Fluid and Electrolytes Balance and Disturbance PDF

Fluid and Electrolytes: Balance and Disturbance NISHA SIVAPALAN RN MSN  Objectives: By the end of this lecture the students will be able to: Identify the way in which fluids and electrolytes...

Fluid and Electrolytes: Balance and Disturbance NISHA SIVAPALAN RN MSN  Objectives: By the end of this lecture the students will be able to: Identify the way in which fluids and electrolytes are distributed throughout the body Describe the cause, clinical manifestations, management, and nursing interventions for different Fluid abnormalities Describe the cause, clinical manifestations, management, and nursing interventions for the different electrolyte abnormalities Identify types of I.V. Fluids and how they’re used Identify Complications associated with I.V. Therapy Identify Nursing considerations for patients receiving I.V. therapy. 2 NISHA SIVAPALAN MSN  Outline Definition of fluid &electrolyte balance, Homeostasis Distribution of body fluids Factors affecting fluid &electrolyte in the body Composition of body fluids Processes of regulation of body fluid &electrolyte balance Fluid Imbalance -F.V.D &dehydration, F.V.E &over hydration Edema Electrolyte Imbalance Nursing process for fluid &electrolyte imbalance NISHA SIVAPALAN MSN 3  INTRODUCTION Fluid and electrolyte balance is dependent upon dynamic processes that are crucial for life and homeostasis. Potential and actual disorders of fluid and electrolyte balance occur in every setting, with every disorder, and with a variety of changes that affect healthy people (e.g., increased fluid and sodium loss with strenuous exercise and high environmental temperature, inadequate intake of fluid and electrolytes) as well as those who are ill Homeostasis: maintenance of a constant internal equilibrium in a biologic system that involves positive and negative feedback mechanisms 4 NISHA SIVAPALAN MSN  Fluid distribution/Compartments INTRAVASCULAR “BLOOD 25%” 1. Intracellular fluid (ICF) ECF 2. Extracellular fluid (ECF) INTERSTITIAL Fluid distribution “75%” ICF To maintain proper fluid balance, the distribution of fluid between the two compartments must remain relatively constant 5 NISHA SIVAPALAN MSN Approximate sizes of body compartments in a 70-kg adult NISHA SIVAPALAN MSN 6  Diffusion Active transport Osmosis Movement Solutes move from an area of Solutes move from an Fluid moves passively higher concentration to an area of lower from areas with more area of lower concentration concentration to an area fluid (and fewer solutes) of higher concentration to areas with less fluid (and more solutes). Energy NO energy is required YES NO energy is requirement adenosine triphosphate required (ATP). Transport passive transport active transport passive transport mechanism Result equal distribution of solutes With the help of this, in stops when enough fluid within the two areas. sodium-potassium has moved through the pump, sodium ions move membrane to equalize from ICF (an area of the solute concentration lower concentration) to on both sides of the ECF (an area of higher membrane concentration). Type of mechanism cellular cellular cellular 7 NISHA SIVAPALAN MSN Systemic Routes of Gains and Losses Healthy people gain fluids by drinking and eating, and their daily average I&O of water are approximately equal I&O NISHA SIVAPALAN MSN 8 Systemic Routes of Gains and Losses Kidneys -The usual daily urine volume in the adult is 1 to 2 L. A general rule is that the output is approximately 1 mL of urine per kilogram of body weight per hour (1 mL/kg/h) in all age groups Skin - Sensible perspiration refers to visible water and electrolyte loss through the skin (sweating). The chief solutes in sweat are sodium, chloride, and potassium. Actual sweat losses can vary from 0 to 1000 mL every hour, depending on factors such as the environmental temperature. Fever , exercise, burns etc greatly increase insensible water loss through the lungs and the skin Lungs- The lungs normally eliminate water vapor (insensible loss) at a rate of approximately 300 mL every day. The loss is much greater with increased respiratory rate or depth, or in a dry climate. Gastrointestinal