Week 4_GI_Part 1_Fluids and Electrolytes PDF

Living with Digestive and Elimination Challenges Nausea and Vomiting, Constipation and Diarrhea, AND Fluid and Electrolytes Part 1 – Fluids and Electrolytes Lewis (2019)Chapter 19(p. 352-382), Chapter 44(p.1013-1017) Chapter...

Living with Digestive and Elimination Challenges Nausea and Vomiting, Constipation and Diarrhea, AND Fluid and Electrolytes Part 1 – Fluids and Electrolytes Lewis (2019)Chapter 19(p. 352-382), Chapter 44(p.1013-1017) Chapter 45 (p. 1056-1061; 1061 – 1063) Prepared by: Professor Hyacinth Jackson & Dr. Rupi Khaira, RN 1 Fluids and Volume AND Electrolytes FLUIDS AND ELECTROLYTES 2  Fluids and Electrolytes Learning Objectives 1. Describe the etiology, the complications, the collaborative care, and the nursing management of fluid and electrolyte imbalances. 2. Determine the signs and symptoms, and complications of the following disorders: – Fluid volume deficit; Fluid volume excess; Hypo/hypernatremia; Hypo/hyperkalemia; Hypo/hypercalcemia 3. Examine the diagnostic tests and relating these to the purpose, nursing care, normal values and the interpretation of abnormal values. 4. Identify priority nursing problems associated with each of the disorders listed in the Course Outline. 5. Integrate the role of multidisciplinary team members when providing care to a client with fluid and electrolyte imbalances. 6. Discuss the role of CCAC for the provision of client care in the community setting. 3  Homeostasis State of equilibrium in body Naturally maintained by adaptive responses Body fluids and electrolytes are maintained within narrow limits 4  Why nurses need to understand fluid and electrolytes? Important to anticipate the potential for alterations in fluid and electrolyte balance associated with certain disorders and medical therapies, to recognize the signs and symptoms of imbalances, and to intervene with the appropriate action. 5 FLUIDS AND VOLUME 6  Composition of body fluids (water content of body) 60% of body weight in adult 45% to 55% in older adults 70% to 80% in infants – Varies with gender, body mass, and age 7 Changes in Water Content with Age 8  Fluid Compartments Intracellular fluid (ICF): Located within cells 42% of body weight Extracellular fluid (ECF)-found outside cell – Intravascular (plasma) – Interstitial – lymph – Transcellular 30% of body weight 9  Gerontologic Considerations Structural changes in kidneys decrease ability to conserve water Hormonal changes lead to decrease in ADH and ANP Loss of subcutaneous tissue leads to increased loss of moisture Reduced thirst mechanism results in decreased fluid intake Nurse must assess for these changes and implement treatment accordingly 10  Fluid and Electrolyte Imbalances Common in most clients with illness – Directly caused by illness or disease (e.g., burns or heart failure) – Result of therapeutic measures (IV fluid replacement or diuretics) 11  Fluid volume deficit (hypovolemia) Abnormal loss of normal body fluids (diarrhea, fistula drainage, hemorrhage, NG drainage, vomiting, excessive diuresis), inadequate intake , or plasma-to-interstitial fluid shift Dehydration refers to loss of pure water alone without corresponding loss of sodium. Fluid volume deficit includes accompanying electrolyte disorder. 12  Fluid Volume deficit (hypovolemia) Clinical Manifestations Decreased urine output Hypotension Concentrated urine Thirst (urinalysis) Increased pulse rate Output greater than intake Decreased skin turgor Sudden weight loss Dry mucous membranes Decreased venous filling Weakness Hemoconcentration Possible weight gain (Hemoglobin and Hct Changes in mental status elevated b/c more concentration) BUN and creatinine Increased serum sodium elevated Decreased cardiac output Cool and clammy 13  Fluid volume deficit Volume decreases during dehydration. – This causes Na2+ in the blood to increase (more concentrated). – The hematocrit (Hct) will also rise above 45% because of the loss of fluid and higher concentration. Hct is a ratio of the volume of RBC : to whole blood (RBCs, WBC’s, and platelets). Approx 37-49% So if RBC’s increase, Hct increases. It is a direct relationship.  