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  1. 1. Fluid and Electrolytes Ms. Cherry Ann G. Garcia RN, MAN-IP [email_address]
  2. 2. Homeostasis <ul><li>State of equilibrium in body </li></ul><ul><li>Naturally maintained by adaptive responses </li></ul><ul><li>Body fluids and electrolytes are maintained within narrow limits </li></ul>
  3. 3. Water Content of the Body <ul><li>60% of body weight in adult </li></ul><ul><li>45% to 55% in older adults </li></ul><ul><li>70% to 80% in infants </li></ul><ul><ul><li>Varies with body fat, age and gender </li></ul></ul>
  4. 4. Compartments <ul><li>Intracellular fluid (ICF) </li></ul><ul><li>Extracellular fluid (ECF) </li></ul><ul><ul><li>Intravascular (plasma) </li></ul></ul><ul><ul><li>Interstitial </li></ul></ul><ul><ul><li>Transcellular </li></ul></ul>
  5. 5. Fluid Compartments of the Body
  6. 6. Intracellular Fluid (ICF) <ul><li>Located within cells </li></ul><ul><li>40% of total body weight </li></ul>
  7. 7. Extracellular Fluid (ECF) <ul><li>One-third of body weight </li></ul><ul><li>Between cells (interstitial fluid), lymph, plasma, and transcellular fluid </li></ul>
  8. 8. Transcellular Fluid <ul><li>Part of ECF </li></ul><ul><li>Small but important </li></ul><ul><li>Approximately 1 liter </li></ul>
  9. 9. Transcellular Fluid <ul><li>Includes fluid in </li></ul><ul><ul><li>Cerebrospinal fluid </li></ul></ul><ul><ul><li>Gastrointestinal tract </li></ul></ul><ul><ul><li>Pleural spaces </li></ul></ul><ul><ul><li>Synovial spaces </li></ul></ul><ul><ul><li>Peritoneal fluid spaces </li></ul></ul>
  10. 10. Electrolytes <ul><li>Substances whose molecules dissociate into ions (charged particles) when placed into water </li></ul><ul><ul><li>Cations: positively-charged </li></ul></ul><ul><ul><li>Anions: negatively-charged </li></ul></ul>
  11. 11. Functions of Electrolytes <ul><li>Promote neuromuscular irritability </li></ul><ul><li>Regulate acid and base balance </li></ul><ul><li>Regulate distribution of body fluids among body fluid compartments </li></ul>
  12. 12. Measurement of Electrolytes <ul><li>International standard is millimoles per liter ( mmol/L ) </li></ul><ul><li>U.S. uses milliequivalent ( mEq ) </li></ul><ul><ul><li>Ions combine mEq for mEq </li></ul></ul>
  13. 13. Electrolyte Composition <ul><li>ICF </li></ul><ul><ul><li>Prevalent cation is K + </li></ul></ul><ul><ul><li>Prevalent anion is PO 4 3- </li></ul></ul><ul><li>ECF </li></ul><ul><ul><li>Prevalent cation is Na + </li></ul></ul><ul><ul><li>Prevalent anion is Cl - </li></ul></ul>
  14. 14. Mechanisms Controlling Fluid and Electrolyte Movement <ul><li>Diffusion </li></ul><ul><li>Facilitated diffusion </li></ul><ul><li>Active transport </li></ul><ul><li>Osmosis </li></ul><ul><li>Hydrostatic pressure </li></ul><ul><li>Oncotic pressure </li></ul>the natural tendency of a substance to move from an area of higher concentration to one of lower concentration the pressure created by the weight of fluid against the wall that contains it the process by which fluid moves across a semi-permeable membrane from an area of low solute concentration to an area of high solute concentration Osmotic pressure exerted by proteins physiologic pump that moves fluid from an area of lower concentration to one of higher concentration type of passive transport that allows substances to cross membranes with the assistance of special  transport proteins
  15. 15. Facilitated Diffusion Some molecules and ions such as glucose, sodium ions and chloride ions are unable to pass through the lipid bilayer of cell membranes.
