Fluids and Electrolytes Imbalances PDF

Fluids and electrolytes imbalances NRSG 224  Fluid and electrolyte Balance Fluid is found in the Intracellular (ICF)and extracellular (ECF)compartments of the body ECF is composed of; – Interstitial (water that surrounds the body cells and includes lym...

Fluids and electrolytes imbalances NRSG 224  Fluid and electrolyte Balance Fluid is found in the Intracellular (ICF)and extracellular (ECF)compartments of the body ECF is composed of; – Interstitial (water that surrounds the body cells and includes lymph – Intravascular-In the blood vessels (plasma) – Transcellular-fluids in specific compartments of the body such as; CSF, digestive juices and synovial fluid in the  Control of Fluid Balance Primary control is through pressure sensors or vascular system which; – Stimulate or inhibit the release of ADH (Pituitary gland) When Fluid in vascular system is decreased more ADH is released and water is retained If pressure is increased, less ADH is released and kidneys eliminate more water Movement of Fluids and Electrolytes in the body Movement of fluid and electrolytes in the body is by; – Active and passive transport systems Active Transport: Depends on Adenosine Triphosphate (ATP) for energy e.g sodium-potassium pump Passive transport: Diffusion, filtration and osmosis  Definition of Terms Filtration is movement of both H20 and smaller molecules through a semi-permeable membrane. – Promoted by hydrostatic pressure difference between areas e.g. capillaries Osmosis: lower substance concentration to higher concentration. The substance exert osmotic pressure The term osmolarity refers to concentration of substances in the body fluid Normal osmolarity of blood is between270-300 milliosmoles per litre (mOsm/L)  Osmolarity is tonicity. Tonicity is the relative concentration of solutes dissolved in solution which determine the direction and extent of diffusion Fluids or solutions can be classified as isotonic, hypotonic, or hypertonic. A fluid that has the same osmolarity as the blood is called isotonic. For example, a 0.9% saline solution (normal saline) is isotonic to the blood and is often used as a solution for intravenous (IV) therapy. A solution that has a lower osmolarity than blood is called hypotonic.  When a hypotonic solution is given to a patient, the water leaves the blood and other ECF areas and enters the cells. Hypertonic solutions exert greater osmotic pressure than blood. When a hypertonic solution is given to a patient, water leaves the cells and enters the bloodstream and other ECF spaces.  Note: In a healthy adult, nearly all fluid is contained in the intracellular, intravascular, or interstitial spaces, with the intracellular space holding about two- thirds of total body water  Fluid-balance Assessment. To get a complete picture, any assessment must be broad yet thorough and be founded on a good clinical knowledge base Nurses must be responsive to Patients anxieties as some may have conditions they feel shy to share e.g. incontinence in an older man Interpersonal skills are vital because a history is one of the main elements of a fluid-balance assessment.  Fluid-balance Assessment Older patients with a fluid imbalance present additional challenges when it comes to assessment. The physiological changes associated with ageing, such as – decreases in their glomerular filtration rate, ability to concentrate urine, thirst sensation – and aldosterone secretion, affect older patients’ ability to withstand changes in fluid balance.  In addition, two important assessment tools are invalid in many older patients. – The first is skin turgor, which is not reliable when the patient’s skin has lost its elasticity. – The second is the assessment of mucous membranes in older people, which may be dry as a result of decreased salivation rather than a fluid deficit.  History-taking is a key part of any fluid-balance assessment. A range of factors could precipitate either fluid loss or fluid gain. During the history-taking, any of the following conditions should be noted and explored: Fluid loss as a result of inadequate intake - this may be caused by nausea, gastrointestinal complaints, social circumstances, confusion or conditions such as arthritis or a cerebrovascular accident, which can make it physically difficult to eat or take fluids. Older people may also restrict their fluid intake in an attempt to alleviate continence problems or because mobility problems make it difficult for them to get to a toilet; - Excessive fluid loss as a result of vomiting, diarrhoea, increased insensible losses or the excessive use of laxatives or diuretics;  Fluid gain associated with renal, cardiac or hepatic insufficiency or excess sodium in the diet or in medications. Visual assessment During conversation, is the patient constantly trying to moisten his or her lips? This may be a sign of dry mucous membranes caused by fluid deficit. Nurses should also assess the patient’s skin turgor, as a loss of elasticity may indicate a fluid deficit, but remember that this may not be a reliable method of assessment for older patients. In the absence of any other causative factors, such as low plasma- albumin levels, peripheral oedema may indicate fluid overload.  