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Fluid and electrolyte imbalance
- 2. Fluid and electrolyte with in the body are necessary to maintain health and function in all body system. INTRODUCTION
- 3. • Water is the primary content of our body. It accounts for about 50-60% of body weight in the adult. Water content varies with body mass, gender and age. In people with over 65 years of age body water may decrease up to 45-50 % of total body weight. Water Contents Of The Body
- 4. Body fluids Distribution • Intracellular fluid(ICF) 40% body weight • Extracellular fluid(ECF) 20% body weight • Interstitial fluid - 15% body weight • Plasma -5% body weight
- 5. MOVEMENT OF BODY FLUIDS • Fluids and electrolyte constantly shift from compartment to compartment to facilitate body processes such as tissue oxygenation, acid base balance and urine formation Mechanisms controlling fluid & electrolyte movement • Diffusion • Facilitateddiffusion • Active transport (SodiumPotassiumPump) • Osmosis
- 6. DIFFUSION FACILITATED DIFFUSION ACTIVE TRANSPORT Sodium potassium pump It is the movement of fluids or substances across the membrane
- 7. OSMOSIS Osmotic Movement of Fluids Movement of water from low solute to high through a semipermeable membrane until concentration gradient is equal
- 8. Fluid Movement in Capillaries As plasma flows through the capillary bed, four factors determine if fluid moves out of the capillary and into the interstitial space or if fluid moves back into the capillary from the interstitial space.
- 9. Water balance is the result of interaction of thirst & ADH to maintain a stable plasma tonicity (OP) The sensation of thirst promotes water intake ADH regulates urinary water excretion. REGULATION OF WATER BALANCE
- 10. REGULATION OF WATER INTAKE AND OUTPUT The volume of water gained each day varies among individuals averaging about 2,500 milliliters daily for an adult. 60% from drinking 30% from moist foods 10% as a bi-product of oxidative metabolism of Nutrients called water of metabolism Water Output Water normally enters the body only through the mouth, but it can be lost by a variety of routes including: Urine (60% loss) (6% loss) (sensible perspiration) (6% loss) Evaporation from the skin (insensible perspiration) Evaporation from the skin and the lungs is a 28% loss)
- 11. Hypothalamic - Pituitary regulation Renal regulation Adrenal cortical regulation Cardiac regulation Gastro-intestinal regulation
- 15. Fluid Volume Deficit Fluid Volume Excess Hypernatremia/ Hyponatremia Hyperkalemia/ Hypokalemia Hypercalcemia/ Hypocalcemia Hyperphosphatemia/ Hypophosphatemia Hypermagnesemia /Hypomagnesemia Hyperchloremia / Hypochloremia FLUID AND ELECTROLYTE DISORDERS
- 16. Age Illness Injury or blood loss Gender Renal function Gastro intestinal function 3rd space loss (Burns) Activity level Level of consciousness Body temperature Stress Factors Affecting Fluid Imbalance
- 17. • Fluid Intake is less than Fluid Output: • Hypovolemia —water and electrolyte losses about equal • Clinical Dehydration—more water lost than electrolytes • Fluid volume deficit + hypernatremia Hypovolemia or Dehydration FLUID VOLUME DEFICIT (FVD)
- 18. Causes of FVD Prolonged fever GI Losses: Watery diarrhea, Vomiting, drainage from tubes Loss of plasma or whole blood: Burns, Hemorrhage, Traumas, Surgery Excessive sweating Renal failure Hyperglycemia Inability to drink or express thirst (confused) Concentrated tube feedings Third-space shifts Use of diuretics
- 19. Acute weight loss , Decreased skin turgor Oliguria , Concentrated urine Postural hypotension , Weak,rapid heart rate Flattened neck veins , Increased temperature Decreased central venous pressure , Cramps Cool, clammy skin related to peripheral vasoconstriction Thirst Anorexia , Nausea Lassitude , Muscle weakness Clinical Manifestations of FVD
- 20. Assessment Health history Physical Assessment Diagnosis Test Serum osmolality Hemoglobin and Hematocrit Urine specific gravity CVP readings Assessment and Diagnosis Test of FVD
- 21. Treatment Fluid management Correct with oral fluid replacement Oral rehydration therapy IV therapy Antiemetic drugs Antidiarrheal drugs Medical Management Of FVD
- 22. TYPES OF IV FLUIDS
