Fluids and Electrolytes Chapter 6 PDF

Fluids and Electrolytes CHAPTER 06 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 1 OBJECTIVES • Describe the extracellular and intracellular fluid compartment • Describe the composition of the extracellular and intracellular body fluid compartments • Discuss...

Fluids and Electrolytes CHAPTER 06 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 1 OBJECTIVES • Describe the extracellular and intracellular fluid compartment • Describe the composition of the extracellular and intracellular body fluid compartments • Discuss the mechanisms of fluid transport and fluid balance. • Id the causes, signs and symptoms and treatment of fluid imbalances • Describe the major function of all of the major electrolyte - Na++, K+, Ca++, Mg++, and chloride. Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 2 OBJECTIVES (cont’d) • Id the causes and signs and symptoms, and treatment of electrolyte imbalances. • List data to be collected in assessing fluid and electrolyte status • Discuss the medical treatment and nursing management of persons with fluid and electrolyte imbalances’ • Explain why older persons are at increased risk for fluid and electrolyte imbalances • Id the major causes of each acid-base imbalance. • List the four types of acid base imbalances • Explain the management of acid base imbalances Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 3 Know your key terms • Can you overdose on potassium? • Can potassium be given IV push? • Why is the potassium the most important lyte? • What is considered: • hyponatremia ? • Hypocalcemia? • Hypokalemia? • What is the significance of a potassium > 7.0 • What is the significance of a potassium < 3.0 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 4 Need to know lab values • SERUM ELECTROLYTES: • Sodium (Na+): 135-145 mEq/L • Potassium (K+): 3.5 -5.0 mEq/L • Calcium (Ca++): 9.0-10.5 mg/dL • Magnesium (Mg++): 1.3 – 2.1 mEq/L • Phosphorus (PO4): 3.0 – 4.5 mg/dL • Chloride (Cl): 98 -106 mEq/L Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 5 Need to know lab values • SERUM ELECTROLYTES: • Sodium (Na+): 136-145 mEq/L • Potassium (K+): 3.5 -5.0 mEq/L • Calcium (Ca++): 8.4-10.2 mg/dL • Magnesium (Mg++): 1.5 – 2.0 mEq/L • Phosphorus (PO4): 3.0 – 4.5 mg/dL • Chloride (Cl): 95 -105 mEq/L Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 6 Hypovolemia due to dehydration • As you are getting dehydrated • Fluid is lost from the blood (low volume = low B/P) • Blood becomes more osmotic (concentrated or thicker) • The BODY senses it: • If you don’t replace the fluid • it starts to draw fluid from the tissues (EC compartment) • If you still don’t replace the fluid • the tissues become more concentrated than the cells • the cells sense it and start to lend fluid to equalize the EC compartment concentration leading to cellular dehydration • If nothing is done cells become dehydrated: • The shifting is all done towards the blood volume to try to save us or we will die • Called a compensatory mechanism (survival mechanism) and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. • Which Elsevier cellsitems are the most important? 7 Fluid and Electrolytes: Illustration • Body contains fluid compartments: • Fluid travels back and forth between these compartments • Every choice you make about fluids you drink has a consequence • Blood PH 7.35-7.45 (small margin of error) • Body fluids affect blood PH (correct PH is vital to survival) • Theater: • Popcorn • Pickles • Coke • Our body has to continuously adjust the Amt. of fluid between these compartments • Diseases/conditions affect fluid/lyte balances • Nurses must have a basic understanding of Fluid’s & Lytes to help: • Maintain • Detect Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 8 Homeostasis PAGE 82 • Defined as: • Is the process of Maintaining relatively constant conditions in fluid compartments of the body • To maintain internal balance: • body must be able to regulate fluids • 50 -60% of the body is made up of H2O • All organs and structures of the body are involved in homeostasis: • Delivery of O2, glucose, to the cells • Removal of Co2, and waste products from the cells • When the body cannot maintain homeostasis- we get sick Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 9 Body Fluid Compartments • Body Fluids are found IC or EC • Intracellular fluid • Fluid within a cell • Most of body’s fluids found within the cell • Extracellular fluid • Fluid outside the cell can be found in the: • Intravascular fluid compartment( IV compartment) • In blood vessels in the form of plasma or serum • Interstitial fluid (IS): • fluid surrounding cells, includes: • lymph • Digestive secretions • Cerebrospinal fluid • EC fluid transports nutrients/wastes Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 10 Table 06.1 (pg. 83 • Distribution of fluid: • Women have more fat, (some): • Less water content (fat carries less water) (54% water) • Men tend to have more muscle (lean) (some): • Have More water content (60% water) • Infants have a higher percent of total body water: • 75% total water content • Dehydrate easier • Smaller bodies • If child has diarrhea and vomiting (spells trouble) • Fever and milk (milk raises fever, increases phlegm) •Elsevier Vomiting and milk ( rest period in between) items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 11 • Electroyte Composition: Table 6.2 page 83 Water • 50-60% • Solutes: (particles in the water) • Electrolytes (carry a charge) • Sodium Na+ • Potassium K+ • Chloride Cl- • Calcium ca++ • Magnesium mg+ • Non-electrolytes: • Urea Creatinine • Protein bilirubin • Glucose Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 12 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 13 Electrolytes (page 83) • Electrolytes are dissolved substances in body fluid: • Electrolytes carry an electrical charge when dissolved in water • ie: sodium, potassium, calcium, chloride, bicarbonate, and magnesium • Maintain balance between positive and negative charges • For every positively charged cation, there is a negatively charged anion • Cations and anions combine to balance one another • There has to be a balance between Cations and Anions: • to have homeostasis • Levels of electrolytes are measured in mEq/L • Lytes: can move from one fluid compartment to another • Normal levels be in the two compartments Elsevier items andwill derived itemsdifferent © 2007 by Saunders, an imprint of Elsevier, Inc. 14 Electrolytes : page 83 • Sodium (Na): (Neuro-muscular activity) • Most abundant electrolyte • primary electrolyte in extracellular fluid (EC) • Major role is in regulating: • body fluid volumes, • muscular activity, • nerve impulse conduction, • and acid-base balance • Remember: • water goes where sodium is (water follows sodium) • Patients with HYPERNATREMIA: retain water (edema) • Salt gets taken away from the diet • Meds can be given to rid of excess sodium (Lasix: diuretic) Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 15 Potassium • Potassium (K+) (Cardiac Conductivity) • • • • • • Found mainly in the intracellular fluid: (inside the cell) Is major intracellular cation (98-99%) Maintains fluid osmolality and volume within the cell Essential for normal membrane excitability: Important for transmitting nerve impulses Needed for: • protein synthesis • Synthesis and breakdown of glycogen, • maintain plasma acid-base balance • Single most important electrolyte of the body • Low K+ Leads to cardiac irregularities (R on T phenomenon) • Death by chemicals or by electrocution • Babies: No “K+” before “P” = • the pt will become severely hyperkalemic • you will kill the pt’s kidneys, Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 16 Potassium Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 17 Potassium Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 18 Potassium Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 19 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 20 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 21 Important to know • K+ is for cardiac electro-conductivity • Na+ is for muscular activity & coordination • C++ is for muscle contraction & relaxation • Mg+ is for metabolism plays a role in other electrolytes • Chloride is for dehydration/fluids Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 22 Electrolytes • Chloride (Cl): • Extracellular anion • Bound with other ions, sodium or potassium • Regulates osmotic pressure between fluid compartments • helps in regulating acid-base balance • Was not common to see hypo-chloremia • Now more common due to bottled water • Nsg Home pts frequently have chloride deficiency • what kind of water do we give them? Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 23 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 24 • Calcium (Ca++): Calcium • Usually combined with phosphorus • Forms mineral salts for bones and teeth • 99% concentrated in the bones and teeth; • 1% is in the extracellular fluid • Protein bound calcium (Stored) • Ionized calcium (circulating) (Chvostek's sign and trousseau's sign) • Mexican attack (L/T Alkalosis---lowers circulating (ionized) C+) • Ingested through the diet and absorbed through the intestine • Promotes transmission of nerve impulses; • helps regulate muscle contraction and relaxation, • plays a role in clotting. • Calcium and phosphorous have: • an inverse property or reciprocal relationship • Calcium is up/ phosphorous is down Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 25 Calcium (cont’d page 84) • The body is vigilant about calcium • If serum calcium levels falls • More calcium is absorbed in the GI tract • Kidneys will reabsorb more • Or pulled out of the bones • To restore blood levels Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 26 Chvostek’s sign Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 27 Chvostek's sign Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 28 Magnesium • Magnesium (Mg2+) (2rd most abundant lyte to K+) • 50% to 60% found in the bone, • 39% to 49% in the intracellular fluid, • 1% in the extracellular fluid • Responsible for : • metabolism of carbohydrates and proteins, • storage and use of intracellular energy, and neural transmission • Important in heart, nerve, and muscle function • Excreted thru the kidneys • Rate of excretion is controlled by : • sodium and calcium excretion • EC fluid volume • Parathyroid hormone • Mag: keeps potassium in the body Elseviercheck items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. • If K+ is low Mag+ level 29 