  16. 16. Sodium–Potassium Pump Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
  17. 17. Fluid Movement in Capillaries <ul><li>Amount and direction of movement determined by: </li></ul><ul><ul><li>Capillary hydrostatic pressure </li></ul></ul><ul><ul><li>Plasma oncotic pressure </li></ul></ul><ul><ul><li>Interstitial hydrostatic pressure </li></ul></ul><ul><ul><li>Interstitial oncotic pressure </li></ul></ul>
  18. 18. Fluid Exchange Between Capillary and Tissue
  19. 19. Fluid Shifts <ul><li>Plasma to interstitial fluid shift results in edema: </li></ul><ul><ul><li>Elevation of hydrostatic pressure </li></ul></ul><ul><ul><li>Decrease in plasma oncotic pressure </li></ul></ul><ul><ul><li>Elevation of interstitial oncotic pressure </li></ul></ul>
  20. 20. Fluid Shifts <ul><li>Interstitial fluid to plasma </li></ul><ul><ul><li>Fluid drawn into plasma space with increase in plasma osmotic or oncotic pressure </li></ul></ul><ul><ul><li>Compression stockings decrease peripheral edema </li></ul></ul>
  21. 21. Fluid Movement between ECF and ICF <ul><li>Water deficit (increased ECF) </li></ul><ul><ul><li>Associated with symptoms that result from cell shrinkage as water is pulled into vascular system </li></ul></ul>
  22. 22. Fluid Movement between ECF and ICF <ul><li>Water excess (decreased ECF) </li></ul><ul><ul><li>Develops from gain or retention of excess water </li></ul></ul>
  23. 23. Fluid Spacing <ul><li>First spacing </li></ul><ul><ul><li>Normal distribution of fluid in ICF and ECF </li></ul></ul><ul><li>Second spacing </li></ul><ul><ul><li>Abnormal accumulation of interstitial fluid (edema) </li></ul></ul>
  24. 24. Fluid Spacing <ul><li>Third spacing </li></ul><ul><ul><li>Fluid accumulation in part of body where it is not easily exchanged with ECF </li></ul></ul>
  25. 25. Regulation of Water Balance <ul><li>Hypothalamic regulation </li></ul><ul><li>Pituitary regulation </li></ul><ul><li>Adrenal cortical regulation </li></ul><ul><li>Renal regulation </li></ul>
  26. 26. Hypothalamic Regulation <ul><li>Osmoreceptors in hypothalamus sense fluid deficit or increase </li></ul><ul><ul><li>Stimulates thirst and antidiuretic hormone (ADH) release </li></ul></ul><ul><ul><li>Result in increased free water and decreased plasma osmolarity </li></ul></ul>
  27. 27. Pituitary Regulation <ul><li>Under control of hypothalamus, posterior pituitary releases ADH </li></ul><ul><li>Stress, nausea, nicotine, and morphine also stimulate ADH release </li></ul>
  28. 28. Adrenal Cortical Regulation <ul><li>Releases hormones to regulate water and electrolytes </li></ul><ul><ul><li>Glucocorticoids </li></ul></ul><ul><ul><ul><li>Cortisol </li></ul></ul></ul><ul><ul><li>Mineralocorticoids </li></ul></ul><ul><ul><ul><li>Aldosterone </li></ul></ul></ul>
  29. 29. Factors Affecting Aldosterone Secretion
  30. 30. Renal Regulation <ul><li>Primary organs for regulating fluid and electrolyte balance </li></ul><ul><ul><li>Adjusting urine volume </li></ul></ul><ul><ul><ul><li>Selective reabsorption of water and electrolytes </li></ul></ul></ul><ul><ul><ul><li>Renal tubules are sites of action of ADH and aldosterone </li></ul></ul></ul>
  31. 31. Effects of Stress on F&E Balance