- 23. Nursing Management Deficient fluid volume Risk for imbalanced fluid volume Readiness for enhanced fluid balance Currently in balance but have many risk factors Restore fluid loss Identify patients at risk Maintain balance between fluid intake and output Prevent fluid imbalance Nursing Diagnosis VS –Vital Signs LOC changes Safe environment I and O , Daily weights Lab values Skin turgor and integrity IV access Urinary catheter Nursing Management and Diagnosis Of FVD
- 24. Fluid intake or fluid retention exceeds the body’s fluid needs Also called overhydration or fluid overload The goal of treatment is to restore fluid balance, correct electrolyte imbalances if present, and eliminate or control the underlying cause of the overload FLUID VOLUME EXCESS (FVE)
- 25. Compromised regulatory mechanisms: Renal failure ,Congestive heart failure, Cirrhosis of liver, Cushing’s syndrome Corticosteroid administration Stress condition causing the release of ADH and aldosterone Excessive intake of sodium-containing foods. Drugs that can cause sodium retention Administration of excess amount of sodium containing IV fluids. Pathophysiology of fluid imbalance typically focuses on hypovolemia Causes of FVE
- 26. Increase in total body weight causes weight gain over a short period of time. Peripheral edema Distended neck veins and peripheral lines. CVP over 11 cm H2O Crackles and wheezes in lungs Polyuria Ascites, pleural effusion Bounding pulse Pulmonary edema Clinical Manifestations of FVE
- 27. Assessment and Diagnosis Test of FVE Assessment Health history Risk factors such as medication, heart failure, renal diseases etc. Physical Assessment Weight, vital signs, peripheral pulses, jugular venous distention, edema, lung sounds, urine output and mental status Diagnosis Test Serum osmolality Urine specific gravity CVP readings .
- 28. Medical Management Of FVE Fluid Management Fluid intake should be restricted in clients who have fluid volume excess. Dietary Management Sodium restricted diet is prescribed. e.g. Fruits and vegetables, low salt breads, unsalted popcorns, fresh meat . Nursing Management Assess the presence or worsening of FVE. Encourage sodium restrictions Monitor the clients response to diuretics. Teach self monitoring of weight Maintain strict intake output chart Skin care. Pharmacological Management Pharmacological measures to manage fluid Counter regulatory hormones (e.g. angiotensin II, sympathetic hormones, vasopressin)
- 29. Nursing Diagnosis Of FVE Fluid volume overload related to decreased cardiac output as evidence by ejection fraction of 35%, Edema in lower extremities, Jugular distention, Bilateral crackles, Weight gain, and pleural effusions noted in lungs bilaterally.
- 30. Water intoxication: Water intoxication also known as water poisoning or dilutional hyponatremia, is a potentially fatal disturbance in brain functions that results when the normal balance of electrolytes in the body is pushed outside safe limits by over-hydration. Third Spacing: Occurs when fluid accumulates in areas that normally have no fluid or minimal amount of fluid, such as with ascites, and edema associated with burns.
- 31. Electrolytes are substances whose molecules dissociate, or splits, into ions when placed in water. Ions are electrically charged particles ELECTROLYTE REFERANCE INTERVAL Anions Bicarbonate Chloride Phosphate Cations Potassium Magnesium Sodium 22 – 26 mEq/L 96 – 106 mEq/L 2.4 - 4.4 mEq/L 3.5 – 5.0 mEq/L 1.5 – 2.5 mEq/L 136 – 145 mEq/L Electrolyte Distribution in Body Fluid
- 32. CHLORIDE Hyperchloremia Hypochloremia MAGNESIUM Hypermagnesemia Hypomagnesemia PHOSPHATE Hyperphosphatemia Hypophosphatemia CALCIUM Hypercalcemia Hypocalcemia POTASSIUM Hyperkalemia Hypokalemia SODIUM Hyponatremia Hypernatremia ELECTROLYTE DISORDERS
- 33. Hyponatremia refers to serum sodium level that is below normal( less than 135mEq/L) Sodium Imbalance-Hyponatremia Causes Diuretic medications kidney diseases, adrenal deficiency can cause excessive sodium excretion in urine. Vomiting , diarrhea and GI suction Administration of repeated tap water enemas Excessive sweating Loss of skin surface in burns SIADH were water excretion is impaired Pathophysiology Loss of sodium containing fluids or from excess water Hypo-osmolality with a shift of water into the cell Extracellular expansion or contraction
- 34. TYPES Hypovolemic hypernatremia: sodium loss is higher than water loss Euvolemic hypernatremia: sodium levels are almost normal Hypervolemic hypernatremia: total weight gain increases Redistributive hypernatremia: Water shifts from the intracellular to the extracellular compartment, with a resultant dilution of sodium. Clinical Manifestations Muscle cramps Weakness Fatigue Anorexia, nausea, vomiting Abdominal cramps Diarrhea If sodium falls below 120mEq/L Headache, altered sensorium, personality changes Irritability, tremors, depression Muscle twitching Hyponatremia