Clinical signs Postural hypotension may become evident when the patient moves from a lying to a standing position. To be significant and to suggest fluid depletion, a drop of at least 15mmHg will be noted in the systolic pressure, with a drop of 10mmHg in the diastolic pressure. Serial bodyweights are an accurate method of monitoring fluid status. Nurses must ensure that patients use the same scales, wear the same amount of clothing and weigh themselves at the same time every day.  Extracellular Fluid Volume Imbalances ECF volume deficit (hypovolemia) and ECF volume excess (hypervolemia) are common clinical conditions. ECF volume imbalances are typically accompanied by one or more electrolyte imbalances, particularly changes in the serum sodium level. Fluid Volume Deficit (FVD) Fluid volume deficit can occur with abnormal loss of body fluids (e.g., diarrhoea, fistula drainage, haemorrhage, polyuria), inadequate intake, or a shift of fluid from plasma into interstitial fluid.  The term fluid volume deficit is not interchangeable with the term dehydration. Dehydration refers to loss of pure water alone without a corresponding loss of sodium.  ECF Volume Deficit Causes – Insensible water loss or perspiration (high fever, heatstroke) – Diabetes insipidus (DI) ( there is either decreased production of ADH (central DI), or normal ADH secretion with resistance in the kidneys to its effects (nephrogenic DI).) – Osmotic diuresis – Haemorrhage – GI losses: vomiting, NG suction, diarrhoea, fistula drainage – Overuse of diuretics – Inadequate fluid intake – Third-space fluid shifts: burns, intestinal obstruction  Clinical Manifestations – Restlessness, drowsiness, lethargy, confusion – Thirst, dry mucous membranes – Decreased skin turgor, ↓ capillary refill – Postural hypotension, weak rapid pulse, – ↓ CVP- central venous pressure is a measure of pressure in the vena cava, can be used as an estimation of preload and right atrial pressure ( an important assessment of haemodynamic status in ICU) – ↓ Urine output, concentrated urine – ↑ Respiratory rate – Weakness, dizziness – Weight loss – Seizures, coma  ECF Volume Excess Fluid volume excess may result from excessive intake of fluids, abnormal retention of fluids (e.g., heart failure, renal failure), or a shift of fluid from interstitial fluid into plasma fluid. Although fluid shifts between the interstitial space and plasma do not alter the overall volume of ECF, these shifts result in changes in the intravascular volume Note: osmolarity refers to the number of particles of solute per liter of solution, whereas the term osmolality refers to the number of particles of solute per kilogram of solvent. Causes Excessive isotonic or hypotonic IV fluids Heart failure Renal failure Primary polydipsia SIADH (syndrome of inappropriate antidiuretic hormone.) Cushing syndrome (S&S due to exposure to glucocorticoids as cortisol) Long-term use of corticosteroids  Clinical Manifestations Headache, confusion, lethargy Peripheral edema Jugular venous distention Bounding pulse, ↑ BP, ↑ CVP Polyuria (with normal renal function) Dyspnea, crackles, pulmonary edema Muscle spasms  Collaborative Management The goal of treatment for fluid volume excess is removing fluid without producing abnormal changes in the electrolyte composition or osmolality of ECF. The primary cause must be identified and treated. Diuretics and fluid restriction are the primary forms of therapy. Restriction of sodium intake may also be indicated. If the fluid excess leads to ascites or pleural effusion, an abdominal paracentesis or thoracentesis may be necessary.  Collaborative Management Laboratory evaluation include: – Blood urea nitrogen (BUN) level and its relationship with serum creatinine – FVD patient-BUN will be elevated out of proportion to the serum creatinine level (10:1), haematocrit level is greater then normal as red cell become suspended in a decreased plasma volume – Urine concentration is evaluated by Specific gravity (SG) in FVD it will be above 1.20 (indicating healthy renal conservation of fluid) – Replacement of vital electrolytes and essential minerals that enable the body to function properly  Nursing Management Extracellular Fluid Volume Imbalances Nursing Diagnoses Nursing diagnoses and collaborative problems for the patient with fluid imbalances include, but are not limited to, the following: ECF volume deficit: Deficient fluid volume related to excessive ECF losses or decreased fluid intake Potential complication: hypovolemic shock Nursing