Fluid & Electrolyte Balance Concepts

ATI Chapter 44 & Iggy Chapter 13 Fluid and Electrolyte Imbalances Copyright © 2018 Elsevier Inc. All rights reserved.  Concepts The priority concept in this chapter is  FLUID AND ELECTROLYTE BALANCE The exemplar in this chapter is dehydration The inte...

ATI Chapter 44 & Iggy Chapter 13 Fluid and Electrolyte Imbalances Copyright © 2018 Elsevier Inc. All rights reserved.  Concepts The priority concept in this chapter is  FLUID AND ELECTROLYTE BALANCE The exemplar in this chapter is dehydration The interrelated concept in this chapter is  PERFUSION Copyright © 2018 Elsevier Inc. All rights reserved. 2  Homeostasis Proper functioning of all body systems; requires fluid and electrolyte balance Intracellular fluid (ICF) two thirds of body water body fluid within cells Extracellular fluid (ECF) One third of body water Body fluids outside of the cell membrane Intravascular fluid: liquid part of blood or plasma Interstitial fluid: located between the cells and outside of the blood vessel Transcellular fluids: secreted by epithelial cells (cerebrospinal, pleural peritoneal, synovial fluids) Copyright © 2018 Elsevier Inc. All rights reserved. 3  Homeostasis skin, lungs, GI tract, kidneys are the key system in homeostasis They also adjust levels of Homeostasis is the electrolytes like body’s way of sodium and maintaining a potassium, stable internal When the body is helping to keep environment When there’s In the healthy dehydrated, the blood pressure despite changes excess water, they adult 55-60% of kidneys conserve and overall body outside. The filter out more, body wt is body water by function stable. kidneys play a key producing dilute fluid concentrating Essentially, the role in this process urine. urine. kidneys help by regulating the ensure that the balance of water, body’s internal salts, and waste conditions remain products. balanced and healthy. Dehydration occurs when the body loses more fluids than it takes in, disrupting the balance of electrolytes and leading to potential health issues. Key points for nursing understanding include: Causes: Dehydration can result from inadequate fluid intake, excessive sweating, vomiting, diarrhea, or certain medical conditions (e.g., diabetes). Signs and Symptoms: Common symptoms include thirst, dry mouth, decreased urine output, dark-colored urine, fatigue, dizziness, and confusion. In severe cases, it can lead to hypotension, rapid heart rate, and altered mental status. Assessment: Assess for clinical signs and symptoms of dehydration, including thirst, weight loss, dry mucous membranes, sunken-appearing eyes, decreased skin turgor, increased capillary refill time, hypotension and postural hypotension, tachycardia, weak and thready peripheral pulses, flat neck veins when the patient is in the supine position, and oliguria (low urine output). Interventions: Treatment involves rehydrating the patient with oral or intravenous fluids, depending on the severity. Electrolyte balance should also be restored as needed. Education: Patients should be educated on the importance of adequate fluid intake, recognizing early signs of dehydration, and strategies to stay hydrated, especially during illness or heat. Understanding these aspects helps nurses effectively monitor and manage patients at risk for dehydration.  hypovolemia Hypovolemia refers to a decreased volume of blood in the body, often due to Dehydration: Due to fluid loss. It can lead to inadequate fluid intake, Risks for Hypovolemia: reduced blood flow to excessive sweating, organs and is a critical diarrhea, or vomiting. condition requiring prompt attention. Blood Loss: From trauma, Severe Burns: Leading to Diuretic Use: Excessive surgery, or conditions like fluid loss from damaged urination can lead to gastrointestinal bleeding. skin. significant fluid loss. Chronic Illnesses: Conditions like diabetes or heart failure can contribute.  Symptoms of Thirst: Increased hypovolemia in a thirst as the body patient can vary in signals the need severity but may for fluids. include: Dry Mouth and Decreased Urine Skin: Mucous Output: Urine membranes may may be dark and appear dry, and concentrated; skin may lack reduced frequency elasticity. of urination. Dizziness or Lightheadednes Fatigue: General s: Especially when weakness and standing tiredness. (orthostatic hypotension). Rapid Heart Low Blood Rate: Increased Pressure: heart rate as the Hypotension, body tries to particularly in maintain blood severe cases. pressure. Confusion or Irritability: Cool, Clammy Altered mental Skin: Due to status may occur, reduced blood flow especially in older to the skin. adults. Recognizing these symptoms early is crucial for timely intervention.  