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Fluids & Electrolytes Imbalances - BMH/Tele

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  • 1. Fluids & Electrolytes Imbalances
  • 2. Body Fluid Compartments
    • 2/3 (65%) of TBW is intracellular fluid (ICF)
    • 1/3 extracellular fluid (ECF)
      • 25 % interstitial fluid (ISF)
      • 5- 8 % in plasma [(IVF) intravascular fluid]
      • 1- 2 % in transcellular fluids – CSF, intraocular fluids, serous membranes, and in GI, respiratory and urinary tracts (third space)
  • 3.
  • 4. Function of Body H 2 O
    • Transports nutrients, electrolytes, & O 2
    • Excretion of Waste Products
    • Regulates Body Temperature
    • Lubrication of Joints & Muscles
    • Medium for Food Digestion
    • (Kee & Paulanka, 2000, p. 2)
  • 5.
    • Fluid compartments are separated by membranes that are freely permeable to water.
    • Movement of fluids due to:
      • Diffusion
      • Osmotic pressure
      • Active transport
      • Hydrostatic pressure
      • Reabsorption
    Movement of Fluids
  • 6. DIFFUSION
        • Solutes shift from an area of greater concentration to an area of higher concentration
        • Passive process
  • 7. OSMOSIS
        • Movement of fluid across membrane from a lower solute concentration to a higher solute concentration
        • Passive process
  • 8. ACTIVE TRANSPORT
        • Solutes move from an area of lower concentration to an area of higher concentration
        • Process requires energy
  • 9. Hydrostatic Pressure
    • Capillary filtration
    • Movement of fluid through capillaries results from blood pushing against walls of the capillary. It forces fluids and solutes through the capillary wall
  • 10. REABSORPTION
        • Prevents too much fluid from leaving capillaries no matter how much hydrostatic static pressure is inside them
  • 11.
    • Capillary colloid osmotic pressure
      • Colloids do not cross the membrane and pull water into the blood stream
      • Aka plasma expander
        • Albumin, plasma protein fraction, dextran, hetastarch
    • Interstitial hydrostatic pressure
    • Tissue colloid osmotic pressure
  • 12. Solutes – Dissolved Particles
    • Electrolytes – charged particles
      • Cations – positively charged ions
        • Na + , K + , Ca ++ , H +
      • Anions – negatively charged ions
        • Cl - , HCO 3 - , PO 4 3-
    • Non-electrolytes - Uncharged
        • Proteins (i.e. albumin), urea, glucose, O 2 , CO 2
  • 13.
    • Body fluids are:
      • Electrically neutral
      • Osmotically maintained
        • Specific number of particles per volume of fluid
  • 14. Homeostasis maintained by:
    • Ion transport
    • Water movement
    • Kidney function
  • 15. TONICITY:
      • Isotonic – A solution that has the same solute concentration as another solution to which it’s being compared
        • i.e. sodium in blood vs. 0.9% NSS
  • 16.
      • Hypertonic - A solution that has a higher solute concentration than another solution to which it’s being compared
        • Dextrose 5% in NSS
    TONICITY:
  • 17.
      • Hypotonic - A solution that has a lower solute concentration than another solution to which it’s being compared
        • 0.45%NSS
    TONICITY:
  • 18. Balance
    • Fluid and electrolyte homeostasis is maintained in the body
    • Neutral balance: input = output
    • Positive balance: input > output
    • Negative balance: input < output
  • 19. Fluid Gain & Loss
    • Routes of Gain and Loss:
    • Kidneys (urine)
    • Skin (perspiration)
    • Lungs (respiration)
    • GI Tract (feces)
    • (Smeltzer et al, 2008)
  • 20. Fluid Gain & Loss
    • Average Intake of Body H 2 O
    • = 2600 ml/day
    • Liquid = 1500 ml
    • Solid Foods = 800 ml
    • Oxidation = 300 ml
    • (Priff, 2006, p.6)
  • 21. Fluid Gain & Loss
    • Sensible Loss
    • Fluid loss that can be measured
      • Urination
      • Defecation
      • Bleeding
      • Wound drainage
      • Gastric drainage
      • Vomiting
    • (Priff, 2006, p.6)
  • 22. Fluid Gain & Loss
    • Insensible Loss
    • Fluid loss that cannot be measured
      • Perspiration
      • Respiration
      • Changes in humidity levels, respiratory rate and depth, and fever affect insensible loss
    • (Priff, 2006, p.6)
  • 23. Fluid Gain & Loss
    • Average Output of Body H 2 O
    • = 2600 ml/day
    • Urine = 1500 ml
    • Feces = 100 ml
    • Lungs = 400 ml
    • Skin = 600 ml
    • (Priff, 2006, p.6)
  • 24.