  32. 32. Cardiac Regulation <ul><li>Natriuretic peptides are antagonists to the RAAS </li></ul><ul><ul><li>Produced by cardiomyocytes in response to increased atrial pressure </li></ul></ul><ul><ul><li>Suppress secretion of aldosterone, renin, and ADH to decrease blood volume and pressure </li></ul></ul>
  33. 33. Gastrointestinal Regulation <ul><li>Oral intake accounts for most water </li></ul><ul><li>Small amounts of water are eliminated by gastrointestinal tract in feces </li></ul><ul><li>Diarrhea and vomiting can lead to significant fluid and electrolyte loss </li></ul>
  34. 34. Insensible Water Loss <ul><li>Invisible vaporization from lungs and skin to regulate body temperature </li></ul><ul><ul><li>Approximately 600 to 900 ml/day is lost </li></ul></ul><ul><ul><li>No electrolytes are lost </li></ul></ul>
  35. 35. Gerontologic Considerations <ul><li>Structural changes in kidneys decrease ability to conserve water </li></ul><ul><li>Hormonal changes lead to decrease in ADH and ANP </li></ul><ul><li>Loss of subcutaneous tissue leads to increased loss of moisture </li></ul>
  36. 36. Gerontologic Considerations <ul><li>Reduced thirst mechanism results in decreased fluid intake </li></ul><ul><li>Nurse must assess for these changes and implement treatment accordingly </li></ul>
  37. 37. Fluid and Electrolyte Imbalances <ul><li>Common in most patients with illness </li></ul><ul><ul><li>Directly caused by illness or disease (burns or heart failure) </li></ul></ul><ul><ul><li>Result of therapeutic measures (IV fluid replacement or diuretics) </li></ul></ul>
  38. 38. Extracellular Fluid Volume Imbalances <ul><li>ECF volume deficit (hypovolemia) </li></ul><ul><ul><li>Abnormal loss of normal body fluids (diarrhea, fistula drainage, hemorrhage), inadequate intake, or plasma-to-interstitial fluid shift </li></ul></ul><ul><ul><li>Treatment: replace water and electrolytes with balanced IV solutions </li></ul></ul>
  39. 39. Causes of Volume deficit <ul><li>High fever heat stroke </li></ul><ul><li>DI </li></ul><ul><li>Hemorrhage </li></ul><ul><li>GI losses </li></ul><ul><li>Overuse of diuretics </li></ul><ul><li>Inadequate fluid Intake </li></ul><ul><li>Third-space fluid shifts </li></ul>
  40. 40. Clinical manifestations <ul><li>Restlessness,lethargy, confusion </li></ul><ul><li>Thirst </li></ul><ul><li>Decreased skin turgor </li></ul><ul><li>Postural hypotension </li></ul><ul><li>Decreased urine output </li></ul><ul><li>Increased resp. rate </li></ul><ul><li>Wt. Loss </li></ul><ul><li>Seizures, coma </li></ul>
  41. 41. Extracellular Fluid Volume Imbalances <ul><li>Fluid volume excess (hypervolemia) </li></ul><ul><ul><li>Excessive intake of fluids, abnormal retention of fluids (CHF), or interstitial-to-plasma fluid shift </li></ul></ul><ul><ul><li>Treatment: remove fluid without changing electrolyte composition or osmolality of ECF </li></ul></ul>
  42. 42. Causes <ul><li>Excessive isotonic or hypotonic IV fluids </li></ul><ul><li>Heart failure </li></ul><ul><li>Renal failure </li></ul><ul><li>SIADH </li></ul><ul><li>Cushing syndrome </li></ul><ul><li>Long-term use corticosteroids </li></ul>
  43. 43. Manifestations-Clinical <ul><li>Headache, confusion, lethargy </li></ul><ul><li>Peripheral edema </li></ul><ul><li>Distended neck veins </li></ul><ul><li>Bounding pulse, </li></ul><ul><li>Polyuria </li></ul><ul><li>Dyspnea, crackles, pulmonary edema </li></ul><ul><li>Wt. Gain </li></ul><ul><li>Seizures, coma </li></ul>
