Presentation on fluid and electrolyte imbalance

1. FLUID AND ELECTROLYTE
IMBALANCES

2. FLUID???
 BODY FLUIDS, BODILY FLUIDS, OR BIOFLUIDS, SOMETIMES BODY
LIQUIDS
Total body water is 60%of body weight
Male(60-67%) > female(52-55%)
 fluid relative to body weight ∝ 1
percentage of body fat
Total fluid is divided into ECF and ICF

3. DISTRIBUTION OF FLUID

4. ELECTROLYTES
Positive and negative ions present in body
Necessary to maintain equilibrium or homeostasis
Major cations: SODIUM, POTASSIUM, CALCIUM, MAGNESIUM, AND
HYDROGEN IONS.
Major anions:CHLORIDE, BICARBONATE, PHOSPHATE, SULFATE, AND
PROTEINATE IONS
expressed in terms of milliequivalents (mEq) per litre

5. MAJOR ELECTROLYTES : NORMAL RANGES
ELECTROLYTE NORMAL RANGES
SODIUM 135-145 mEq/l
POTASSIUM 3.5-5.3 mEq/l
CHLORIDE 98-105 mEq/l
CALCIUM 8.6-10.4 mg/dl
MAGNESIUM 1.5-2.5 mEq/l
PHOSPHATE 2.5-4.5 mg/dl
BICARBONATE 22-26 mEq/l

6. HOMEOSTATIC MECHANISMS
Kidney functions
Heart and blood vessels
Lung function
Pituitary functions
Adrenal function
ANP
Baroreceptors
Parathyroid functions
RAAS Mechanism
ADH and thirst
Osmoreceptors

8. RAAS MECHANISM

9. HYPOVOLEMIA/ FLUID VOLUME DEFICIT
Loss of extracellular fluid volume exceeds the intake of fluid
Water and electrolytes are lost in the same proportion
Ratio of serum electrolytes to water remains the same
FVD may occur alone or in combination
Don’t confuse FVD with dehydration!!

10.  Vomiting
 Diarrhea
 GI suctioning
 Sweating
 No hunger
 Hemorrhage
 Burns
 Diuresis
 Adrenal
insufficiency
 Diabetes
insipidus

12. ASSESSMENT AND DIAGNOSTIC FINDINGS
• History taking
• Physical assessment
• BUN
• CBC (mainly haematocrit)
• Electrolyte values

13. MEDICAL MANAGEMENT
Correct the cause
Correcting fluid loss : isotonic fluids(initially)
hypotonic fluids (later)
Determine the amount of IVF replacement
Fluid challenge test
Correcting electrolyte imbalances

14. CONT.…
Accurate and frequent assessments of:
 Intake and output
 Weight, vital signs
 Central venous pressure
 Level of consciousness
 Breath sounds
 Skin colour

15. NURSING MANAGEMENT
Intake and output monitoring
Check cbc , electrolytes and urine specific gravity
Assess for postural hypotension
Assess tissue perfusion
Oral care and skin care
Check tongue turgor

16. HYPERVOLEMIA/ FLUID VOLUME EXCESS
An isotonic expansion of the ECF
 Abnormal retention of water and sodium
 Approximately in the same proportions
 Isotonic retention of body substances
 Serum sodium concentration remains essentially normal.

17. CAUSES OF HYPERVOLEMIA
Decreased
renal Na
excretion
Massive
sodium intake
Increase red
blood cell
production

18. CLINICAL MANIFESTATIONS
Edema
Distended neck veins
Tachycardia
 Increased blood pressure
 Pulse pressure, and central venous pressure
 Increased weight
Increased urine output
 Shortness of breath and wheezing

19. ASSESSMENT AND DIAGNOSTIC FINDINGS
• Decreased haematocrit
• Respiratory alkalosis and hypoxemia
• Decreased serum sodium and osmolality(<275mOsmol/kg)
• BUN and creatinine levels increase
• Urine specific gravity decreases
• Urine sodium level drops due to increased aldosterone production

20. MEDICAL MANAGEMENT
Correct the cause
Administering diuretic
Control fluid intake
Manage salt intake (nutritional therapy)
Manage pulmonary effusion (complication of FVE)
Hemodialysis

21. NURSING MANAGEMENT
Intake output monitoring
Assess degree of edema
Assess for breath sounds
Sodium and fluid restriction
Semi fowlers position
Assess vitals frequently

22. ELECTROLYTE
IMBALANCES

23. HYPONATREMIA
Most common electrolyte disorder
Serum sodium levels < 135meq/lit
Frequency higher in elderly and hospitalized patients
Sodium homeostasis is maintained by:
Thirst ,ADH, Aldosterone