  • 25.
  • 26. Balancing Systems
    • Renal System (kidneys)
      • RF = difficulty maintaining fluid balance
      • Na + & K + are either filtered or reabsorbed via the renal system
  • 27. Balancing Systems
    • Antidiuretic Hormone (ADH)
      • Water-retaining hormone
      • Hypothalamus senses low blood volume & increased serum osmolality; triggers its release from the pituitary gland
      • Prompts kidneys to retain H 2 O
      • Increases concentration of urine
  • 28. Balancing Systems
    • Renin-Angiotensin-Aldoseterone System (RAAS)
      • Release of renin triggered by low pressures
      • Angiotensin II potent vasoconstrictor and triggers the release of aldosterone from the adrenal cortex
      • Aldosterone = fluid retention and secretion of K + ; triggers the thirst center
  • 29. Balancing Systems
    • Atrial Natriuretic Peptide (ANP)
      • Released when atrial pressures increase
      • Opposes the RAAS (shuts it off)
      • Key Functions of ANP:
        • Suppresses serum renin levels
        • Decreases aldosterone release
        • Increases glomerular filtration rate (excretion of Na + and H 2 O)
        • Decreases ADH release
        • Decreases vascular resistance by causing vasodilation
  • 30. Balancing Systems
    • Thirst Mechanism
      • Simplest mechanism in maintaining fluid balance
      • Increases after even small fluid loss
      • Increase in salty foods dries mucous membranes, which stimulates the thirst center in the hypothalamus
  • 31. Hypovolemia
    • A decreased blood volume that may be caused by internal or external bleeding, fluid losses, or inadequate fluid intake.
    • (Taber’s Online Dictionary, 2007)
    • A.K.A. Fluid Volume Deficit (FVD) or Extracellular Fluid Volume Deficit (ECFVD)
  • 32. Hypovolemia
    • FVD occurs when the loss of ECF exceeds the intake of fluid.
    • (Smeltzer et al, 2008)
    • Hypovolemia or FVD ≠ dehydration
    • Dehydration is loss of H 2 O only!!
    • FVD -> Fluid Loss = Electrolyte Loss
    • Ratio Remains the Same (usually)
  • 33. Hypovolemia
    • Signs & Symptoms
    • Weight Loss
    • Decreased Skin Turgor
    • Oliguria
    • Concentrate Urine
    • Postural Hypotension
    • Weak, rapid pulse
    • Flattened Neck Veins
    Signs & Symptoms Increased Temp Cool, clammy skin Thirst Anorexia Nausea Muscle Weakness Muscle Cramps
  • 34. Hypovolemia
    • Treatment:
    • Infusion of Isotonic IV solutions for hypotensive patients
    • Infusion of Hypotonic IV solutions for normotensive patients
    • Hypovolemia d/t blood loss – blood transfusion
  • 35. Hypervolemia
    • ECF -> H 2 O gain is balanced with retention of sodium
    • Usually secondary to retention of sodium
    • Concentration of sodium to H 2 O is balanced – serum sodium levels usually WNL
    • A.K.A. Extracellular Fluid Volume Excess (ECFVE)
  • 36. Hypervolemia
    • Hormonal Imbalances - ADH
    • Can occur secondary to heart failure, renal failure, or cirrhosis of liver
    • Fluid overload related to administration of excessive IV fluids
    • Dietary: Excessive sodium intake
  • 37. Hypervolemia
    • Signs & Symptoms
    • JVD
    • Edema
    • Crackles
    • Tachycardia
    • Elevated B/P
    • Weight Gain
    • Increased Urine Output
    • SOB/Wheezing
  • 38. Hypervolemia
    • Treatment:
    • Treat the underlying cause!!!