Tract- The usual loss through the gastrointestinal (GI) tract is 100 to 200 mL daily, diarrhea and fistulas cause large losses. NISHA SIVAPALAN MSN 9 Laboratory Tests for Evaluating Fluid Status Osmolality is the concentration of fluid that affects the movement of water between fluid compartments by osmosis. In healthy adults, normal serum osmolality is 275 to 290 mOsm/kg Urine-specific gravity measures the kidneys’ ability to excrete or conserve water. The normal range of urine specific gravity is 1.010 to 1.025 BUN (Blood Urea Nitrogen) is made up of urea, which is an end product of the metabolism of protein by the liver. The normal BUN is 10 to 20 mg/dL (3.6 to 7.2 mmol/L) Creatinine is the end product of muscle metabolism. The normal serum creatinine is approximately 0.7 to 1.4 mg/dL (62 to 124 mmol/L) Hematocrit measures the volume percentage of red blood cells (erythrocytes) in whole blood and normally ranges from 42% to 52% for men and 35% to 47% for women NISHA SIVAPALAN MSN 10 Homeostatic Mechanisms Kidney Functions - normally filter 180 L of plasma every day in the adult and excrete 1 to 2 L of urine Heart and Blood Vessel Functions - The pumping action of the heart circulates blood through the kidneys under sufficient pressure to allow for urine formation Lung Functions - Through exhalation, the lungs remove approximately 300 mL of water daily in the normal adult Pituitary Functions - The hypothalamus manufactures ADH, which is stored in the posterior pituitary gland and released as needed to conserve water Adrenal Functions - Increased secretion of aldosterone causes sodium retention (and thus water retention) and potassium loss Parathyroid Functions- PTH influences bone reabsorption, calcium absorption from the intestines, and calcium reabsorption from the renal tubules. NISHA SIVAPALAN MSN 11 Other Mechanisms Baroreceptors- located in the left atrium and the carotid and aortic arches, respond to changes in the circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Renin–Angiotensin–Aldosterone System Antidiuretic Hormone and Thirst - Oral intake is controlled by the thirst center located in the hypothalamus Osmoreceptors -Located in hypothalamus, sense changes in sodium concentration. Natriuretic Peptides -affect fluid volume and cardiovascular function through the excretion of sodium (natriuresis), direct vasodilationetc NISHA SIVAPALAN MSN 12 Fluid regulation cycle NISHA SIVAPALAN MSN 13  FLUID VOLUME DISTURBANCES Fluid volume deficit (F.VD) HYPOVOLEMIA FVD, or hypovolemia, occurs when loss of ECF volume exceeds the intake of fluid. It occurs when water and electrolytes are lost in the same proportion as they exist in normal body fluids; thus, the ratio of serum electrolytes to water remains the same. DEHYDRATION Condition in which there is loss of water alone, with increased serum sodium levels. Possible causes of Fluid volume deficit (F.VD).: ✔ Abnormal fluid losses, such as those resulting from vomiting, diarrhea, GI suctioning, sweating; ✔ Decreased intake, as in nausea or lack of access to fluids; and third-space fluid shifts, or the movement of fluid from the vascular system to other body spaces (e.g., with edema formation in burns, ascites with liver dysfunction). ✔ Additional causes include diabetes insipidus, adrenal insufficiency, osmotic diuresis, hemorrhage, and coma. NISHA SIVAPALAN MSN 14 SIGNS AND SYMPTOMS OF F.V.D ✔ Acute Weight loss. Labs indicate: ✔ Decrease in skin turgor. ✔ Increased Hb and hematocrit ✔ Concentrated urine, Oliguria in severe cases ✔ Increased serum and urine osmolality, specific gravity ✔ Prolonged capillary filling time ✔ Increased BUN , creatinine ✔ Low CVP, flattened neck veins, tachycardia, Hypotension ✔ Dry skin and cricked lips, sunken eyes ,muscle cramps, nausea ✔ Cold extremities, dizziness, weakness ✔ Thirst, decrease salivation ✔ Mental status changes may lead to coma. NISHA SIVAPALAN MSN 15 MEDICAL MANAGEMENT OF PATIENTS WITH F.V.D Correction of fluid loss If the deficit is not severe, the oral route is preferred, provided the patient can drink. However, if fluid losses are acute or severe, the IV route is required. Isotonic electrolyte solutions (e.g., lactated Ringer solution, 0.9% sodium chloride) are frequently the first-line choice to treat the hypotensive patient with FVD because they expand plasma volume As soon as the patient becomes normotensive, a hypotonic electrolyte solution (e.g., 0.45% sodium chloride) is often used to provide both electrolytes and water for renal excretion of metabolic wastes. NISHA SIVAPALAN MSN 16  NURSING CARE OF PATIENTS WITH F.V.D ✔ Monitor vital signs ✔ Weigh the patient daily. An acute loss of 0.5 kg (1.1 lb) represents a fluid loss of approximately 500 mL (1 L of fluid weighs approximately 1 kg, or 2.2 lb). ✔ Measure C.V.P daily, if applicable ✔ Assess patient's ability to ambulate ✔ Monitor and measures fluid I&O at least every 8 hours, and sometimes hourly ✔ Check on lab investigation daily & report for any abnormality ✔ Skin and tongue turgor are monitored on a regular basis. Tissue turgor is best measured by pinching the skin over the sternum, inner aspects of the thighs, or forehead. In the person with FVD, there are additional longitudinal furrows and the tongue is smaller because of fluid loss. ✔ Increase fluid intake as water, juices or administration of intravenous solution ✔ If the patient is reluctant to drink because of oral discomfort, assist with frequent mouth care and provide nonirritating fluids. ✔ Offer small volumes of oral rehydration solutions (e.g., Rehydralyte, Elete, Cytomax) Nursing diagnoses Deficient fluid volume. Risk for imbalanced fluid volume. Readiness for enhanced fluid balance. NISHA SIVAPALAN MSN 17  Hypervolemia , Fluid volume excess (FVE) An isotonic expansion of the ECF caused by the abnormal retention of water and sodium in approximately the same proportions in which they normally exist in the ECF. Most often secondary to an increase in the total-body sodium content, which, in turn, leads to an increase in total-body water. Etiology ✔ Increase intake as in too rapid administration of intravenous fluid containing sodium or too rapid administration of nasogastric tube feeding ✔ Decrease urine output as in kidney or liver disorders ✔ Physical disorders e.g. heart failure, cirrhosis of the liver ✔ Excess ingestion of sodium e.g. from substances that contain large amounts of sodium chloride ✔ Stress from surgery or other physical trauma NISHA SIVAPALAN MSN 18 SIGNS AND SYMPTOMS OF FLUID VOLUME EXCESS (FVE) ✔ Acute weight gain 0.9% sodium chloride ✔ Peripheral edema ✔ Crackles ✔ Elevated CVP/distended neck veins Labs : ✔ Shortness of breath Decreased hemoglobin and hematocrit ✔ Hypertension Decreased serum and urine osmolality ✔ Tachypnea Decreased urine specific gravity ✔ Increased urine output NISHA SIVAPALAN MSN 19  Medical Management of Fluid volume excess (FVE) Management of FVE is directed at the causes. When the fluid excess is related to excessive administration of sodium-containing fluids, discontinuing the infusion may be all that is needed. Symptomatic treatment consists of administering diuretics and restricting fluids and sodium. Side effects of diuretics :Electrolyte imbalances -Hypokalemia (Potassium supplements can be prescribed to avoid this complication), Hyponatremia,Hypomagnesemia Dialysis to remove excess fluids and waste products in renal failure NISHA SIVAPALAN MSN 20  Nutritional Therapy for FVE Dietary restriction of sodium(low sodium diet with250 mg of sodium per day) -average daily diet not restricted in sodium contains 6 to 15 g of salt A mild sodium-restricted diet allows light salting of food and no addition of salt to seasoned foods. Patients are advised to read food labels to determine salt content. Seasoning substitutes like lemon juice, onions, and garlic can decrease sodium 9 intake. Most salt substitutes contain potassium and must therefore be used cautiously by patients taking potassium-sparing diuretics. Patients should avoid salt substitutes containing ammonium chloride, which can be harmful to patients with liver damage. Use distilled water if the local water supply is very high in sodium. Avoid water softeners that add sodium to water in exchange for other ions. Protein intake may be increased in malnourished or low serum protein levels to increase