Fluids and Electrolytes PDF - Nursing Education

Fluids and Electrolytes  OBJECTIVES  Define normal ranges of electrolytes  Compare/contrast intracellular, extracellular extracellular, and intravascular volumes  Describe the clinical manifestations of various electrolyte imbalances. electrolyte imbalances.  Catio...

Fluids and Electrolytes  OBJECTIVES  Define normal ranges of electrolytes  Compare/contrast intracellular, extracellular extracellular, and intravascular volumes  Describe the clinical manifestations of various electrolyte imbalances. electrolyte imbalances.  Cation vs. Anion  A cation is an atom or a group of atoms bearing one or more positive electric charges.  An anion is an atom or a group of atoms bearing one or more negative electric charges.  Milliequivalent is chemical combining power of the ion = combining power of the hydrogen ion (H+) Normal Plasma Ranges of Electrolytes Cations Concentration  Sodium 135 – 145 mEq/L  Potassium 3.5 – 5.0 mEq/L  Calcium 8.0 – 10.5 mEq/L  Magnesium 1.5 -2.5 mEq/L Normal Plasma Electrolytes Anions Concentration  Chloride 95 -105 mEq/L  Bicarbonate 24 - 30 mEq/L  Phosphate 2.5- 4.5 mEq/L  Sulfate 1.0 mEq/L  Organic Acids 2.0 mEq/L (Lactate)  Total Protein 6.0 -8.4 mEq/L  Fluids  Intracellular  Extracellular  Interstitial  Intravascular Females v Males  Intracellular v Extracellular  Intracellular = K +, Mg +, PO 4 -, SO 4 -, and proteins  Extracellular = Na +, Ca +, Mg + , Cl-, HCO 3 - and lactate  Compositions of ions are maintained  Movement of water is passive Body Fluid Compartment Percentages Body Fluids 75% 20%  Balance  Fluid and electrolyte homeostasis is maintained in the body – Neutral balance: input = output – Positive balance: input > output – Negative balance: input < output  Electrolytes  Substances minerals, salts  An element or compound when melted or dissolved, separates into ions  Able to carry electrical current  Positive charge- cations  Negative charge- anions  Where sodium goes, water follows  Diffusion – movement of particles down a concentration gradient.  Osmosis – diffusion of water across a selectively permeable membrane  Active transport – movement of particles up a concentration gradient ; requires energy  Osmosis  Movement of solvent through semipermeable membrane from area of lesser concentration to higher concentration  mOsm 280-295mOsm/kg  Osmosis Terms  Crystalloids  Colloids  Solvent  Osmolality  Tonicity  Cont. Osmosis Terms  Isotonic  Saline  Hypertonic  Hypotonic  Osmotic pressure  Oncotic pressure  Solutions  Hypertonic: higher osmotic pressure,pulls fluid from cells  Isotonic: neutral osmotic pressure, solution with same osmolarity as blood  Hypotonic: solution of lower osmotic pressure, moves fluid into cells, causes them to enlarge  Diffusion  Movement of solute in solution across membrane from area of higher concentration to lower concentration  Diffusion Terms  Filtration  Hydrostatic pressure  Edema  Filtration  Water & diffusable substances move together in response to fluid pressure  Active transport  Requires energy to move solute across a membrane  E.g. Na & K pump!  Edema  Intravascular volume moves to the interstitum  e.g. CHF, pulmonary edema, edema generalized, anaphylaxis Cont. Edema  IV Solutions  D5W: isotonic  D10W: hypertonic .45% NS: hypotonic .9% NS: isotonic  3%-5%: hypertonic  D5 in.9% NS: hypertonic  D5 in.45% NS: hypertonic  LR: isotonic  D5 in LR: Hypertonic  Homeostasis  Internal balance or equilibrium  Body fluids are regulated by fluid intake, hormonal controls & fluid output  Responds to disturbances in fluids & lytes to prevent or repair damage  Hormonal regulation  Hormones regulate fluid intake through various mechanisms  ADH stored in posterior pituitary gland, release in response to changes in blood osmolarity  Aldosterone released by adrenal cortex, great NA conserver  RAA system to combat hypovolemia  Renin- angiotensin-aldosterone  Renin: proteolytic enzyme secreted by kidneys responds to decreased renal perfusion, produces Angiotensin I  Angiotensin I causes vasoconstriction  Angiotensin I converted to II (by ACE enzyme), causes massive vasoconstriction, stimulates release of aldosterone  Dysfunction and/or Trauma  Leads to:  Decreased amount of water in body  Increased amount of Na + in the body  Increased blood osmolality  Decreased circulating blood volume  Hyponatremia  Na145mEq/L  Critical level > 160 mEq/L  P/E: thirst, dry & flushed skin, dry & sticky tongue, mucus membranes, fever, agitation, convulsions, restlessness, irritability  Hypokalemia  K5.5 (5.3)  P/E: anxiety, dysrhythmias, paresthesias, weakness, abd