    • Renal Failure – dialysis
    • Heart Failure – diuretics, etc.
    • Dietary – low-salt diet and/or fluid restriction
    • Discontinuation of IV infusions
  • 39. Intracellular Fluid Volume Excess
    • A.K.A. Water Intoxication
    • An excess of H2O or decrease in solute concentration in the intravascular space
    • (Kee & Paulanka, 2000, p.34)
    • Causes cellular edema
    • Usually occurs in cerebral cells first
  • 40. Intracellular Fluid Volume Excess
    • Causes:
    • Excessive non-solute water intake
    • Solute deficit (electrolyte & protein)
    • Increased secretion of ADH
    • Kidney Dysfunction
  • 41. Intracellular Fluid Volume Excess
    • Signs & Symptoms
    • Headaches & ↑ Perspiration (early s/s)
    • Apprehension, irritability
    • Confusion, disorientation
    • Increase ICP -> ↑ B/P, ↓ HR, ↑ RR
    • Nausea/vomiting
    • Weight Gain
  • 42. Intracellular Fluid Volume Excess
    • Treatment:
    • Goal: Decrease excess H 2 O intake and promote H 2 O excretion
  • 43. Extracellular Fluid Volume Shift
    • A.K.A. “Third-spacing”
    • Permanent fluid shift from intravascular space to interstitial space
    • Nonfunctional fluid shift & physiologically useless
  • 44. Extracellular Fluid Volume Shift
    • Simple: Blister or Sprain
    • Serious: Massive injuries, burns, ascites, abdominal surgery
  • 45. ELECTROLYTES
  • 46. ELECTROLYTES Compounds, that when placed in a solution, conduct an electric current and emit dissociated particles of electrolytes (ions) that carry either a positive charge (cation) or negative charge (anion) (Kee & Paulanka, 2000, p. 42)
  • 47. ELECTROLYTES Na + & Cl - -> ECF K + -> ICF Mg + = -> ICF Ca + -> almost equal in ICF & ECF (Kee & Paulanka, 2000, p. 42)
  • 48. ELECTROLYTES Terms: Anabolism -> formation of new tissue Catabolism -> tissue breakdown (Kee & Paulanka, 2000, p. 46)
  • 49. Potassium
    • Reference Range:
    • 3.5 – 5.1 mEq/L
  • 50. Potassium
    • Potassium is gained by intake and lost by excretion.
    • If either is altered, hyperkalemia or hypokalemia may result!
    • Regulated by aldosterone and insulin
  • 51. Potassium
    • Potassium levels directly affect cell, nerve, & muscle function:
      • Maintains the electrical neutrality and osmolality of cells
      • Aids in neuromuscular transmission of nerve impulses
      • Assists skeletal and cardiac muscle contraction and electrical conductivity
      • Affects acid-base balance in relationship to hydrogen (another cation)
  • 52. Potassium
    • Hypokalemia is K + < 3.5
    • Hyperkalemia is K + > 5.1
  • 53. Hypokalemia
    • Levels < 3.5
    • Mildly Low Levels usually asymptomatic
    • If level < 3.2, usually accompanied by symptoms
  • 54. Hypokalemia
    • Causes of Hypokalemia:
    • Increased Urine Output
    • Malnutrition
    • Vomiting and/or Diarrhea
    • Hypomagnesemia
    • DKA
  • 55. Hypokalemia
    • May be a result of acid-base imbalances = alkalosis
    • In alkalosis, potassium moves into the cell to maintain balance, which may lead to hypokalemia
  • 56.  
