Fluid and Electrolytes PDF

Fluid and Electrolytes Fundamentals of Nursing Taylor 10th ed. Chapter 41 Lincy Jojan Ph.D., NP, MSN Acknowledgements: Wei Liu Ph.D., MANP, RN, CNE Fran Gallina MSN, RN Susan Zori, DNP, RN, NEA-BC Fluid Facts  Water – primary...

Fluid and Electrolytes Fundamentals of Nursing Taylor 10th ed. Chapter 41 Lincy Jojan Ph.D., NP, MSN Acknowledgements: Wei Liu Ph.D., MANP, RN, CNE Fran Gallina MSN, RN Susan Zori, DNP, RN, NEA-BC Fluid Facts  Water – primary body fluid & most critical element; the fundamental solvent for all biochemical processes in the body  Total body water or fluid comprises about 50-60% avg. adult weight  Loss of 5 - 10% body fluid = SERIOUS  Loss of 15 - 20% body fluid = may be FATAL  Fluid gained each day should (I) = fluid lost each day (O) Fluid Compartments Intracellular Fluid (ICF) Extracellular Fluid (ECF) = Fluid outside of = fluid within cells cells  ~2/3 (70%) of total  ~1/3 (30%) of total body water body water  Three divisions: – Interstitial (fluid that surrounds tissue cells including lymph) – Intravascular/ plasma (liquid part of the blood) – Transcellular (minor compartment)  Variations in Fluid Content  Fat has a tiny amount of water; lean tissue (muscle) has lots of water.  Females have less body fluid than males.  Age variations exist in regards to water content of fluid compartments Older adults (after the age of 60) have less percentage (45%) of body fluid Infants have considerably more total body fluid and ECF than adults = 60% of H20 is found in ECF 40% of H20 is found in ICF What might this mean in regards to fluid loss for an infant?? What age groups at higher risk for alterations in balance??  Fluid Balance Example Fluid Intake Fluid Output Gain Loss Sensible – seen Ingested water 1100 – 1400 ml Urine 1200 - 1500 ml Ingested in food 800 – 1000 ml Sweat 100 ml Oxidation of nutrients 300 ml Feces 200 ml Insensible – unseen Skin (evaporation) 500 ml Lungs 400 ml Total 2200 – 2700 ml Total 2200 – 2700 ml Net Intake and Output How to calculate net fluid intake and net fluid output? A client drinks 1000 mL (I) of water, eats food containing 500 mL (I) of water, and the client vomits 250 mL (O) emesis over 24 hours.  The 24-hour net gastric fluid intake is 1000 (I) + 500 (I) – 250 (O) = 1250 mL A client has a NG tube in place. The NG irrigation fluid is 200 mL (I), the NG drainage output is 1300 mL (O), and emesis is 300 mL (O) over 24 hours.  The 24-hour net gastric fluid output is 1300 (O) + 300 (O) – 200 (I) = 1400 mL Electrolytes  Work with fluid to keep the body healthy and in balance  They are solutes that are found in various concentrations and measured in terms of milliequivalent (mEq) units  Can be negatively charged (anions) or positively charged (cations)  For homeostasis body needs: Total body anions (e.g. chloride, bicarbonate, phosphate) = Total body cations (e.g. sodium, potassium, calcium, hydrogen, magnesium)  Major electrolytes in the ECF include sodium, chloride, calcium, bicarbonate  Major electrolytes in the ICF include potassium, phosphorus, magnesium Regulation and Homeostatic Mechanisms of Fluid & Electrolyte Balance Osmosis Diffusion Major method of transporting Passive movement of body fluid electrolytes or other particles Movement of water (or other down the concentration gradient solute) from an area of lesser to (from higher to lower one of greater concentration concentration) Active transport Capillary filtration Movement of ions against Movement across a membrane, osmotic pressure to an area of under pressure, from higher to higher pressure; requires energy lower pressure by adenosine triphosphate (ATP) Osmosis, Diffusion & Active Transport Diffusion Active Transport Osmosis Filtration and Osmosis  Osmolarity & IV fluid  Normal serum (blood) osmolality = 275-295 mOsm/L  ISOTONIC solution: A solution that has osmolarity equal to serum (blood)  HYPOTONIC solution: A solution that has LOW osmolarity is one that is < serum osmolarity  HYPERTONIC solution: A solution that has HIGH osmolarity is one that is > serum osmolarity IV fluid – Isotonic Total osmolality close to that of the ECF; replace ECF 0.9% Sodium Chloride (NS-Normal Saline) Lactated Ringer’s solution  Has the same osmolality as blood solutions on both sides of the semipermeable membrane are equal in concentration. Expand the blood volume without causing a shift from one compartment to another  Expands ECF & ICF volume  Used to treat fluid volume deficit from hemorrhage, severe vomiting & diarrhea, heavy drainage from GI suction, fistulas & wounds; 1st line resuscitation fluid IV fluid – Hypotonic Hypotonic to plasma; replace ICF 0.45%NS (1/2-strength normal saline) 0.33%NS (1/3-strength normal saline)  A solution of lower osmotic pressure moves fluid into the cells, causing them to expand. Shift ECF to ICF with decrease in ECF  Used to “dilute” plasma particularly in hypernatremia  Treats cellular dehydration (as in diabetic ketoacidosis) & hypernatremia (high serum Na+)  Do not use for patients with increased intracranial pressure risk or third spacing risk – increased fluid to brain cells & third space  Can worsen existing hypovolemia & hypotension – fluid pulled out of IVC  IV fluid – Hypertonic Hypertonic to plasma 3%, 5% NS D5% in NS D5% in LR D10% in water (D10W), D20%, D50%  A solution of higher osmotic pressure – pulls fluid from the cells, causing them shrink. Shift ICF to ECF with decrease in ICF.  Used to treat severe hyponatremia (low serum Na+), SIADH & cerebral edema  Temporarily treating hypovolemia if plasma expander is unavailable  Fosters normal BP and good urinary output (often used postoperatively)  Used with caution for renal or cardiac disease. Why??  Regulation of fluid & Electrolytes  Hypothalamus –The amount of fluid the body desires is monitored by the thirst response, which is controlled by the hypothalamus; thirst receptors (osmoreceptors) continuously monitor serum osmolality (concentration). If it rises, thirst mechanism is triggered  Pituitary regulation- posterior pituitary releases ADH (antidiuretic hormone) in response to increasing serum osmolality. Causes renal tubules to retain H2O. As water is retained in the vascular space, vascular volume and blood pressure increase  CV System – pumps fluid & nutrients throughout body Secretes Atrial Natriuretic Peptide (ANP) when blood volume or BP is elevated to inhibit reabsorption of Na & H20  ↓ fluid volume & ↓BP Regulation of Fluid & Electrolytes (cont’d )  Lungs – regulate fluid by releasing water as vapor with every exhalation  Small intestine – absorbs 85% to 95% of fluid from ingested food and delivers it into the vascular system  Renal regulation – kidneys are the master chemists of the body & major regulator of fluid output − Filter 170 to 180 L of plasma daily − Nephron receptors sense low osmolality and kidney secretes Renin. − Renin – Angiotensin – Angiotensin I – Angiotensin II − Angiotensin II causes Na and H2O retention by kidneys, vasoconstriction & stimulates adrenal cortex to secrete Aldosterone which causes kidneys to excrete K+ & H+ and retain Na Fluid Volume Deficit – FVD (commonly known as Hypovolemia)  Loss of both H20 and electrolytes (mainly Na+) from ECF – isotonic fluid loss  Causes Severely decreased intake of H2O & salt Increased output o Loss of blood/plasma - hemorrhage, burns o GI losses – vomiting, diarrhea, tubes o Renal losses – diuretic, diseases o Profuse sweating/diaphoresis “Third spacing fluid shift”– fluid shift out of vascular space into interstitial or transcellular spaces (e.g. pleural, peritoneal, pericardial areas, joint cavities, the bowel)  FVD (Hypovolemia): Assessment Cardiovascular:  Decreased BP & orthostatic hypotension  Diminished peripheral pulses; quality 1+ (thready)  Increased HR - tachycardia  Flat neck veins when supine  Elevated Hematocrit (Hct) - hemoconcentration Gastrointestinal:  Thirst  Decreased motility; diminished bowel sounds, possible constipation FVD (Hypovolemia): Assessment (cont’d) Neuromuscular: Integumentary:  Decreased CNS activity (restlessness,  confusion, lethargy to coma) Dry