Nursing Actions Monitor vital signs (especially blood pressure and heart rate). Assess for signs of dehydration (e.g., dry mucous membranes, Assessment: decreased skin turgor). Evaluate urine output (decreased output may indicate hypovolemia). Fluid Administer intravenous fluids (crystalloids or colloids) as ordered to restore volume. Replacement: Encourage oral hydration if appropriate. Electrolyte Check electrolyte levels and replace them as needed, especially sodium and potassium. Monitoring: Patient Position the patient supine or with legs elevated to promote venous return, Trendelenburg if needed with low blood pressure. Positioning: Teach patients about the importance of hydration and recognizing Education: signs of fluid loss, change positions slowly, call don’t fall. Record all assessments, interventions, and the patient's response to Documenting: treatment.  Hypervolemia Symptoms of hypervolemia, or fluid overload, can include: Swelling (Edema): Noticeable swelling in the legs, ankles, or feet. Weight Gain: Rapid increase in weight due to excess fluid. Shortness of Breath: Difficulty breathing, especially when lying down (orthopnea). Increased Blood Pressure: Elevated blood pressure due to increased blood volume. Jugular Vein Distension: Swelling of the neck veins. Coughing: May produce frothy or pink-tinged sputum, indicating pulmonary congestion. Fatigue: General tiredness and weakness. Decreased Urine Output: May occur as the  Hypervolemia, or fluid overload, can be caused by several factors, including: Heart Failure: The heart's inability to pump effectively can lead to fluid accumulation. Intravenous Fluid Administration: Kidney Dysfunction: Overzealous IV fluid Impaired kidney administration can function reduces the overwhelm the body’s ability to excrete excess capacity to excrete fluid. excess fluid. Hormonal Liver Disease: Imbalances: Conditions like cirrhosis Conditions like can lead to fluid hyperaldosteronism retention due to altered lead to increased protein levels and sodium and water circulation. retention. Medications: Certain Excessive Fluid Intake: medications, such as Overconsumption of corticosteroids or fluids, particularly in NSAIDs, can cause fluid patients with restricted retention. fluid output.  Nursing actions for managing hypervolemia include: Monitor vital signs, Restrict fluid Administer Elevate the Assessment: Medication Fluid Management: Administration: Patient Positioning: particularly blood pressure and heart intake as diuretics as head of the bed rate. prescribed. ordered to to improve Assess for signs of Educate the promote fluid breathing and edema (swelling) in excretion. reduce extremities and patient about other areas. the importance Monitor for discomfort. Evaluate lung sounds of adhering to effectiveness for crackles, cough, dyspnea indicating fluid and side effects fluid in the lungs. restrictions. of diuretics. Track daily weight to identify rapid weight gain. Decreased H/H, tachycardia, bounding pulse, HTN, tachypnea Distended neck veins and increase urine output, skin is cool to touch and pale Teach patients Monitor electrolyte Record all Education: Monitoring Labs: ion: Documentat about recognizing levels and kidney assessments, signs of fluid function tests interventions, and overload and the (BUN, creatinine) patient responses importance of to assess for to treatment. adhering to complications. dietary restrictions (e.g., sodium).  Filtration Filtration in the kidneys refers to the process by which blood is filtered in the nephrons. During filtration, water, ions, and small molecules (like glucose and waste products) pass from the blood into the Bowman's capsule, forming a fluid called filtrate. Larger molecules, such as proteins and blood cells, are retained in the bloodstream. This initial filtration is crucial for the kidneys to regulate water balance, electrolyte levels, and waste removal from the body. 12 reserved. Copyright © 2018 Elsevier Inc. All rights Hydrosta “Water-pushing pressure” Force that pushes water outward from a confined space through a tic membrane Amount of water in any body fluid space determines pressure Pressure Oncotic is the colloid osmotic pressure which is not lost in the urine. Example: Blood pressure Moving whole blood from the heart to capillaries where filtration occurs to exchange water, nutrients, and waste products between the blood and tissues 1 3 reserved. Copyright © 2018 Elsevier Inc. All rights Clinical Develops with changes in normal hydrostatic pressure differences Significanc e: Edema Osmosis: In the human body, when red blood cells are placed in a hypotonic solution (like pure water), water moves into the cells through osmosis, causing them to swell and potentially burst. Diffusion: In the lungs, oxygen diffuses from the alveoli (where its concentration is high) into the bloodstream (where its concentration is lower), allowing oxygen to be transported throughout the body.  