Fluid and Electrolytes Engage

Electrolytes and Their Functions

• Electrolytes are crucial for maintaining water balance, blood pH, nutrient movement, waste removal, and proper muscle, heart, nerve, and brain function.
• Nurses use critical thinking to evaluate electrolyte lab results and anticipate appropriate interventions based on reference ranges.

Basic and Comprehensive Metabolic Panels

• Basic Metabolic Panel (BMP) and Comprehensive Metabolic Panel (CMP) indicates kidney function, blood bicarbonate level, blood sugar level, blood chloride level, blood potassium level, blood sodium level, and liver function.
• Kidney function is indicated by blood urea nitrogen (BUN) and Creatinine (CR) levels.
• Blood bicarbonate level is indicated by carbon dioxide (CO2).
• Blood sugar level is indicated by glucose.
• Liver function is indicated by Calcium (Ca+), liver enzymes, alkaline phosphatase (ALP), alanine transaminase (ALT), aspartate aminotransferase (AST), bilirubin (total), albumin, and proteins (total).

Body Fluid Compartments and Osmolality

• Osmolality, measured in urine (reference range: 50 to 1,200 mOsm/kg), assesses renal function and hydration.
• Osmosis is the final water balance mechanism, facilitating passive water flow between body compartments via semi-permeable cell membranes.
• Water moves from low to high solute concentration areas to maintain equilibrium and homeostasis.

Role of the Kidneys

• Kidneys maintain fluid and electrolyte balance by removing cellular waste and excess fluid through urination.
• They filter the blood, eliminate wastes, and return needed water and electrolytes to circulation.

Types of Fluid Loss

• Sensible fluid loss occurs daily through sweat, urine, and liquid stool.
• Insensible fluid loss is harder to measure and occurs from the respiratory system, skin, and water in formed stool.

Risk Factors for Fluid and Electrolyte Imbalances

• Dehydration, hypovolemia, overhydration, medications, and disorders of the heart, kidney, or liver.
• Other factors include incorrect IV fluids/feedings, profuse sweating, vomiting, and diarrhea which can increases water loss.

Electrolyte Reference Values

• Potassium (K+): 3.5 to 5 mEq/L
• Sodium (Na+): 136 to 145 mEq/L
• Calcium (Ca2+): 9 to 10.5 mg/dL
• Magnesium (Mg2+): 1.3 to 2.1 mEq/L

Nursing Responsibilities

• Vital for nurses to be knowledgeable about electrolyte reference ranges and deviations to identify abnormal findings, report to the provider, and anticipate interventions.

Hypokalemia

• PNs should review laboratory values and, if out of range, report the results to the RN/provider.
• Hypokalemia can arise due to medications, certain cardiac conditions, gastrointestinal losses, metabolic alkalosis, decreased oral potassium intake, excessive alcohol use, chronic kidney disease, diabetic ketoacidosis, excessive sweating, and folic acid deficiency.
• Treatment begins with identifying the cause, provider may prescribe potassium supplementation to restore levels to the expected range via oral medications or IV infusion.
• Oral supplements can cause gastrointestinal distress, so should be administered with or following a meal.

IV Potassium Considerations

• Potassium is a high-alert IV medication & doses must be double-checked and diluted in 100-1,000 mL of compatible solution.
• Potassium cannot be administered directly from the vial.
• The dose should not exceed 40 mEq/L (unless severe hypokalemia), and the rate of administration is commonly set at 10-20 mEq/hour.
• Monitor clients on a continuous ECG and check potassium levels periodically.

Dietary Potassium Sources

• Foods high in potassium include baked potatoes (941 mg per medium), prune juice (707 mg per cup), carrot juice (689 mg per cup), and white beans (595 mg per ½ cup).

Hyperkalemia Causes and Management

• Hyperkalemia can occur from renal failure, dehydration, diabetes mellitus, medications, trauma, excess potassium intake, burns, transfusions of packed red blood cells, acidosis and sepsis.
• Renal failure is the most common cause of hyperkalemia which often results from potassium-sparing diuretics, NSAIDs, and ACE inhibitors.
• Mild hyperkalemia is often asymptomatic while high potassium levels can cause cardiac dysrhythmias, muscle weakness, or paralysis, and defined as levels greater than 7 mEq/L.
• Routine blood tests (BMP/CMP) measures levels and provider may prescribe an ECG.
• Start treatment the same way as hypokalemia, start treatment with the cause to remove excess potassium and stabilize the heart.