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 30 Solutes: Non-Electorlytes • Non-electrolytes • Substances dissolved in the body fluids include: • Urea, • protein, • glucose, • Creatinine, • bilirubin • These solutes do not carry an electrical charge • Very important diagnostically • Measured in mg/dL Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 31 Transport of Water and Electrolytes • Membranes • Selectively permeable membranes • Separate fluid compartments • control movement of water and certain solutes • Maintain unique composition of each compartment of the body while allowing transport of nutrients and wastes to and from cells • Some solutes cross membranes more easily than others • The larger the molecule, the slower it will travel Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 32 Transport Processes0923 • Diffusion • The random movement of particles in all directions Natural tendency: - a substance moves from an area of high concentration to an area of lower concentration - EX: 02 moves from alveoli to capillary : alveoli (O2 hi conc) to capillaries (O2 lo conc) & transported to the body • Facilitated diffusion : • A carrier protein transports the molecules through membranes • toward an area of lower concentration Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 33 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 34 Transport Processes pg. 84 • Active transport: • Requires a carrier protein • Transports substances from an area of equal or greater concentration • Electrolytes: glucose, sodium, potassium are actively transported across cell membranes • EX: sodium pump: • Sodium concentration is greater outside the cell • When the sodium is inside the cell, active transport is needed to pump the Na+ out of the cell into an area of higher concentration Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 35 Transport Processes • Filtration: • Transfer of water and solutes through a membrane from an area of high pressure to an area of low pressure • AKA: Hydrostatic pressure • A combination of pressures of: • the force of gravity on the fluid • the pumping action of the heart • Needed to: • Move fluid out of capillaries into tissues • Filter plasma through the kidneys • B/P Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 36 Transport Processes • The movement of water and solutes between intracellular & extracellular compartments • AKA – fluid shifts • Osmosis: • Movement across a membrane from: • a less concentrated to a more concentrated solution • Involves movement of water only: • sometimes force of movement across membrane carries solutes along • If a fluid compartment has less water and more sodium: • water from another compartment moves to the more concentrated compartment by osmosis • to create a better fluid balance • Wherever Na+ goes water goes Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 37 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 38 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 39 Osmolality • Concentration of solution determined by number of dissolved particles per kg water • Hi osmolality = very concentrated • Lo osmolality = dilute • The more water a solution has, the less concentrated • Osmolality: • Controls water movement and distribution by : • regulating the concentration of fluid in each body fluid compartment • The osmolality of intracellular fluid and extracellular fluid tends to equalize because of the constant shifting of water Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 40 Osmolality • Changes in osmolality of ICF affects the osmolality of ECF, and vice versa • The osmolality of IC fluid is maintained by K+ • The osmolality of EC fluid is maintained by Na+ • Note : osmolality is a term referring to concentration of particles in water • Blood • Urine Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 41 Regulatory Mechanisms Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 42 Kidneys pg 195 • Main regulators of fluid balance adjustments • Adjusts fluid: • Fluid volume • Distribution • composition • Adjustments are made by: • Kidney • Circulatory system • Triggered by: sympathetic Nervous system, hormones and thirst center. Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 43 Kidneys pg 195 • Main regulator of fluid balance: • Controls EC fluid by adjusting: • • • • • Concentration of electrolytes Osmolality of body fluid Volume of EC fluid Blood volume PH • Controlled by hormones • Nephron: • The functioning unit of the kidney (works by filtration) • Glomerulus is the filtering portion of the Nephron, • The tubules are responsible for secretion and reabsorbtion Nephrons: conduct work of the kidney through filtration, re-absorption, and secretion Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 44 Kidneys • Filtration primary function of the Nephron: • About 20% of plasma filtered into Glomerulus capsule • Most remaining plasma leaves kidney through the renal vein • Filtrate (the fluid that does not leave the kidney) • then moves through the tubules, • where it is transformed into urine by: • tubular reabsorption and secretion Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 45 Kidneys • Tubular reabsorption (a secondary filtering) • Tubules will select what will be excreted • Most of the glomerular filtrate