Management Extracellular Fluid Volume Imbalances ECF volume excess: – Excess fluid volume related to increased water and/or sodium retention – Impaired gas exchange related to water retention leading to pulmonary edema – Risk for impaired skin integrity related to edema – Activity intolerance related to increased water retention, fatigue, and weakness – Disturbed body image related to altered body appearance secondary to edema – Potential complications: pulmonary edema, ascites  Nursing Implementation Intake and Output. Use 24-hour intake and output records to give valuable information regarding fluid and electrolyte problems. Accurately record intake-and-output flow sheet to identify sources of excessive intake or fluid losses. Intake should include oral, IV, and tube feedings and retained irrigants. Output includes urine, excess perspiration, wound or tube drainage, vomitus, and diarrhoea.  Estimate fluid loss from wounds and perspiration. Measure the urine specific gravity according to agency policy. Readings of greater than 1.025 indicate concentrated urine, whereas those of less than 1.010 indicate dilute urine. Cardiovascular Changes. Monitor patient for – cardiovascular changes to prevent or detect complications from fluid and electrolyte imbalances. – Signs and symptoms of ECF volume excess and deficit are reflected in changes in blood pressure, pulse force, and jugular venous distention. – In fluid volume excess the pulse is full, bounding, and not easily obliterated. – Increased volume causes distended neck veins (jugular venous distention) and increased blood pressure – In mild to moderate fluid volume deficit, compensatory mechanisms include sympathetic nervous system stimulation of the heart and peripheral vasoconstriction. – Stimulation of the heart increases the heart rate and, combined with vasoconstriction, maintains the blood pressure within normal limits. – A change in position from lying to sitting or standing may elicit a further increase in the heart rate or a decrease in the blood pressure (orthostatic hypotension). – If vasoconstriction and tachycardia provide inadequate compensation, hypotension occurs when the patient is recumbent. – Severe fluid volume deficit can cause flattened neck veins and a weak, thready pulse that is easily obliterated. – Severe, untreated fluid deficit will result in shock. Respiratory Changes. – Both fluid excess and fluid deficit affect respiratory status. – ECF excess can result in pulmonary congestion and pulmonary edema as increased hydrostatic pressure in the pulmonary vessels forces fluid into the alveoli – The patient will experience shortness of breath and moist crackles on auscultation. – The patient with ECF deficit will demonstrate an increased respiratory rate because of decreased tissue perfusion and resultant hypoxia. Neurologic Changes. – Changes in neurologic function may occur with fluid volume excesses or deficits. – ECF excess may result in cerebral edema from increased hydrostatic pressure in cerebral vessels. – Alternatively, profound volume depletion may cause an alteration in sensorium secondary to reduced cerebral tissue perfusion. Assessment of neurologic function includes evaluation of – level of consciousness, which includes responses to verbal and painful stimuli and determination of a person’s orientation to time, place, and person; – pupillary response to light and equality of pupil size; and – voluntary movement of the extremities, degree of muscle strength, and reflexes. – Nursing care focuses on maintaining patient safety.  Daily Weights. – Accurate daily weights provide the easiest measurement of volume status. – An increase of 1 kg (2.2 lb) is equal to 1000 mL (1 L) of fluid retention (provided the person has maintained usual dietary intake or has not been on nothing-by- mouth [NPO] status). – Obtain the weight under standardized conditions, that is, weigh the patient at the same time every day, wearing the same garments, and on the same carefully calibrated scale. – Remove excess bedding and empty all drainage bags before the weighing. – Remove excess bedding and empty all drainage bags before the weighing. – If the patient has items present that are not there every day, such as bulky dressings or tubes, note this along with the weight. Skin Assessment and Care. – Detect clues to ECF volume deficit and excess by inspecting the skin. – Examine the skin for turgor and mobility. Normally a fold of skin, when pinched, will readily move and, on release, rapidly return to its former position. – Skin areas over the sternum, abdomen, and anterior forearm are the usual sites for evaluation of tissue turgor – In older people, decreased skin turgor is less predictive of fluid deficit because of the loss of tissue elasticity. – In ECF volume deficit, skin turgor is diminished, and there is a lag in the pinched skinfold’s return to