Fluid and Electrolyte Imbalances PDF

Fluid and Electrolyte Imbalances D r. Am an d a S a ff o rd , D N P , M S N , R N Learning Objectives After attending lecture and completing the learning activities, you will be able to accomplish the following: 1. Compare the distribution and movement of fluid in body compartments. 2. Describe...

Fluid and Electrolyte Imbalances D r. Am an d a S a ff o rd , D N P , M S N , R N Learning Objectives After attending lecture and completing the learning activities, you will be able to accomplish the following: 1. Compare the distribution and movement of fluid in body compartments. 2. Describe the causation, pathophysiologic process, and clinical manifestations of edema. 3. Describe the control of cell volume and the effect of isotonic, hypotonic and hypertonic solution on cell size. 4. Identify select intravenous fluids as isotonic, hypertonic or hypotonic. 5. Discuss the roles of anti-diuretic hormone and the renin- angiotensin-aldosterone system in the regulatory processes for water balance in the body. 6. Apply concepts of altered fluid and electrolyte balance to selected clinical exemplars. SCHOOL OF NURSING WOLTERS KLUWER Objective 1 Compare the distribution and movement of fluid in body compartments. Copyright © 2023 Wolters Kluwer · All Rights Reserved  balance Fluids and Homeostasis Fluids in the Body ◦ 60% of healthy adult's weight is water ◦ Water necessary for normal cellular function ◦ Medium for metabolic reactions ◦ Transports nutrients, waste products ◦ Acts as lubricant, insulator, shock absorber ◦ Helps to regulate, maintain body temperature What other types of fluids exist in the body?  Distribution and Composition of Body Fluids Fluid Compartments Intracellular Extracellular (ICF) (ECF) Blood Intravascular/ Interstitial vessels Plasma In tissues In Transcellular between cells Movement of Body Fluids Movement/shifting of body fluid across cell and capillary membranes accomplished by: 1. Osmosis 2. Diffusion 3. Filtration 4. Reabsorption  Osmosi s Movement of water across cell membranes from less concentrated homeostasis solution to more concentrated solution LOWER Stimulated by the Solute concentration gradient concentration  SolutesThe stuff that dissolves HIGHE  Solvents R Solute concentration Factors of Osmosis Osmotic Pressure Osmolality Measurement of concentration Serum=blood The normal osmolality of mOsm/kg urine blood is 300 Tonicity 1.Isotonic solution Dehydrated if the 2.Hypertonic solution concentration is high 3.Hypotonic solution Hydrostatic pressure- the pushing pressure Osmotic pressure- pulling pressure prevents osmosis  Diffusion Movement of a SOLUTE Rate of diffusion varies by: ◦ Size of molecules ◦ Concentration of solution HIGHE ◦ Temperature of solution R Solute concentration LOWER Solute concentration  Filtration Reabsorption Pressure of blood pushing on Capillary osmotic pressure the capillary walls forces pulls fluid from the fluid movement interstitial space back into the vascular space Objective 5 Discuss the roles of anti-diuretic hormone and the renin-angiotensin-aldosterone system in the regulatory processes for water balance in the body. Copyright © 2023 Wolters Kluwer · All Rights Reserved Maintaining Homeostasis Fluid intake ◦ 2,500 mL/day at moderate activity and temperature ◦ Thirst regulator in hypothalamus ◦ Activated by cellular dehydration ◦ Decrease is blood volume Fluid output ◦ 1,400–1,500 mL/day of urine ◦ Sensible & Insensible fluid loss  Factors in Maintaining Homeostasis Anti diuretic hormone- not pee Kidneys primary regulator of fluid balance using hormones: ◦ ADH- responds to osmolarity changes ◦ RAAS- responds to kidney perfusion changes Maintaining Homeostasis: ADH Maintaining Homeostasis: RAAS  The active part Perfusion- decrease in blood; a drop in blood pressure Objectives 3 & 4 Describe the control of cell volume and the effect of isotonic, hypotonic and hypertonic solution on cell size. Identify select intravenous fluids as isotonic, hypertonic or hypotonic. Copyright © 2023 Wolters Kluwer · All Rights Reserved  o rdi ng to ified ac c Cla s s , to n icity ) as pH ti o n n c e ntra e r um (c o d to s 70- a re t y ( 2 comp osmolari IV a plasm SM/ L) Solutions O 300 M Normal IV- Thick; clear; thin; expensive cheap Crystalloids Colloids Plasma Hypertonic Isotonic Hypotonic Expanders Isotonic IV Solutions Same