is returned to the circulation as needed • Water and selected solutes move from the tubules into the capillaries • Remain in tubules for excretion, • most water and sodium is reabsorbed into the bloodstream • Tubular reabsorption: • Adjusts volume • Adjusts what will be excreted or kept • Prevents excessive fluid loss through the kidneys Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 46 Kidneys • Tubular secretion • The last phase in the work of the kidneys • Filtrate turns into urine • Various substances are excreted • drugs, hydrogen ions, • potassium ions, Creatinine, • Histamine, other waste products • This Process: • eliminates some excess substances to maintain fluid and electrolyte balance, • as well as metabolic waste products Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 47 Hormones • Hormones that affect fluid volume • Renin : • Hormone secreted when blood volume or B/P drops • Renin goes to liver: • Liver releases angiotensin I • Angiotensin I • goes to the lungs and converted to angiotensin II • Angiotensin II (very powerful vasoconstrictor) • Starts to constrict blood vessels to bring up B/P • Angiotensin II also releases Aldosterone by adrenals Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 48 Hormones • Aldosterone: • Acts on kidney tubules • increases reabsorption of sodium • decreases reabsorption of potassium (excretes K+) • Because Sodium retention causes water retention, • Remember H20 follows Na+ • Aldosterone acts as a volume regulator • Aldosterone can be triggered by: • Hi K+ levels • Lo sodium levels Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 49 Hormones • Antidiuretic hormone (ADH) • Produced by hypothalamus, • triggers the Pituitary to release ADH into the blood stream • ADH Causes kidneys to reabsorb more water, • Less water is excreted (urine is more concentrated) • Also In increase in blood osmolality stimulates ADH release • Other factors that trigger release of ADH: • Stress • Hypotension • Pain • Surgery • meds Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 50 Hormones • Atrial natriuretic factor (ANF) • Hormone released by the atria • Made in response to stretching of the atria by increased blood volume • Fluid overload • Stimulates excretion of : • sodium and water by the kidneys, • decreased synthesis of Renin, • decreased release of Aldosterone, • induces vasodilation • Reduces blood volume • lowers blood pressure Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 51 Thirst (pg. 85) • Regulates fluid intake • Increased plasma osmolality (concentrated blood/dehydration) • stimulates osmoreceptors in the hypothalamus to trigger the sensation of thirst • Hi sodium and less water in the body make a person thirsty • Person then drinks more water; • kidneys will conserve water until osmolality returns to normal Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 52 Figure 14-1 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 53 Fluid Gains and Losses • In healthy adult, • 24-hour fluid I&O approximately equal • Fluids gained : • by drinking and eating and • Fluids lost • through the kidneys, skin, lungs, and GI tract • The usual adult urine volume: • is between 1 and 2 L/day, or 1 ml/kg of body weight per hour • In kidneys, • water loss varies: • with the amount of solute excreted • And with the level of Antidiuretic hormone circulating Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 54 Fluid Gains and Losses • Insensible losses: • Losses through the: • skin occur by sweating • lungs by evaporation at 300 to 400 ml/day • GI tract, the usual loss of fluid is about 100 to 200 ml/day Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 55 Age-Related Changes Affecting Fluid Balance • Aging kidney : • slower to adjust to changes in acid-base, fluid, and electrolyte balances • Older adult : • has a reduced sense of thirst • may be in a state of chronic dehydration • Total body water declines with age; • greatest loss is from the intracellular fluid compartment • Cellular dehydration – “why is grandpa acting weird?” Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 56 Age-Related Changes Affecting Fluid Balance • s/s of fluid imbalances in the elderly: • Disorientation • Confusion • Constip • Falls (postural hypotension) • Hx of cardiac or renal insufficiency • Chronic conditions affect mental status and mobility • Acute fluid deficits R/T: • Trauma NPO status • INFXN Meds • Fever Flu • Skin turgor – sternum/forehead Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 57 Age-Related Changes Affecting Fluid Balance • Limited reserves to maintain fluid balance when abnormal losses happen • Anti-hypertensive's, diuretics, and antacids can also contribute to imbalances • Unless contraindicated, • fluid requirements for older adults, • based on ideal body weight, are 30 ml/kg for ages 55 to 65 25 ml/kg 65 years and older Review figure 14-1 regulation of body fluid volume Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 58 Assessment of Fluid and Electrolyte Balance • Health history • Does the pt. have conditions that contribute to fluid or electrolyte imbalances • Vomiting, diarrhea, • diabetes, Salicylate poisoning, • congestive heart failure, • ulcerative colitis, kidney diseases, burns, cerebral injuries, hormonal imbalances; • On