  44. 44. Nursing Management Nursing Diagnoses <ul><li>Hypovolemia </li></ul><ul><ul><li>Deficient fluid volume </li></ul></ul><ul><ul><li>Decreased cardiac output </li></ul></ul><ul><ul><li>Potential complication: hypovolemic shock </li></ul></ul>
  45. 45. Nursing Management Nursing Diagnoses <ul><li>Hypervolemia </li></ul><ul><ul><li>Excess fluid volume </li></ul></ul><ul><ul><li>Ineffective airway clearance </li></ul></ul><ul><ul><li>Risk for impaired skin integrity </li></ul></ul><ul><ul><li>Disturbed body image </li></ul></ul><ul><ul><li>Potential complications: pulmonary edema, ascites </li></ul></ul>
  46. 46. Nursing Management Nursing Implementation <ul><li>I&O </li></ul><ul><li>Monitor cardiovascular changes </li></ul><ul><li>Assess respiratory status and monitor changes </li></ul><ul><li>Daily weights </li></ul><ul><li>Skin assessment </li></ul>
  47. 47. Nursing Management Nursing Implementation <ul><li>Neurologic function </li></ul><ul><ul><li>LOC </li></ul></ul><ul><ul><li>PERLA </li></ul></ul><ul><ul><li>Voluntary movement of extremities </li></ul></ul><ul><ul><li>Muscle strength </li></ul></ul><ul><ul><li>Reflexes </li></ul></ul>
  48. 48. Electrolyte Disorders Signs and Symptoms Electrolyte Excess Deficit Sodium (Na) Hypernatremia Thirst CNS deterioration Increased interstitial fluid Hyponatremia CNS deterioration Potassium (K) Hyperkalemia Ventricular fibrillation ECG changes CNS changes Hypokalemia Bradycardia ECG changes CNS changes
  49. 49. Electrolyte Disorders Signs and Symptoms Electrolyte Excess Deficit Calcium (Ca) Hypercalcemia Thirst CNS deterioration Increased interstitial fluid Hypocalcemia Tetany Chvostek’s, Trousseau’s signs Muscle twitching CNS changes ECG changes Magnesium (Mg) Hypermagnesemia Loss of deep tendon reflexes (DTRs) Depression of CNS Depression of neuromuscular function Hypomagnesemia Hyperactive DTRs CNS changes
  50. 50. Sodium <ul><li>Imbalances typically associated with parallel changes in osmolality </li></ul><ul><li>Plays a major role in </li></ul><ul><ul><li>ECF volume and concentration </li></ul></ul><ul><ul><li>Generation and transmission of nerve impulses </li></ul></ul><ul><ul><li>Acid–base balance </li></ul></ul>
  51. 51. Hypernatremia <ul><li>Elevated serum sodium occurring with water loss or sodium gain </li></ul><ul><li>Causes hyperosmolality leading to cellular dehydration </li></ul><ul><li>Primary protection is thirst from hypothalamus </li></ul>
  52. 52. Differential Assessment of ECF Volume
  53. 53. Imbalances in ECF Volume
  54. 54. Hypernatremia <ul><li>Manifestations </li></ul><ul><ul><li>Thirst, lethargy, agitation, seizures, and coma </li></ul></ul><ul><li>Impaired LOC </li></ul><ul><li>Produced by clinical states </li></ul><ul><ul><li>Central or nephrogenic diabetes insipidus </li></ul></ul>
  55. 55. Hypernatremia <ul><li>Serum sodium levels must be reduced gradually to avoid cerebral edema </li></ul>
  56. 56. Nursing Management Nursing Diagnoses <ul><li>Risk for injury </li></ul><ul><li>Potential complication: seizures and coma leading to irreversible brain damage </li></ul>