- 35. Diagnostic test A healthy sodium level is between 135 and 145 mmol/l and a person is considered to be hyponatremic if the level falls to below 135 mmol/l. The hyponatremia is considered severe if this level falls to below 125 mmol/l. Management Increase the intake of food high in sodium. In mild cases, frequent drinking of water with added sodium chloride or with isotonic (.9%) saline solution by IV over 6-12 hours. In more severe cases, 2-5 liters within 24-48 hours. If hypernatremia is associated with water intoxication, restrict water to 500-1000ml in 24 hours. Administer 3 % saline Hyponatremia
- 36. Nursing Diagnosis Risk for acute confusion related to electrolyte imbalance Risk for injury related to altered sensorium and decreased level of consciousness Risk for electrolyte imbalance related to excessive loss of sodium and/or excessive intake or retention of water Potential complication: severe neurologic changes Nursing management Identify clients with risk for hyponatremia Monitor fluid losses and gains Monitor presence of anorexia, nausea, vomiting and abdominal cramping Check specific gravity of urine Monitor client with cardiovascular diseases Avoid giving large water supplements to clients receiving isotonic tube feeding Use extreme caution when administering hypertonic saline solution Hyponatremia
- 37. Condition in which the serum sodium level rises more than 145mEqlL Sodium Imbalance-Hypernatremia Causes Water deprivation in clients who are unable to respond to thirst due to altered mental status Hypertonic tube feeding with inadequate water supplement Increased insensible water loss Excessive ingestion of salt Excessive parenteral administration of sodium containing solution. Profuse sweating Diabetes insipidus Excessive water loss with diarrhea Heat stroke Pathophysiology Due to etiological factors An elevated serum sodium may occur with water or sodium gain Hypernatremia causes hyperosmolarity Hyperosmolarity causes a shift of water out of cells Cellular dehydration
- 38. CLINICALFEATURES • Thirst. If it is not relieved it can alter the neurologic function • Restlesness • Agitation • Irritability • Dry mouth • Flushed skin • Disorientation • Progress into seizures ,coma and death TYPES OF HYPERNATREMIA Hypovolemic hypernatremia(low volume) • Inadequate intake of water ,excessive loss of water from urinary tract, severe watery diarrhea are the major causes. Hypervolemic hypernatremia(high volume) • Salt poisoning is the major cause in children Euvolemic hypernatremia: • Total body weight decreased Hypernatremia
- 39. Hypernatremia MANAGEMENT Monitor serum electrolytes Restrict fluids Strict intake and output chart Give plenty of oral fluids especially plain water. Monitor vitals signs
- 40. •Risk for injury related to altered sensorium and seizures •Risk for fluid volume deficit related to excessive intake of sodium and/or loss of water •Risk for electrolyte imbalance related to excessive intake of sodium and/or loss of water •Potential complication: seizures and coma leading to irreversible brain damage Nursing Diagnosis Hypernatremia • Measure serum sodium levels every 6 hrs. or daily • Identify clients risk for hypernatremia • Monitor fluid losses and gains • If tube feeding is used , give sufficient water • Record fluid intake and output accurately, checking body fluid loss to prevent dehydration Nursing Management
- 41. Potassium is the major ICF cations, with 98% of the body potassium being intracellular. Potassium concentration within muscle cells is approximately 140 mEq/L; potassium concentration in ECF is 3.5 to 5.0 mEq/L. Potassium Functions of Potassium Disruptions in the dynamic equilibrium between ICF and ECF potassium often cause clinical problems. Potassium regulates intracellular osmolality and promotes cellular growth. Potassium is required for glycogen to be deposited in muscle and liver cells. Potassium also plays a role in acid-base balance . Sources of Potassium Diet is the source of potassium. The typical Western diet contains approximately 50 to 100 mEq of potassium daily, mainly from fruits, dried fruits, and vegetables. Many salt substitutes used in low-sodium diets contain substantial potassium.