drugs: diuretics and cathartics; • DM Stroke or trauma • medical interventions: such as gastric suctioning • Complaints of : • fatigue, palpitations, dizziness, edema, • muscle weakness or cramps, Dyspnea, • confusion mayitems be© 2007 associated withof Elsevier, fluidInc. imbalances Elsevier items and derived by Saunders, an imprint 59 Assessment of Fluid and Electrolyte Balance • Vital signs • Pulse , respiration, temperature, and blood pressure • may point towards changes in fluid and electrolyte balance. • Fever : • can be associated with fluid volume excess or deficit. • Pulse rate and quality: • may change in response to blood volume alterations; • electrolyte affect heart rate and rhythm. • H/R goes up with low volume (comp mech) • Blood pressure: • is directly related to blood volume. • Respirations are minimally affected by electrolyte changes. • Will beElsevier affected by excess fluid vol, heart failure, pulmonary edema items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 60 Assessment of Fluid and Electrolyte Balance • Intake and output • Accurate I & O • All fluids entering or leaving documented • A changing urine output • reflect attempts by the kidneys to maintain or restore balance, • reflect a problem that causes fluid disturbances • Low U/O- dehydration • Hi U/O – volume excess (30cc/hr or 1 mg/kg) • Urine color, give clues to fluid balance • Clear, pale urine reflects the excretion of excess water, • Darker, concentrated urine indicates the kidneys are retaining water • Body wt: 1 liter of fluid = 2.2 lbs • Pt mayElsevier accumulate 10 lbs of fluid before pitting edema is noticeable items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 61 Assessment of Fluid and Electrolyte Balance • Skin • Characteristics • Moisture, turgor, and temperature reflect fluid balance. • Dry, flushed skin—dehydration. • Pale, cool, clammy skin—severe fluid volume deficit that occurs with shock. • Moist, edematous tissue seen with excess fluid volume • Facial characteristics • Severely dehydrated patient : • has a pinched, drawn facial expression. • Soft eyeballs and sunken eyes = severely deficient fluid volume. • Puffy eyelids and fuller cheeks = excess fluid volume • Really need labs to verify Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 62 Assessment of Fluid and Electrolyte Balance • Skin turgor • • • • pinching the skin over the sternum, the inner aspects of the thighs, forehead In dehydration, skin flattens more slowly after the pinch is released (+ tenting) • Edema: • Reflects water and sodium retention, • R/T-excessive reabsorption /inadequate secretion of sodium, • Seen with kidney failure • Pitting depression remains in the tissue after pressure is applied with a fingertip (4+ point scale) Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 63 Assessment of Fluid and Electrolyte Balance • Mucous membranes • Tongue turgor: • In a healthy person: • tongue has one longitudinal furrow. • Fluid volume deficit: additional longitudinal furrows, • tongue is smaller. • Sodium excess -tongue looks red and swollen. • Moisture of the oral cavity • A dry mouth : • R/T: deficient fluid volume / oral breathing. Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 64 Assessment of Fluid and Electrolyte Balance • Mucous membranes • Veins • JVD: • Excess fluid volume: • HOB elevated 30 – 45 degrees • JVD is (+) if visible > 3cm above the sternal angle • Deficient fluid volume: • Jugular veins will be flat or not visibly distended • veins in the hands can suggest either a fluid volume deficit or excess. • Hand veins: • Raise the hand: note how long it takes for veins to empty • Usually 3-5 secs, > fluid volume excess • Place hand in dependent position: Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 65 TEST # 1 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 66 Diagnostic Tests and Procedures • Urine studies: • Urine pH : kidney function (4.5 – 8.0) • Determines if kidney’s respond appropriately to metabolic acidbase imbalances • Fresh urine is > acidic early am • Urine more alkalotic after eating • Diet affects PH: fruits/veggies– alkaline meat: acidic • If urine has to go to lab - >1-2 hours (frig) (>four hrs = alkaline) • Urine specific gravity • Norm: 1.016 – 1.022 • A measure of urine concentration, good indicator of fluid balance • Hi - concentrated – def fluid vol • Low – excess fluid vol • Also used to asses renal function Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 67 Diagnostic Tests and Procedures • Urine studies: • Osmolality : measures renal function • Done with specific gravity • Measures the number of dissolved particles in a solution • More accurate measurement of kidney’s ability to concentrate urine • Dilute: fluid excess or kidneys cant concentrate urine • In aging renal failure, the urine will be concentrated Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 68 Diagnostic Tests and Procedures • Urine Creatinine clearance tests • Detect glomerular damage in the kidney • A 24-hour specimen is required • Know how to start the test and how to maintain • Restrictions (exercise, coffee, protein, tea, colas) • Results higher in males vs females (muscle mass based) • Urine sodium: diagnostic for: • Sodium intake and fluid volume status • Higher the Na+ intake