Fluid and Electrolyte Disturbances PDF

Fluid and Electrolyte Disturbances Fluid Imbalances  Hypovolemia 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 Dehydration- loss of water...

Fluid and Electrolyte Disturbances Fluid Imbalances  Hypovolemia 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 Dehydration- loss of water ONLY  Hypovolemia Cause/s: ABNORMAL DECRESED FLUID LOSS INTAKE THIRD SPACING Vomiting Nausea Edema in burns Diarrhea Lack of access Ascites in liver GI suctioning to fluids dysfunction Profuse diaphoresis Other causes: Diabetes insipidus, adrenal insufficiency, hyperglycemia, hemorrhage, coma  Hypovolemia Clinical Manifestations “FEWCHART” F - Flat neck veins E - Eyes sunken W - Weight loss C - Concentrated urine (SG> 1.025, oliguria) H - Hypotension A - Anxiety R - Rapid, weak pulse; Respirations increased T - Temperature elevated  Hypovolemia Medical Management Fluid replacement therapy Mild- moderate Increase oral fluids Oral rehydration salts (e.g., Hydrite) Severe IV Therapy If with hypotension, give isotonic fluid Once normotensive, give hypotonic fluids  Hypovolemia Medical Management (cont’d) Antidiarrheals, if with diarrhea Loperamide (Diatabs) Antiemetics, if with nausea/vomiting Metoclopramide (Plasil)  Hypovolemia Nursing Management Monitor I&O and daily weights, as ordered Monitor vital signs; WOF for hypotension and tachycardia Monitor skin and tongue turgor Hypovolemia Poor skin turgor seen in hypovolemia  Hypovolemia Normal tongue appearance Dry tongue  Hypovolemia Nursing Management (cont’d) Encourage small, frequent sips of oral fluids; Consider likes and dislikes of patient Regulate IV fluid to prescribed rate Administer medications, as prescribed  Hypervolemia Hypervolemia refers to 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. Fluid overload  Hypervolemia Causes Heart failure Kidney injury Liver cirrhosis Excessive salt intake Excessive administration of sodium- containing fluids in patients with impaired regulatory mechanisms  Hypervolemia Clinical Manifestations Edema Distended neck veins Puffy eyelids Crackles Weight gain Hypertension Bounding pulse Tachypnea, dyspnea Increased urine output; dilute urine  Hypervolemia Medical Management Low sodium diet (mild restriction to as low as 250 mg/day) Diuretics Thiazide diuretics- mild to moderate hypervolemia Loop diuretics- severe hypervolemia Potassium supplementation, to prevent hypokalemia while on diuretics Dialysis for severe renal impairment  Hypervolemia Nursing Management Monitor I&O as ordered Weigh daily, WOF rapid weight gain (1kg= 1L of fluid) Monitor breath sounds, especially if with IV therapy Monitor for presence of edema Feet and ankles for ambulatory patients Sacral area for bed ridden patients  Hypervolemia Nursing Management (cont’d) Encourage bed rest – this favors diuresis Regulate IVF as prescribed Place on semi- Fowlers position if with dyspnea Reposition at regular intervals to prevent pressure ulcers Emphasize need to read food labels Instruct to avoid foods high in sodium Encourage use of seasoning substitutes such as lemon juice, onions, and garlics Electrolyte Imbalances  Sodium Most abundant electrolyte in the ECF ECF concentration: 135- 145 mEq/L Functions: Controls body water distribution Establishes the electrochemical state necessary for muscle contraction and nerve impulse transmission  Hyponatremia Serum sodium level < 135 mEq/L Causes: Vomiting, diarrhea, gastric suctioning Medications: diuretics, lithium, cisplatin, heparin, and NSAIDs Decreased aldosterone (Addison’s disease) Water intoxication CHF Chronic renal failure  Hyponatremia Hyponatremia develops when: There is too much water relative to the amount of sodium Too little sodium relative to the amount of water Hyponatremia  Hyponatremia Medical Management Sodium replacement Sodium-rich diet for those who can eat and drink NaCl tablets PLR or PNSS IV infusion, for those who cannot take sodium by mouth Water restriction Indicated for hyponatremic patients with normal or excess fluid volume Hypertonic saline solution Indicated for severe hyponatremia  Hyponatremia