mouth/oral mucosa & skin  Possible fever  Poor turgor  Skeletal muscle weakness  Sunken eyeballs   Third-spacing signs Hyperactive deep tendon reflexes Renal: Respiratory:  Decreased output – oliguria, anuria  Increased RR  Increased urine specific gravity (normal SG 1.015-1.025)  Weight loss FVD (Hypovolemia): Interventions  Prevention  Oral rehydration therapy (fluid containing sodium)  IV therapy  Monitor electrolytes – possible supplement treatment  Medications – e.g. antiemetics, antidiarrheals  Monitor HR & BP (postural BP changes), Resp, Renal, GI status  Assess for signs of hypovolemic shock  Assess skin & maintain skin integrity  Monitor daily weights (most effective) – with third spacing, a pt may have severe FVD even though body weight remains unchanged.  Comparison of I & O  Urine volume and concentration Fluid Volume Excess – FVE (commonly known as Hypervolemia)  Fluid overload is an excess of isotonic fluid – overhydration  Common causes: kidney diseases, heart failure  Excess fluid volume in the intravascular area - hypervolemia  Excess fluid volume in interstitial spaces – edema  Types of edema Localized Generalized – anasarca Third spacing (ascites, pitting edema, pulmonary edema)  Causes: Increased Na/H2O retention Excessive intake of Na (PO or IV) Excessive intake of H2O ( PO or IV) (Water intoxication) Syndrome of inappropriate antidiuretic hormone (SIADH) Pathophysiology of Edema  Capillary Hydrostatic Pressure: CHF  Colloid Oncotic Pressure ( Plasma Proteins ) Cirrhosis, Malnutrition Obstructed Lymphatic's: Breast Cancer, Lymphoma Kidney Malfunction: Renal disease, Trauma Increase capillary permeability: Allergies, Infection, Gross tissue Trauma, Toxins, Burns Medications: Steroids, NSAID, Estrogen FVE (Hypervolemia): Assessment CV: GI: Elevated pulse – 4+ bounding Increased motility elevated BP & CVP, distended neck Stomach cramps & hand veins, ventricular gallop Nausea & Vomiting (S3) Renal: Decreased hematocrit (hemodilution) Weight gain Resp: Increased urine output & Dyspnea, Moist cough decreased specific gravity of urine Crackles, tachypnea, SOB (normal SG 1.015-1.025) Integumentary: Neuromuscular: Periorbital edema Altered LOC, headache, skeletal Pitting or non-pitting edema muscle twitching FVE (Hypervolemia): Interventions ↓Interstitial Fluid Maintain Skin Integrity  Low Na diet, ↓H2O  Protect from injury intake  Keep skin clean & dry  Diuretics: Furosemide,  ↑ protein diet Bumetanide  Intravenous hypertonic  Use draw sheet therapy: Albumin Other Promote Circulation  Semi-Fowlers position  Avoid constricting  Accurate I & O clothes, positions  Urine volume and  Exercise concentration  TEDs, pneumatic,  Daily weights critical!! compression stockings  Monitor electrolytes Serum Chemistry Serum “Chem” or “Metabolic profile” or “SMA” Sodium (Na+) 135 – 145 mEq/L Potassium (K+) 3.5 – 5.0 mEq/L Chloride (Cl-) 97 - 107 mEq/L Calcium (Ca2+) 8.6 – 10.2 mg/dL Phosphate (PO4-) 2.5 – 4.5 mg/dL Magnesium (Mg2+) 1.3 -2.3 mEq/L Blood urea nitrogen (BUN) 10 – 20 mg/dL Creatinine 0.7 – 1.2 mg/dL Glucose 70 – 100 mg/dL  Electrolytes Electrolyte Intake Distribution Loss Function Potassium K Fruits Low in ECF Loop diuretics loss Allows for Potatoes High in ICF Thiazide diuretics loss normal muscle Instant Coffee Potassium sparing function: Brazil nuts diuretics  loss cardiac, skeletal Absorbs easily Aldosterone loss ACE inhibitors  loss Vomiting, Diarrhea loss Gastric suction loss Polyuria loss Oliguria  loss Calcium Ca Dairy products Low in ECF Acute pancreatitis loss Necessary for Canned fish Mostly in bones Chronic diarrhea and blood with bones and intracellular undigested fat loss coagulation, Broccoli Ionized Ca is Loop diuretics loss muscle Oranges active Thiazides diuretics  loss contraction Requires Vit. D If Ca, if Inverse For absorption phosphate  relationship with phosphate  Electrolytes (cont’d) Electrolyte Intake Distribution Loss Function Magnesium Mg Dark, green ¯ ECF ­ ETOH level loss Function of leafy vegs Mostly in bones Increases renal neuromuscular Whole grains excretion  