- 42. Hyperkalemia can be classified according to serum potassium level are Mild (5.5–6.5 mmol/l) Moderate (6.5–7.5 mmol/l) Severe (>7.5 mmol/l) Potassium Imbalance-Hyperkalemia CAUSES Impaired renal excretion, untreated renal failure Traumatic injuries Massive intake of potassium Potassium sparing diuretic therapy Acid base imbalances Inadequate urine output Rapid IV administration of potassium Pathophysiology Reduced renal excretion. Excessive intake or leakage of potassium from the intracellular space. Acute and chronic renal failure. Massive tissue breakdown as in habdomyolysis.
- 43. CLINICAL FEATURES • ECG changes: Tall peaked T wave, depressed ST segment • Arrhythmias, cardiac arrest • Muscle fatigue • Weakness • Nausea • Skeletal muscle weakness and paralysis • Hyper activity of smooth muscles, leading to GI disturbances. ASSESMENT • History collection includes current manifestations, duration of symptom and precipitating factors of salt substitutes and potassium supplements. • Assess the apical and peripheral pulses, muscle strength, ECG pattern • Tests serum electrolytes, RFT, ABG Hyperkalemia
- 44. MANAGEMENT Management of hyperkalemia mainly focus on returning the serum potassium and to stabilize the conducting system of heart. IV Calcium gluconate, 1amp slow IV over 10 minutes Insulin: Bolus injection of short acting insulin; if blood glucose is<250mg/dl, 25 gm of glucose should also be given Sodium bicarbonate Diuretics Dialysis Oral potassium binders Hyperkalemia
- 45. • Activity intolerance related to skeletal muscle weakness • Risk for decreased cardiac output related to hyperkalemia • Risk for ineffective health maintenance related to inadequate knowledge of recommended diet • Excess fluid volume related to renal failure Nursing Diagnosis • Check vital signs • Continuous cardiac monitoring to identify any arrhythmias • Instruct the patient to avoid food items rich in potassium like banana, tomatoes, green leafy vegetables, apricots, oranges etc. • Repeat electrolytes • Avoid administration of potassium conserving diuretics, potassium supplements Nursing Management Hyperkalemia
- 46. Hypokalemia Hypokalemia is when blood's potassium levels are too low. Hypokalemia is generally defined as a serum potassium level of less than 3.5 mEq/L (3.5 mmol/L). CAUSES Decreased intake of potassium rich food Vomiting Renal excreation Nasogastric suctioning Adrenal gland secrets excess aldosterone. Pathophysiology Inadequate potassium intake Increased potassium excretion Shift of potassium from the extracellular to the intracellular space.
- 47. Hypokalemia Multisystem Effects of Hypokalemia Musculoskeletal: Fatigue, leg cramps, muscle weakness Gastrointestinal: Nausea, vomiting anorexia Cardiovascular: Dysrrythmias, irregular pulse and ECG changes Urinary : Dilute urine, polyuria , polydypsia Neurologic: Confusion ,depression lethargy Respiratory: Respiratory arrest(severe)
- 48. •Administration of inj. KCl 40mEq/l in iv fluids •Oral potassium supplements •Use potassium sparing diuretics if diuretic therapy is going on •Treat diarrhea or vomiting •Discontinue diuretics or laxatives Management •Advice to report any chest discomfort •Advice to take more potassium rich food like banana, oranges •Advice to take oral potassium supplements properly •Be aware of clients at risk of hypokalemia Nursing Management Hypokalemia
- 49. CALCIUM IMBALANCES Calcium is necessary for the metabolic process of bones and teeth . Normal serum level is 8.5- 10mg/dl. Responsible for contraction, formation of bones etc For oocyte activation For myocardial contraction Vital role in nerve impulse transmission Major component in blood clotting systems. ROLES OF CALCIUM
- 50. Serum calcium levels exceeds 11mg/dl HYPERCALCEMIA CAUSES Over activity of parathyroid gland Excessive intake of calcium supplements Cancer: lung and breast cancer increase risk of hypercalcemia Hereditary factors Increased reabsorption of calcium from bones Renal failure decreases the amount of calcium loss CLINICAL MANIFESTATION Fatigue Weakness Anorexia ,nausea , vomiting Irritability Headache Abdominal pain and constipation Decreased neuromuscular excitability
- 51. HYPERCALCEMIA Nursing Intervention Monitor clients at risk of hypercalcemia Increase client mobilization Encourage fluid intake Discourage excessive conception of milk and products MANAGEMENT Restore calcium levels Treat the underlying cause. Administer calcitonin
- 52. Decreased calcium level <8mg/dl HYPOCALCEMIA CAUSES Other electrolyte imbalance Massive administration of banked blood Medications like diuretics anticonvulsants CLINICAL FEATURES Tetany Trousseaurs sign: carpel spasm induced by inflating a bp cuff above systolic pressure for 5 minit's Chvostek’s sign: contraction of facial muscle in response to a light tap over the facial nerve in front of the ear.
