Fluid and Electrolyte Imbalance Update 12.23.2023 PDF

Care for the person with basic Fluid and Electrolyte health needs NUR1275 Faculty  Basic Fluid & Electrolyte Health Needs Exemplars NCLEX Client Need Curriculum Course Outcomes Categories Threads Fluids: Physiological Integrity  Clinica...

Care for the person with basic Fluid and Electrolyte health needs NUR1275 Faculty  Basic Fluid & Electrolyte Health Needs Exemplars NCLEX Client Need Curriculum Course Outcomes Categories Threads Fluids: Physiological Integrity  Clinical Outcome 1: Apply components Fluid  Physiological Judgement of clinical reasoning to Volume Adaptation  Communicatio formulate clinical judgement to Deficit  Basic Care and n deliver safe, patient-centered Comfort  Quality care. Fluid  Reduction of Risk Improvement Outcome 2: Apply principles of Volume Potential  Health inter-professional collaboration Excess  Pharmacological and Outcomes to manage care for the adult Parenteral Therapies  Legal/Ethical Person with basic health needs Electrolyt Safe and Effective Care  Collaboration Outcome 3: Implement the es: Environment  Evidence- nursing process to achieve Hypo/Hyper  Management of Care based Practice patient health outcomes for the  Safety and Infection  Diversity adult Person with basic health Sodium Control  Nursing needs. Chloride Health Promotion and Process Outcome 4: Demonstrate Potassiu Maintenance  Informatics professional core values Homeostasis: maintenance of a constant internal equilibrium in a biologic system Kidneys regulate fluid and electrolyte balance by retaining and excreting fluids and electrolytes filtered from blood, in response to hormones such as aldosterone and antidiuretic hormone (ADH). Cardiovascular system regulates fluid balance by circulating blood to kidneys creating adequate pressure to allow for the formation of urine. Lungs maintain homeostasis by insensible fluid losses from exhalation and regulation of CO2, which affects acid-base balance. Pituitary functions to regulate fluid and electrolyte balance through ADH. Increased ADH = reabsorption of fluids by kidneys resulting in fluid retention  Pathophysiolo gy Osmosis: fluid shifts from area of less concentration to area of greater concentration Osmolality: osmotic pressure (milliosmoles of solute/kg of solvent) Osmolarity: osmotic pressure (milliosmoles of solute/L of solvent) Note: Osmolality is used to measure solute in blood or  Understanding TONICITY “Tonicity is the ability of Causes movement of solutes to cause an water from intracellular osmotic driving force (ICF) to extracellular that promotes water (ECF) or ECF to ICF movement from one compartment to Generally, refers to another.” NACL content HYPOTONI HYPERTONI (Cheever, et al., ISOTONIC C 2022) C  EXEMPLAR: Fluid Volume Deficit Causes Too much fluid leaving the body Not enough fluid entering the body Or…BOTH Nursing Process & Clinical Judgement What ASSESSMENTS would you perform? What CUES would you RECOGNIZE? How would you ANALYZE the CUES to FORMULATE a HYPOTHESIS based on CUES?  ASSESSMENT Blood Pressure (including orthostatic), HR (rapid thready pulse), RR, urine output, specific gravity, mental status, skin color and skin turgor, capillary refill, weight, strict I & O, serum electrolytes, increased thirst, increased temperature, cool clammy skin (vasoconstriction), dry mucous membranes GERONTOLOGIC CONSIDERATIONS Cardiac function NOTE: skin turgor and Renal function thirst drive are not reliable Respiratory function indicators for Muscle mass/skin turgorolder adults >65 NURSING DIAGNOSIS & PLANNING GENERATE SOLUTIONS Fluid Volume Deficit PES format: (problem) related to _______(etiology) as evidenced by (signs and symptoms—subjective & objective) _____&_______ When formulating the plan of care consider the type of dehydration and SAFETY to promote HEALTH OUTCOMES  Minimize fluid loss IMPLEMENTATION Replace fluids (oral or IV) Monitor for complications TAKING ACTION Evaluate effectiveness The nurse must COLLABORATE with the health care provider to determine the most appropriate IV solution to administer based on the type of fluid loss/dehydration. COMMUNICATE tasks that may be delegated to the LPN, UAP  The nurse uses evidence-based SAFETY FIRST! practice to deliver Safe Effective Care.  