  57. 57. Nursing Management Nursing Implementation <ul><li>Treat underlying cause </li></ul><ul><li>If oral fluids cannot be ingested, IV solution of 5% dextrose in water or hypotonic saline </li></ul><ul><li>Diuretics </li></ul>
  58. 58. Hyponatremia <ul><li>Results from loss of sodium-containing fluids or from water excess </li></ul><ul><li>Manifestations </li></ul><ul><ul><li>Confusion, nausea, vomiting, seizures, and coma </li></ul></ul>
  59. 59. Nursing Management Nursing Diagnoses <ul><li>Risk for injury </li></ul><ul><li>Potential complication: severe neurologic changes </li></ul>
  60. 60. Nursing Management Nursing Implementation <ul><li>Caused by water excess </li></ul><ul><ul><li>Fluid restriction is needed </li></ul></ul><ul><li>Severe symptoms (seizures) </li></ul><ul><ul><li>Give small amount of IV hypertonic saline solution (3% NaCl) </li></ul></ul>
  61. 61. Nursing Management Nursing Implementation <ul><li>Abnormal fluid loss </li></ul><ul><ul><li>Fluid replacement with sodium-containing solution </li></ul></ul>
  62. 62. Potassium <ul><li>Major ICF cation </li></ul><ul><li>Necessary for </li></ul><ul><ul><li>Transmission and conduction of nerve and muscle impulses </li></ul></ul><ul><ul><li>Maintenance of cardiac rhythms </li></ul></ul><ul><ul><li>Acid–base balance </li></ul></ul>
  63. 63. Potassium <ul><li>Sources </li></ul><ul><ul><li>Fruits and vegetables (bananas and oranges) </li></ul></ul><ul><ul><li>Salt substitutes </li></ul></ul><ul><ul><li>Potassium medications (PO, IV) </li></ul></ul><ul><ul><li>Stored blood </li></ul></ul>
  64. 64. Hyperkalemia <ul><li>High serum potassium caused by </li></ul><ul><ul><li>Massive intake </li></ul></ul><ul><ul><li>Impaired renal excretion </li></ul></ul><ul><ul><li>Shift from ICF to ECF </li></ul></ul><ul><li>Common in massive cell destruction </li></ul><ul><ul><li>Burn, crush injury, or tumor lysis </li></ul></ul>
  65. 65. Hyperkalemia <ul><li>Manifestations </li></ul><ul><ul><li>Weak or paralyzed skeletal muscles </li></ul></ul><ul><ul><li>Ventricular fibrillation or cardiac standstill </li></ul></ul><ul><ul><li>Abdominal cramping or diarrhea </li></ul></ul>
  66. 67. Nursing Management Nursing Diagnoses <ul><li>Risk for injury </li></ul><ul><li>Potential complication: dysrhythmias </li></ul>
  67. 68. Nursing Management Nursing Implementation <ul><li>Eliminate oral and parenteral K intake </li></ul><ul><li>Increase elimination of K (diuretics, dialysis, Kayexalate) </li></ul>
  68. 69. Nursing Management Nursing Implementation <ul><li>Force K from ECF to ICF by IV insulin or sodium bicarbonate </li></ul><ul><li>Reverse membrane effects of elevated ECF potassium by administering calcium gluconate IV </li></ul>
  69. 70. Hypokalemia <ul><li>Low serum potassium caused by </li></ul><ul><ul><li>Abnormal losses of K + via the kidneys or gastrointestinal tract </li></ul></ul><ul><ul><li>Magnesium deficiency </li></ul></ul><ul><ul><li>Metabolic alkalosis </li></ul></ul>
  70. 71. Hypokalemia <ul><li>Manifestations </li></ul><ul><ul><li>Most serious are cardiac </li></ul></ul><ul><ul><li>Skeletal muscle weakness </li></ul></ul><ul><ul><li>Weakness of respiratory muscles </li></ul></ul><ul><ul><li>Decreased gastrointestinal motility </li></ul></ul>
  71. 73. Nursing Management Nursing Diagnoses <ul><li>Risk for injury </li></ul><ul><li>Potential complication: dysrhythmias </li></ul>
