Fluid and Electrolyte Imbalance

• Fluid and Electrolyte Imbalance involve the disruption of the balance of fluids and electrolytes in the body.

Hypotonic Solution

• Fluid osmolality is less than cell osmolality.
• Water moves into the cell causing it to swell.

Isotonic Solution

• Fluid osmolality equals cell osmolality.
• There is no net movement of water.

Hypertonic Solution

• Fluid osmolality is greater than cell osmolality.
• Water moves out of the cell causing it to shrink.

IV Solutions

• 0.45% Saline is a Hypotonic solution
• 0.9% Saline is an Isotonic solution.
• Lactated Ringers is an Isotonic solution.
• D5W is an Isotonic solution.
• 5% Dextrose in 0.9% is a Hypertonic solution.
• Colloids are volume expanders.

Hypotonic Solutions Effect

• Fluid moves out of the vessel and into the cells, causing them to swell.
• 0.45% Normal Saline is one example.

Isotonic Solutions Effect

• Fluid stays where it is put.
• 0.9% Normal Saline, Lactated Ringers and 5% dextrose in water (D5W) are examples of Isotonic Solutions.

Hypertonic Solutions Effect

• Fluid enters the vessel from the cell.
• 5% dextrose in 0.9% normal saline and 5% dextrose in 0.45% normal saline are examples.

Fluid Movement in Capillaries

• Capillary Hydrostatic Pressure forces water out of capillaries.
• Plasma Oncotic Pressure pulls water into capillaries.
• Interstitial Oncotic Pressure pulls water out of tissue.
• Interstitial Hydrostatic Pressure forces water into tissue.

Factors Causing Abnormal Fluid Shifts

• Changes in capillary and interstitial pressures can cause shifts, resulting in edema or dehydration.
• Increased venous hydrostatic pressure inhibits fluid return to the capillary, causing edema; causes include fluid overload, heart failure, liver failure, venous return obstruction, and venous insufficiency.
• Decreased plasma oncotic pressure causes fluid to stay in the interstitial space, resulting in edema caused by low plasma protein, renal disorders, liver disease, and malnutrition.
• Increased interstitial oncotic pressure causes plasma proteins to accumulate in the interstitial space, resulting in edema caused by trauma, burns, and inflammation.

Regulation of Water Balance

• The human body maintains fluid balance through water intake, use, and excretion.
• Daily water intake should be 2000 to 3000 mL.
• Insensible water loss, which is invisible vaporization from the lungs and skin, regulates body temperature.
• Increased body metabolism leads to increased water loss.
• Sensible perspiration, which is excess sweating, is caused by exercise, fever, or high temperatures.

Hypothalamic-Pituitary Regulation

• Body fluid deficit triggers osmoreceptors in the hypothalamus, stimulating thirst and releasing ADH.
• ADH makes the kidneys more permeable to water, increasing water reabsorption into the blood and decreasing excretion in urine.

Adrenal Cortical Regulation

• Glucocorticoids (cortisol) are secreted
• They are anti-inflammatory which increases serum glucose levels, and are increased in response to stress and physical trauma.
• Mineralocorticoids (aldosterone) increases Na+ retention (water follows) and K+ excretion through the renin-angiotensin-aldosterone system (RAAS).

Cardiac and GI Regulation

• Increased blood volume causes the release of hormones, including atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP).
• RAAS and ADH secretions are suppressed.
• Na+ and water excretion is promoted, decreasing BP and blood volume.
• The gastrointestinal system secretes 8000 mL of GI fluids daily the majority of which is reabsorbed
• Diarrhea and vomiting prevent GI reabsorption, leading to significant fluid and electrolyte loss.

Fluid Volume Imbalances

• Fluid volume deficit (hypovolemia) is caused by abnormal loss of body fluids, inadequate intake, or shift from plasma to interstitial fluid. Abnormal loss of body fluids can be caused from: diarrhea, fistula drainage, hemorrhage, etc. Correct the cause and replace fluids.

• Fluid volume excess (hypervolemia) is caused by abnormal retention of fluids (i.e., heart failure, renal failure), excessive intake of fluids, or shift of fluid from interstitial fluid to plasma. Identify and treat the cause, and remove fluid without electrolyte changes.

Nursing Management: Fluid Volume Deficit

• Weigh the patient at the same time every day using the same scale and clothing.
• Record intake and output
• Monitor labs (↑ BUN, Na, Hematocrit)
• Monitor VS (↑ HR, weak pulse, orthostatic hypotension).
• If respiratory rate increases administer oxygen
• Assess level of consciousness, gait, and muscle strength to prevent falls.
• Assess for skin tenting and dry oral mucosa, and apply creams.
• Administer oral and IV fluids to encourage oral intake.