Diffusion Where does diffusion occur in the body? The lungs are where oxygen and carbon dioxide gas diffuse. The kidneys are responsible for the diffusion of water, Free minerals, and movement ofwaste products particles (solute) across permeable membrane from area of higher to lower concentration Important in transport of most electrolytes; other particles diffuse through cell membranes Sodium pumps Glucose cannot enter most cell membranes without help of insulin Copyright © 2018 Elsevier Inc. All rights reserved. Osmosi s and Filtratio n Act together at capillary membrane to maintain normal ECF and ICF volumes Osmosis and our Kidneys The water in your blood then travels to your kidneys. Kidneys are some of the most complex parts of the body, and they use osmosis as well. Kidneys are made up of two parts - the cortex and medulla. The cortex is the outer part and the medulla is the inner part of the kidney. The kidneys are made up of groups of cells called renal pyramids. Each pyramid contains little units called nephrons. Nephrons look like a bunch of tubes connected to each other. Nephrons are important because they help filter waste out of your blood and put it into your urine.  Fluid Balance Closely linked to/affected by electrolyte concentrations Fluid intake Fluid loss  Minimum urine amount needed to excrete toxic waste products is 400 to 600 mL/day  Insensible water loss—through skin, lungs, stool  Normal healthy Urine output is 2000- 2500mL/day Copyright © 2018 Elsevier Inc. All rights reserved. 18  Hormonal Regulation of Fluid Balance Aldosterone A hormone your adrenal glands release that helps regulate blood pressure by managing the levels of sodium and potassium in your blood. Aldosterone regulates the salt and water balance of the body by increasing the retention of sodium and water and the excretion of potassium by the kidneys (and to a lesser extent by the skin and intestines). It also has a limited effect on the metabolism of fats, carbohydrates, and proteins. Antidiuretic hormone: ADH is a hormone that is produced in a part of the brain called the hypothalamus. It is then stored and released from the pituitary, a small gland at the base of the brain. ADH acts on the kidneys to control the amount of water excreted in the urine Natriuretic peptides Atrial natriuretic peptide (ANP): hormone released by the heart cells due to atrial wall stretching, very specific. Brain natriuretic peptide (BNP): hormone released by the heart cells due to ventricle wall stretching BNP tells your blood vessels to open wider and your kidneys to get rid of water and salt through urine (pee). This helps reduce the workload on your heart by lowering blood pressure and reducing the amount of blood your heart has to pump. Copyright © 2018 Elsevier Inc. All rights reserved. 19  Significance of Fluid Balance: Renin– Angiotensin II Pathway Blood (plasma) volume and intracellular fluid most important to keep in balance Kidneys are major regulator of water and sodium balance; maintain blood and perfusion pressure to all tissues/organs When the kidneys sense a low parameter, they secrete renin Renin–angiotensin II pathway is greatly stimulated with shock, or when stress response is stimulated 20  ACE Inhibitors Disrupt renin– With less Greater By locking Patients with angiotensin II angiotensin II, excretion of angiotensin II hypertension pathway by less water and receptors, often take reducing vasoconstricti sodium in blood ACE- inhibitor amount of on and urine, Monitor pressure medications ACE produced reduced Kidney lowers peripheral Function resistance ACE Inhibitor should not be given to patients with GFR 145 Skin flushing o Edema d Confusion Low grade fever i Polydipsia (excessive thirst) u Late serious signs: swollen dry tongue, GI= m Nausea and vomiting, Increased muscle tone Hyponatremia 5 heart: think tight and contracted ST elevation and peaked T waves Severe=Vfib or cardiac standstill Hypotension, bradycardia GI thing tight and contracted Diarrhea Hyperactive bowel sounds Neuro: tight and contracted Paralysis in extremities Increased DTR Profound weakness in muscles (heavy legs) Tx diuretics, IV sodium bicarbonate, IV calcium gluconate (potassium binders), dialysis  Potassium (+) Hypokalemia Hypokalemia (not enough potassium): Heart: low and slow Flat T waves, ST depression, prominent U wave Muscular low and slow decreased DTR muscle cramping Flaccid paralysis GI low and slow decreased motility, hypo bowel sounds constipation abdominal distention paralytic ileus=lead to SBO, small bowel obstruction an Emergency Tx replace with potassium: oral supplement or IV (must dilute IV Potassium and infuse slowly due to irritation to vein and burning. Never PUSH!  Calcium Normal level: 9.0 to 10.5 mg/dL Absorption requires active form of vitamin D Hypercalcemia Hypocalcemia >10.5