Nursing Management Nursing Problems Hypovolemia – Deficient fluid volume – Decreased cardiac output – Potential complication: hypovolemic shock Can result in drowsiness, lethargy, confusion p. 322; 15  Nursing Management Nursing Implementation So how do we treat hypovolemia? – Replace lost fluids with fluids of similar concentration – Restore blood volume and BP – Usually isotonic fluid such as normal saline or lactated Ringer’s solutions are given IV 16  Fluid volume excess (hypervolemia) Excess of isotonic fluid (water and sodium) in the extracellular compartment. Elderly and those with renal and cardiac failure are at risk  Fluid volume excess (hypervolemia) Causes: – Results from retention of excessive intake of fluid or sodium or shift in fluid from interstitial to intravascular space. – Excessive intake of fluids: IV replacement treatment using N/S or lactated Ringer’s, blood or plasma, excessive salt intake – Fluid retention: renal failure, CHF, cirrhosis of the liver, steroid therapy 18  Fluid Volume Excess Clinical Manifestations Weight gain Increased blood pressure Edema Increased central venous Bounding pulses pressure (CVP) Shortness of breath; Increased pulmonary artery orthopnea; tachypneic pressure (PAP) Pulmonary congestion on x-ray Jugular vein distention Abnormal breath sounds: Change in mental status crackles (rales) (lethargy or confusion) Change in respiratory pattern Oliguria Third heart sound S3 Specific gravity changes Intake greater than output Azotemia Decreased hemoglobin or Change in electrolytes hematocrit Restlessness and anxiety 19  Nursing Management Nursing Problems Hypervolemia – Excess fluid volume – Ineffective airway clearance – Risk for impaired skin integrity – Disturbed body image – Potential complications: pulmonary edema, ascites Labs: Low Hct, normal serum Na, lower K+ and BUN 20  Nursing Management Nursing Implementation So how do we treat hypervolemia? – Restriction of sodium and fluid intake – Diuretics to promote fluid loss; morphine and nitroglycerine to relieve air hunger and dilate blood vessels; digoxin to strengthen the heart – Hemodialysis 21  Fluid volume excess (hypervolemia) Nursing tx: diuretics and fluid removal, fluid restrictions, restriction of sodium many be indicated if fluid excess leads to ascites or pleura effusion, an abdominal paracentesis or thoracentesis may be necessary. Hypervolemia: rate of IV infusion should be monitored carefully when large volumes of fluid or electrolytes are involved. Careful of pts with tube feedings and supplemental water. NG pts should not be allowed to drink water as in will increase the loss of electrolytes. Irrigate with isotonic saline solution, not water. Water caused diffusion of electrolytes into the gastric lumen from mucosal cells, electrolytes are then suctioned away. Pitting edema, 1+=slight, 2mm indentation, 4+=8mm 22  Nursing Management Nursing Implementation Overall: – I&O – Monitor cardiovascular changes – Assess respiratory status and monitor changes – Daily weights – Skin assessment 23  Fluid Volume Assessment Lab Values Lab Test Hypovolemia Hypervolemia Other factors influencing result BUN (blood urea nitrogen) Increases Decreases Low: inadequate dietary Reflects difference protein, severe liver between rates of urea failure synthesis in liver and its High: prerenal failure; excretion by the excessive protein intake, kidneys. (Urea is main end GI bleeding, catabolic product of protein