Fluid Volume Disturbances & Electrolyte Imbalances PDF

Fluid Volume Disturbances & Electrolyte Imbalances BSN214: Adult Medical Surgical Nursing 1 Theory Week 3 Semester 2, 2024-25 Document is Classified as OPEN fchs.ac.ae 1 ...

Fluid Volume Disturbances & Electrolyte Imbalances BSN214: Adult Medical Surgical Nursing 1 Theory Week 3 Semester 2, 2024-25 Document is Classified as OPEN fchs.ac.ae 1  Learning outcomes 1. Describe the composition of body fluid compartments. 2. Describe the process involved in the regulation of water and electrolyte movement between the body fluid. 3. Discuss the assessment for fluid volume disturbances (fluid excess & fluid deficit). 4. Outline the body Acid-Base Balance and regulation 5. Describe the etiology , clinical manifestation, and nursing management for sodium, potassium, calcium and magnesium & phosphorus imbalances. Document is Classified as OPEN fchs.ac.ae 2  Fluid & Electrolyte Balance Fluid and electrolyte balance is a dynamic process that is crucial for life and homeostasis. The nurse’s role is to help prevent and treat any fluid and electrolyte or acid-base balance disturbances. Homeostasis: It is the state of equilibrium in the internal environment of the body, naturally maintained by keeping the composition and volume of body fluids within narrow limits of normal. Document is Classified as OPEN fchs.ac.ae 3  Amount & composition of body fluids Document is Classified as OPEN fchs.ac.ae 4  Fluid Compartments Intracellular fluid (ICF) Extracellular fluid (ECF)  Intravascular (plasma)  Interstitial Transcellular Fluid Document is Classified as OPEN fchs.ac.ae 5  Body Fluid components Document is Classified as OPEN fchs.ac.ae 6  Regulation of body fluid compartments Diffusion: Diffusion is the movement of particles from the area of higher concentration to the area of lower concentration. Osmosis is a process by which molecules of a solvent tend to pass through a semipermeable membrane from a less concentrated solution into a more concentrated one. Osmotic pressure is the amount of force (Hydrostatic pressure) applied to a solution that prevents solvent from moving across a semipermeable membrane. Document is Classified as OPEN fchs.ac.ae 7  Regulation of body fluid compartments Oncotic pressure (colloid-osmotic pressure) is the osmotic pressure caused by proteins. Hydrostatic pressure - The pressure exerted by a fluid at equilibrium at any point in time due to the force of gravity. Filtration- Hydrostatic pressure in the capillaries tends to filter fluid out of the intravascular compartment into the interstitial fluid. - Movement of water and solutes occurs from an area of high hydrostatic pressure to an area of low hydrostatic pressure. Document is Classified as OPEN fchs.ac.ae 8  Regulation of body fluid compartments Sodium- Potassium Pump It is an example of active transport; energy must be expended for the movement to occur against a concentration gradient. Actively moves sodium from the cell into the ECF and potassium into the cell. Please watch the video on Sodium Potassium pump https://www.youtube.com/watch?v=AkiaMiGnPuQ Document is Classified as OPEN fchs.ac.ae 9  Fluid Shifts Plasma (Intravascular fluid) Interstitial fluid Interstitial fluid edema Plasma (Intravascular fluid) Elevation of hydrostatic pressure Fluid is drawn into plasma space whenever there is Decrease in plasma increased plasma osmotic oncotic pressure or oncotic pressure Wearing of compression Elevation of interstitial stockings is a therapeutic oncotic pressure action on this effect Document is Classified as OPEN 10  Fluid Movement Between Extracellular and Intracellular Water deficit ( ECF) is Water excess ( ECF) associated with symptoms develops from the gain or that result from cell retention of excess water shrinkage as water is pulled Management ( Losing ) into the vascular system Kidney: urine output (1 ml/kg/hr). Management (Gain): Skin: sensible (sweating) & Dietary intake of fluid insensible losses and food or enteral (evaporation) feeding Lungs: insensible losses Parenteral fluids (evaporation) GI tract Document is Classified as OPEN 11 Daily Fluid Gain and Loss 12 Document is Classified as OPEN  Laboratory Tests for Evaluating Fluid Status 1- Osmolality (mOsm/kg): measures the solute concentration per kilogram in blood and urine*. Serum osmolality: primarily reflects the concentration of sodium (280-300mOsm/kg). Urine osmolality: determined by urea, creatinine and uric acid (200-800mOsm/kg). 