Evaluation Evaluating Outcomes Urine Output: minimum 1 mL/Kg/hr Vital Signs: BP, HR, RR within normal limits Physical Assessment: moist mucous membranes, skin warm and dry, good skin turgor, mental status WNL Laboratory Tests: monitor hemoglobin and hematocrit, electrolytes (primarily Na+ and Cl-), report abnormal or unanticipated findings Prevent Complications: s/s of overhydration, IV patency, worsening symptoms Educate: teach client how to prevent and recognize s/s of FVD EXEMPLAR: Fluid Volume Excess CAUSES Impaired regulatory mechanisms Renal failure, heart failure, liver disease Too much sodium intake Oral or IV Increased cortisol Prolonged steroid therapy Severe stress Hyperaldosteronism (Cushing’s) Nursing Process & Clinical Judgement What ASSESSMENTS would you perform? What CUES would you RECOGNIZE? How would you ANALYZE the CUES to FORMULATE a HYPOTHESIS based on CUES?  ASSESSMENT System Specific Changes NEURO—altered LOC RESPIRATORY—crackles, hypoxia, dyspnea CARDIAC—JVD, bounding pulse, increased BP/HR GI—nausea, decreased appetite SKIN—edema (see previous slide) NURSING DIAGNOSIS & PLANNING GENERATE SOLUTIONS Nursing Diagnosis: Fluid Volume Deficit (PES) NURSING COLLABORATIVE INTERVENTIONS INTERVENTIONS Treat underlying cause Pharmacologic therapy (diuresis) LOOP DIURETICS: Furosemide, Bumetanide THIAZIDE DIURETICS: Hydrochlorothiazide K+ SPARING DIURETICS: Spironolactone  In addition to fluid restriction and close IMPLEMENTATION monitoring of the client, the most common pharmacologic intervention for TAKING ACTION acute Fluid Volume Excess is Furosemide (Lasix).  Evaluation Evaluating Outcomes  Urine Output: output > than intake  Vital Signs: BP, HR, RR within normal limits  Physical Assessment: decreased edema, clear (or improving) lung sounds, mental status WNL, daily weights decreasing  Laboratory Tests: closely monitor serum electrolytes (primarily sodium, chloride, potassium, magnesium, calcium), ABG’s if indicated, report abnormal or unanticipated findings  Prevent Complications: s/s of hypokalemia (or other electrolyte imbalances), cardiac monitoring, report adverse effects of meds STAT  Educate: teach client how to prevent and recognize s/s of FVE, medication compliance and self-care management  EXEMPLAR: Sodium and Chloride Imbalance Sodium Range: 135—145 mEq/L Chloride Range: 96—106 mEq/L  ASSESSING FOR SODIUM IMBALANCES Sodium (Na+) is the #1 electrolyte responsible for fluid balance Regulated by thirst, ADH and renin-angiotensin-aldosterone system Causes and treatment Loss or gain of Na+ is usually associated with loss or gain of water Water intoxication https://www.goodmornin gamerica.com/wellness/ video/family-woman-die d-water-intoxication-spe aks-102012210  NURSING DIAGNOSIS & PLANNING GENERATE SOLUTIONS HYPONATREMIA & HYPERNATREMIA Nursing Diagnosis: FVD or FVE, Risk for Electrolyte Imbalance; Planning goal: correct imbalance Na+ Imbalance occurs due to an imbalance of water rather than Na+ Clinical Manifestations are largely associated with those of FVD or FVE Chloride (Cl-) and Na+ bond well in water, therefore an imbalance in Na+ is often associated with a Cl- imbalance Where Salt goes, water will follow.  