state, steroid therapy catabolism). Creatinine will also rise in Normal 3.6-7.1 mmol/L severe hypovolemia. Creatinine (serum) ·Elevated when 50% or Product of muscle more of the nephrons are metabolism destroyed Male 53-106 Female 44-97 mcmol/L 24  Fluid Volume Assessment Lab Values Lab Test Hypovolemia Hypervolemia Significance Hematocrit Increases Decreases Low: anemia, hemorrhage with Measures portion of subsequent hemodilution blood volume occupied (occurring after 12-24 hours by RBCs approx) Female: 0.370-0.460 High: chronic hypoxia (chronic Male: 0.420-0.520 pulmonary disease, living at high altitude, smoking ++, recent transfusion) Urine Specific Gravity High Low -Increases with any condition (S.G.) causing hypoperfusion of Measures degree of kidneys leading to oliguria, i.e., concentration of urine; dehydration, shock. determined by number -Decreases when renal tubules and weight of solute lose their ability to reabsorb particles in urine. water and concentrate urine as 1.010 to 1.030 in early pyelonephritis.  Fluid Volume Assessment Lab Values Lab Test Hypovolemia Hypervolemia Other factors influencing result Serum Albumin High Low Low: malnutrition, 35 to 55 g/L liver failure High: rare except in hemoconcentration Serum Sodium Typically High but May be low, normal Serum sodium Na 135-145 mEq/L can be normal or low or high generally reflects fluid status and not sodium balance Urine osmolality High Low Low: diuresis, hyponatremia, sickle cell anemia High: SIADH  Fluids and Electrolytes Watch the YouTube Video: https://www.youtube.com/watch?v=eQIVK47wJ us ELECTROLYTES 28  Electrolytes Substances whose molecules dissociate into ions (charged particles) when placed into water – Cations: positively charged (Na, K, Ca2, Mg2) – Anions: negatively charged (HCO3, CL, PO4 3) – Measurement; International standard is millimoles per liter (mmol/L), U.S. uses milliequivalent (mEq) – Ions combine mEq for mEq 29  Electrolyte Composition ICF – Prevalent cation is K+ – Prevalent anion is PO43- ECF – Prevalent cation is Na+ – Prevalent anion is Cl- 30 SODIUM (NA2+)  Sodium (Na2+) aka SALT 3 functions include to maintain: – Blood pressure – Blood volume – PH balance  Sodium (Na+) Serum levels; 135-145mEq/L Responsible for water balance and determination of plasma osmolality – Osmolality is a measure of the number of dissolved particles in a fluid. Cation+,plays a major role in – ECF volume and concentration (movement of Cl- closely associated with Na+) Imbalances can exist in different volume states: euvolemia (normal volume), hypovolemia (low volume), hypervolemia (increased volume) 33  Na+ (continued) – Generation and transmission of nerve impulses – Acid–base balance (combining HCO3 and CL to alter pH) – Impacted by hormonal control (aldosterone, ADH) Dietary level: current recommendation 500mg-2300mg/day, Western diet; 4000-6000mg/day!!! Primary source; table salt (NaCL) 34  Hypernatremia Elevated serum sodium occurring with water loss or sodium gain Causes hyperosmolality leading to cellular dehydration Primary protection is thirst from hypothalamus Sodium intake in excess of water intake can lead to hypernatremia Serum Na2+ level > 145mEq/L 35  Hypernatremia Big and Bloated Skin – Flush “red and rosy”….think of Santa Claus – Edema “waterbed skin” – Low grade fever Polydipsia: excess thirst (because of the excess salt in the body) Late and serious signs – Swollen dry tongue (red beefy) – GI: Nausea and vomiting – Increased muscle tone *NCLEX TIP*  Hypernatremia (cont’d) Manifestations – Thirst, lethargy, agitation, seizures, and coma – Skin would be rough and dry caused by “DRIED” out. Impaired LOC Produced by clinical states – Central or nephrogenic diabetes insipidus 37  Hypernatremia D : Dry mucous membranes; decreased urinary output, DTR increased R : Red