  72. 74. Nursing Management Nursing Implementation <ul><li>KCl supplements orally or IV </li></ul><ul><li>Should not exceed 10 to 20 mEq/hr </li></ul><ul><ul><li>To prevent hyperkalemia and cardiac arrest </li></ul></ul>
  73. 75. Calcium <ul><li>Obtained from ingested foods </li></ul><ul><li>More than 99% combined with phosphorus and concentrated in skeletal system </li></ul><ul><li>Inverse relationship with phosphorus </li></ul>
  74. 76. Calcium <ul><li>Bones are readily available store </li></ul><ul><li>Blocks sodium transport and stabilizes cell membrane </li></ul><ul><li>Ionized form is biologically active </li></ul>
  75. 77. Calcium <ul><li>Functions </li></ul><ul><ul><li>Transmission of nerve impulses </li></ul></ul><ul><ul><li>Myocardial contractions </li></ul></ul><ul><ul><li>Blood clotting </li></ul></ul><ul><ul><li>Formation of teeth and bone </li></ul></ul><ul><ul><li>Muscle contractions </li></ul></ul>
  76. 78. Calcium <ul><li>Balance controlled by </li></ul><ul><ul><li>Parathyroid hormone </li></ul></ul><ul><ul><li>Calcitonin </li></ul></ul><ul><ul><li>Vitamin D </li></ul></ul>
  77. 79. Hypercalcemia <ul><li>High serum calcium levels caused by </li></ul><ul><ul><li>Hyperparathyroidism (two thirds of cases) </li></ul></ul><ul><ul><li>Malignancy </li></ul></ul><ul><ul><li>Vitamin D overdose </li></ul></ul><ul><ul><li>Prolonged immobilization </li></ul></ul>
  78. 80. Hypercalcemia <ul><li>Manifestations </li></ul><ul><ul><li>Decreased memory </li></ul></ul><ul><ul><li>Confusion </li></ul></ul><ul><ul><li>Disorientation </li></ul></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>Constipation </li></ul></ul>
  79. 81. Nursing Management Nursing Diagnoses <ul><li>Risk for injury </li></ul><ul><li>Potential complication: dysrhythmias </li></ul>
  80. 82. Nursing Management Nursing Implementation <ul><li>Excretion of Ca with loop diuretic </li></ul><ul><li>Hydration with isotonic saline infusion </li></ul><ul><li>Synthetic calcitonin </li></ul><ul><li>Mobilization </li></ul>
  81. 83. Hypocalcemia <ul><li>Low serum Ca levels caused by </li></ul><ul><ul><li>Decreased production of PTH </li></ul></ul><ul><ul><li>Acute pancreatitis </li></ul></ul><ul><ul><li>Multiple blood transfusions </li></ul></ul><ul><ul><li>Alkalosis </li></ul></ul><ul><ul><li>Decreased intake </li></ul></ul>
  82. 84. Hypocalcemia <ul><li>Manifestations </li></ul><ul><ul><li>Positive Trousseau’s or Chvostek’s sign </li></ul></ul><ul><ul><li>Laryngeal stridor </li></ul></ul><ul><ul><li>Dysphagia </li></ul></ul><ul><ul><li>Tingling around the mouth or in the extremities </li></ul></ul>
  83. 85. Tests for Hypocalcemia Fig. 17-15
  84. 86. Nursing Management Nursing Diagnoses <ul><li>Risk for injury </li></ul><ul><li>Potential complication: fracture or respiratory arrest </li></ul>
  85. 87. Nursing Management Nursing Implementation <ul><li>Treat cause </li></ul><ul><li>Oral or IV calcium supplements </li></ul><ul><ul><li>Not IM to avoid local reactions </li></ul></ul><ul><li>Treat pain and anxiety to prevent hyperventilation-induced respiratory alkalosis </li></ul>
  86. 88. Phosphate <ul><li>Primary anion in ICF </li></ul><ul><li>Essential to function of muscle, red blood cells, and nervous system </li></ul><ul><li>Deposited with calcium for bone and tooth structure </li></ul>
