure

Edema

Ascites
fluid within the peritoneal cavity

Pleural effusion
fluid within the pleural space

Pericardial effusion
fluid within the pericardium

Pulmonary edema
fluid within the alveoli

Concepts Related to Fluid Intake


Fever 101 - 103 increases 24 hour fluid
needs by at least 500 ml
Fever > 103 increases 24 hour fluid
needs by at least 1000 ml

Concepts Related to Fluid Output

Normal Urinary Output


1 ml of urine per kilogram of body weight
per hour
30 - 50 ml per hour

Anuria -- no urine output


Oliguria -- decreased urine output
Polyuria -- increased urine output

Concepts Related to Fluid Output

Includes

urine
vomitus
diarrhea
drainage
perspiration

Concepts Related to Fluid


Volume Deficit
Low urine output
Urine specific gravity high
Poor skin turgor
Poor tongue turgor
Dry mucous membranes
Decreased or absent of tearing
Decreased or absent salivation

Concepts Related to Fluid


Volume Deficit
Body weight decreases
Thirst increases
Skin may be warm and flushed in
moderate FVD
Skin may be cold and clammy in severe
FVD
Decreased intraocular pressure

Concepts Related to Fluid


Volume Deficit
Pulse rate elevates
Heart rate elevates
Blood pressure decreases
Neck veins flat
Hand veins flat
CVP decreases

4 - 11 CM of water

Types of Fluid Replacement

Crystalloids
Dextrose
Saline

Colloids
Albumin
Plasma protein fraction

Types of Fluid Replacement

Colloid Substitutes
Dextran
Hetastarch

Blood Transfusions
Packed Red Blood Cells
Whole Blood

Thiazide Diuretics

Examples
Chlorothiazide (Diuril)
Hydrochlorothiazide (HCTZ, Esidrix)

Actions

Inhibit sodium resorption in the kidney


Cause a loss of Na+, Cl- , Mg++, and K+
decrease ECF volume
Hyperglycemia, Hyperuricemia

Loop Diuretics
Furosemide (Lasix)
Ethacrynic acid (Edecrin)
Bumetanide (Bumex)
Actions

Act in the limbs of Henles loop


Cause the loss of sodium, chloride, and
potassium
Hyperuricemia

Potassium Sparing Diuretics


Sprinolactone (Aldactone)
Amiloride
Triamterene (Dyrenium)
Actions

inhibit sodium reabsorption


hyponatremia, hypokalemia,
hyperchloremia

Osmotic Diuretics

Mannitol
Increases osmotic pressure and causes
intracellular and interstitial fluids to enter
the vascular spaces

Actions

Hyponatremia
Hypochloremia
Increased extracellular volume