- 53. HYPOCALCEMIA MANAGEMENT Oral calcium supplements IV Calcium gluconate Diet rich in calcium Nursing Management Be aware of clients risk for hypocalcemia Be prepared to take seizure precautions Safe administration of calcium supplements Educate people about osteoporosis
- 54. Phosphate Imbalance Phosphate imbalances are seen in patients with acute kidney injury which alters kidneys ability to excrete phosphate. Normal serum level is 2.5-4.5mg/dl. HYPOPHOSPHATEMIA Serum phosphate level is <1.2mg/dl CAUSES Alcoholism, Burns Starvation Diuretic use
- 55. CLINICAL FEATURES Muscle weakness Fatigue Confusion Bone pain HYPOPHOSPHATEMIA MANAGEMENT Increase intake of diary products Phosphate supplements in diet Treat underline cause IV phosphate is administered when serum phosphate is <1mgldL
- 56. HYPERPHOSPHATEMIA Plasma phosphate level > 4.5mE/L CLINICAL FEATURES Anorexia, Nausea Vomiting, Muscle cramps Pain, Parasthesia TREATMENT Limiting high phosphate containing foods like milk and milk products. Administer calcium or aluminum products for the execration of phosphate
- 57. MAGNESIUM IMBALANCES Magnesium is an intracellular cation. it’s required for the ATP of Sodium- Potassium pump. Serum level is 1.5-2mE/L HYPERMAGNESEMIA Serum level above 2.1mEq/l CAUSES Women receiving milk of magnesia Renal failure
- 58. HYPERMAGNESEMIA MANAGEMENT Avoid magnesium containing food like banana, orange, peanuts etc. Avoid administering magnesium. CLINICAL FEATURES Nausea Vomiting Lethargy
- 59. HYPOMAGNESEMIA Serum level drops below 1.3mEq/L HYPOMAGNESEMIA Chronic alcoholism Prolonged starvation or fasting. Critically ill patients Malabsorption syndrome
- 60. HYPOMAGNESEMIA CLINICALFEATURES lethargy and weakness tremor carpopedal spasm muscle cramps tetany MANAGEMENT IV Magnesium correction Oral correction of magnesium
- 61. CLORIDE IMBALANCES Hypochloremia Chloride level less than 95 mEq/L. The normal adult value for chloride is 97-107 mEq/L. CAUSES Loss of body fluids from prolonged vomiting, diarrhea, sweating or high fevers. Drugs such as: bicarbonate, corticosteroids, diuretics, and laxatives.
- 62. . CLINICAL FEATURES dehydration. weakness or fatigue. difficulty breathing. diarrhea or vomiting, caused by fluid loss HYPOCLOREMIA MANAGEMENT • Nonsteroidal anti-inflammatory drugs • Hydrochloric acid (HCl) and carbonic anhydrase inhibitors • Administer normal saline or half strength saline to replace chloride. • Stop diuretics
- 63. HYPERCLOREMIA HYPERCLOREMIA Chloride levels at or above 110 mEq/L CAUSES • Loss of body fluids from prolonged vomiting, diarrhea, sweating or high fever (dehydration). • High levels of blood sodium. • Kidney failure • Diabetes insipidus
- 64. HYPERCLOREMIA • Dehydration - due to diarrhea, vomiting, sweating. • Hypertension. • Cardiovascular dysfunction Edema • Weakness. • Thirst CLINICAL FEATURES MANAGEMENT Drinking 2–3 quarts of fluid every day Receiving intravenous fluids Eating a better, more balanced diet Avoiding alcohol, caffeine, and aspirin.