its original state (referred to as tenting). – The skin may be cool and moist if there is vasoconstriction to compensate for the decreased fluid volume. – Mild hypovolemia usually does not stimulate this compensatory response  Consequently, the skin will be warm and dry. Volume deficit may also cause the skin to appear dry and wrinkled. These signs may be difficult to evaluate in the older adult because the patient’s skin may be normally dry, wrinkled, and non-elastic. Oral mucous membranes will be dry, the tongue may be furrowed, and the individual often complains of thirst. Routine oral care is critical for the comfort of a patient who is dehydrated or fluid restricted for management of fluid volume excess. – Edematous skin may feel cool because of fluid accumulation and a decrease in blood flow secondary to the pressure of the fluid. – The fluid can also stretch the skin, causing it to feel taut and hard. – Assess edema by pressing with a thumb or forefinger over the edematous area. – A grading scale is used to standardize the description if an indentation (ranging from 1+ [slight edema; 2-mm indentation] to 4+ [pitting edema; 8-mm indentation]) remains when pressure is released. – Evaluate for edema in areas where soft tissues overlie a bone, with preferred sites being the tibia, fibula, and sacrum – Good skin care for the person with ECF volume excess or deficit is important. – Protect edematous tissues from extremes of heat and cold, prolonged pressure, and trauma. – Frequent skin care and changes in position will prevent skin breakdown. – Elevate edematous extremities to promote venous return and fluid reabsorption. – Dehydrated skin needs frequent care without the use of soap. – Applying moisturizing creams or oils increases moisture retention and stimulates circulation.  Other Nursing Measures – Carefully monitor the rates of infusion of IV fluid solutions. – Be cautious about any attempts to “catch up,” particularly when large volumes of fluid or certain electrolytes are involved. – This is especially true in patients with cardiac, renal, or neurologic problems. – Patients receiving tube feedings need supplementary water added to their enteral formula. – The amount of additional water depends on the osmolarity of the feeding and the patient’s condition. – Do not allow the patient with nasogastric suction to drink water because it will increase the loss of electrolytes. – Occasionally the patient may be given small amounts of ice chips to suck. – Irrigate nasogastric tubes with isotonic saline solution, not with water  Water causes diffusion of electrolytes into the gastric lumen from mucosal cells. The suction then removes the electrolytes, increasing the risk of electrolyte imbalances.  Electrolyte Imbalances Sodium Imbalances Sodium, the main cation of ECF, plays a major role in maintaining the concentration and volume of ECF and influencing water distribution between ECF and ICF. Sodium plays an important role in the generation and transmission of nerve impulses, muscle contractility, and the regulation of acid-base balance.  Because sodium is the primary determinant of ECF osmolality, Sodium imbalances are typically associated with parallel changes in osmolality. Serum sodium is measured in milliequivalents per liter (mEq/L) or millimoles per liter (mmol/L).  The serum sodium level reflects the ratio of sodium to water, not necessarily the loss or gain of sodium. Changes in the serum sodium level may reflect a primary water imbalance, a primary sodium imbalance, or a combination of the two. Sodium imbalances are typically associated with imbalances in ECF volume  The GI tract absorbs sodium from foods. Typically, daily intake of sodium far exceeds the body’s daily requirements. Sodium leaves the body through urine, sweat, and feces. The kidneys are the primary regulator of sodium balance. The kidneys regulate the ECF concentration of sodium by excreting or retaining water under the influence of ADH. Aldosterone also plays a role in sodium regulation by promoting sodium reabsorption from the renal tubules.  Hypernatremia Hypernatremia, an elevated serum sodium, may occur with water loss or sodium gain. Because sodium is the major determinant of the ECF osmolality, hypernatremia causes hyperosmolality. In turn, ECF hyperosmolality causes a shift of water out of the cells, which leads to cellular dehydration. The primary protection against the development of hyperosmolality is thirst..  Normal level of sodium in blood is 135- 145mmol/L or mEq /L. Hypernatremia refers to sodium level or concentration ˃145mEq/L in blood. Hypernatremia is not a problem in an alert person who has access to water, can sense thirst, and is able to swallow.  