the higher the number • With good GFR • Na+ increases during the day • In Na+ Elsevier restriction urine sodium will be low items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 69 Diagnostic Tests and Procedures • Urine potassium • A measure of renal tubular function • 24 hr urine collection • Excretion is higher during the noc • Normal levels are 25-125 mEq/24 hours Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 70 Diagnostic Tests and Procedures • Blood studies • Serum hematocrit • Percentage blood volume composed of red blood cells • Hi HCT = deficient fluid vol – dehydration (bld concentrated) • Low HCT = excess fluid vol R/T dilution • Levels different in males and females • Serum Creatinine • A metabolic waste product • Indicator of renal function (hi levels = bad kidneys • 0.6 – 1.1 (very small # - any changes are important) • Blood urea nitrogen (BUN) • A measure of renal function/age related • Increases with dehydration or deficient fluid vol • Low = fluid vol overload Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 71 Diagnostic Tests and Procedures • Serum osmolality: • Measures blood concentration • Hi osmo – R/T deficient fluid vol • Low osmo R/t fluid excess • Serum albumin • A plasma protein that helps maintain blood volume • creates colloid osmotic pressure • Low albumin – leads to fluid shift into IS compartment • L/T low blood volume and IS edema • Serum electrolytes • Sodium, potassium, chloride, and calcium Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 72 Fluid Imbalances pg 201 • Deficient fluid volume • Less water than normal in the body • 2 types: • Isotonic extracellular fluid deficit • Hypovolemia • Hypertonic extracellular fluid deficit • Dehydration • Causes: • - Decreased intake, abnormal fluid losses, or both loss of water from excessive bleeding, severe vomiting/diarrhea, severe burns Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 73 • s/s: • R/T how fast deficient volume develops • Gradual loss is insidious • Sudden: • Body compensates: decreased U/O • Tachycardia • Hypotension R/T low blood volume • Txtmt: • Depends on causes and s/s Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 74 • 1123 stopped here Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 75 Deficient fluid volume • Causes : • Inadequate fluid intake • Excess fluid loss • Hyperglycemia • Inadequate ADH production or effect (no renal response) • Fever • Altered cap permeability (sepsis) • S/S: • Alt LOC- cerebral perfusion constipation • Fatigue-tissue perfusion hyperthermia • All are a R/F injury Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 76 Deficient fluid volume • R/F impaired skin integrity -poor perfusion • Ineffective peripheral tissue perfusion • R/T – low CO due to low bld volume Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 77 Fluid Imbalances • Excess fluid volume • An increase in body water • Extracellular fluid excess • Isotonic fluid excess • Intracellular water excess • Hypotonic fluid excess • From renal or cardiac failure with retention of fluid, • increased production of Antidiuretic hormone or Aldosterone, L/T water retention • overload with isotonic IV fluids, or administration of dextrose 5% in water (D5W) after surgery or trauma Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 78 Fluid Imbalances • Excess fluid volume: • Body compensates for excess fluid vol • Increased renal filtration (Na+ and water excretion) • Decreased prod of ADH • S/S: • Depend on how fast it occurs • Sudden – L/T cardiac failure and Pulm edema • Fluid retention or excess or hypotonic fluid adm (Nsg) • Confusion • Act intolerance – impaired gas exchange due to Pulm edema • R/F injury- LOC • Impaired skin integrity – edema • Ineffective tissue perfusion R/T –low CO and heart failure Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 79 Electrolyte Imbalances EXAM II BEGINS HERE 0923 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 80 Hyponatremia • Lower than normal sodium in the blood serum • Can be actual deficiency of sodium or increase in body water that dilutes the sodium excessively • Assessment • Symptoms: headache, muscle weakness, fatigue, apathy, confusion, abdominal cramps, and orthostatic hypotension • Take blood pressures with the patient lying or sitting and then standing to determine if a significant drop Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 81 Hyponatremia • Causes: • Excess fluid intake without Na+ • Excess Na+ loss • NVD or diaphoresis with only water replacement • Use of distilled water as irrigant in body cavities • Excess ADH secretion: head injuries, severe stress • SIADH • CHF • Liver cirrhosis • Nephrotic syndrome • Na+ holds water in EC compartment Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 82 Hyponatremia • Causes: • Low serum sodium • Too much water in the EC compartment • Cells become more concentrated • Water will then go into the cells to even compartments out • Cell swells (cellular edema) • Brain cells are most sensitive • Fluid accumulates in the brain cells • Leads to ICP • c/o: H/A’s, weakness, fatigue, apathy, alt LOC, confusion, abd cramps, orthostatic hypotension • How doElsevier youitems doandorthostatic pressures? derived items © 2007blood by Saunders, an imprint of Elsevier, Inc. 83 