Fluids and Electrolytes Midterm PDF

Fluids and Electrolytes Prepared by: Jerome Madriaga, RN  COURSE OUTLINE STUDENTS WILL BE ABLE TO MANIFEST KNOWLEDGE AND DEMONSTRATE SKILLS IN PROVIDING NURSING INTERVENTIONS TO PATIENT WITH FLUID AND ELECTROLYTE IMBALANCES. TOPIC 1 FLUIDS AND ELECTROLYTES T...

Fluids and Electrolytes Prepared by: Jerome Madriaga, RN  COURSE OUTLINE STUDENTS WILL BE ABLE TO MANIFEST KNOWLEDGE AND DEMONSTRATE SKILLS IN PROVIDING NURSING INTERVENTIONS TO PATIENT WITH FLUID AND ELECTROLYTE IMBALANCES. TOPIC 1 FLUIDS AND ELECTROLYTES TOPIC 2 IV FLUIDS TOPIC 3 ELECTROLYTE IMBALANCES TOPIC 4 ACID BASE IMBALANCE TOPIC 5 ELIMINATION DISORDERS EVALUATION POST TEST  TOPIC 1 FLUIDS AND ELECTROLYTES AND THEIR NORMAL VALUES AND FUNCTIONS AMOUNT AND COMPOSITION OF BODY FLUIDS Approximately 60% of a typical adult’s weight consists of fluids (Water and Electrolytes). Body fluid is located in two fluid compartment: INTRCELLULAR & EXTRACELLULAR SPACE. The ECF compartment is further divided into three; intravascular, interstitial, and transcellular fluid spaces: INTRAVASCULAR SPACE – plasma, the effective circulating volume. Approximately 3L of the average 6L of blood volume in adults is made up of plasma. The remaining 3L is made up of erythrocytes, leukocytes, and thrombocytes. INTERSTITIAL SPACE – contains the fluid that surrounds the cells. 11-12L in an adult. TRANSCELLULAR SPACE – smallest division of the ECF compartment and contains approximately 1L.  TRANSPORT OF BODY FLUIDS Body fluid normally moves between the two major compartments or spaces in an effort to maintain equilibrium between the spaces. Third-space fluid shifting – Loss of ECF into a space that does not contribute to equilibrium between the ICF and the ECF.  ELECTROLYTES ELECTROLYTES are active chemicals. The major cations in body fluid are sodium, potassium, calcium, magnesium, and hydrogen ions. Major anions are chloride, bicarbonate, phosphate, sulfate, and proteinate ions. Normal movement of fluids throughout the capillary wall into the tissues depends on hydrostatic pressure at both the arterial and the venous ends of the vessel and the osmotic pressure exerted by the protein of plasma. ELECTROLYTE NORMAL VALUE Sodium 135 – 145 mEq/L Potassium 3.5 – 5.0 mEq/L Chloride 98 – 106 mEq/L Calcium 8.5 – 10.5 mEq/L Magnesium 1.8 – 3.0 mEq/L Phosphorus 2.5 – 4.5 mEq/L Bicarbonate 24 – 31 mEq/L  REGULATION OF BOD FLUID COMPARTMENTS OSMOSIS and OSMOLALITY - When two different solutions are separated by a membrane that is impermeable to the dissolved substance, fluid shifts through the membrane from the region of low solute concentration to the region of high solute concentration until the solutions are equal concentrations. TONICITY - Is the ability of all solutes to cause an osmotic driving force that promotes water movement from one compartment to another. - Three other terms associated with osmosis.  OSMOTIC PRESSURE – amount of hydrostatic pressure needed to stop the flow of water by osmosis.  ONCOTIC PRESSURE – pressure exerted by proteins.  OSMOTIC DIURESIS – increase urine output cause by excretion of substance.  REGULATION OF BOD FLUID COMPARTMENTS DIFFUSION - Is the natural tendency of a substance to move from an area of higher concentration to lower concentration. FILTRATION - Hydrostatic pressure in the capillaries filter fluid out of the intravascular compartment into the interstitial fluid. The kidneys filter 180L of plasma per day. SODIUM-POTASSIUM PUMP - Sodium concentration is greater in ECF than the ICF, sodium tends to enter the cell by diffusion. Conversely, the high intracellular potassium concentration is maintained by pumping potassium into the cell. In definition these movement is called active transport.  