cramping & diarrhea  *** EKG changes bradycardia, heart blocks, dysrhythmias, QRS widens, cardiac arrest  Hypocalcemia  Ca11.0  P/E: anorexia, N/V, weakness, lethargy, low back pain, (from kidney stones), decreased LOC, personality changes,  cardiac arrest  *** EKG changes  Hypomagnesemia  Mg 3.0mEq/L  P/E: hypoactive DTR’s, decreased rate & depth of RR’s, hypotension, flushing  Hypophosphatemia  Hypophosphatemia  Serum level < 2.5 mg/dL Caused by Alcoholism, excessive antacid intake, low vitamin D Inadequate phosphate intake Increased phosphate excretion Shift from extracellular phosphate into the intracellular space Asymptomatic Symptoms General weakness (identify other electrolytes with this sign) Medication Acetazolamide, pentamidine…  Hyperphosphatemia  Hyperphosphatemia  Serum level > 7 mEq/L Caused by – Excessive intake of phosphorus – Kidney disease  Asymptomatic  Increase symptoms of an underlying disease – Ex. uncontrolled diabetes, hypocalcemia  Mineral and bone disorders and calcification.  Medication – Sevelamer Carbonate  Cont. Hyperphosphatemia  Positive Chvostek (low calcium levels)  Trousseau sign (low calcium levels)  Asymptomatic  Increase symptoms of an underlying disease – Ex. uncontrolled diabetes, hypocalcemia  Mineral and bone disorders and calcification.  Medication – Sevelamer Carbonate  Hypochloremia Hypochloremia Serum level < 95 mEq/L Caused by Loop diuretics-excessive usage Nasogastric suction Vomiting Urine chloride 40 mEq/L, related to volume overload (dilution). Hypochloremia Hypochloremia Serum level < 95 mEq/L Caused by (look for cause) CHF Loop diuretics-excessive usage Nasogastric suction Vomiting Urine chloride 40 mEq/L, related to volume overload (dilution). Symptoms Metabolic alkalosis No specific signs and symptoms Medication IV Normal Saline  Hyperchloremia Hyperchloremia Serum level > 107 mEq/L Caused by Bicarbonate loss Metabolic acidosis Renal Secretion of hydrogen in urine leads to alkalotic urine and acidosis of the blood Symptoms Fatigue Muscle weakness Excessive thirst High blood pressure Medication Calcium chloride, Magnesium sulfate, Cholestyramine  Fluid Volume  Fluid volume deficits – Two main categories  Volume  Osmolality  Fluid volume overload – Excess fluid in the extracellular space  Imbalance electrolytes  Heart failure  Kidney failure  Fluid volume deficit  P/E: postural hypotension, tachycardia, dry mucus membranes, poor skin turgor, thirst, confusion, rapid weight loss, slow vein filling, lethargy, oliguria, weak pulse  e.g. fever, hemorrhage, diuretics, GI losses  Hypovolemia  Dehydration  Fluid volume excess  P/E: rapid weight gain, edema, hypertension, polyuria, neck vein distention, increased venous pressure, crackles in lungs  Dyspnea  Orthopnea  Polyuria  Ascites  anasarca  Diagnostic Test  Laboratory Blood Test – Serum electrolytes – Serum hematocrit – Hemoglobin – BUN – Creatinine – Renal function test – Liver function test  Medications causing disturbances  Diuretics- metab alkalosis, hyper/hypo K  Steriods- metab alkalosis  K supplements- GI upset, ulcers, diarrhea  Respiratory center – respiratory acidosis, decreased RR, depth RR  Antibiotics- nephrotoxicity, hyper K(Vancomycin), hyper Na (Zosyn)  Calcium carbonate- mild metb alkalosis with N/V  Mg hydroxide (MOM)- hypo K  Laxatives – Dulcolax Risk factors for Volume Imbalances  Age: very young or very old  Chronic disease: cancer, CHF, endocrine diseases (Cushings, DM), malnutrition, COPD, renal failure, changes in LOC  Trauma: crush injuries, head injuries, burns  Therapies: diuretics, steriods, IV therapy, TPN Risk factors for Volume Imbalances  GI Losses: vomiting, diarrhea gastroenteritis, NG suctioning, fistulas  Renal Losses: diuretics, Diabetes Inspidus, kidney disease, adrenal insufficiency, osmotic diuresis  Third spacing – peritonitis intestinal obstruction, ascites, burns  Hemorrhage  Altered intake - NPO  Nursing Care  Assessment – Respiratory – Circulatory – Integumentary  Monitor Intake and Output  Monitor daily weight  Nursing Care  Monitor Laboratory Test – Hypo or hypervolemia – Hematocrit – BUN – Creatinine – Urine Specific gravity – Serum sodium – Serum osmolality  Imbalance  Cont. Nursing Care  Assessment  Medication  Cellular regulation  Cognition  Cont. Nursing Care  Communication  Perfusion  Thermoregulation  Elimination  Bed position – Semi Fowlers  Cont. Nursing Care  Monitor fluid intake  Input  Diet – Fluids – Fluid restriction – Food – NPO  Output – Intake of Sodium – Urine – Stool – Sweat  Input = Output  Evaluation  Assessment and monitoring  Medication  Diet  Fluids  Patient and family education