Nursing Management: Fluid Volume Excess

• Weigh the patient at the same time every day using the same scale and clothing.
• Record intake and output
• Monitor labs (↓ BUN, Na, Hematocrit)
• Monitor VS (full and bounding pulse, hypertension, JVD).
• If pulmonary congestion/edema , shortness of breath, and/or moist crackles are present administer oxygen
• Assess patient for risk of falls
• Assess for cool skin, edema, taut skin, and pitting, change positions frequently.
• Implement fluid restrictions and monitor patient carefully.

Diuretics

• Loop Diuretics: Example Furosemide. Used to treat Edema and HTN;
• Thiazide Diuretics: Example hydrochlorothiazide. Used to treat Edema and HTN
• K+ Sparing Diuretics: Example Spironolactone Used to treat Edema and HTN - Can be used to treat diuretic-induced hypokalemia, and severe heart failure

Sodium

• Sodium range is 135 to 145.
• Sodium plays a major role in maintaining ECF volume.
• Influences water distribution between ECF and ICF.
• Generates nerve impulses, muscle contractility and regulates acid-base balance.
• Reflects the ratio of sodium to water, and is regulated by kidneys.

Hypernatremia

• Hypernatremia is usually caused by ↑ sodium intake, ↓ water intake and ↑ water loss.
• Other causes include: Diabetes insipidus, Primary hyperaldosteronism, Cushing syndrome and Uncontrolled diabetes
• CLINICAL MANIFESTATIONS in include Intense thirst, dry tongue, dry mucous membranes, Flushed skin and Edema

Hypernatremia Nursing Interventions

• Treat the underlying cause
• Water Deficit: Fluid replacement orally, IV fluids, Sodium Excess: Na excretion with diuretics and Restrict Na in diet
• Be careful that Sodium does not decrease rapidly = rapid shift of water into cells = cerebral edema

Hyponatremia

• Hyponatremia is usually caused by↑ sodium loss, ↓ sodium intake ↑ water gain.
• Other causes include: SIADH, Heart failure, Primary hypoaldosteronism and Cirrhosis
• CLINICAL MANIFESTATIONS in include CNS symptoms such as Headache, Irritability, and Difficulty concentrating

Hyponatremia Nursing Interventions

• Maintain accurate I&O
• For a Water Deficit: Fluid replacement orally and/or IV fluids as well as Withhold all diuretics
• For a Water Excess: Implement Fluid restriction as well as Administer Loop diuretics
• Sodium should not increase rapidly

Potassium

• Potassium range is 3.5 to 5.0
• Major ICF cation (98% of body’s K+ is in cell)
• Sodium-potassium pump maintains the difference
• Pump pumps K+ INTO cell whilst Moving Na+ OUT of cell (stimulated by insulin)
• Affects neuromuscular & cardiac function
• Main source is diet (Kidneys regulate 90% of K+ into urine)

Hyperkalemia Causes

• Increased K+ Intake
• K+ moves out of cells
• The body has aFailure to eliminate K+
• Other causes: Diabetes, Renal disease, Adrenal insufficiency, medications

Hyperkalemia Clinical Manifestations

• Cell excitability in nerves and muscles
• Cardiac conduction changes (ECG such as tall/peaked T waves, ST depression, and Widening QRS)
• Fatigue, Muscle weakness/cramps, Decreased reflexes G-I hyperactivity (diarrhea, vomiting and cramping)

Hyperkalemia Nursing Interventions

• STOP PO and IV K+
• Utilize continuous EKG monitoring, and closely Monitor serum K+
• INCREASE K+ EXCRETION such as Thiazide or loop diuretics, or Kayexalate if ordered

Hypokalemia Causes

• Increased loss of K+ such as Through G-1 losses (Diarrhea, vomiting or NG suction), Renal losses (Duiretics and/or Hyperaldosteronism), Skin losses as well as dialysis
• Shift from ECF TO 1CF such as Increased insulin release or with Alkalosis

Hypokalemia Clinical Manifestations

• Cardiac changes in ECG (flattened T wave, Depressed ST segment, and U wave present)
• Muscle Weakness (Soft and "flabby" muscles) as well as Paresthesia
• In conjunction these symptoms leads to respitory arrest
• There is also Reduced Gi motility (Constipation and nausea)

Hypokalemia Nursing Interventions

• Oral/1V KCI supplements however safety must be regarded when administered
• Increase Potassium Rich diet, and monitor for signs of infiltration Keep close ECG monitoring as well as regular monitoring of levels, and urine output