capillary oncotic pressure and pull fluid out of the tissues into vessels. NISHA SIVAPALAN MSN 21  Nursing care of patients with fluid over load (Hypervolemia) ✓ Monitor vital signs ✓ Weigh the patient daily, An acute weight gain of 1 kg is equivalent to a gain of approximately 1 L of fluid ✓ Measure fluid intake & output regularly and maintain intake and output chart daily ✓ Assess breath sounds at regular intervals in at-risk patients, if IV fluids are given ✓ Assess the degree of edema ✓ Monitor serum electrolytes & report any abnormality ✓ Dietary restriction of sodium NURSING DIAGNOSES ✓ Administration of diuretics as ordered Eg: Lasix ◼Excess fluid volume ✓ Provide regular period of rest ◼Risk for impaired skin integrity ✓ Avoid over-the-counter medications containing sodium. ◼Disturbed body image ✓ If fluid retention persists, hidden sodium sources like water supply should be considered. ✓ If dyspnea or orthopnea is present, semi-Fowler position to promote lung expansion. ✓ Assess & provide skin care daily ✓ The patient is turned and repositioned at regular intervals because edematous tissue is more prone to skin breakdown than normal tissue NISHA SIVAPALAN MSN 22  EDEMA Definition: Edema is accumulation of fluid in interstitial space leading to soft tissue swelling. This swelling may occur throughout the body (generalized) or may be limited to specific part of the body (localized) Grading of edema: Grade 1: Immediate rebound with 2 millimeter (mm) pit. Grade 2: Less than 15-second rebound with 3 to 4 mm pit. Grade 3: Rebound greater than 15 seconds but less than 60 seconds with 5 to 6 mm pit. Grade 4: Rebound between 2 to 3 minutes with an 8 mm pit. NISHA SIVAPALAN MSN 23 Pathophysiology of Edema 1 Increased Capillary Fluid Pressure This occurs when there is an increase in hydrostatic pressure within the capillaries, pushing more fluid into the interstitial space. Common causes include venous obstruction or heart failure. 2 Decreased Capillary Oncotic Pressure A reduction in plasma protein concentration, particularly albumin, leads to decreased oncotic pressure. This can result from conditions like liver disease or malnutrition. 3 Increased Interstitial Oncotic Pressure This happens when there's an accumulation of proteins or other osmotically active substances in the interstitial space, often seen in inflammatory conditions or lymphatic obstruction. preencoded.png  Types of Edema Localized Edema Generalized Edema Anasarca This type of edema is confined to a This is an extreme form of generalized This type affects multiple body areas specific area of the body. For example, edema characterized by widespread simultaneously. It's commonly seen in ankle edema in rheumatoid arthritis or swelling of the skin and subcutaneous conditions like cardiac failure or localized swelling due to an injury or tissues. It's often associated with kidney injury. Generalized edema can infection. It's often caused by local severe heart failure, liver disease, or be indicative of systemic issues factors affecting fluid balance in that kidney disorders. affecting fluid balance throughout the particular region. body. preencoded.png  Ascites Definition Clinical Manifestations Ascites is the accumulation of fluid in the ▪ Abdominal distension, shortness of breath, and a peritoneal cavity. sense of pressure. ▪ The increased abdominal girth can lead to Causes- cirrho sis, nep hro tic synd ro m e, and discomfort and altered body image. certain m alig nancies. ▪ In severe cases, respiratory difficulties due to diaphragmatic compression. Diagnosis and Assessment Management ❑ Physical examination ✓ Addressing the underlying cause and managing ❑ Imaging studies (ultrasound or CT managing symptoms. CT ✓ Sodium and fluid restriction, diuretic therapy, therapy, paracentesis for symptom relief, nutritional support preencoded.png  Assessing and Monitoring Edema Visual Inspection Pitting Test Circumference Weight Monitoring ✓ Observe for swelling in ✓ Apply firm pressure to the Measurement ✓ Daily weight checks can help dependent areas such as feet edematous area for 5 ✓ Use a tape measure to track track fluid retention. and ankles in ambulatory seconds. changes in limb ✓ Sudden weight gain may patients and the sacral region ✓ Measure the depth of the pit circumference for indicate worsening edema. in patients confined to bed.. and how long it takes to monitoring the Peripheral ✓ Note any skin changes, rebound. Grade on a scale of edema including shiny appearance. 