Medical Management Drug Therapy: AVP receptor antagonists “vaptans” MOA: act on AVP receptors in the renal tubules to promote aquaresis Conivaptan HCl (Vaprisol) IV- hospitalized patients with moderate to severe hyponatremia C/I: seizure, delirium, coma Tolvaptan (Samsca)- oral medication for clinically significant hypervolemic and euvolemic hyponatremia  Hyponatremia Nursing Management Monitor I&O and daily weights Monitor laboratory values Monitor the progression of manifestations For patients who are able to consume by mouth, encourage foods and fluids with high sodium content Broth made with one beef cube (900mg) 8 oz of tomato juice (700mg) Administer IV fluids, as prescribed  Hyponatremia Nursing Management (cont’d) WOF signs of circulatory overload: Cough, dyspnea, puffy eyelids, dependent edema, excessive weight gain in 24 hours, crackles) Institute safety precautions: Keep side rails up Supervised ambulation  Hypernatremia Serum Sodium Level > 145 mEq/L Causes: “MODEL” M - Medications, meals O - Osmotic diuretics D - Diabetes insipidus E - Excessive water loss L - Low water intake  Hypernatremia Clinical Manifestations Extreme thirst- first sign Dry, sticky mucous membranes Oliguria Firm, rubbery turgor Red, dry, swollen tongue Restlessness, tachycardia, fatigue Disorientation, hallucination  Hypernatremia Medical Management Safety Alert! Serum sodium correction should be done gradually Too rapid reduction in sodium level renders the plasma temporarily hypo-osmotic to the brain tissue  Hypernatremia Medical Management Treat underlying cause Sodium correction Hypotonic electrolyte solution- first line IV of choice: 0.3% NaCl Isotonic non saline solution- second line D5 W- indicated when water needs to be replaced without sodium  Hypernatremia Nursing Management Provide oral fluids at regular intervals Restrict sodium in diet, as prescribed Monitor behavioral changes Promote safety Monitor intake and output  Potassium Most abundant electrolyte in the ICF Normal serum concentration: 3.5 to 5 mEq/L Has an inverse relationship with sodium; direct relationship with magnesium Functions: Maintains ICF volume Neuromuscular excitability Regulates contraction and rhythm of heart  Hypokalemia Serum Potassium Level 5 mEq/L Less common than hypokalemia More life-threatening because cardiac arrest is more frequently associated with its occurrence  Hyperkalemia Causes: “CARED” C - Cellular movement of K+ from ICF to ECF A - Addison’s disease (hypoaldosteronism) R - Renal failure E - Excessive K+ intake D - Drugs (Spironolactone, ACE inhibitors, NSAIDs)  Hyperkalemia Potassium Neuromuscular irritability In hyperkalemia, “everything is high and fast”  Hyperkalemia Clinical Manifestations “MURDER” M – Muscle weakness (late sign) U – Unable to calm down (irritability, anxiety) R – Respiratory failure (sec. to muscle weakness) D – Decreasing cardiac contractility (tachycardia →bradycardia) E – Early sign: muscle twitch/cramps R – Rhythm abnormalities: Tall, peaked T waves and prolonged PR interval (most dangerous)  Hyperkalemia Medical Management Obtain ECG to detect changes Potassium restriction (diet and meds) Calcium gluconate IV Emergency management for extremely high K+ levels MOA: calcium antagonizes the action of hyperkalemia on the heart but does not lower serum K+ level S/E: hypotension, bradycardia  Hyperkalemia Medical Management (cont’d) Sodium polystyrene sulfonate (Kayexalate) Cation exchange resin Administer via PO or retention enema MOA: Increases fecal potassium excretion through binding of potassium in the lumen of the gastrointestinal tract. C/I: paralytic ileus  Hyperkalemia Medical Management (cont’d) Hyperkalemia protocol: Regular insulin (IV) + D50W: causes temporary shift of potassium into the cells Beta-2 agonist (Salbutamol) Nebulized MOA: moves potassium into cells S/E: tachycardia, chest discomfort Dialysis  Hyperkalemia Nursing Management Monitor I&O and closely monitor signs of muscle weakness and dysrhythmias Monitor vital signs, use apical pulse Administer medications, as prescribed Encourage patient to strictly adhere to potassium restriction.  