Hypernatremia secondary to water deficiency is often the result of an impaired level of consciousness or an inability to obtain fluids Several clinical states can produce hypernatremia from water loss A deficiency in the synthesis or release of ADH from the posterior pituitary gland (central diabetes insipidus) or a decrease in kidney responsiveness to ADH (nephrogenic diabetes insipidus) can result in profound diuresis, thus producing a water deficit and hypernatremia.  several causes for hypernatremia disease; Inadequate water Nasogastric tube intake feed Diabetes insipidus Use of hypertonic Burns saline Excessive sweating, Intravenous Severe watery sodium bicarbonate diarrhoea, Hypertonic dialysis Vomiting Hyper Excessive use of Aldosteronism. laxative,  Sign and symptoms for hypernatremia Weakness Confusion Irritability Oedema Dry mouth (Dry oral mucosa) Tachycardia Low Skin turgor, Oliguria. In severe elevation of sodium seizures and coma  Diagnosis and Treatment for Hypernatremia Disease: Diagnosis; Sodium / Electrolytes, Urine Osmolality / Serum Osmolality Note: An osmole is the number of moles in a compound that contributes to the osmotic pressure. The main difference between osmolarity and osmolality is that osmolarity is a measure considering the volume of a solution whereas osmolality is measured considering the mass of a solution Treatment for Hypernatremia Disease: Stop underlying cause such as – vomiting, diarrheal, sweating. Stop use of laxatives. Withhold diuretics. Correction of hyperglycaemia. (ask class why) Use isotonic fluid (0.9% saline) to restore circulating volume in Hypovolemic shock. Correction of the water loss requires an assessment of the current water deficit and ongoing rate of water losses.  Hyponatremia Generally defined when the sodium in blood falls below 135mEq/L. Severe Hyponatremia considered when the serum sodium level is less than 125mEq/L. Hyponatremia is frequently related to hypovolemia or fluid overload. Sharp nursing assessment skills and proper care can prove invaluable in the treatment of patient and prevention of complication  Signs and symptoms Clinical picture can be confusing, because mild hyponatraemia can cause significant symptoms if the drop in sodium level is sudden, whereas severe chronic hyponatraemia can cause no symptoms, due to cerebral adaption. However, the following symptoms may occur: Mild - anorexia, headache, nausea, vomiting, lethargy. Moderate - personality change, muscle cramps and weakness, confusion, ataxia. Severe - drowsiness.  Signs These are again highly variable and depend on the level and rate of fall of the serum sodium. They may include: Neurological signs: – Decreased level of consciousness. – Cognitive impairment (eg, short-term memory loss, disorientation, confusion, depression). – Focal or generalised seizures. – Brainstem herniation - seen in severe acute hyponatraemia; signs include coma; fixed, unilateral, dilated pupil; respiratory arrest.  Signs of hypovolaemia – – dry mucous membranes, – tachycardia, – diminished skin turgor. Signs of hypervolemia – – pulmonary rales – jugular venous distention – peripheral oedema – ascites.  Nursing Intervention for Hyponatremia Patient: Strictly maintain fluid intake and output of patient hourly. Check weight everyday to monitor the fluid volume status. Monitor and observe skin turgor to identify dehydration and accurately record state of hydration. Monitor vital signs carefully and note respiratory rate and depth to identify pulmonary oedema.  Check and monitor the hyponatremia patient for signs of oedema and hypertension. Monitor for signs of circulatory overload, as indicated Ensure high sodium containing food such as milk, meat, eggs, carrots, beets and celery. Ensure adequate dietary sodium intake of 90 to 250 mEq Day. Monitor and observe for neuromuscular changes such as declining levels of consciousness, fatigue and muscular weakness.  Give supplemental oxygen to lethargy or unconscious patient as needed. Patient with sodium imbalances often are confused and act as crazy. Ensure safety measure; – Maintain quiet environment. – Keep bed in low locked position. – Keep side rails up to prevent fall. – Keep nurse call within reach and instruct patient to call nurse for any assistance.  Carefully monitor hyponatremia patient for any sign of convulsion and notify to physician. Take seizure precautions as order. Monitor laboratory serum sodium levels as ordered to determine the effectiveness of IV fluids. Administer prescribed medication as order. Carefully administer the 3% or 5% sodium containing fluid by using infusion pump as prescribed.  Monitor IV site for patency, signs of infiltration such as redness or irritation. Identify the specific cause of hyponatremia such as sodium loss or fluid excess. Give mouth care frequently as dry mouth and saliva production decreased. Irrigate nasogastric tube with normal saline instead of plain water. Prepare patient for dialysis as indicated. Address acute life threatening conditions and initiate supportive care