SYSTEMIC ROUTES OF GAINS AND LOSSES KIDNEYS - Usual daily urine volume is 1-2L. 1ml of urine per kg of body weight per hour(IN ALL AGE GROUP) SKIN - Sensible perspiration refers to visible water and electroltye loss through sweating. LUNGS - Normally eliminates water vapor at a rate of approximately 300ml every day. GASTROINTESTINAL TRACT - Usual loss is 100 – 200 mL daily.  LABORATORY TESTS OSMOLALITY - Concentration of fluid that affects the movement of water between fluid compartments by osmosis. Measure the solute concentration per kilogram in blood and urine. OSMOLARITY - Concentration of solutions (mOsm/L). URINE-SPECIFIC GRAVITY - kidney’s ability to excrete water. Normal lab range 1.010 – 1.025. BLOOD UREA NITROGEN - Made of urea, which is an end product of the metabolism of protein by the liver. Normal BUN is 10 – 20mg/dL CREATININE - End product of muscle metabolism. Normal lab range 0.7 to 1.4mg/dL. HEMATOCRIT - Measure the volume percentage of RBCs, in whole blood and normally rnages from 42 – 52% in men and 35% - 47% in women.  Homeostatic Mechanism - the body is equipped with remarkable homeostatic mechanisms to keep the composition and volume of the body fluid within normal range. ORGANS INVOLVED IN HOMEOSTASIS  KIDNEY - Regulate fluid and electrolyte balance. They act both autonomously and in response to bloodborne messengers, such as aldosterone and antidiuretic hormone. - Regulate ECF volume - Regulate normal electrolyte levels in the ECF - Regulate pH of the ECF - Excretion of metabolic wastes and toxins.  Head and Blood Vessels - Pumping actions circulate blood through the kidneys under sufficient pressure for urine formation  Lungs - Removes 300ml of water daily.  Pituitaru Gla  Homeostatic Mechanism  Pituitary Gland - ADH maintain the osmotic pressure of the cells.  Adrenal Gland - Aldosterone has a profound effect on fluid balance.  Parathyroid Gland - Regulate calcium and phosphate balance.  Renin-Angiotensin-Aldosterone System - Aldosterone is a volume regulator and is also released as serum potassium increases, sodium decreases.  Antidiuretic Hormone - ADH and the thirst mechanism role is to maintain sodium concentration and oral intake of fluids the release of ADH  increase reabsorption of water and decreases urine output.  Natriuretic Peptides - Is a hormone affecting fluid and cardiovascular function through the excretion of sodium and direct vasodilation. TOPIC 2 INTRAVENOUS FLUIDS  PARENTERAL FLUID THERAPY When no other route of administration sis available, fluids are given by IV, outpatient diagnostic, surgical settings, and even homes to replace fluids, administer medications, and provide nutrients. PURPOSE - Provide water, electrolytes, and nutrients to meet daily requirements - Replace water and correct electrolyte deficits - Administer medications and blood products TOPIC 3 ELECTROLYTE IMBALANCES 2. 1 Type of IV Solutions  IV SOLUTIONS Solutions are often categorized as isotonic, hypotonic, or hypertonic, according to whether their total osmolality is same as, less than, or greater than that of blood. ISOTONIC - Fluids that are classified to have a total osmolality close to the ECF and do not cause cells to shrink or swell. - Normal Saline (0.9% Sodium Chloride)  only IV solution that is compatible with BT.  IV SOLUTIONS HYPOTONIC - Lower osmolarity than the extracellular space. Water moves from extracellular space to intracellular space. To replace cellular fluid, provide free water to kidneys for excretion of body wastes, treatment for hypernatremia and prevent dehydration, and causes cells to swell.  