Hyperkalemia Nursing Management: Avoid fruits and vegetables, legumes, whole-grain breads, lean meat, milk, eggs, coffee, tea, and cocoa Caution patients to use salt substitutes sparingly if they are taking other supplementary forms of potassium or potassium- sparing diuretics  Calcium Located primarily in the bones and teeth; the rest can be found circulating in the serum Functions: Bone mineralization Stabilizes the resting membrane potential of neurons thereby preventing their spontaneous activation Regulation of muscle contraction – causes actin and myosin filaments to slide into each other Cardiac contractility and conduction  Calcium Types of Calcium: Ionized calcium Protein-bound calcium Calcium complexed to anions Normal Values: Ionized calcium: 4.5 to 5.1 mg/dL Total calcium: 8.5 to 10.5 mg/dL  Hypocalcemia Serum calcium level < 8.5 mg/dL Causes: Primary Hypoparathyroidism Surgical hypoparathyroidism Radical neck dissection Massive administration of citrated blood Pancreatitis Kidney injury Prolonged bed rest/bed ridden patients  Extracellular Calcium Hypocalcemia Increased cell membrane permeability to sodium Increased neuromuscular irritability “Everything is high and fast”  Hypocalcemia Clinical Manifestations: Tetany: general muscle hypertonia, with tremor and spasmodic or uncoordinated contractions occurring with or without efforts to make voluntary movement  Hypocalcemia Latent Tetany: Numbness, tingling, and cramps in the extremities Stiffness of hands and feet  Hypocalcemia Overt Tetany: Bronchospasm Laryngospasm (+) Trousseau’s sign: carpopedal spasm resulting from occlusion of the blood flow to the arm for 3 minutes (+) Chvostek’s sign: sharp tapping over the facial nerve causes spasm or twitching of mouth, nose, eye Seizures Dysrhythmias - torsades de pointes Photophobia  Hypocalcemia Chvostek sign: a contraction of the facial muscles elicited in response to light tap over the facial nerve in front of the ear  Hypocalcemia Trousseau sign: a carpopedal spasm induced by inflating a blood pressure cuff above systolic blood pressure.  Hypocalcemia Clinical Manifestations: Hypotension ECG Changes: prolonged QT interval and lengthened ST segment Labs: hypomagnesemia  Hypocalcemia Medical Management Calcium salts IV Calcium gluconate (4.5mEq) Calcium chloride (13.5mEq)  Hypocalcemia Nursing Management: - Administer via slow IV/slow IV infusion - Assess IV site for evidence of infiltration - Do not use PNSS as it increases renal calcium loss; use D5W instead to dilute solution - Do not use concurrently with solutions containing phosphates or bicarbonate  Hypocalcemia Medical Management Vitamin D - increases calcium absorption from the GI tract Calcium supplements (to be taken with meals) High calcium diet Milk products Green, leafy vegetables Canned salmon Canned sardines Fresh oysters  Hypocalcemia Nursing Management: - Encourage intake of calcium-rich foods - Advise to quit smoking and consume alcohol and caffeine in moderation - Advise to avoid overuse of laxatives and antacids that contain phosphorus  Hypocalcemia Nursing Management Monitor and maintain airway patency Institute seizure precautions Reduce environmental stimulation Identify and modify triggers Padded side rails Bed in lowest position Oxygen and suction readily available  Hypercalcemia Serum Calcium Level > 10.5 mg/dL Causes: Malignancies Hyperparathyroidism Thiazide diuretics Vitamin A and D toxicity Chronic lithium use Theophylline toxicity  Extracellular Calcium Hypercalcemia Decreased cell membrane permeability to sodium Decreased neuromuscular irritability “Everything is low and slow”  Hypercalcemia Increased Blood Calcium level Decreased neuromuscular Increased Calcium excitability excretion by kidneys Cognitive Musculoskeletal Cardiac Precipitate GI Disturbance dysfunction symptoms symptoms formation Nephrolithiasis  Hypercalcemia Clinical Manifestations: “BACK ME UP” B - Bone pain A - Arrhythmias (heart blocks, shortened QT interval and ST segment C - Cardiac arrest (MOST DANGEROUS), constipation K - Kidney stones M - Muscle weakness E - Excessive urination U - Uhaw (thirst) P - Pathologic fractures  Hypercalcemia Medical Management 0.9% NaCl solution Temporarily dilutes serum calcium and increases urinary calcium excretion Furosemide (Lasix) Used in conjunction with PNSS Promotes diuresis and enhances calcium excretion Calcitonin IM Lowers calcium level by increasing calcium and phosphorous deposition into bones Useful for patients with heart disease or kidney injury  Hypercalcemia Medical Management (oncologic origin) Corticosteroids Decrease bone turn over and tubular reabsorption for patients with sarcoidosis, myelomas, lymphomas, and leukemia  Hypercalcemia Medical Management (oncologic origin)​a. Pamidronate disodium (Aredia) - Biphosphonate - Inhibits osteoclastic activity - S/E: fever, transient leukopenia b. Mithramycin - Cytotoxic antibiotic - Inhibits bone resorption and thus lowering serum calcium level  Hypercalcemia Nursing Management Encourage early and frequent ambulation Encourage oral fluids up to 3-4 L/day Encourage high fiber diet Implement safety precautions, as necessary Assess for signs of digitalis toxicity, especially in patients taking digoxin (Calcium enhances effects of digoxin) Monitor heart rate and rhythms  Magnesium Intracellular cation Has a direct relationship with potassium and calcium Normal Serum Mg++: 1.3-2.3 mg/dL 1/3 is protein-bound 2/3 are free cations – the active component Absorbed in the small intestine  Magnesium Functions Activator of IC enzyme systems Plays a role in CHO and CHON metabolism Affects neuromuscular irritability and contractility Has a sedative effect- inhibits release of ACh Vasodilator and decreases peripheral resistance  Hypomagnesemia Serum Mg++ level < 1.3 mg/dL Frequently associated with hypokalemia and hypocalcemia Hypoalbuminemia= Hypomagnesemia  Hypomagnesemia Causes: “FAT GUM” F - Fistulas A - Alcohol withdrawal T - Tube feedings/TPN (magnesium def) G - Gastric suctioning prolonged U - Uncontrolled BM (diarrhea) M - Malabsorption disorders (small intestine)  Serum Magnesium Hypomagnesemia Increased ACh release Increased neuromuscular irritability “Everything is high and fast”  Hypomagnesemia Clinical Manifestations Cramps, spasticity (+) Trousseau and Chvostek sign Insomnia Mood changes Anorexia, vomiting Increased tendon reflexes Hypertension Similar to hypocalcemia  Hypomagnesemia Clinical Manifestations ECG changes: Depressed ST segment Prolonged QRS Dysrhythmias PVCs SVT Torsades de pointes Ventricular fibrillation  Hypomagnesemia Medical Management High-magnesium diet for mild deficiencies Green leafy vegetables Nuts Seeds Legumes Whole grains Seafoods Peanut butter Cocoa  Hypomagnesemia Medical Management Magnesium supplements Magnesium sulfate IV For patients with overt manifestations of hypomagnesemia Administered using an infusion pump at a controlled rate  Hypomagnesemia Nursing responsibilities: Magnesium sulfate IV - Monitor vital signs - Monitor urine output; (refer if U/O2.3 mg/dL Rare electrolyte abnormality Falsely elevated Mg++ may result from: Hemolyzed blood specimen Blood drawn from an extremity with a torniquet that was applied too tightly Causes: Kidney injury Excessive intake of magnesium- containing antacids DKA  Serum Magnesium Hypermagnesemia Decreased ACh release “Everything is low and slow” Decreased neuromuscular irritability Hypermagnesemia Clinical Manifestations Flushing Hypotension Muscle weakness Drowsiness Hypoactive reflexes Respiratory depression Cardiac arrest Coma Diaphoresis  Hypermagnesemia Medical Management Avoid giving magnesium to patients with kidney injury Discontinue all sources of magnesium if with severe hypermagnesemia Calcium gluconate IV - Calcium antagonizes magnesium Ventilatory support, if with respiratory depression Hemodialysis If with adequate renal function: Furosemide (Lasix) PLR or PNSS  Hypermagnesemia Nursing Management Monitor vital signs, noting hypotension and shallow respirations Assess deep tendon reflexes Assess level of consciousness Caution on use of OTC medications “When you are a nurse, you know that every day you will touch a life, or a life will touch yours...” Gracias future nurses!