Hyperkalemia Interventions

• PNs should report out-of-range lab results to the RN or provider.
• The provider may recommend decreases in dietary potassium and avoiding salt substitutes containing potassium chloride.
• Commonly used by those with sodium restrictions, these substitutes increases potassium levels.

Hyponatremia Risks and Causes

• PNs should report out-of-range lab results to the RN or provider.
• Multiple factors can place a client at risk for developing hyponatremia: medications, chronic vomiting or diarrhea, drinking excess amounts of water, excess alcohol intake, heart, kidney, and liver problems and severe burns.
• hyponatremia often stems from excess water in the body, not a sodium deficit which results from drinking too much water, causing excessive sodium loss.
• Thiazide diuretics commonly causes urinary loss, GI losses such as prolonged diarrhea/vomiting, diseases causing fluid retention/excess excretion such as heart failure/cirrhosis/kidney conditions.

Hyponatremia Treatment

• Routine serum electrolyte tests are performed and can be determined using either BMP or CMP.
• Provider may prescribe a urinalysis.
• Treatment should be initiated to treat underlying cause and correct sodium levels.
• Fluid restriction can be implemented to correct dilutional effects or IV fluids if caused by sodium/fluid loss, potential medication modification/discontinuation and treatment of certain diseases.

Patient Education for Hyponatremia

• Encourage moderation, check urine color, discuss sports electrolyte drinks with provider for demanding activities, and check thirst levels.

Specific Calcium Information

• Adults need to increase intake of calcium to reduce risk of developing osteoporosis especially women.
• 99% is stored bones and teeth and plays a role such mineralization of bone, muscle contraction, nerve transmission, clotting of blood, hormone secretion, normal functioning of heart.
• Absorption of calcium depends on a supple of vitamin D, requires 600 IU for adults and 800 IU for adults > 50.
• Excretion occurs in the kidneys and controlled by parathyroid hormone.
• Client's ionized calcium levels is estimated at 50% of their levels.

Calcium RDA

• 0-6 months: 200 mg
• 7 - 12 months: 260 mg
• 1 - 3 years: 700 mg
• 4 - 8 years: 1,000 mg
• 9 - 13 years: 1,300 mg
• 4 - 18 years: 1,300 mg
• 19 - 50 years: 1,000 mg
• 51-70 years: 1,200 mg (Female), 1,000 mg (Male)
• 71+ Years: 1,200 mg

Hypocalcemia Risks

• Hypocalcemia can occur from medications reducing calcium absorption, inadequate vitamin D, hormonal changes (menopause), hypoparathyroidism, renal disease, multiple blood transfusions, electrolyte imbalances of magnesium/phosphate, sepsis and low albumin levels.
• Stimulant laxatives, longterm use of glucocorticoids and loop diuretics, proton-pump inhibitors and histamine-2 blockers lowers gastric acid and calcium levels.
• Hormone changes (menopause) occurs due to decreased estrogen production which causes decreased estrogen production and bone loss from osteopenia.

Hypocalcemia Effects and Treatment

• Affects respirstory, cardiac, neurologic, sensory, neuromuscular, and integumentary system which can cause chest pain, dysrhythmias, heart failure, and syncope.
• Neuromuscular manifestations can cause numbness/tingling of fingers/toes, muscle cramping and spasms, confusion, depression, psychosis, dementia, lethargy, seizures, and personality changes, and respiratory changes.
• Tested during a CMP or BMP.
• Treatment includes calcium and vitamin D supplements, diet changes, or calcium injections depending on the severity

Food Hight In Calcium

• High calcium includes American cheese, paramesan cheese, yogurt and almond milk.

Hypercalcemia Causes

• Hypercalcemia is often from hyperparathyroidism, cancer, vitamin D toxicity, medications, or renal failure.
• Hyperparathyroidism: parathyroid gland secretes excess amount of PTH leads to high absorption of calcium.