IV SOLUTIONS HYPERTONIC - Higher osmolarity than the extracellular space. Water moves out from intracellular space into the extracellular space. Causing the cell to shrink. 2.2 Managing Systemic Complications  Systemic Complications FLUID VOLUME OVERLOAD - Causes the blood pressure and central venous pressure to increase. S/Sx Crackles Distended neck veins Edema RAPID weight gain Dyspnea  Systemic Complications AIR EMBOLISM - Most often associated with cannulation of central veins and directly related to the size of the embolus and the rate of entry. Air  central veins  right ventricle  lodges against the pulmonary valve  blood flow obstruction. S/Sx Palpitations, dyspnea, wheezing, cyanosis, weak rapid pulse, altered mental status.  Systemic Complications INFECTION - Pyogenic substances in either the infusion solution or IV administration set can cause infection. S/Sx Abrupt temperature elevation, headache, tachycardia, tachypnea, nausea and vomiting, chills, general body malaise. 3. 1 SODIUM IMBALANCES  HYPONATREMIA - Serum sodium level loss. It can occur during extreme temperatures, because of excessive fluid intake before exercise or prolonged exercise that results in a decrease in serum sodium.  PATHOPHYSIOLOGY - Imbalance of water rather than sodium. Low urine sodium occurs as the kidney retains sodium to compensate for nonrenal fluid loss. High urine sodium concentration is associated with renal salt wasting. - A deficiency of aldosterone, as occurs in adrenal insufficiency, also predisposes to sodium deficiency and use of certain medications.  CAUSES Diarrhea Sodium Diet Deficiency IV Fluid Overload Diuretics SIADH Addison Vomiting Excessive Physical Exertion  CLINICAL MANIFESTATIONS Loss of appetite Orthostatic Hypotension Shallow Respiration Muscle Spasm Seizure/Stupor Abdominal Cramps Lethargic  MEDICAL MANAGEMENT Sodium Replacement IV Fluids AVP Receptor Antagonists - Treat hyponatremia by stimulating free water excretion. Incorporation of Sodium Chloride  Nursing MANAGEMENT Monitor I&O Weigh client daily Increase Sodium intake/diet Restrict/Decrease oral fluid intake  HYPERNATREMIA - Serum sodium level that are high, caused by a gain of sodium in excess of water of by a loss of water more than sodium. With water loss, the patient loses more water than sodium; as a result, the serum sodium concentration increases, and the increased concentration pulls fluid out of the cell. PATHOPHYSIOLOGY - Common cause is fluid deprivation in patients who cannot respond to thirst. Hypertonic enteral feedings without adequate water supplements leads to hypernatremia, as does watery diarrhea and greatly increased insensible water loss.  CAUSES Cushing’s Hypertonic Solutions Diabetes Insipidus Burns Increase Intake of Na+  CLINICAL MANIFESTATIONS FATIGUE RESTLESS, AGITATED INCREASED REFLEXES EXTREME THIRST DECREASED URINE OUTPUT, DRY MOUTH/SKIN  MEDICAL MANAGEMENT IV fluids Diuretics Synthetic ADH medication  if D.I. is the main cause.  Nursing MANAGEMENT Monitor I&O Restrict Sodium Intake Monitor Neurological Behavior 3. 2 POTASSIUM IMBALANCES  HYPOKALEMIA - Usually indicates a deficit in total potassium stores.  PATHOPHYSIOLOGY - potassium-losing diuretics, diarrhea, Vomiting, Gastric suctioning, hyperaldosteronism, insulin therapy, poor nutrition,  hypokalemia  DIAGNOSTIC FINDINGS Electrocardiogram Arterial Blood Gas Blood Chemistry  CLINICAL MANIFESTATIONS “Everything will be low & slow” Muscle GI Tract Heart Lungs Blood Pressure  MEDICAL MANAGEMENT Potassium IV Supplement AVOID!!! - IV BOLUS!!! GO FOR!!! - INFUSION PUMP!!! Potassium Oral Supplement - Potassium Citrate  Nursing MANAGEMENT DIET: Foods rich in potassium Monitor ECG Hold Diuretics Hold Digoxin  HYPERKALEMIA - Seldom occurs in patients with normal renal function. In older adults, there is an increased risk for hyperkalemia due to decreases in renin and aldosterone.  