flushed skin, restless, progressing to confusion I : Increased temp, increased urine concentration E: Elevated HR D : Decreased weight  Hypernatremia – Fluid Excess Fluid excess from Na+ retention can occur from excessive salt intake, increased renal retention, or Cushing’s syndrome. “EDEMA” – E : Edema (pitting) – D : Decrease in the Hct – E : Elevated weight – M : Mental status decreased (lethargic) – A : A flushing of the skin  Hypernatremia Does not matter if it is caused by fluid deficit or fluid excess from sodium retention, the nurse needs to “RESTRICT” R: restrict fluid intake if experiencing retention E : Evaluate for cerebral changes such as headaches, nausea, seizures S : Strict intake and output; seizure precautions T : The BP is elevated (fluid excess) R : review origin of hypernatremia I : If fluid deficit, administer Hypotonic IV fluids C : Check daily weights; neuro assessments T : The excess fluid may be removed with diuretics  Hyponatremia Results from loss of sodium-containing fluids or from water excess Manifestations – Confusion, nausea, vomiting, seizures, and coma Fluid restriction is often all that is needed to treat the problem For severe symptoms (seizures) – Small amounts of intravenous hypertonic saline solution (3 % NaCl) Serum Na2+ level < 135 mEq/L 41  Hyponatremia Depressed & Deflated Depends on the cause (too much or little fluid) 3 priorities to watch for: – Neuro: Seizures and coma – Heart: tachycardia and weak thready pulse – Respiratory failure/arrest (not breathing)  Hyponatremia vs Hypernatremia Both include neurological S+S/deficits – restlessness and fatigue – Abdominal cramping SEVERE SIGNS OF HYPERNATREMIA: – NAUSEA/VOMITING – RED BEEFY TONGUE – INCREASED MUSCLE TONE *NCLEX TIP*  Hyponatremia Can be caused by sodium loss from OR too much fluid retention Assessment: Na+ loss (“COLD”) – C : Cold and clammy skin, cramps in abdomen – O : Oliguria – L : LOC changes, confusion and seizures** – D : decreased BP, decreased muscle strength  Hyponatremia Too much fluid retention Assessment: Water excess (“HIGH”) – H : hypertension – I : Increase in muscle twitching and cramping; increase urine – G : Gain in weight – H : Headaches, confusion and seizure**  Hyponatremia Hyponatremia caused by sodium loss OR water excess, with both the neurological changes will be consistent SEIZURE precautions. Plus returning the level of sodium to the normal range. Central Pontine Myelinolysis: corrected the hyponatremia too fast Hyponatremia – Seizure precaution “SODIUM” – S : Seizure precautions! May administer IV hypertonic solution containing 3% NaCl – O : Occurs in diabetes acidosis, renal disease’ client’s NPO; perspiring; vomiting and diarrhea; – D : Deficit of sodium: 0.9% NaCl or 0.45% NaCl – I : If retaining fluids, restrict fluids; Irrigate NG tube with NS solution – U : Understand the cause of hyponatremia – M : Monitor BP, I & O; weight, skin turgor, neuro assessment, maintain fall precautions  Nursing Management Nursing Problems Hypernatremia – Risk for injury related to altered sensorium and seizures secondary to abnormal CNS function Hyponatremia – Risk for injury related to altered sensorium and decreased level of consciousness secondary to abnormal CNS function 48  Nursing Management Nursing Implementation I&O Monitor cardiovascular changes Assess respiratory status and monitor changes Daily weights Skin assessment 49  Nursing Management Nursing Implementation (cont’d) Neurological function (Recall Health assessment class) – LOC – PERLA – Voluntary movement of extremities – Muscle strength – Reflexes 50 POTASSIUM (K+)  Potassium Major cation of ICF Serum level: 3.5-5.0mEq/L Necessary for – Transmission and conduction of nerve and muscle impulses – Maintain heart and muscle contraction – Control via sodium-potassium pump (contained within cell membrane of all cells/utilizes ATP) – Inverse relationship between Na+ and K+ reabsorption in the kidney; factors that cause Na+ retention cause K+ loss in the urine. 