  87. 89. Phosphate <ul><li>Involved in acid–base buffering system, ATP production, and cellular uptake of glucose </li></ul><ul><li>Maintenance requires adequate renal functioning </li></ul><ul><li>Essential to muscle, RBCs, and nervous system function </li></ul>
  88. 90. Hyperphosphatemia <ul><li>High serum PO 4 3  caused by </li></ul><ul><ul><li>Acute or chronic renal failure </li></ul></ul><ul><ul><li>Chemotherapy </li></ul></ul><ul><ul><li>Excessive ingestion of phosphate or vitamin D </li></ul></ul>
  89. 91. Hyperphosphatemia <ul><li>Manifestations </li></ul><ul><ul><li>Calcified deposition in soft tissue such as joints, arteries, skin, kidneys, and corneas </li></ul></ul><ul><ul><li>Neuromuscular irritability and tetany </li></ul></ul>
  90. 92. Hyperphosphatemia <ul><li>Management </li></ul><ul><ul><li>Identify and treat underlying cause </li></ul></ul><ul><ul><li>Restrict foods and fluids containing PO 4 3  </li></ul></ul><ul><ul><li>Adequate hydration and correction of hypocalcemic conditions </li></ul></ul>
  91. 93. Hypophosphatemia <ul><li>Low serum PO 4 3  caused by </li></ul><ul><ul><li>Malnourishment/malabsorption </li></ul></ul><ul><ul><li>Alcohol withdrawal </li></ul></ul><ul><ul><li>Use of phosphate-binding antacids </li></ul></ul><ul><ul><li>During parenteral nutrition with inadequate replacement </li></ul></ul>
  92. 94. Hypophosphatemia <ul><li>Manifestations </li></ul><ul><ul><li>CNS depression </li></ul></ul><ul><ul><li>Confusion </li></ul></ul><ul><ul><li>Muscle weakness and pain </li></ul></ul><ul><ul><li>Dysrhythmias </li></ul></ul><ul><ul><li>Cardiomyopathy </li></ul></ul>
  93. 95. Hypophosphatemia <ul><li>Management </li></ul><ul><ul><li>Oral supplementation </li></ul></ul><ul><ul><li>Ingestion of foods high in PO 4 3  </li></ul></ul><ul><ul><li>IV administration of sodium or potassium phosphate </li></ul></ul>
  94. 96. Magnesium <ul><li>50% to 60% contained in bone </li></ul><ul><li>Coenzyme in metabolism of protein and carbohydrates </li></ul><ul><li>Factors that regulate calcium balance appear to influence magnesium balance </li></ul>
  95. 97. Magnesium <ul><li>Acts directly on myoneural junction </li></ul><ul><li>Important for normal cardiac function </li></ul>
  96. 98. Hypermagnesemia <ul><li>High serum Mg caused by </li></ul><ul><ul><li>Increased intake or ingestion of products containing magnesium when renal insufficiency or failure is present </li></ul></ul>
  97. 99. Hypermagnesemia <ul><li>Manifestations </li></ul><ul><ul><li>Lethargy or drowsiness </li></ul></ul><ul><ul><li>Nausea/vomiting </li></ul></ul><ul><ul><li>Impaired reflexes </li></ul></ul><ul><ul><li>Respiratory and cardiac arrest </li></ul></ul>
  98. 100. Hypermagnesemia <ul><li>Management </li></ul><ul><ul><li>Prevention </li></ul></ul><ul><ul><li>Emergency treatment </li></ul></ul><ul><ul><ul><li>IV CaCl or calcium gluconate </li></ul></ul></ul><ul><ul><li>Fluids to promote urinary excretion </li></ul></ul>
  99. 101. Hypomagnesemia <ul><li>Low serum Mg caused by </li></ul><ul><ul><li>Prolonged fasting or starvation </li></ul></ul><ul><ul><li>Chronic alcoholism </li></ul></ul><ul><ul><li>Fluid loss from gastrointestinal tract </li></ul></ul><ul><ul><li>Prolonged parenteral nutrition without supplementation </li></ul></ul><ul><ul><li>Diuretics </li></ul></ul>