1+ to 4+. preencoded.png Management Strategies for Edema in FVE Diuretic Therapy Sodium and Fluid Restriction ▪ Medications like furosemide help ▪ Limiting sodium intake to 2-3 increase urine output, reducing grams per day and restricting fluid volume. fluid intake. ▪ Careful monitoring of ▪ Patient education on reading electrolytes and renal function is food labels and proper fluid essential. measurement. Limb Elevation and Compression Advanced Interventions ▪ Elevating affected limbs above ▪ In severe cases, treatments like heart level and using paracentesis for ascites or compression stockings. dialysis. ▪ Proper sizing and application ▪ These require specialized technique should be taught to nursing care and monitoring. patients. preencoded.png Nursing care of patients with edema: ✔ Salt restricted diet ✔ Use diuretics as ordered ✔ Maintain intake & output chart ✔ Weigh the patient daily ✔ Frequently change the patient’s position ✔ Skin care ✔ Elevation of edematous limb ✔ Getting regular exercise ✔ Avoiding sitting or standing in one position for long periods NISHA SIVAPALAN MSN 29  PARENTERAL FLUID THERAPY When no other route of administration is available, fluids are administered by IV in hospitals Purpose To provide fluid, electrolytes, and nutrients to meet daily requirements To replace water and correct electrolyte deficits To administer medications and blood products Types of Intravenous Solutions Isotonic Fluids Has a total osmolality close to that of the ECF and do not cause red blood cells to shrink or swell. Hypotonic Fluids Purpose of hypotonic solutions is to replace cellular fluid, because it is hypotonic compared with plasma. Hypertonic Fluids These solutions draw water from the ICF to the ECF and cause cells to shrink. NISHA SIVAPALAN MSN 30 NISHA SIVAPALAN MSN 31 NISHA SIVAPALAN MSN 32 Nursing Management of the Patient Receiving Intravenous Therapy ✔ The ability to perform venipuncture to gain access to the venous system for administering fluids and medication is an expected nursing skill in many settings. ✔ Selecting the appropriate venipuncture site and type of cannula and being proficient in the technique of vein entry. ✔ Infusion therapy is initiated with the type and amount of solution, additives (if any), and rate of flow. ✔ When administering parenteral fluids, the nurse monitors the patient’s response to the fluids, considering the fluid volume, the fluid content, and the patient’s clinical status. NISHA SIVAPALAN MSN 33  Complications of I.V. therapy 1. Infiltration During infiltration, fluid may leak from the vein into surrounding tissue. This occurs when the access device dislodges from the vein. 2. Infection I.V. therapy involves puncturing the skin, one of the body’s barriers to infection. Look for purulent drainage at the site, tenderness, erythema, warmth, or hardness on palpation. Signs and symptoms that the infection has become systemic include fever, chills, and an elevated white blood cell count. 34 NISHA SIVAPALAN MSN  Complications of I.V. therapy 3. Phlebitis and thrombophlebitis Phlebitis is inflammation of a vein. Thrombophlebitis is an irritation of the vein along with the formation of a clot. causes: Poor insertion technique or the pH or osmolality of the infusing solution or medication Signs: pain, redness, swelling, or induration at the site; a red line streaking along the vein; fever; or a sluggish flow of the solution. 4. Air embolism occurs when air enters the vein. It can cause a decrease in blood pressure, an increase in the pulse rate, respiratory distress, an increase in ICP, and a loss of consciousness 35 NISHA SIVAPALAN MSN ELECTROLYTES IMBALANCE Electrolytes ▪ Electrolytes in body fluids are active chemicals (cations that carry positive charges and anions that carry negative charges). ▪ Major cations in body fluid- sodium, potassium, calcium, magnesium, and hydrogen ions. ▪ Major anions in body fluid - chloride, bicarbonate, phosphate, sulfate, and proteinate ions. ▪ Electrolyte concentration in the body is expressed in terms of milliequivalents (mEq) per liter NISHA SIVAPALAN MSN 36 Roles of Major Electrolytes 1 Fluid Balance Electrolytes regulate the distribution of water between intracellular and extracellular spaces. This maintains proper hydration and cell volume. 