loss junction Antacids Chronic diarrhea loss Phosphate PO4 Milk ¯ ECF Oliguria decreases Necessary for Processed food ­ ICF & bones excretion  loss production of ATP, Insulin & Epi energy source for shift cellular metabolism phosphate Inverse relationship into cells with calcium  In blood if Ca  Hyponatremia & Hypernatremia Electrolyt Hypo (too little) Interventions Hyper (too much) Interventions e < 135 mEq/L > 145 mEq/L Sodium Decreased LOC, For Na loss: Agitation, delirium, For Water loss: lethargy, Replace Na - usually coma, seizures, IV fluid: D5W; confusion, fever; Oral glucose- seizures, and NS Bounding pulses, electrolyte coma; Muscle For gain in H20: dyspnea , solution; twitching and Restrict fluid hypertension; May also use 0.45 weakness, For neuro Thirst, increased NS to prevent diminished DTRs; signs/severe: 3% or viscosity of saliva, swing to Oliguria or anuria; rough tongue, dry hyponatremia & Nausea, vomiting, 5% NS IV slowly to flushed skin cerebral edema and abdominal prevent fluid Excess Na: cramps overload Restrict Na intake, Treat the cause pt with heart failure Treat the cause  Hypokalemia & Hyperkalemia Electrolyt Hypo (too little) Interventions Hyper (too much) Interventions e < 3.5mEq/L > 5.0 mEq/L Potassiu Life threatening Administer K+ by Most dangerous Restrict K intake; m cardiac PO, IV; electrolyte disorder – 10% Calcium dysrhythmias; Cardiac Gluconate; ECG changes Repeat K+ level post dysrhythmias, IV Insulin & include elevated U replacement; arrest; Glucose; waves (specific to Monitor urine output; ECG changes include Loop Diuretics; hypokalemia), Close monitoring of peak T waves, Dialysis flattened T K+ levels in pts. on widened QRS, waves, depressed prolonged PR ST segment; Dig; observe for interval, flattened P Muscle weakness; signs Dig toxicity waves, depressed ST Abdominal segment; distention, Muscle weakness; constipation; Nausea, diarrhea, abdominal cramps; Effects of potassium on the ECG  Critical Thinking Potassium IV additives Which of the following interventions will the nurse undertake when administering parenteral K additives?  Check urine output  Monitor the IV site for phlebitis  Place on cardiac monitor if > 10 mEq/hr  Infuse via infusion pump  Assure of adequate mixing of K in solution  Monitor for elevated K levels  Monitor for decreased Na levels !!! E R V NE  Administer potassium by slow IV push method  Hypocalcemia & Hypercalcemia Electrolyt Hypo (too little) Interventions Hyper (too much) Interventions e < 8.9 mg/dL > 10.5 mg/dL Calcium + Chvostek’s sign; Replace calcium – IV Respiratory IV therapy – NS; + Trausseau sign; calcium gluconate depression/arrest IV phosphate; Laryngospasm; slowly via pump & Cardiac Limit dietary Ca Cardiac observe for dysrhythmias/ intake; dysrhythmias; infiltration; arrest Loop diuretics; Hyperactive Seizure precautions; Weakness and Monitor for renal Reflexes; Emergency airway muscle flaccidity; calculi – strain Numbness & management CNS depression; urine; tingling fingers; equipment nearby; Bone pain, Assess for signs Hyperactive bowel Ca & Vit D rich diet or pathological dig toxicity sounds, cramping, supplements fractures, renal diarrhea calculi due to calcium loss from bones; Decreased bowel sounds, anorexia, nausea, vomiting, constipation  Chvostek’s Trousseau’s https://www.youtube.com/watch?v=kvmwsTU0InQ  Hypomagnesaemia & Hypermagnesaemia Electrolyt Hypo (too little) Interventions Hyper (too much) Interventions e < 1.3 mEq/L > 2.1 mEq/L Magnesiu + Chvostek’s sign; High Mg foods- Respiratory Monitor for resp. m + Trausseau sign; assess for dysphagia; depression/arrest depression & Monitor for signs of Cardiac Dig toxicity; Cardiac changes in muscle dysrhythmias IV magnesium dysrhythmias/ strength Hyperactive deep sulfate; arrest Dialysis tendon reflexes, Seizure precautions Hypotension, Loop diuretics seizures; bradycardia with IV fluid Anorexia, Flaccid muscle Calcium gluconate dysphagia, paralysis; hypoactive bowel Flushing & feeling of sounds, warmth (acute constipation, elevation) paralytic ileus