  • 57. Treatment
    • Oral or IV Potassium Chloride Replacement
    • D/C or adjust medications that may cause hypokalemia
    • Reverse alkalosis, if cause
    • Monitor closely for arrhythmias
    • Monitor Respiratory Status
    • Monitor LOC
    • Monitor GI symptoms
  • 58. Hyperkalemia
    • Levels > 5.1
    • Mildly elevated levels usually asymptomatic
  • 59. Hyperkalemia
    • Causes of Hyperkalemia:
    • Renal Failure
    • Meds (ACEIs, ARBs, K + sparing diuretics, NSAIDs)
    • Addison’s Disease
    • Aldosterone Insufficiencies
    • Dig Overdose
    • Beta-Blocker Therapy
  • 60. Hyperkalemia
    • May be a result of acid-base imbalances = acidosis
    • In acidosis, excess hydrogen ions move into cells and push potassium into ECF, which may lead to hyperkalemia as potassium moves out of the cell to maintain balance.
  • 61.  
  • 62. Treatment
    • Medications:
      • Cation-exchange resins (bind with K + and excreted via feces)
      • IVP insulin and glucose (K + binds to insulin)
      • IV Ca ++ (protect the heart from the effects of hyperkalemia)
      • Sodium bicarbonate (to reverse acidosis)
      • Diuretics (non-K + sparing)
      • Beta 2 Adrenergic agonists (epinephrine, albuterol)
    • D/C meds that may cause hyperkalemia
    • Restrict foods with K +
    • Dialysis for renal failure
    • Monitor closely for arrhythmias
    • Monitor Blood Pressure
    • Monitor GI symptoms
  • 63. Sodium
    • Reference Range:
    • 136 – 145 mEq/L
  • 64. Sodium
    • Accounts for 90% of ECF cations
    • Almost all Na + is found in ECF; 10% in ICF
    • Na + attracts fluid and helps preserve ECF volume and fluid distribution
    • Na + helps transmit impulses in nerve and muscle fibers and combines w/ Cl - abd HCO 3 to regular acid-base balance
  • 65. Sodium
    • Excreted mainly via the kindeys (GU)
      • Also via the GI tract and perspiration
    • Increased Na+ levels trigger thirst and the ADH
    • Sodium-Potassium pump helps maintain normal Na+ levels
      • Pump also creates an electrical charge for both cardiac and neuromuscular function
  • 66. Sodium
    • Hyponatremia is Na + < 136
    • Hypernatremia is Na + > 145
  • 67. Hyponatremia
    • Causes an osmotic fluid shift from plasma into brain cells
  • 68. Hyponatremia
    • Signs & Symptoms:
    • Nausea/Vomiting
    • Headache
    • Malaise
    • Confusion
    • Diminished Reflexes
    • Confusion
    • Convulsions
    • Stupor or Coma
  • 69. Hyponatremia
    • Causes of Hyponatremia:
    • ↑ Vasopressin/ADH
    • SIADH
    • Adrenal Insufficiency
    • Diuretics
    • Hypervolemia
    • Liver Failure
    • Heart Failure
  • 70. Treatment
    • Administration of oral or IV Na + (3%) Supplements
    • Encourage foods high in Na +
    • Fluid restriction
    • Monitor Neuro Status
    • Monitor for Arrhythmias
    • Normovolemic hyponatremia
      • Vaprisol (conivaptan) – IV infusion
      • Samsca (tolvaptan) - PO
  • 71. Hypernatremia
    • Causes
    • Dehydration/Hypovolemia
    • Diabetes Insipidus
    • Ingestion of Hypertonic Solutions
    • IV Infusion of Hypertonic Solutions
    • Cushing’s Syndrome
    • Hyperaldosteronism
    • Loss of pure water
      • (excessive sweating or respiratory infections)
  • 72. Signs & Symptoms
    • Thirst
    • Lethargy
    • Neurologic Dysfuntion
      • Due to dehydration of brain cells
      • Irritablility
      • Weakness
      • Seizures