PATHOPHYSIOLOGY - Decreased renal excretion of potassium, rapid administration of potassium, untreated kidney injury, hypoaldosteronism  HyperKALemia  DIAGNOSTIC FINDINGS Electrocardiogram Arterial Blood Gas Blood Chemistry  CLINICAL MANIFESTATIONS Muscle Weakness Low urine output Respiratory Arrest Poor Cardiac Contraction Early Muscle cramping/twitching Abnormal EKG  MEDICAL MANAGEMENT Obtain ECG Administration of cation exchange resins (e.g., sodium polystyrene sulfonate) Administration of IV Calcium Gluconate Administration of IV Sodium Bicarbonate Regular Insulin and a Hypertonic Dextrose Solution Loop Diuretics  Nursing MANAGEMENT DIET: Restrict Potassium Monitor ECG Monitor Vital Signs Monitor and Observe muscle weakness and dysrhythmias Monitor Serum-Potassium levels 3. 3 CALCIUM IMBALANCES - HYPOCALCEMIA Occurs in a variety of clinical situations. A patient may have a total- body calcium deficit but a normal serum calcium level. Older adults and those with disabilities, who spend and increased amount of time in bed, have an increased risk for hypocalcemia.  PATHOPHYSIOLOGY - Hypoparathyroidism/surgery of the thyroid, massive administration of citrated blood, pancreatitis, kidney injury, unhealthy lifestyle  hypocalcemia.  DIAGNOSTIC FINDINGS Arterial Blood Gas Blood Chemistry  CLINICAL MANIFESTATIONS Chvostek Sign Trousseau Sign Mental Status Changes Hyperactive bowel sounds Dry brittle hair, nails, and bones. Seizures/Tetany  MEDICAL MANAGEMENT Parenteral Calcium Chloride Calcium Salt If with hyperphosphatemia  Aluminum Hydroxide  NURSING MANAGEMENT GO FOR!!! - DIET - Increase Vitamin D - Milk - Salmon, Sardines, Oysters Turn Patient’s head to side  if seizure occurs! Avoid!!! - Smoking and Alcoholic Beverages - Laxatives W.O.F!!! -  HYPERCALCEMIA - Excessive amount of calcium levels in the blood and is a dangerous imbalance when severe.  CAUSES  Increased Ca+ intake  Hyperparathyroidism  Glucocorticoids  Hyperthyroidism  Poor Calcium Excretion  Addison’s disease  Lithium Toxicity  DIAGNOSTIC FINDINGS Blood Chemistry ECG Double-Antibody PTH test X-rays Urinalysis  CLINICAL MANIFESTATIONS Weak muscles ECG changes Absent - Tendon Reflex - Minded - Bowel Motility Kidney Calculi Formation  MEDICAL MANAGEMENT Administer - Calcium Reabsorption Inhibitors - Bisphosphonates' - Prostaglandin Synthesis Inhibitors Dialysis  NURSING MANAGEMENT GO FOR!!! - DIET - Increase oral fluid intake - Decrease Calcium Rich Food Turn Patient’s head to side  if seizure occurs! Avoid!!! - Strenuous Activity - Thiazides - Calcium Supplements 3.4 MAGNESIUM IMBALANCES  HYPOMAGNESEMIA - Refers to a below-normal serum magnesium concentration.  PATHOPHYSIOLOGY - Suctioning, diarrhea, intestinal fistulas, inflammatory bowel disease, alcohol consumption, diabetic ketoacidosis,  hypomagnesemia.  DIAGNOSTIC FINDINGS Blood Chemistry  CLINICAL MANIFESTATIONS Tachycardia EKG changes Torsade de pointes Rapid shallow breathing Diarrhea Mental Status Changes Insomnia  MEDICAL MANAGEMENT Magnesium Salt IV MAGNESIUM SULFATE  NURSING MANAGEMENT GO FOR!!! - DIET - Increase magnesium intake Monitor - Deep tendon reflexes - ECG Put patient into seizure precaution  HYPERMAGNESEMIA - Serum magnesium high level, a rare electrolyte abnormality because kidneys efficiently excrete magnesium.  PATHOPHYSIOLOGY - Kidney injury  slight elevation of serum magnesium. - Untreated Diabetic Ketoacidosis  catabolism  release of magnesium. - Excessive use of magnesium-based antacid  decrease GI motility  increase serum magnesium levels.  