IMPLEMENTATION COLLABORATIVE MANAGEMENT: Treatment is aimed at prevention and TAKING ACTION correcting the imbalance without overcorrecting Hyponatremia: Na+ < 135 Hypernatremia: Na+ > 145 mEq/L mEq/L Sodium Replacement Assess sources of Na+ intake Fluid (Water) Restriction (meds, dietary, Na+ containing antacids) Pharmacologic (ADH receptor Administer hypotonic IV fluids to antagonist) gradually decrease Na+  ASSESSING for CHLORIDE IMBALANCES Cl- helps maintain fluid HYPOCHLOREMIA: Contributing Factors balance along with Pathological: Addison’s Disease, decreased Cl- intake Na+ (osmotic or absorption, sweating, GI losses, Na+ and K+ deficiency, acid-base imbalances (respiratory acidosis, pressure) diabetic ketoacidosis, metabolic alkalosis), cystic fibrosis Cl- helps maintain Medically Induced: medications (diuretics, bicarbonate overuse), rapid removal of ascites fluid acid-base balance (paracentesis), hypotonic IV solutions Cl- is produced in the HYPERCHLOREMIA: Contributing Factors stomach where it Pathological: head injury, hypernatremia, dehydration, kidney injury, severe diarrhea, respiratory alkalosis, bonds with hydrogen metabolic acidosis, hyperparathyroidism to form Hydrochloric Medically Induced: excess NaCl IV infusions, some Acid (HCl) medications such as diuretics, salicylate overdose NURSING DIAGNOSIS & PLANNING GENERATE SOLUTIONS Monitor: Cl-, Na+, K+ ABG Analysis Urine electrolytes IMPLEMENTATION TAKING ACTION Treat underlying cause HYPERCHLOREMIA Administer appropriate IV fluid Treatment is aimed at treating Pharmacologic therapy the signs and symptoms of acidosis EVALUATION EVALUATING OUTCOMES Monitor serum electrolytes, ABG’s (if appropriate), strict Intake and Output, Vital Signs Assess for decrease of neurological symptoms Ensure safety is maintained  Range: EXEMPLAR: Potassium Imbalance 3.5—5 mEq/L Potassium (K+) is an intracellular ion, (98% of K+ is inside cells) Extracellular K+ (2%) maintains neuromuscular and cardiac function Sodium-Potassium pump is the mechanism in which K+ is “pumped” into cells Minor changes in K+ levels can have significant pathological implications  Recognizing Cues and Analyzing ASSESSING Cues for Potassium Imbalances is for K+ essential to prompt intervention and Imbalances management to prevent life- threatening complications  NURSING DIAGNOSIS & PLANNING GENERATE SOLUTIONS Nursing Diagnosis for K+ Imbalance Risk for decreased cardiac output Electrolyte imbalance Ineffective tissue perfusion  IMPLEMENTATION NURSING TAKING ACTION INTERVENTIONS NOTE: Salt Monitor for signs and symptoms substitutes of K+ imbalance may be high in Check daily lab values prior to Potassium administration of diuretics Report abnormal findings Continuous cardiac monitoring; recognize subtle ECG changes Assess for dietary sources of K+  IMPLEMENTATION MEDICAL TAKING ACTION MANAGEMENT HYPOKALEMIA HYPERKALEMIA Oral potassium Cation exchange resin such as Sodium replacement polystyrene sulfonate (Kayexalate) Requires functioning GI tract for excretion Emergency treatment to rapidly K-DUR reduce K+ levels include calcium gluconate, IV insulin and dextrose, beta 2 agonist (Albuterol) IV potassium replacement Emergency treatment requires close monitoring and is more complex health need Dialysis may be used to treat NEVER, NEVER Give K+ IV Push!! hyperkalemia  Failure to comply with quality and SAFETY FIRST! safety may have Legal and Ethical implications.  EVALUATION EVALUATING OUTCOMES Cardiovascular—monitor ECG for signs of improving cardiac effects of K+ imbalance Musculoskeletal—improvement in muscle cramps weakness Laboratory results—K+ within normal limits, ABG (note correcting acid-base imbalance may correct K+ imbalance) Prevention—assess client understanding of K+ imbalance, medication compliance and follow-up care for repeat labs  FOOD FOR THOUGHT How will you manage care for clients with fluid and electrolyte imbalances? How will you promote health outcomes? How will safety be maintained? What role does informatics play in client care? What psychosocial implications affect care? Does diversity impact the care of the person  References Cheever, K. H., Hinkle, J. L., Overbaugh, K. J. (2022). Brunner & Suddarth’s textbook of medical-surgical nursing (15th ed.). Wolters Kluwer. Frandsen, G. & Pennington, S. S., (2021). Abram’s clinical drug therapy rationales for nursing practice (12th ed.). Wolters Kluwer.