      • Coma
    • Edema
    • Decreased vascular volume
  • 73. Treatment
    • Administration of IV Fluids
      • (Isotonic Salt-Free)
    • Encourage foods low in Na +
    • Push P.O. Fluids
    • Monitor Neuro Status
    • Monitor for Arrhythmias
  • 74. Magnesium
    • Reference Range:
    • 1.8 – 2.4 mEq/L
  • 75. Magnesium
    • 2 nd most abundant ICF cation (K + #1)
    • 60% Mg+ found in bones, < 1% ECF
    • Mg+ performs the following functions:
      • Promotes enzyme reactions in carbohydrate metabolism
      • Helps produce ADP (adenosine triphosphate)
      • Helps with protein synthesis
      • Influences vasodilation (normal CV function)
      • Helps Na + and K + ions cross cell membranes
  • 76. Magnesium
    • Mg+ performs the following functions:
      • Regulates muscle contractions
      • Affects irritability and contractility of cardiac and skeletal muscle
      • Influences Ca ++ levels
        • maintain Ca ++ levels in ECF
  • 77. Magnesium
    • Hypomagnesemia is Mg + < 1.8
    • Hypermagnesemia is Mg + > 2.4
  • 78. Hypomagnesemia
    • Results in cardiac dysrhythmias and irritates the nervous system (tetany)
  • 79. Hypomagnesemia
    • Causes of Hypomagnesia:
    • Malnutrition
    • Chronic Diarrhea
    • Malabsorption
    • ETOH Abuse
    • Diuretics
    • AMI
    • Pancreatitis
  • 80. Hypomagnesemia
    • Does not produce specific EKG changes
    • May contribute to arrhythmias caused by digoxin toxicity, ischemia, or potassium imbalances
    • (Woods et al, 2005, p. 358)
  • 81. Hypomagnesemia
    • Replacement of Mg – PO or IV
    • PO = Mg Oxide 400mg tabs
    • MgSo 4 IV administration is usually given at a rate of 1 gram/hr (1 gram/100 ml)
    • Encourage foods high in magnesium
  • 82. Hypomagnesia
    • Monitor…
    • Monitor EKG for Arrhythmias
    • Monitor for muscle cramps
  • 83. Hypermagnesemia
    • Severe hypermagnesemia is associated with AV blocks and intraventricular conduction disturbances
  • 84. Calcium
    • Reference Range:
    • 8.5 – 10.1 mg/dl
  • 85. Calcium
    • 99% Ca ++ in bones; 1% in serum & soft tissue (measured in blood serum levels)
    • Is found in both ECF and ICF
    • Can be measured in 2 ways:
      • Total serum calcium (total Ca ++ in blood)
      • Ionized calcium level (various forms of Ca ++ in ECF)
    • 41% ECF Ca ++ is bound to protein; 9% bound to citrate or other organic ions
  • 86. Calcium
    • Ca ++ functions in the following ways:
      • Responsible for formation of bones and teeth
      • Helps maintain cell structure & function
      • Plays a role in cell membrane permeability and impulse transmission
      • Affects contraction of cardiac muscle, smooth muscle, and skeletal muscle
      • Participates in blood-clotting process
  • 87. Calcium
    • Calcium helps potassium & sodium move into and out cells in the sodium-potassium pump mechanism
  • 88. Hypocalcemia
    • Causes:
    • Vitamin D Deficiency
      • Vitamin D promotes Ca ++ absorption in intestines, resorption from bones, and kidney resorption all of which raise Ca ++ levels
    • Deficiency of parathyroid hormone
    • Inefficient parathyroid hormone
  • 89. Hypocalcemia
    • Causes:
    • Deficiency of parathyroid hormone (PTH)
      • Calcitonin, secreted by PTH, helps regulate Ca++
      • Decreases absorption of Ca++ and enhances its excretion by the kidneys
  • 90. Hypocalcemia
    • Hypocalcemia May Cause…