as the blood. Same concentration Osmolarity is same as body Stays fluid (270-300 mOsm/L) where you Used to increase ECF put them No or equal movement of fluid into and out of intracellular space  Normal Saline 0.9% saline sodium chloride- normal  LR Used in volume replacement, fluid maintenance Copyright © 2023 Wolters Kluwer · All Rights Reserved © UAB. All Rights Reserved. Hypotonic IV Solutions O- get big Osmolarity lower than It shift into the cell and plasma (< 270 mOsm/L) out the blood vessel Causes water to move INTO the cell (cell swells) ½ NS 0.45% sodium chloride ¼ NS D5W 5% dextrose in water (sugar water) Used in hypernatremia, dehydration Would not want to give a hypotonic solution- any type of edema in the brain or brain injuries (contraindicated- very bad) Copyright © 2023 Wolters Kluwer · All Rights Reserved © UAB. All Rights Reserved.  r Hype tonic IV Solutions shrink What is in the blood Osmolarity higher than vessels is very concentrated plasma (> 300 mOsm/L) Fluid overflow Causes water to move is a concern OUT of cells and into the vessel (cells shrink) 3% Saline D5NS 5% dextrose in normal saline Used in hyponatremia, fluid volume overload Copyright © 2023 Wolters Kluwer · All Rights Reserved © UAB. All Rights Reserved. Objectives 6 Apply concepts of altered fluid and electrolyte balance to selected clinical exemplars. Copyright © 2023 Wolters Kluwer · All Rights Reserved  They hold any electrical charge when Regulating Electrolytes dissolved into water They help us do lots of things in our body Maintain fluid balance Contribute to acid–base regulation Facilitate enzyme reactions Transmit neuromuscular reactions Copyright © 2023 Wolters Kluwer · All Rights Reserved © UAB. All Rights Reserved.  The Need to Knows about Electrolytes 2 7 In cell Simple Function Normal value Hyper- Hypo- Causes Causes Symptoms Symptoms Mg+ 1.3-2.1 k PO34- 3.0-4.5 n o K+ 3.5-5.0 w Ca+ 9-10.5 Cl- 98-106 Out cell Na+ 136-145 Copyright © 2023 Wolters Kluwer · All Rights Reserved © UAB. All Rights Reserved. Basic Electrolyte Functions brain Copyright © 2023 Wolters Kluwer · All Rights Reserved Compensation Body continually tries to compensate for a fluid and electrolyte imbalance by shifting fluids and electrolytes from one component to another Rare for only one type of imbalance to occur Copyright © 2023 Wolters Kluwer · All Rights Reserved © UAB. All Rights Reserved.  Magnesium Mg+ (1.3- 2.1 mEq/L) 3 0 Intracellular cation Small ECF amount Principally regulated by PTH Works with the Sodium- Potassium Pump in regulating ICF balance Nerve/ Smooth muscle relaxant ( ↓ BP) Copyright © 2023 Wolters Kluwer · All Rights Reserved © UAB. All Rights Reserved.  HyperMaGnese HypoMaGnesem Magnesium Mg+ (1.3-2.1 mEq/L) mia Causes: Rare; bowel ia Causes: malabsorption, renal disorders, renal failure wasting, poor dietary intake, hypocalcemia, alcoholism Assessment: Muscles are too relaxed! Assessment: Muscles are Hypotension, decreased DTR, excited! (tense) lethargy, respiratory Tachycardia, depression hypertension, twitching, If you hit the knee, it barely tremors, Ifincreased DTR you hit the knee, moves it will shoot up Treatment: Mag supplements/ replacement Calcium Ca+ (9-10.5 mg/L) 3 2 Primarily ICF Cation essential for healthy teeth and bones Function in neuromuscular transmission Muscle contractions Levels controlled by Vit D, calcitonin, and PTH Copyright © 2023 Wolters Kluwer · All Rights Reserved © UAB. All Rights Reserved.  Calcium HyperCAlcemia HypoCAlcemia Causes: rare; Causes: thyroidectomy hyperparathyroidism, drug (low levels of PTH), low Ca+ Ca+ toxicity intake, low Vit D Assessment: Assessment: Bone pain, kidney stones, Convulsions, tetany, (9-10.5 mg/dL) polyuria, decreased DTR, numbness/tingling digestive issues hands/fingers, + Chvostek’s sign and + Treatment: treat cause, low Trousseau’s sign calcium diet Treatment: IV calcium Know these replacement, dietary replacement Phosphorous PO34- (3.0-4.5 mg/dL) Major anion in ICF; small ECF amount Forms bones and teeth; Muscle contraction Regulates calcium levels Copyright © 2023 Wolters Kluwer · All Rights Reserved © UAB. All Rights Reserved. HyperPHOSphate HypoPHOSphate Phosphorous PO34- mia mia Causes: Rare; renal failure, Causes: malnutrition, acidosis, hypocalcemia alkalosis, hepatic encephalopathy, alcoholism Assessment: Muscles are Assessment: Muscles are excited! too relaxed! Convulsions, tetany, Confusion, lethargy, muscle cramps/spasms, muscle weakness (3.0-4.5 mg/dL) Treatment: dietary Treatment: Phos restrictions supplement, dietary replacement, IV phos Potassium K+ (3.5-5 mEq/L) The major intracellular cation; small amount in ECF Plays role in cellular depolarization and repolarization, i.e. cellular excitability Vital in muscle activity: CARDIAC SENSITIVE Copyright © 2023 Wolters Kluwer · All Rights Reserved © UAB. All Rights Reserved.  