2- Osmolarity: describes the concentration of solution (mOsm/L). Document is Classified 13 as OPEN  Laboratory Tests for Evaluating Fluid Status 3- Urine specific gravity: Measure the kidney’s ability to excrete or conserve water. (1.010-1.025). Less reliable indicator of concentration than urine osmolality. SG varies inversely with urine volume, Why? 4- Blood Urea Nitrogen (BUN) : The end product of the metabolism of protein (muscle and dietary intake). Normal BUN is 10-20 mg/dl.(3.6-702mmol/L). High BUN: GI bleeding, dehydration, fever and sepsis. Low BUN: low-protein diet, starvation, liver disease. Document is Classified 14 as OPEN  Laboratory Tests for Evaluating Fluid Status 5- Creatinine: The end product of muscle metabolism. The best indicator of renal function is Creatinine level than BUN, Why? Normal serum creatinine (0.7-1.4 mg/dl) (62-124 mmol/L). Increase when renal function decreases. 6- Hematocrit: Measure the volume percentage of RBCs in whole blood (42%- 52% male)(35%-47% female). What are the conditions ↑ and ↓ Hct level? Document is Classified 15 as OPEN  Fluid Volume Disturbances Fluid volume deficit (FVD): (Hypovolemia) Fluid volume excess (FVE): (Hypervolemia) 16 Document is Classified as OPEN  Fluid Volume Deficit FVD: Loss of extracellular fluid exceeds the intake ratio of water, and electrolytes are lost in the same proportion as they exist in normal body fluids. Dehydration refers to loss of water alone with increased serum sodium level. May occur in combination with other imbalances. Causes: fluid loss from vomiting, diarrhea, GI suctioning, sweating, decreased intake, and inability to gain access to fluid. Risk factors: diabetes Insipidus, adrenal insufficiency, osmotic diuresis, hemorrhage, coma, and third space shifts 17 Document is Classified as OPEN  Fluid Volume Deficit Manifestations: Rapid weight loss. Decreased skin turgor. Oliguria and concentrated urine. Postural hypotension, rapid and weak pulse. Increased temperature, cool and clammy skin due to vasoconstriction. Thirst. Nausea. Muscle weakness, and cramps. Document is Classified as OPEN 18  Fluid Volume Deficit Laboratory data: Elevated BUN in relation to serum creatinine. Increased hematocrit (why?), & possible serum electrolyte changes Physical exam Assess skin dryness, mucous membrane, conjunctiva. Assess the vital signs. Assess mental status: confusion and lethargy. – Neuromuscular assessment of muscle tone and strength, movement, coordination, and tremors. – Assess I & O chart. 19 Document is Classified as OPEN  Fluid Volume Deficit Medical Management: Reverse the cause when possible Provide oral fluids Administer IV Fluid and blood transfusion. Drug Therapy: (Depends on cause: antiemetic, anti-diarrhea). Isotonic electrolyte solutions (lactated Ringer’s, 0.9%sodium chloride) are used for hypotensive pt with low FVD. Hypotonic solutions (0.45% sodium chloride) are used when pt becomes normotensive, to provide both electrolytes and water for renal excretion of waste product. Document is Classified 20 as OPEN  Fluid Volume Deficit Nursing Management: Measuring I & O Daily body weight Evaluate tongue turgor (more than one longitudinal groove and tongue is smaller because of fluid loss) Measuring urine specific gravity (normal 1.015- 1.025), Urine SG will increase in relation to the kidney’s attempt to conserve water. 21 Document is Classified as OPEN  Fluid Volume Excess FVE: refers to an expansion of the ECF caused by abnormal retention of water and sodium. This may be related to fluid overload or diminished homeostatic mechanisms. Causes: Excessive dietary sodium or sodium-containing IV solutions Heart failure Renal failure Primary polydipsia Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Long-term use of corticosteroids 22 Document is Classified as OPEN  Fluid Volume Excess Manifestations: Medical management: Edema; distended neck Corner stone is directed at the veins; cause, restriction of fluids and Abnormal lung sounds sodium, and the administration (crackles); shortness of of diuretics. breath; and wheezing Drug therapy – osmotic Tachycardia with bounding diuretics first, then loop diuretic pulse; increased BP, pulse such as Lasix pressure, and CVP; Monitor responses to Increased weight; increased medications such as diuretics. UOP Dialysis Possible seizures and coma Nutritional therapy Document is Classified as OPEN 23  Fluid Volume Excess Nursing Management: Weights daily, serum electrolytes, ECG, and albumin level Assessment of cardiopulmonary, renal, mental, lung sounds, edema & skin. VS every 4 hrs and PRN; I&O each shift and PRN, Check IV fluids hourly. Use semi-Fowler’s position for orthopnea Monitor responses to medications- diuretics Promote adherence to fluid restrictions, patient teaching related to sodium and fluid restrictions Skin care, positioning/turning- the patient is very prone to skin breakdown and infections Teaching patients about edema ( beware whether localized like RA, generalized-anasarca, or ascites) 24 Document is Classified as OPEN Isotonic Solution Hypotonic solution Hypertonic Solution Normal Saline Half- Strength Saline Normal saline or R/L (NaCl.9%), Dextrose (NaCl 0.45%), with contain 5% dextrose water (D5W), R/L. osmolality of (D 5%NaCl0.9%),(D Fluids have the total 154mOsm/L. 5%NaCl0.45%), higher osmolality of the ECF, Purpose of use: concentration of and do not cause cell replace cellular fluid, dextrose (D50%W), to swell or shrink. provide free water for (DW 10%) are Isotonic fluid expand excretion of body hypertonic. ECF volume, i.e, 1L wastes. These solutions draw fluid expand ECF by1L, Used to treat water from the ICF to and plasma by 0.25L hypernatremia & because it is a other hyperosmolar the ECF and cause crystalloid fluid and conditions. cells to shrink. diffuses quickly into Excessive infusion can Rapid or excessive ECF. lead to intravascular depletion,↓ BP, admiration may cause cellular edema and EC volume excess and death. circulatory overload. Document is Classified as OPEN 25  Electrolytes Are substances whose molecules split into ions when placed in water. Major cations: Major anions:  Sodium (Na+) Chloride (Cl-)  Potassium (K+) Bicarbonate (HCO3-)  Calcium (Ca++) Phosphate (PO43-)  Magnesium (Mg++)  Hydrogen ions (H+) Electrolyte concentrations differ in the fluid compartments. Document is Classified as OPEN fchs.ac.ae 26  Acid-Base Balance Regulating their acidity and alkalinity and measured by pH An Important for regulating homeostasis An acid is a substance that releases hydrogen ions (H+) in solution. (e.g. Hydrochloric acid (HCL) ). Bases, or alkalis, have a low hydrogen ion concentration and can accept hydrogen ions in solution Body fluids are slightly alkaline 7.35 and 7.45 Document is Classified as OPEN fchs.ac.ae 27  Acid-Base Balance- Normal Values Parameter Arterial Blood Mixed Venous Blood pH 7.35-7.45 7.32-7.42 PCO2 35-45 mm Hg 38-52mm Hg PO2 >80 mm Hg 24-48mmHg HCO3 22-26 mEq/L 19- 25 mEq/L Document is Classified as OPEN fchs.ac.ae 28  Regulation of the Body pH Respiratory Regulation Renal Regulation The lungs help regulate The kidneys maintain acid- acid-base balance by base balance by selectively eliminating or retaining excreting or conserving carbon dioxide (CO2). bicarbonate( HCO3) which When combined with is base/ alkaline) and water, carbon dioxide hydrogen ions. forms carbonic acid (CO2 + H2O = H2CO) Document is Classified as OPEN 29  Electrolyte Imbalances Sodium: hyponatremia and hypernatremia Potassium: hypokalemia and hyperkalemia Calcium: hypocalcemia and hypercalcemia Magnesium: hypomagnesemia and hypermagnesemia Phosphorus: hypophosphatemia and hyperphosphatemia Chloride: hypochloremia, hyperchloremia 30 Document is Classified as OPEN  Sodium (Na)  Normal range (135 – 145 mEQ/L)  Imbalances typically associated with parallel changes in osmolality  Plays a major role in - ECF volume and concentration - Generation and transmission of nerve impulses - Acid-base balance Document is Classified as OPEN fchs.ac.ae 31  Hypernatremia Elevated serum sodium occurring with water loss or sodium gain (> 145 mEq/L) Causes: hyperosmolality leading to cellular dehydration Primary protection is thirst from the hypothalamus Manifestations: include thirst, lethargy, agitation, seizures, and