Hyponatremia • Medical treatment • The usual treatment is restriction of fluids while the kidneys excrete excess water • Diuretic: Furosemide (Lasix) • Sodium replacement therapy • IVF- NS or L/R • Less than 115 sodium leads to convulsions an death • Hypertonic sodium chloride 3% • Nursing care • Administer prescribed medications and IV fluids • Measure fluid intake and output and assess mental status Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 84 Hyponatremia • Medical treatment • SIADH: • Find cause • Diuretics • Vaptans – block ADH • Demeclocycline • Lithium • Urea's – induce water loss without excess sodium loss • Ns for irrigations, give meds /IVF • I&O • Assess LOC • safety Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 85 Hypernatremia • Higher than normal concentration of sodium in the blood • • • • • • • Very serious imbalance; can lead to death if not corrected Occurs with: excessive loss of water (EC Fluid vol deficit) excessive retention of sodium Leads to fluid shifting L/T- water coming out of the cell – cellular dehydration Causes: • N/VD, profuse sweating, insufficient ADH Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 86 Hypernatremia • Signs and symptoms • • • • • • • • Thirst, flushed skin, dry mucous membranes, low urine output, restlessness, increased heart rate, convulsions, postural hypotension Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 87 Hypernatremia • Medical treatment • Oral or IV replacement of water to restore balance • A low-sodium diet often prescribed • Monitor IVF (especially in renal or cardiac pts) • Nursing Care: • Teach I/O & S/S • Diet restrict Hi sodium foods (see box 14-5) • Salt substitute is encouraged (know is K+ is restricted) Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 88 Hypokalemia • Low serum potassium • May result in gastrointestinal, renal, cardiovascular, and neurologic disturbances • Can cause abnormal, potentially fatal, heart rhythm • Signs and symptoms • Anorexia, abdominal distention, • vomiting, diarrhea • weakness, , muscle cramps, dysrythmias (abnormal cardiac rhythms), • postural hypotension, Dyspnea, shallow respirations, • confusion, and nocturia depression, Polyuria (excessive urination), • K+ wasting diuretics • corticosteroids Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 89 Hypokalemia • Medical treatment • Potassium replacement by the IV or oral route • Nursing care • Monitoring at-risk patients for decreased bowel sounds, • a weak and irregular pulse, • decreased reflexes, and decreased muscle tone • Cardiac monitors may be used to detect dysrythmias • Administer oral or IV potassium • Urine output should be no less than 30 ml/hr Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 90 Hypokalemia • Nsg care: • Monitor BS • Cardiac rhythm • If on dig – low K+ increases R/F dig toxicity • Adm K+ supplement with full glass of water • To decrease gastric irritation • Straw (stains teeth) • Enc fruits/veggies see chart 14-6 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 91 Hypokalemia • IV K+ • Always dilute • Never IV push • 10 mEq’s per hour • Central line if possible • Slow rate – rapid infusion leads to cardiac arrest • Cardiac monitor • Pump • Shake • Monitor IV site • U/O has to be > 30 cc/hr for 2 consecutive hrs Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. • No P ---NO k+ L/T Hyperkalemia, renal damage 92 Hyperkalemia • High serum potassium • Patients at risk: decreased renal function HD • Pts in metabolic acidosis, • Pts taking potassium supplements • A serious imbalance because of the potential for lifethreatening dysrythmias • Severe traumatic accidents (crush injuries) • Release a lot of K+ - crushed cells • Multiple blood transfusions of old blood • Consider Renal pts Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 93 Hyperkalemia • Signs and symptoms • Explosive diarrhea and vomiting; • muscle cramps and weakness, • paresthesias, • irritability, anxiety, • abdominal cramps, and • decreased urine output Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 94 Hyperkalemia • Medical treatment • Correct the underlying cause • Restrict potassium intake • Polystyrene Sulfonate (Kayexelate) • Intravenous calcium gluconate • Insulin • D50 • Sodium bicarbonate • Lasix • albuterol lokelma Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 95 Hyperkalemia 0923 • Nursing care • Patients with low urine output or those taking potassium-sparing diuretics must be monitored carefully for signs and symptoms • K+ sparing diuretics • Renal funx • Carefully monitor flow rate of IV fluids, • Monitor IV site • which should not exceed 10 mEq/hr through peripheral veins • Cardiac monitor • Screen the results of laboratory studies Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 96 Chloride Imbalance • Usually bound to other electrolytes; • Associated with other electrolyte imbalances • Hyper-chloremia • Usually found in metabolic acidosis • Hyper-chloremia • Usually occurs with sodium loss • Because it’s bound with sodium • Also seen persistent N/V • Uncontrolled DM Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 97 Calcium Imbalance • Controlled by parathyroid glands (PTH) • Hypocalcemia results from: • diarrhea, inadequate dietary intake of calcium or vitamin D, • multiple blood