24. DILUTIONAL HYPONATREMIA
Sodium level is diluted by an increase in the ratio of water to sodium
Predisposing conditions for this type of hyponatremia :
 SIADH
 Hyperglycaemia
 Use of tap-water enemas
 Irrigation of nasogastric tubes with water instead of NS
Psychogenic polydipsia

26. CLINICAL MENIFESTATIONS

27. MEDICAL MANAGEMENT
Sodium replacement:
 Careful administration of sodium by mouth
 By nasogastric tube, or the parenteral route
 IV RL or isotonic saline (0.9% NS)
 Sodium not greater than 12 mEq/L in 24 hours
 Avoid neurologic damage due to osmotic demyelination
 Not to be overcorrected (above 140 mEq/L) too rapidly

28. CONT….
Water restriction: in a patient with normal or excess fluid volume
 Restricting fluid to a total of 800 ml in 24 hours
 If edema exists alone, sodium is restricted
 If edema and hyponatremia occur together, both sodium and water are restricted

29. NURSING MANAGEMENT
Assess for the
risk
Monitor
intake and
output
Observe CNS
changes
Urine sodium
&specific
gravity
Lithium
toxicity& GI
manifestations

30. HYPERNATREMIA
Serum sodium levels exceeding 145 mEq/L or 145 mmol/L
Seen in about 1% of hospitalised patients
7% of ICU admitted patients
Mortality rate approx. 41% but not as a primary cause
Primary cause:
Sodium gain
Water deficit

31. CAUSE OF HYPERNATREMIA
Fluid deprivation in unconscious patients
Administration of hypertonic enteral feedings
 Insensible water loss ( hyperventilation, burns)
Deficiency of ADH
Malfunction of either haemodialysis or peritoneal dialysis
 excessive use of sodium bicarbonate

32. Diuretics
Dehydration
Diabetes insipidus
Diarrhea
Docs(iatrogenic)
Diseases
6 D’s of hypernatremia

34. MEDICAL MANAGEMENT
The infusion of a hypotonic electrolyte solution
 0.3% sodium chloride
 Dextrose 5% in water ( non saline )
D5w is indicated when water needs to be replaced without sodium
 Diuretics also may be prescribed to treat the sodium gain
Salt restriction

35. NURSING MANAGEMENT
 Assess for:
• Abnormal losses of water
• low water intake
• for large gains of sodium
Ingestion of over-the-counter medications
Notes the patient’s thirst or elevated body temperature
 Monitors changes in behaviour, restlessness, disorientation, and lethargy.

36. HYPOKALEMIA
Serum potassium levels <3.5 mEq/l is hypokalemia
Potassium maintain osmolarity of ECF and ICF
Vital for cell excitability and muscle contraction
Maintain transmembrane electric potential

37. CAUSES OF HYPOKALEMIA
GI loss
Metabolic alkalosis
Prolonged intestinal suctioning
Hyperaldosteronism
Potassium losing diuretics
Corticoid therapy
Penicillin’s/Amphotericin B
Hyper insulinemia
Poor dietary intake
Anorexia nervosa

39. MEDICAL MANAGEMENT
Correct the ongoing losses
Use potassium sparing diuretics
Oral KCL replacement 40-60meq/day
Control hyperglycemia
Dietary management of potassium supplements
Iv line ≤20meq/dose, Central venous line≤ 60meq/dose

40. https://www.ncbi.nlm.nih.gov/pmc/articl

41. NURSING MANAGEMENT
Monitor early sign and symptoms of hypokalemia
Obtain ECG
Monitor closely for signs of digitalis toxicity
 Precautions for oral and IV potassium administration
Urine output not less than 30ml/hr
Prevent hyperglycemic crisis

42. HYPERKALEMIA
Serum potassium levels > 5.3mEq/l
Less common than hypokalemia
More fatal
Caution!! Pesudohyperkalemia
Less common in normal renal function patients

43. CAUSES
The Body “CARED” Too Much About K+
C- cellular movement of k+ from ICF to ECF( burns, tissue damage)
A-adrenal insufficiency/ Addison's
R-renal failure
E-excessive k+ intake
D-drugs(k+ sparring, ACE inhibitors, NSAIDS)

46. MEDICAL MANAGEMENT
Administer IV calcium gluconate
Monitor BP ,to detect hypotension
 IV administration of sodium bicarbonate
 IV administration of regular insulin and a hypertonic dextrose
 Beta-2 agonists
Cation exchange resins, peritoneal dialysis, haemodialysis