52  Potassium Kidneys eliminate 90% of K+, thus if renal function impaired, toxic levels may be retained. Dietary level: 40-60mEq/day, Western diet inclusive of K+ salt substitutes may contain K+ K+ is crucial in the maintenance of cardiac rhythms/function And acid–base balance 53  Potassium Imbalances (cont’d) Factors causing potassium to move from the ECF to ICF: – Insulin – Alkalosis – β-adrenergic stimulation – Rapid cell building 54  Potassium Imbalances (cont’d) Factors causing potassium to move from ICF to ECF: – Acidosis – Trauma to cells – Exercise 55  Hyperkalemia K level > 5.0 meq/L; Critical Level >6.5mEq/L Just think about it as: – High = tight and crampy So as you relate this to the heart this = hyper heart as well!! What will you see? – ST elevation and peaked T waves – Severe = ventricle fibrillation or cardiac standstill – Hypotension and bradycardia (See next slide for visual ECG changes) Hyperkalemia  Hyperkalemia If K remains elevated the client is at risk of “DEATH” D : Dysrhythmias – Irregular rhythm, bradycardia E : ECG changes – Tall Peaked T waves A : Abd cramping; diarrhea T : The muscles twitch H : Hypotension, has irritability/restlessness  Hyperkalemia What about other areas of the body? – GI: it is also tight and contracted – Diarrhea – Hyperactive bowel sounds – Neuromuscular: also tight and contracted – Paralysis in extremities – Increased DTR (deep tendon reflexes) – high action and contraction – “Severe/profound” increased muscle weakness (feeling of heaviness) *NCLEX TIP: SEVERE/PROFOUND REFER TO LATE AND SERIOUS SIGNS = PRIORITY NURSING ACTION  Hyperkalemia High serum potassium caused by: – Massive intake – Impaired renal excretion (acute or chronic renal failure) – Shift from ICF to ECF (acidosis, tissue necrosis, GI hemorrhage, hemolysis) – Medications (eg. Potassium sparing diuretics, beta blockers, ACE inhibitors) Common in massive cell destruction – Burn, crush injury, or tumour lysis 61  Hyperkalemia Most common cause of hyperkalemia is renal failure, or massive intake of K+. Metabolic acidosis is associated with shift of potassium ions from ICF to ECF as hydrogen ions move into cell. Potassium sparing diuretics (aldactone) and ACE inhibitors may contribute to hyperkalemia. Both reduce the kidneys ability to excrete potassium, hence contribute to the development of hyperkalemia. 62  Hyperkalemia (cont’d) Clinical Manifestations – Weak or paralyzed skeletal muscles – Ventricular fibrillation or cardiac standstill – Abdominal cramping or diarrhea Lab values: Serum K+ levels > 5.0 mEq/L 63  Nursing Management: Hyperkalemia Nursing Problems Risk for injury related to lower extremity muscle weakness and seizures Potential complication: dysrhythmias – Monitor ECG changes 64  Nursing Management: Hyperkalemia Nursing Implementation So what to do for a high potassium level? Eliminate oral and parenteral K+ intake Increase elimination of K+ (loop diuretics, dialysis, Kayexalate - antidote) Force K from ECF to ICF by IV insulin or sodium bicarbonate (metabolic acidosis) Reverse membrane effects of elevated ECF potassium by administering calcium gluconate IV 65  Hyperkalemia: Nursing Interventions Organize nursing care for this imbalance by remembering “DROPS” D: Dysrhythmia, spiked or tall T wave (peaked), widened QRS, prolonged PR interval - monitor R: Review and monitor K+ levels ongoing O: Orders: Kayexalate or dextrose with regular insulin P: Provide potassium-restricted foods, Potassium loosing diuretics (Lasix) S: Stop infusion of Potassium; salt substitutes are not allowed  Hypokalemia Less than < 3.5 mEq/L; Critical level