HyperKalemia HypoKalemia Potassium Causes: renal failure, K+ Causes: diuretic use, sparing diuretics, acidosis, severe vomiting, excessive burns gastric suctioning, fluid overload Flat or depressed T- Assessment: wave EKG changes: PEAKED T Assessment: K+ WAVES, paresthesia, diarrhea, Confusion, Lethargy, weakness muscle weakness, (3.5-5.0 mEq/L) constipation, slow thready Treatment: IV insulin followed pulse, flattened T wave or by glucose, Sodium Polystyrene ST depression (Kayexalate) Treatment: Replacement Sodium Na+ (136-145 mEq/L) Most abundant electrolyte in ECF Contributes to serum osmolarity​ Helps to regulate ECF balances Primary functions: Muscle contractions, skeletal and cardiac Nerve impulse transmission General homeostasis, water balance Fluid shift Where sodium goes, water flows (water magnet) Copyright © 2023 Wolters Kluwer · All Rights Reserved © UAB. All Rights Reserved.  HyperNAtremia HypoNAtremia Sodium Causes: excessive Causes: sweating, decreased sodium intake, diuretic use, Sodium excess (kidney vomiting, diarrhea, failure, Cushing's, etc...) excessive GI suction, water Na+ (136-145 mEq/L) Decreased fluid volume- intoxication Primary dehydration Assessment: Assessment: Coma, seizures, neuro Thirst, dry mouth, Fever, hypotension, decreased Irritability, restlessness, N/V, Urine output DTR, abdominal cramping Decreased UOP Dark Treatment: pee Treatment: IV fluids high in sodium, fluid Re-hydrate, but Limit restriction sodium intake Chloride Cl- (98-106 mEq/L) Most abundant anion in ECF Paired with sodium to maintain neutral electricity Primary Functions: Regulates acid-base balance, serum Os, and fluid balance Normal saline is sodium chloride!! Remember Copyright © 2023 Wolters Kluwer · All Rights Reserved © UAB. All Rights Reserved. HyperCLoremia HypoCLoremia Chloride Cl- (98-106 mEq/L) Causes: diarrhea, renal Causes: NOT COMMON; failure sodium loss Assessment: Assessment: Mimics hyperNAtremia Mimics hypoNAtremia and metabolic acidosis Treatment: increase salt Treatment: diuretics, IV intake, adding chloride to IV fluids fluids Fluid Volume Imbalanc es Hypovolemia Hemorrhage Dehydration Hypervolemia Water Intoxication Edema Hemoconcentration & Diagnostic Tests elevated Osmolality 300 Serum electrolytes Complete blood count Serum Osmolality Urine specific gravity Copyright © 2023 Wolters Kluwer · All Rights Reserved © UAB. All Rights Reserved. Hypovolemia: Fluid Volume Deficit/ Dehydration Copyright © 2023 Wolters Kluwer · All Rights Reserved  Dehydration Loss of extracellular Decreased Increased fluid (ECF) volume Intake Output Not by Causes includemouth NPO Diarrhea decreased fluid intake or Difficulty increased fluid swallowing Dysphagia Burns output Lack of Vomiting Access Dehydration Assessment Findings hyperNA Tented, dry skin Dry mucous membranes Decreased LOC Prolonged capillary refill time Changes in vital signs ↑ RR ↑ HR Flat neck veins Decreased or absent urine output Copyright © 2023 Wolters Kluwer · All Rights Reserved © UAB. All Rights Reserved. Dehydration Diagnostics ↑ Urine Specific Normal < 1.010 Gravity ↑ Serum Na+ ↑ BUN Normal 5-25 mg/dL Normal 42-52%; ↑ Hemoconcentration- will 37-47% Hematocrit look false Copyright © 2023 Wolters Kluwer · All Rights Reserved © UAB. All Rights Reserved. Hypervolemia: Fluid Volume Overload/ Edema Copyright © 2023 Wolters Kluwer · All Rights Reserved  edema Fluid Overload  Too much fluid in the intravascular space  Increase in serum sodium levels  increase in total body water  Interstitial fluid volume excess (edema/third spacing)  Common causes include:  Heart failure  Renal failure  Liver failure More Volume = More Pressure Fluid Overload 51 Assessment Think lungs Findings Fluid Overload ↓ Urine Diagnostics Specific Normal < 1.010 Gravity Not concentrated ↓ Serum Na+ Normal 5-25 BU↓N mg/dL Normal 42-52%; ↓ Hematoc 37-47% rit © UAB. All Rights Reserved.