Calcium

• Normal calcium range is 8.6 – 10.2
• A major cation that's heavily prevalent in bones and teeth
• Plays an important function in the likes of blood clotting, nerve impulses contractions of muscles
• Important to receive an active from if Vitamin D whether that's through ingestion, or even simply sun exposure
• Also regulated by parathyroid hormones, and calcitronin

Hypercalcemia

• Can be caused by "Hyperparathyroidism"
• Various Cancers with effects to things like blood/breast/lung
• Increased amount of Vitamin A & D

Hypercalcemia Clinical Manifestations

• With reduced excitability come reduced muscle function
• Can also lead to cardiac changes, confusion, hallucinations, and even bone pain
• If not managed can result in significant levels of lethargy, heart strain, and a large amount of confusion

Hypercalcemia Nursing Inventions

• STOP ingestion medicines with high Calcium levels Monitor diet, and manage the rates of urine excretion"

Hypocalcemia causes

• Conditions related to PTH deficiency, and can be exasperated by increased levels of alkalolisis, loss of fluids (Diarrhea mainly)
• Negative effects from loop diuretics, Acute Pancreatitis as well as injuries to key glands.

Hypocalcemia clinical manifestation

• Increased levels of Nerve exciability, sustained muscle contraction
• Potential for ECG Changes, and numbness mostly around the mouth/lips

Hypocalcemia Nursing Plans

• In a situation whereby the case is mild; the main priority is a diet with rich calcium focused ingredients along with supplements (Vitamin D)
• Severe instances usually require far more drastic measures (IV, pain management, dialysis.

Magnesium

• Magnesium range is 1.3 – 2.1
• Has a huge role In a broad range of processes that are present in cells
• Effects carbohydrate metabolism, along with DNA/protein synthesis
• Can effect Blood glucose control, and regulation of blood pressure
• Also crucial in production of production ATP (Pottasium and Sodium Pump) Muscle relaxation/contractions as well as certain Neruological Funcitons

Hypermagnesemia

• With potential causes stemming from IV injections of Magnesium (In tandem with failure of Kidney's Can be exasperated by consumption of antacids, and certain thyroid malfunctions

Hypermagnesemia Clinical Manifestations

• Typically displays symptoms such as a general state of lethargy. with potential to face vomiting/naseau' Can also include urinary retention, and a reduced level of bodily functions, which when left for long enough, can put the indiviual in state where deep tendon reflexes, bodily paralysis, coma as a result.

Magnesemia Nursing Plans

• Patients can be provided with drugs who's design is work against bodily Magnesium content.
• Management of fluid retention, and close attention to the bodies Magnesium/Potassium level as well as a diet with restrictions set in place (Limiting Green Veggies, peanuts, buts, bannanas/oranges)

Hypomagnesemia

• Causes can be largely be boiled down to, GI fluid, dietary problems (Fasting) with potential in certain antibiotics

Hypomagnesemia Clinical Manifestations

• Usually presents similarly to Hypoclycemia- Increased state of confusion/dysrythmias deep rooted tremors and cramps

Nursing Inventions for Hypomagnesemia

• Increase levels of Magnesium, in diet, or through supplement consumption

Phosphate

• Phosphate range is 3.0 – 4.5
• Has vital role within the bones/teeth is the form of calcium phosphate.
• Also crucial in regards to muscle energy and metabolism of nutrients.
• Kidneys are used the bodies' excretion processes "

Hyperphosphatemia Causes

Usually results from an increase in Phosphate, or intake through use of laxatives as well as effects (Or the reverse effects" if Hypothyroidism is applied

• Can also appear a kidney's fail/loss to injury.

Clinical Manifestions of HYPERPHOSPHATEMIA

• Unless paired of calcium binding it is usually symptomless "

HYPERPHOSPHATEMIA Nursing Inventions

• Restrict high consumption product's from the Patients diet,
• Admin Calcium CArbonate

Hypophosphatemia Inventions

Hypophosphatemia Causes

• Typically happens from bad nutrient absorbtion Increased urine levels, or in situation where malnutrition effects bodies inter workings.
• If not one of those then Respiratory Issues or Diarrhea is another likely suspect."

Hypophosphatemia Clinical Manifestation

• Typically asymptematic, with clear Bruising, Aenmia, or Constipation in moderate phases
• For larger instances then you'd see CNS levels lowering with various levels of pain, before eventually reaching Heart, respitory failure

HYPOPHOSPHATEMIA Nursing Inventions

• Implement DHP diet that contains Phosphates, if necessary create various Supplements in tandem.