47. NURSING MANAGEMENT
Assess symptoms of hyperkalemia
Cautious IV administration of potassium
Avoid aged (stored) blood, to patients with impaired renal function
Monitor ECG changes
Monitor I/O
Do not draw blood above k+ infusion site

48. HYPOCALCEMIA
Serum calcium levels < 8.6mg/dl

49. CAUSES
A total body calcium deficit
Rest increases bone resorption
Primary hypoparathyroidism
Transient hypocalcemia, with massive administration of citrated blood
Pancreatitis, renal failure
Medications predisposing to hypocalcemia

50. SIGN AND SYMPTOMS
• H

51. MEDICAL MANAGEMENT
Acute symptomatic hypocalcemia is life-threatening
Requires prompt treatment with IV administration of calcium
Too rapid correction can cause cardiac arrest
Calcium ions exert an effect similar to that of digitalis
Vitamin D therapy
Should be diluted in D5W and given as a slow IV

52. NURSING MANAGEMENT
Seizure precautions are initiated
Adequate dietary calcium intake for high risk patients
Status of the airway is closely monitored because laryngeal stridor can occur
Iv site monitoring at Calcium infusion
Diet therapy
Slow IV bolus

53. HYPERCALCEMIA
Excess of calcium in plasma > 10.6mg/dl
Hypercalcemic crisis has mortality of 50%
Most common causes:
Hyperparathyroidism
Malignancy
Life threatening emergency situation

54. C-Calcium supplements
H- Hyperparathyroidism
I-Iatrogenic ,Immobilisation
M-Multiple myeloma,medications
P- Parathyroid hyperplasia
A- Alcohol
N- Neoplasm
Z- Zollinger Ellison Syndrome
E-Excessive VIT D
E- Excessive VIT A
S- Sarcoidosis
CAUSES

55. SIGN AND SYMPTOMS
Decrease neuromuscular excitability
Muscle weakness, incoordination
Severe thirst
Nausea, vomiting
Constipation
• Polyuria
• Bone pain
• Abdominal cramps
• Obstipation
• Acute psychosis

56. MEDICAL MANAGEMENT
Iv administration of 0.9% NS
Diuretics ( frusemide commonly)
Administering IV biphosphate
Calcitonin (given IM)
 Mithramycin, a cytotoxic antibiotic
Dialysis

57. NURSING MANAGEMENT
Patients at risk are encouraged to ambulate
Fluids having sodium should be administered
Encouraged to drink 2-2.5lit of fluid daily.
Provide adequate dietary fibre
Safety precautions are taken
Assess for signs and symptoms of digitalis toxicity
Note ECG changes

58. HYPOMAGNESEMIA
The normal serum magnesium level is 1.5 to 2.5 meq/L
Primarily involved in neuromuscular activity
Approximately 1/3rd serum magnesium is bound to protein
 The remaining 2/3rd exists as free cations
 low serum albumin levels decrease total magnesium.

59. CAUSES
Alcohol withdrawal
Lower GI manifestations
Prolonged GI suction
After long starvation periods
Rapid administration of citrated blood
Diabetic ketoacidosis
The administration of:
• Aminoglycosides, cyclosporine,
cisplatin
• Diuretics, digitalis, and amphotericin

62. MEDICAL MANAGEMENT
 IV MgSo4 must be given by an infusion pump
Rate not to exceed 150 mg/min
 A bolus dose of MgSo4 can produce cardiac arrest
Monitor cardiac rate or rhythm, hypotension, and respiratory distress
 Urine not less than 100 ml over 4 hours
 Calcium gluconate to treat hypocalcemic tetany or hypermagnesemia

63. NURSING MANAGEMENT
Assess vitals, signs of respiratory depression
Initiate seizure precautions
Monitor dysphagia
Semi fowler's position to prevent aspiration
Assess deep tendon reflexes frequently
Maintain urine output >100ml/4hrly

64. HYPERMAGNESEMIA
Mg> 2.5 mEq/l
Excessive magnesium intake
Impaired renal functions
Less common than hypomagnesemia

65. CAUSES
Renal impairment
Excessive mgso4 intake:
• Treatment of eclampsia
• Excessive use of antacids
Addison’s disease
Diabetic ketoacidosis

67. MEDICAL MANAGEMENT
Avoid unnecessary administration
Discontinue parenteral+ oral doses
Monitor for respiratory depression:
• Iv calcium
• Ventilatory support
Diuretics
0.45% NS
IV calcium gluconate
(ANTIDOTE)
Patient with renal impairment Patient without renal impairment

68. NURSING MANAGEMENT
Nurse monitors the vital signs
Noting hypotension and shallow respirations
Also observes for decreased patellar reflexes
 changes in the level of consciousness
 Caution is essential when preparing
• 2-ml ampules or 50-ml vials differ in concentration.