    • Laryngospasm
    • Cardiac Arrhythmias
    • EKG Δ ’s -> prolonged QT interval
  • 91. Hypocalcemia
    • Management…
    • PO or IV calcium replacement
    • (depends on severity of symptoms or deficiency)
    • Vitamin D supplement
    • Encourage foods high in calcium
  • 92. Hypercalcemia
    • Causes of Hypercalcemia:
    • Excessive calcium release
    • Increased intestinal calcium absorption
    • ** Decreased renal calcium excretion **
  • 93. Hypercalcemia
    • Hypercalcemia May Cause…
    • Cardiac Arrhythmias
    • EKG Δ ’s -> shortened QT interval
  • 94. Hypercalcemia
    • Severe Hypercalcemia (> 15mg/dl) is a…
    • Medical Emergency
    • May result in
    • Coma or Cardiac Arrest
  • 95. Hypercalcemia
    • Signs & Symptoms…
    • Fatigue
    • Depression
    • Confusion
    • Anorexia
    • N/V
    • Constipation
    • Pancreatitis
    • Increased Urination
  • 96. Hypercalcemia
    • Treatment…
    • Hydration
    • Increased Salt Intake
    • Diuretics
    • Dialysis (renal failure)
    • Glucocorticoids
  • 97. Renal Function
  • 98. Renal Function
    • The main function of the renal system is to excrete bio-waste, regulate water and electrolyte levels, and release of hormones that affect RBC production, bone metabolism, and hypertension.
  • 99. Renal Function
    • Minimal urine output = 30 ml/hr
    • Output affected by fluid intake, hormones, & medications
    • Renal impairment causes imbalances of both fluids and electrolytes
  • 100. Blood Urea Nitrogen
    • Reference Range: 5 -20 mg/dl
    • An end-product of protein metabolism
    • Excreted by the kidneys
    • Elevated levels are indicators of possible dehydration, pre-renal failure, or renal failure
  • 101. Blood Urea Nitrogen
    • Reference Range: 5 -20 mg/dl
    • If BUN ↑ (up to 35 mg/dl) but the creatinine is WNL = DEHYDRATION
    • Usually as a result of…
    • Diarrhea, vomiting, and/or inadequate fluid intake
    • BUN WNL after hydration. If not, may indicate pre-renal or renal failure
  • 102. Creatinine
    • Reference Range: 0.8 – 1.3 mg/dl
    • A by-product of muscle catabolism
    • Excreted by glomerular filtration
    • More specific indicator of renal failure
    • Not influenced by diet or fluid intake
  • 103. Creatinine
    • Reference Range: 0.7 – 1.5 mg/dl
    • If creatinine ↑ (> 2.5 mg/dl) this could be indicative of renal impairment
    • IF both BUN and creatinine are elevated, then renal disorder is present
  • 104. BUN/Creatinine Ratio
    • Reference Range: 10 - 20
    • Low – Suspect acute tubular necrosis , malnutrition, low protein intake, pregnancy, liver disease, hemodialysis
    • High – Reduced renal perfusion (dehydration, heart failure), glomerular disease , tissue or muscle destruction, high protein intake, azotemia (elevated urea levels)
  • 105. References
    • Kee, J. L. (2005). Laboratory and diagnostic tests with nursing implications (7th ed.). Upper Saddle River, NJ: Pearson Prentice Hall.
    • Kee, J. L. & Paulanka, B. J. (2000). Handbook of fluid, electrolyte, and acid-base imbalances. Scarborough, Canada: Delmar Publishers.
    • Priff, N. (ed.). (2006). Nurse’s quick check: Fluids and electrolytes. Ambler, PA: Lippincott, Wilkins, and Williams.
    • Smeltzer, S. C. et al. (2008). Brunner and suddarth’s textbook of medical-surgical nursing (11 th ed.). Philadelphia, PA: Lippincott Williams and Wilkins.
    • Taber’s On-Line Medical Dictionary