DIAGNOSTIC FINDINGS Blood Chemistry ECG findings  CLINICAL MANIFESTATIONS CNS Depression Respiratory Depression Muscle Weakness Hypotension Absent DTR  MEDICAL MANAGEMENT Loop Diuretic Sodium Chloride IV Lactated Ringers IV Calcium Gluconate Hemodialysis  NURSING MANAGEMENT Monitor - Vital Signs - Deep tendon reflexes - Level of Consciousness AVOID!!! - Magnesium containing meds to compromised renal function. - Magnesium Rich Foods TOPIC 4 ACID-BASE IMBALANCES  ACID-BASE IMBALANCE PLASMA pH - Indicator of hydrogen ion concentration and measures the acidity or alkalinity of the blood. These mechanism consist of buffer systems, the kidneys, and the lungs. - Buffer system prevent major changes in the pH of body fluids by removing or releasing hydrogen ion; they can act quickly to prevent excessive changes in hydrogen ion concentration; which is assess when ARTERIAL BLOOD GASES are measured. 4. 1 METABOLIC ACIDOSIS  Metabolic Acidosis - Common clinical disturbance characterized by low pH and a low plasma bicarbonate concentration. PATHOPHYSIOLOGY - Result in direct loss of bicarbonate. CAUSES - Diarrhea, lower intestinal fistulas, ureterostomies, and the use of diuretics. ASSESSMENT AND DIAGNOSTIC FINDINGS - Arterial Blood Gas measurements  low pH (7.35) and low bicarbonate (22mEq/L) - Blood Chemistry  hyperkalemia. - ECG  CLINICAL MANIFESTATIONS Headache Confusion Drowsiness Tachypnea  MEDICAL MANAGEMENT Treatment is directed at correcting the metabolic acidosis. When necessary, bicarbonate is given; however, the administration of sodium bicarbonate during cardiac arrest can result in paradoxical intracellular acidosis. 4.2 METABOLIC ALKALOSIS  Metabolic Alkalosis - A clinical disturbance characterized by a high pH and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of Hydrogen Ions. CAUSES Vomiting, NG Tube Suctioning, pyloric stenosis, use of thiazides, and hypokalemia. ASSESSMENT AND DIAGNOSTIC FINDINGS - Arterial Blood Gas measurements  pH greater than 7.45 and serum bicarbonate concentration greater than 26mEq/L. - Blood Chemistry  hypokalemia.  CLINICAL MANIFESTATIONS Dizziness Respiratory Depression  MEDICAL MANAGEMENT Treatment is aimed at correcting the underlying acid-base disorder. Because of volume depletion from GI loss, the patient’s I&O must be monitored. Sufficient chloride  excretion of excess bicarb. H2 receptor antagonists  decrease HCL. 4.3 RESPIRATORY ACIDOSIS  Respiratory Acidosis - A clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 45mmHg. CAUSES - pulmonary edema, foreign object aspiration, atelectasis, and overdose of sedatives, sleep apnea  Inadequate excretion of CO2 with inadequate ventilation ASSESSMENT AND DIAGNOSTIC FINDINGS - Arterial Blood Gas measurements  pH less than 7.35 and PaCO2 greater than 45mmHg. - Chest X-ray  identify respiratory disease. - Drug Screening  CLINICAL MANIFESTATIONS - Mental cloudiness - Feeling of fullness in the head - Decreased LOC  MEDICAL MANAGEMENT Improve Ventilation Bronchodilators If with respiratory infections  Antibiotics. If with pulmonary embolism  thrombolytics Increase oral fluid intake  moisten mucous  promote expectorate. Semi-fowlers Position. 4.4 RESPIRATORY ALKALOSIS  Respiratory Alkalosis - A clinical disorder in which the pH is greater than 7.45 and the PaCO2 is less than 35mmHg. CAUSES - Hyperventilation ASSESSMENT AND DIAGNOSTIC FINDINGS - Arterial Blood Gas measurements - Toxicology Screen  r/o salicylate intoxication.  MEDICAL MANAGEMENT Treatment of Underlying Cause - Anxiety  breathe slow  paper bag - Antianxiety Agents may be required.