transfusions : • banked blood contains citrates that bind to calcium • In other some including hypoparathyroidism • LOW SERUM CA++ LEVELS : • L/T PTH SECRETION • PTH L/T CA++ RETENTION IN THE KIDNEYS • WITH PHOSPHOROUS EXCRETION BY THE KIDNEYS • THE GI TRACT INCREASES CA++ABSORPTION • BONE RELEASES CA++ FROM THE BONE Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 98 Calcium Imbalance • S/S of hypocalcemia: • Neuromuscular irritability, • Paresthesias: face and hands • Muscle cramps • Critical hypocalcemia: • Convulsions • Arrhythmias • Tetany • Stridor • Spasms Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 99 Calcium Imbalance • Hypercalcemia results from: • High calcium or vitamin D intake, • Hyperparathyroidism, • Immobility - causes release of calcium into the bloodstream (bone resorption) • Continuous hypercalcemia leads to: • Kidney stones • Calcium deposits in they eyes and circulatory system Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 100 Magnesium Imbalance • Hypomagnesaemia: • Causes: • decreased gastrointestinal absorption • excessive gastrointestinal loss, • usually from vomiting and diarrhea, • increased urinary loss (alcoholics) • Often associated with: • Hypokalemia (magnesium keeps potassium in the body) • Hypocalcemia Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 101 Magnesium Imbalance • Hyper-magnesemia: • excessive use of magnesium-containing meds • intravenous solutions in patients with renal failure • preeclampsia of pregnancy Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 102 Acid-Base Disturbances Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 103 Respiratory Acidosis • Respiratory system fails to eliminate the appropriate amount of carbon dioxide to maintain the normal acid-base balance • Caused by pneumonia, drug overdose, head injury, chest wall injury, obesity, asphyxiation, drowning, or acute respiratory failure • Medical treatment • Improve ventilation, which restores partial pressure of carbon dioxide in arterial blood (Paco2) to normal Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 104 Respiratory Acidosis • Nursing care • Assess Paco2 levels in the arterial blood • Observe for signs of respiratory distress: restlessness, anxiety, confusion, tachycardia • Intervention • Encourage fluid intake • Position patients with head elevated 30 degrees Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 105 Respiratory Alkalosis • Low Paco2 with a resultant rise in pH • Most common cause of respiratory alkalosis is hyperventilation • Medical treatment • Major goal of therapy: treat underlying cause of condition; sedation may be ordered for the anxious patient Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 106 Respiratory Alkalosis • Nursing care • Intervention • In addition to giving sedatives as ordered, reassure the patient to relieve anxiety • Encourage patient to breathe slowly, which will retain carbon dioxide in the body Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 107 Metabolic Acidosis • Body retains too many hydrogen ions or loses too many bicarbonate ions; with too much acid and too little base, blood pH falls • Causes are starvation, dehydration, diarrhea, shock, renal failure, and diabetic ketoacidosis • Signs and symptoms: changing levels of consciousness, headache, vomiting and diarrhea, anorexia, muscle weakness, cardiac dysrythmias • Medical treatment: treat the underlying disorder Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 108 Metabolic Acidosis • Nursing care • Assessment of the patient in metabolic acidosis should focus on vital signs, mental status, and neurologic status • Emergency measures to restore acid-base balance. Administer drugs and intravenous fluids as prescribed. Reassure and orient confused patients Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 109 Metabolic Alkalosis • Increase in bicarbonate levels or a loss of hydrogen ions • Loss of hydrogen ions may be from prolonged Nasogastric suctioning, excessive vomiting, diuretics, and electrolyte disturbances • Signs and symptoms: headache; irritability; lethargy; changes in level of consciousness; confusion; changes in heart rate; slow, shallow respirations with periods of apnea; nausea and vomiting; hyperactive reflexes; and numbness of the extremities Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 110 Metabolic Alkalosis • Medical treatment • Depends on the underlying cause and severity of the condition Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 111 Metabolic Alkalosis • Nursing care • Assessment • Take vital signs and daily weight; monitor heart rate, respirations, and fluid gains and losses • Keep accurate intake and output records, including the amount of fluid removed by suction • Assess motor function and sensation in the extremities; monitor laboratory values, especially pH and serum bicarbonate levels Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 112 Metabolic Alkalosis • Intervention • To prevent metabolic alkalosis, use isotonic saline solutions rather than water for irrigating Nasogastric tubes because the use of water for irrigation can result in a loss of electrolytes • Provide reassurance and comfort measures to promote safety and well-being Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 113