Hypercalcemia Effects

• As calcium increases can result in consitpation, abdominal pain, nausea, vomiting, anorexia, confusion, thirst, polyuria. bone pain, and muscle weakness.
• If reaches critical levels arrhythmia, delirium, coma, and/or renal failure can occur, can be life-threatening if not treated.
• Mneumonic is abodminal groans, painful bones, kidney stones, psychiatric moans, and fatigue overtones.
• A ionized calcium and PTH should be tested.
• Imaging can also be ordered.
• Treated by addressing the caus, phosphate by mouth, intraveneous saline bolus and loop dieretics should be administered.

Magnesium Information

• RDA for male 400 to 420 mg/day and female 310 to 320 mg/day

Hypomagnesemia Causes

• Low magnesium by medications, decreased intake, decreased absorption by intestines (Crohns disease & celiac disease), increased excretion (diarrhea/pancreatitis/ or kidney), excess alcohol, diabetes, undertrition, burns and electrolyte imbalances.
• This includes loop/thorazine diuretics, and proton pump inhibitors.

Hypomagnesemia Effects & Treatment

• low magnesium can result in muscle cramps, spasticity, numbness, seizures, cardiac dysrhythmias and if accompanied by other electrolyte balances, the replacement if more difficult. and should encourage clients to increase more magnesium in diet.
• oral magnesium will be initiated and if severe given parenteral magnesium replacement can cause flushing, sweating, and respitory depression if med given too quick.

Recommended Food For Electrolytes & Magnesium,

• Cooked spinach (156 g per cup), pumkin seeds (156 g per ounce), black beans, cooked soybeans, avocados, tofu and salmons.

Hypermgagnesemia Causes

• Most common cause, Acute/Chronic Kidney disease, over intake of antacids or lax, acidosis medications Trauma can lead to excess Mg & can lead to bradycardia , so a full Cardiac output assessment (Patellar reflex) is necessary

Magnesium Interventions

• Report all results that are out of the reference point, severe cases the provider may prescribe calcium
• Administer Calcium Gluconate or Calcium Chloride to decrease magnesium

Fluid Losses & Dehydration Causes

• Due to Loss of Water/Lack of Intake, Body's electrolyte/water balance will be altered & lead to Hypernatremia .& increased osmolarity
• Diarrhea , Vomiting Sweat can also contribute to dehydration
• Manifestation of loss Water/Fluid are cognitive, lethargy, thirst

Hypovolemia Triggers

• Bleeding out / excess Sweating or Fever can disrupt Total Water Volume
• Assess & check their Creantine (CR)Levels/Hemoglobin for hypovolemic signs of dehydration

Hypervolemia Effects on The Body

• Too Much sodium in the body in the extracellular which results in the blood cant pump the body affects kidney's, cirrhosis, inflammation of the Liver

Kidney Failure/Hypovolemina

• Heart cant pump the blood can causes the Fluid to imbalance - Meds help reduce fluid and control Na - BMP-CMP

Treatment of Hypervolemia & Role of Nurse

• Dialysis (severe kidney disease), Nutrition Support, Weigh Ins Check Edema ( Swelling ) Dietician may educated about intake of Fluids

High Risk For Electrolyte Imbalance & Nursing Action

• Take into the account Elderly, and the medications they use and be mindful of the Kidney Function, Childrens must have their ability to swallow

Water Volume & The Use of An iV

• Encourage patients to have water or fluids, as directed. check the area/Vein is not a blood zone.
• IV Access is to make things safer
• When giving an IV A tourniquet (5Cm/10Cm's) is applied give a pulse
• Remove catheter
• Central Lines can Lead to an open Source for Infection
• Make sure staff or aware and have education on IV administration, as facility policy direct and follow Standard Guideline 's.

IV Therapy Information

• Sterile Equip for IV access to prevent Source for Infection to Prevent CLABS- Infusion nurse society Standard
• Tubing will require change every 24/HR to Prevent Infection.
• Primary and the secondary tubing require the set standards.

IV solutions

• Sodium-0.9 (most common Fluid)

Isotonic & Hypertonic Solution

• Isotonic has no movement.
• Hypertonic causes water to leave the cell for it to return to Plasma

Colloidal Solutions

• Can Treat (shock/Hypovolemia).
• Albumin: Be mindful for circulatory overload and Pulmonary Edema.

IV Flow Rates

Flow Rate (mL/hr) = Total Volume (mL) / Infusion Time (hr) Flow rate for 3,000 mL/15 hour rate is 200 mL/HR