coma. If secondary to water deficiency, it often results in impaired LOC Can be produced by clinical states such as central or nephrogenic diabetes insipidus. Document is Classified as OPEN fchs.ac.ae 32  Hypernatremia Medical Management Nursing Management Treat underlying cause Assessment, prevention, If oral fluids cannot be assess for over-the-counter ingested, IV solution of 5% (OTC) medications* high of dextrose in water or sodium. hypotonic saline Offer and encourage fluids Diuretics to meet patient needs and Serum sodium levels must provide sufficient water with be reduced gradually to tube feedings. avoid cerebral edema. Document is Classified as OPEN 33  Hyponatremia  Results from loss of sodium-containing fluids or water excess ( < 135 mEq/L)  Clinical manifestations: confusion, nausea, vomiting, seizures, and coma  Causes: water excess and fluid restriction are needed  If severe symptoms (seizures) occur, a small amount of intravenous hypertonic saline solution (3% NaCl) is given  If associated with abnormal fluid loss, fluid replacement with sodium-containing solution is needed. Document is Classified as OPEN fchs.ac.ae 34  Hyponatremia Medical management Nursing Management Water restriction. Assessment, prevention, & Na replacement (by mouth, NGT, monitoring of dietary sodium and or parenteral route (isotonic: 0.9% fluid intake NACL or RL). Identification and monitoring of Assessment, prevention, & at-risk patients and the effects of monitoring of dietary sodium and medications (diuretics and fluid intake lithium) Identification and monitoring of at- Nursing alert Hyponatremia can risk patients and the effects of be dangerous for persons medications (diuretics and lithium) taking Lithium. Hypertonic solutions, to be Document is Classified as OPEN administered only in ICU  Potassium Normal range 3.5 – 5.5 mm/L Potassium major ICF cation Potassium is necessary for: Transmission and conduction of nerve impulses Maintenance of normal cardiac rhythms Skeletal muscle contraction Acid-base balance Document is Classified as OPEN fchs.ac.ae 36  Hyperkalemia > 5.5 mm/L Clinical Causes Manifestations – Increased retention Skeletal muscles weak or Renal failure paralyzed Potassium-sparing Ventricular fibrillation diuretics Cardiac depolarization is (Amiloride) impaired – Increased intake Repolarization occurs – Mobilization from ICF more quickly Tissue destruction Abdominal cramping or diarrhea Acidosis Document is Classified as OPEN 37  Hyperkalemia Medical Management  Monitor ECG ( look out for dysrhythmia).  Cation exchange resin (Kayexalate orally or by enema)  Stop K+ oral or parenteral intake.  Increase elimination of k+ by administering diuretics (Lasix).  IV sodium bicarbonate( in acidosis) (to force K to ICF)  IV calcium gluconate ( preserve myocardium, How?)  Regular insulin and hypertonic dextrose IV( intracellular shift)  Last resort: perform dialysis Document is Classified as OPEN fchs.ac.ae 38  Hyperkalemia Nursing Management: Assess serum potassium levels Monitor medication effects. Initiate dietary potassium restriction and dietary teaching for patients at risk Document is Classified as OPEN fchs.ac.ae 39  Hypokalemia < 3.5 mm/L Clinical Manifestations: Causes: Potentially lethal ventricular Increased loss of sodium arrhythmias due to: Impaired repolarization Aldosterone Increased digoxin toxicity in Loop diuretics those taking the drug GI losses Skeletal muscle weakness and Associated with Mg paralysis deficiency Muscle cell breakdown leads to myoglobin in plasma and urine. Movement into the cells 40  Hypokalemia Medical Management Nursing Management Administer potassium Monitor lab work. chloride supplements orally Increase dietary intake of or IV. potassium. Increase dietary intake of Monitoring of potassium (ABC fruit and electrocardiogram (ECG) vegetables*) Arterial blood gases (ABGs). Monitor lab values. Providing nursing care related to IV potassium administration Document is Classified as OPEN 41  Calcium (8.6 to 10.2 mg/dL) Obtained from ingested foods. More than 99% combined with phosphorus and concentrated in the skeletal system (stored mainly in Bones) Inverse relationship with phosphorus Ca blocks Na transport and stabilizes the cell membrane