69. HYPOPHOSPHETEMIA
Phosphate < 2.5mg/dl
Accompanied by increase in calcium level
Can be acute or chronic
Life threatening if severe, <1 mg/dl

70. CAUSES
Chronic alcoholism
Protein energy malnutrition
Overzealous administration of simple carbohydrates
Hyperventilation/ respiratory alkalosis
Diabetic ketoacidosis
Vit D deficiency

71. SIGN AND SYMPTOMS
NEUROLOGICAL
SYMPTOMS
• Irritability
• Fatigue
• Apprehension
• Weakness
• Numbness
• Paresthesias
• Confusion
• Seizures
OTHER SYMPTOMS
• Respiratory alkalosis
• Muscle weakness
• Muscle pain
• Rhabdomyolysis
• Hyperglycemia
• Dec platelets

72. MEDICAL MANAGEMENT
Prevention of hypophosphatemia is the goal
Phosphorus should be added to parenteral solutions
Careful monitoring for patients on RT feeds
Rate of IV P should not exceed 10 mEq/h
Monitor iv site infiltration
Risk- tetany from hypocalcemia and metastatic calcification

73. NURSING MANAGEMENT
Malnourished patients receiving parenteral nutrition are at risk
 Calories not to introduce too aggressively
Preventing infection ( decreased granulocytes)
For mild hypophosphatemia encourage foods such as
• milk and milk products, organ meats, nuts, fish, poultry, and whole grains
Document and report early signs of hypophosphatemia

74. HYPERPHOSPHATEMIA
Serum phosphorus levels> 4.5 mg/dl
• Causes:
Renal failure
Chemotherapy for neoplastic disease
Hypoparathyroidism
Respiratory acidosis or diabetic ketoacidosis
High phosphate intake
Profound muscle necrosis

75. SIGN AND SYMPTOMS
Tetany
Soft tissue calcification
Decreasing urine output(oliguria)
Impairing vision
Tachycardia
Hyperreflexia

76. MEDICAL MANAGEMENT
Restriction of dietary phosphate
Vit D supplements
Correcting volume depletion
 Treating metabolic acidosis due to renal failure
Dialysis

77. NURSING MANAGEMENT
 Low-phosphorus diet is prescribed
 Avoid phosphorus-rich foods
• Such as hard cheese, cream, nuts, whole-grain cereals, dried fruits, dried
vegetables, kidneys, sardines, sweetbreads, and foods made with milk.
Avoid laxatives and enemas that contain phosphate.
 Teach the patient to recognize the signs of impending hypocalcemia
 Monitor for changes in urine output.

78. HYPOCHLOREMIA
• Serum chloride level is < 96 mEq/L
• CAUSES:
• . Chloride-deficient formulas
• Salt restricted diets
• GI tube drainage
• Severe vomiting and diarrhea
• Generalised fluid loss

79. SIGN AND SYMPTOMS
Hyperexcitability of muscles
 Tetany, muscle cramps
Hyperactive deep tendon reflexes
 Cardiac dysrhythmias
 Parallel low sodium levels, a water excess may occur
 Hyponatremia can cause seizures and coma.

80. MEDICAL MANAGEMENT
IV 0.9% NS or 0.45% NS
Foods high in chloride are provided
 Tomato juice, salty broth, canned vegetables, processed meats, and fruits
Avoid free water or bottled water
Ammonium chloride, to treat metabolic alkalosis

81. NURSING MANAGEMENT
The nurse monitors intake and output
 Arterial blood gas monitoring
Serum electrolyte levels, level of consciousness
 Muscle strength and movement
Vital and respiratory assessment
Teach the patient about foods with high chloride content

82. HYPERCHLOREMIA
• Serum level exceeds 106 mEq/L
• Causes
• Loss of bicarbonate by GI tract
• Loss of NAHCO3 by kidneys
• Hypernatremia

83. SIGN AND SYMPTOMS
Same as those of metabolic acidosis, hypervolemia, and hypernatremia.
 Tachypnoea
Weakness
Lethargy
 Deep, rapid respirations
Diminished cognitive ability
 Hypertension occur
Accompanied by a high sodium level and fluid retention.

84. MEDICAL MANAGEMENT
• Correct the underlying cause
• Restore fluid electrolyte balance
• IV RL
• IV sodium bicarbonate
• Diuretics
• Restrict sodium and fluids

85. NURSING MANAGEMENT
• Monitor input output
• Vital sign monitoring
• Assess respiratory and neurological status
• Low chloride and low sodium diet
• ABG analysis