2 Transmission of nerve impulse They facilitate nerve impulse transmission. This enables proper sensory perception and muscle control throughout the body. 3 Participate in normal muscular function Electrolytes help maintain the body's normal muscular function. 4 Regulation of acid base balance Electrolytes help maintain the body's acid-base balance. This is crucial for optimal enzyme function and overall health. 5 Regulation of blood clotting Electrolytes help maintain the blood clotting mechanism. preencoded.png NISHA SIVAPALAN MSN 38  SODIUM IMBALANCES ▪ Sodium is the most abundant electrolyte in the ECF ▪ Its concentration ranges from 135 to 145 mEq/L (135 to 145 mmol/L) SODIUM DEFICIT (HYPONATREMIA) Hyponatremia refers to a serum sodium level that is less than 135 mEq/L (135 mmol/L) Causes: Hyponatremia primarily occurs due to an imbalance of water rather than sodium. ✓ Loss of GI fluids. ✓ Excessive use of diuretics (thiazides) ✓ Use of certain medications, such as anticonvulsants (i.E., Carbamazepine [tegretol], ✓ Adrenal insufficiency. ✓ Excessive water supplements for patients receiving hypotonic tube feedings. NISHA SIVAPALAN MSN 39 SODIUM DEFICIT (HYPONATREMIA) Signs and symptoms ✔Anorexia, nausea, vomiting. ✔headache, lethargy, confusion, Seizures. ✔muscle cramps &weakness, dry skin. ✔Hypotension, tachycardia. Labs indicate: decreased serum &urine sodium, urine specific gravity & osmolarity Medical Management Sodium Replacement Careful administration of sodium by mouth, nasogastric tube, or a parenteral route. Water Restriction restricting fluid to a total of 800 mL in 24 hours. If neurologic symptoms are severe (eg, seizures, delirium, coma) administer small volumes of a hypertonic sodium solution Highly hypertonic sodium solutions (2% to 3%sodium chloride) should be administered only in intensive care settings under close observation, because only small volumes are needed to elevate the serum sodium concentration from a dangerously low level. Pharmacologic Therapy IV conivaptan hydrochloride -stimulating free water excretion NISHA SIVAPALAN MSN 40 Nursing management of hyponatremia ∙ Monitor high risk patients for S&S ∙ Give hypertonic I.V.Solutions ∙ Weigh the patient daily& monitor V/S closely ∙ Maintain intake& output chart. ∙ Care of GIT manifestations. ∙ Monitor Serum electrolytes , urine for specific gravity &osmolarity ∙ Stop giving diuretics. ∙ Encourage foods and fluids with high sodium content for patients with abnormal sodium losses ∙ For all patients on lithium therapy, normal salt and oral fluid intake (2.5 L/day) should be encouraged and a sodium restricted diet should be avoided ∙ If enema is prescribed for the patient, do it with NaCl. ∙ Restrict water for patients taking hypotonic solutions When administering fluids to patients with cardiovascular disease, the nurse should assess for signs of circulatory overload (e.g., cough, dyspnea, puffy eyelids, dependent edema, excess weight gain in 24 hours). The lungs are auscultated for crackles NISHA SIVAPALAN MSN 41  SODIUM EXCESS (HYPERNATREMIA) Hypernatremia is a serum sodium level higher than 145 mEq/L (145 mmol/L). It can be caused by a gain of sodium in excess of water or by a loss of water in excess of sodium. Causes: ✔ Water deprivation in patients unable to drink. ✔ Hypertonic tube feedings without adequate water supplements. ✔ Diabetes insipidus. ✔ Excessive administration of corticosteroid, sodium bicarbonate &sodium chloride. ✔ Near drowning in sea water (which contains a sodium concentration of approximately 500 mEq/L). NISHA SIVAPALAN MSN 42 SODIUM EXCESS (HYPERNATREMIA) Signs and symptoms ✔ Thirst ,Fever , tachycardia, hypertension. ✔ Swollen dry tongue and sticky mucous membrane. ✔ Hallucinations, lethargy, irritability, restlessness. ✔ Pulmonary edema ✔ Anorexia, nausea, vomiting. Labs indicate: Increased serum –sodium, urine specific gravity &osmolarity. Medical Management Infusion of a hypotonic electrolyte solution (eg, 0.3% sodium chloride) or an isotonic non saline solution (eg, dextrose 5% in water [D5W]). D5W is indicated when water needs to be replaced without sodium. A rapid reduction in the serum sodium level cause dangerous cerebral edema NISHA SIVAPALAN MSN 43  Nursing management of hypernatremia ∙ Monitor high risk patients for S&S. ∙ Monitor vital signs closely. ∙ Assess for abnormal losses of water or low water intake and for large gains of sodium, as might occur with ingestion of OTC medications that have a high sodium content ∙ Provide oral fluids at regular intervals, in patients who are unable to perceive or respond to thirst. ∙ If enteral feedings are used, sufficient water should be given ∙ Weigh the patient daily. ∙ Put the patient on intake &output chart. ∙ Offer care of GIT manifestations. ∙ Monitor serum electrolytes & urine for specific gravity & osmolarity. ∙ Assess the neurological status of the patient. ∙ Restrict sodium in the diet. ∙ Ensure adequate water intake for patients with diabetes insipidus. NISHA SIVAPALAN MSN 44  POTASSIUM IMBALANCES The normal serum potassium concentration ranges from 3.5 to 5.0 mEq/L (3.5 to 5 mmol/L) POTASSIUM DEFICIT (HYPOKALEMIA) refers to a serum potassium level less than 3.5 mEq/L (135 3.5 mmol/L) Causes: ✓ Potassium-losing diuretics, such as the thiazides and loop diuretics ✓ GI loss-Vomiting and gastric suction, diarrhea ✓ Hyperaldosteronism increases renal potassium wasting and can lead to severe potassium depletion ✓ Inadequate dietary consumption Signs and symptoms Fatigue, anorexia, nausea and vomiting, muscle weakness, polyuria, decreased bowel motility paresthesias, leg cramps, hypotension, hypoactive reflexes. ECG: flattened T waves, prominent U waves, ST depression NISHA SIVAPALAN MSN 45 POTASSIUM DEFICIT (HYPOKALEMIA) Medical & Nursing Management For patients who are at risk for hypokalemia, a diet containing sufficient potassium should be provided. Foods high in potassium include most fruits and vegetables, legumes, whole grains, milk, and meat. Oral or IV potassium supplements -Oral potassium supplements can produce small bowel lesions; therefore, the patient must be assessed for and cautioned about abdominal distention, pain, or GI bleeding. If oral administration of potassium is not feasible, the IV route is indicated. Potassium is never administered by IV push or intramuscularly to avoid replacing potassium too quickly. IV potassium must be administered slowly using an infusion pump at a rate no faster than 10 to 20 mEq/h. NISHA SIVAPALAN MSN 46 POTASSIUM EXCESS (HYPERKALEMIA) Refers to serum potassium level greater than 5.0 mEq/L [5 mmol/L]), it is usually dangerous, because cardiac arrest is more frequently associated with high serum potassium levels. Causes: ❖ Renal failure. ❖ Fluid volume deficit. ❖ burns ❖ Iatrogenic administration of large amounts of potassium intravenously. ❖ Adrenal insufficiency. ❖ Acidosis, especially ketoacidosis. ❖ Rapid infusion of stored blood. ❖ Use of potassium-sparing diuretics. NISHA SIVAPALAN MSN 47  POTASSIUM EXCESS (HYPERKALEMIA) Signs and symptoms ⮚ Tachycardia then Bradycardia. ⮚ Muscular weakness, irritability, dysrhythmias, ⮚ Flaccid paralysis, paresthesia. ⮚ Intestinal colic, cramps,anxiety. ⮚ ECG:tall T waves,prolonged PR interval&QRS duration, absent P waves, ST depression Medical Management ✔ Administer I.V.Calcium gluconate to antagonize the action of hyperkalemia on the heart. ✔ Administer I.V. Sodium bicarbonate to alkalinize the plasma shifting of potassium into the cells. ✔ IV administration of regular insulin and a hypertonic dextrose solution causes a temporary shift of potassium into the cells. Glucose and insulin therapy has an onset of action within 30 minutes and lasts for several hours. ✔ Loop diuretics, such as furosemide (Lasix), increase excretion of water ✔ Dialysis ✔ Beta-2 agonists, such as albuterol move potassium into the cells NISHA SIVAPALAN MSN 48 Nursing management of hyperkalemia ∙ Monitor high risk patient’s for S&S. ∙ Monitor vital signs closely. ∙ Monitor ECG for dysrhythmias. ∙ Monitor serum electrolytes level. ∙ Assess the neurologic status for irritability & muscles for weakness or cramps. ∙ Restrict potassium in the diet. ∙ Teach the patient that labels of cola beverages must be checked carefully because some are high in potassium and some are not. ∙ Administer diuretics as ordered. ∙ Prepare for dilaysis NISHA SIVAPALAN MSN 49  CALCIUM IMBALANCES Calcium plays a major role in transmitting nerve impulses and helps regulate muscle contraction and relaxation, including cardiac muscle. The normal total serum calcium level is 8.6 to 10.2 mg/dL (2.2 to 2.6 mmol/L). CALCIUM DEFICIT (HYPOCALCEMIA) Serum values lower than 8.6 mg/dL [2.15 mmol/L]) Causes: ∙ Hypoparathyroidism (may follow thyroid surgery or radical neck dissection). ∙ Malabsorption & vitamin D deficiency. ∙ Massive transfusion of citrated blood. ∙ Pancreatitis, Peritonitis &chronic diarrhea. ∙ Decreased parathyroid hormone. ∙ Diuretic phase of renal failure. NISHA SIVAPALAN MSN 50 CALCIUM DEFICIT (HYPOCALCEMIA) Signs and symptoms ✓ Hyperactive deep tendon reflexes ✓ Numbness &tingling of fingers & toes ✓ Impaired clotting time& decreased prothrombin ✓ Seizures, carpopedal spasm, irritability, bronchospasm, anxiety Positive Trousseau’s - by using a blood pressure cuff placed around the upper arm and inflate it to a pressure greater than the systolic blood pressure and hold it in place for 3 minutes. If it is positive, the hand of the arm where the blood pressure is being taken will start to contract involuntarily Chvostek’s sign - tap at the angle of the jaw via the masseter muscle and the facial muscles on the same side of the face will contract momentarily ECG: Lengthened ST, prolonged QT interval. NISHA SIVAPALAN MSN 51  CALCIUM DEFICIT (HYPOCALCEMIA) Medical Management IV administration of a calcium gluconate, calcium chloride, and calcium gluceptate. Too rapid IV administration of calcium can cause cardiac arrest, preceded by bradycardia. Therefore, calcium should be diluted in D5W and administered as a slow IV bolus or a slow IV infusion using an infusion pump ✔ Vitamin D therapy may be instituted to increase calcium absorption from the GI tract Nursing Management ⮚ Encourage calcium-containing foods include milk products; green, leafy vegetables; canned salmon; sardines; and fresh oysters. ⮚ Monitor high risk patient’s for S&S. ⮚ Monitor serum electrolytes level. ⮚ Monitor vital signs & bronchospasm closely. ⮚ Assess the reflexes muscles frequently. ⮚ Monitor ECG for dysrhythmias. ⮚ MonitorNISHA for seizures maintain safety precautions for the patient. SIVAPALAN MSN 52 CALCIUM EXCESS (HYPERCALCEMIA) Serum calcium greater than 10.2 mg/dL [2.6 mmol/L] Causes: ∙ Oliguric renal failure. ∙ Hyperparathyrodism & Vitamin D excess. ∙ Prolonged immobilization. ∙ Overuse of calcium supplements corticosteroid therapy. Signs and symptoms ▪ Muscular weakness, lethargy, ▪ Anorexia ,nausea, vomiting, constipation. ▪ Polyuria & Polydypsia. ▪ Hypo active deep tendon reflexes, deep bone pain ▪ Pathologic fractures. ▪ Calcium stones &flank pain. ▪ ECG: shortened QT interval, bradycardia &heart blocks. NISHA SIVAPALAN MSN 53  CALCIUM EXCESS (HYPERCALCEMIA) Medical Management ▪ Treating the underlying cause (eg, chemotherapy for a malignancy, partial parathyroidectomy for hyperparathyroidism) ▪ Calcitonin reduces bone resorption, increases the deposition of calcium and phosphorus in the bones ▪ Administering fluids to dilute serum calcium and promote its excretion by the kidneys ▪ Mobilizing the patient, and restricting dietary calcium intake Nursing Management ∙ Monitor high risk patients for S&S. ∙ Monitor vital signs closely. ∙ Monitor ECG for dysrhythmias. ∙ Monitor serum electrolytes level. ∙ Restrict calcium in diet & offer fiber rich diet. ∙ Monitor for digitalis toxicity. ∙ Administer I.V sodium chloride 0.9% to dilute the serum calcium level &urinary calcium excretion by inhibiting tubular reabsorption. ∙ Encourage to drink 2.8 to 3.8 L of fluid daily. ∙ Maintain safety to prevent the occurrence of fractures. NISHA SIVAPALAN MSN 54