  100. 102. Hypomagnesemia <ul><li>Manifestations </li></ul><ul><ul><li>Confusion </li></ul></ul><ul><ul><li>Hyperactive deep tendon reflexes </li></ul></ul><ul><ul><li>Tremors </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Cardiac dysrhythmias </li></ul></ul>
  101. 103. Hypomagnesemia <ul><li>Management </li></ul><ul><ul><li>Oral supplements </li></ul></ul><ul><ul><li>Increase dietary intake </li></ul></ul><ul><ul><li>Parenteral IV or IM magnesium when severe </li></ul></ul>
  102. 104. IV Fluids <ul><li>Purposes </li></ul><ul><ul><li>Maintenance </li></ul></ul><ul><ul><ul><li>When oral intake is not adequate </li></ul></ul></ul><ul><ul><li>Replacement </li></ul></ul><ul><ul><ul><li>When losses have occurred </li></ul></ul></ul>
  103. 105. IV Fluids <ul><li>Hypotonic </li></ul><ul><ul><li>More water than electrolytes </li></ul></ul><ul><ul><ul><li>Pure water lyses RBCs </li></ul></ul></ul><ul><ul><li>Water moves from ECF to ICF by osmosis </li></ul></ul><ul><ul><li>Usually maintenance fluids </li></ul></ul>
  104. 106. IV Fluids <ul><li>Isotonic </li></ul><ul><ul><li>Expands only ECF </li></ul></ul><ul><ul><li>No net loss or gain from ICF </li></ul></ul>
  105. 107. IV Fluids <ul><li>Hypertonic </li></ul><ul><ul><li>Initially expands and raises the osmolality of ECF </li></ul></ul><ul><ul><li>Require frequent monitoring of </li></ul></ul><ul><ul><ul><li>Blood pressure </li></ul></ul></ul><ul><ul><ul><li>Lung sounds </li></ul></ul></ul><ul><ul><ul><li>Serum sodium levels </li></ul></ul></ul>
  106. 108. D5W <ul><li>Isotonic </li></ul><ul><li>Provides 170 cal/L </li></ul><ul><li>Free water </li></ul><ul><ul><li>Moves into ICF </li></ul></ul><ul><ul><li>Increases renal solute excretion </li></ul></ul>
  107. 109. D5W <ul><li>Used to replace water losses and treat hyponatremia </li></ul><ul><li>Does not provide electrolytes </li></ul>
  108. 110. Normal Saline (NS) <ul><li>Isotonic </li></ul><ul><li>No calories </li></ul><ul><li>More NaCl than ECF </li></ul><ul><li>30% stays in IV (most) </li></ul><ul><ul><li>70% moves out of IV </li></ul></ul>
  109. 111. Normal Saline (NS) <ul><li>Expands IV volume </li></ul><ul><ul><li>Preferred fluid for immediate response </li></ul></ul><ul><ul><li>Risk for fluid overload higher </li></ul></ul><ul><li>Does not change ICF volume </li></ul><ul><li>Blood products </li></ul><ul><li>Compatible with most medications </li></ul>
  110. 113. Lactated Ringer’s <ul><li>Isotonic </li></ul><ul><li>More similar to plasma than NS </li></ul><ul><ul><li>Has less NaCl </li></ul></ul><ul><ul><li>Has K, Ca, PO 4 3  , lactate (metabolized to HCO 3  ) </li></ul></ul><ul><li>Expands ECF </li></ul>
  111. 114. D5 ½ NS <ul><li>Hypertonic </li></ul><ul><li>Common maintenance fluid </li></ul><ul><li>KCl added for maintenance or replacement </li></ul>
  112. 115. D10W <ul><li>Hypertonic </li></ul><ul><li>Provides 340 kcal/L </li></ul><ul><li>Free water </li></ul><ul><li>Limit of dextrose concentration may be infused peripherally </li></ul>
  113. 116. Plasma Expanders <ul><li>Stay in vascular space and increase osmotic pressure </li></ul><ul><li>Colloids (protein solutions) </li></ul><ul><ul><li>Packed RBCs </li></ul></ul><ul><ul><li>Albumin </li></ul></ul><ul><ul><li>Plasma </li></ul></ul>