Functions include transmission of nerve impulses, myocardial contractions, blood clotting, formation of teeth and bone, and muscle contractions. Document is Classified as OPEN fchs.ac.ae 42  Hypercalcemia High serum calcium levels Clinical manifestations: (> 11 mg/dL)  Decreased memory Causes include:  Confusion Hyperparathyroidism  Disorientation Malignancy  Fatigue Vitamin D overdose Management includes: Prolonged immobilization  Loop diuretic  Hydration with isotonic saline IV  Synthetic calcitonin  mobilization Document is Classified as OPEN 43  Hypocalcemia Low serum calcium levels Clinical manifestations: Causes include: positive Trousseau’s sign Decreased production of and Chvostek’s sign. PTH - Others include laryngeal Acute pancreatitis stridor, dysphagia, Multiple drug transfusions numbness, and tingling Alkalosis around the mouth or in the Decreased intake extremities. Document is Classified as OPEN 44  Hypocalcemia Hypocalcemia Signs Chvostek’s sign: Management 1. Treat cause is the contraction of facial 2. Oral or IV calcium muscles in response to a supplements light tap over the facial 3. Treatment of pain nerve in front of the ear. and anxiety to Trousseau’s sign is carpal prevent spam induced by inflating hyperventilation- the BP cuff above the SBP induced respiratory for a few minutes. alkalosis Document is Classified as OPEN 45  Magnesium Imbalances Magnesium (Mg++) is the most abundant intracellular cation after Potassium (K+). The normal serum magnesium level is 1.3 to 2.3mg/dl (0.62 to 0.95mmol/L). It plays a major role in both carbohydrate and protein metabolism. Variation in the Mg level affects neuromuscular irritability and contractility. The document is46 Classified as OPEN  Hypomagnesemia Mg level < 1.3 Causes Alcoholism. Clinical Manifestations GI losses. Neuromuscular irritability Enteral or parenteral feeding Muscle weakness Deficient in Tremors, athetoid movements. magnesium. ECG changes and dysrhythmias Medications Alterations in mood and level of Medical Management consciousness. Diet Oral magnesium Dysphagia is common Magnesium sulfate IV Document is Classified as OPEN 47  Hypomagnesemia Mg level < 1.3 Causes Clinical Manifestations Renal failure Flushing Lowered BP DKA Nausea & vomiting Excessive Hypoactive reflexes administration of Drowsiness, Muscle weakness magnesium* Depressed respirations Medical Management ECG changes, and IV calcium gluconate dysrhythmias loop diuretics Hemodialysis Document is Classified as OPEN 48 Self-study Document is Classified as OPEN 49 Nursing management of the patient receiving Intravenous Therapy 1- Preparing to administer Intravenous Therapy. 2- Choosing an intravenous site. Condition of the vein. Type of fluid and medications to be infused Duration of therapy Patient age and size Whether pt is right or left-handed. Document is Classified 50 as OPEN  IV Site Selection Document is Classified 51 as OPEN  Nursing management 3- Selecting vein puncture devices: Cannulas Needles intravenous delivery systems Peripherally inserted central catheter (PICC) line Document is Classified 52 as OPEN  Nursing management 4- Teaching the patient. 5- Preparing the IV site. 6- Promoting Venipuncture 7- Maintain therapy. 8- Factors affecting the flow. Height of liquid column. Diameter of the tubing Length of the tubing Viscosity of the liquid. 9- Monitoring flow Document is Classified 53 as OPEN  Nursing management 10- Discontinuing of the infusion 11- Managing complications. a. Managing Systemic Complications: Fluid overload. Air embolism Infections. b. Managing Local Complications: Infiltration and extravasation Phlebitis: is an inflammation of a vein. Thrombophlebitis: phlebitis associated with the formation of blood clots. Hematoma. Clotting and Obstruction. Document is Classified 54 as OPEN Reference Smeltzer S.C, Bare, B.G, Hinkle, Cheever (2010).Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (12th ed) Lippincott Lewis, S. Heitkemper, M., Dirksen, S., O’Brien, P.,& Bucher, L. (2011). Medical–Surgical Nursing Assessment and Management of Clinical Problems (8th ed.) Philadelphia, PA,: Mosby Elsevier Potter, P. & Perry, A. (2009). Fundamentals of Nursing (7th ed.) Missouri: Mosby Elsevier Document is Classified as OPEN fchs.ac.ae 55