This document discusses fluid and electrolyte balance and replacement. It covers the body's fluid compartments, composition of body fluids including electrolytes and solutes, kidney function in fluid regulation, hormonal control of fluid balance, causes of fluid imbalances, diagnostic tests, and electrolyte abnormalities including sodium, potassium, calcium and magnesium imbalances. Treatment approaches are provided for restoring normal fluid and electrolyte levels.

1. Management of Fluid and Electrolyte Replacement Hartnell College Pharmacology NRN 130 Laurie Phillips RN, MSN, PHN

2. Homeostasis Tendency to maintain fluid in specific compartments Necessary for cells to carrying out their functions Process involves deliver of elements to the cell such as O2 and glucose and remove waste products such as CO2 When not maintained, illness will occur

3. Body Fluid Compartments Intracellular (ICF) - Fluid within the cell. Most body fluid is found here. Extracellular (ECF) - fluid found outside the cell such as plasma/serum. Responsible for transport of nutrients and waste. intravascular: fluid surrounding the cells interstitial fluid: including lymph fluid other: digestive secretions, CSF, sweat

4. Body Fluid Composition H2O largest portion of body wt. that decreases with age women have a lower % of water storage because of increased fat cells which do not contain as much H2O as other cells Affected by age, sex, and amount of body fat

5. Body Fluid Composition Solutes (electrolytes and nonelectrolytes) Electrolytes - substance that contains an electrical charge when dissolved in H2O; break into ions Cations (NA+, Ca+, Mg+) Anions (Cl-, HCO3-, HPO4-)

6. Body Fluid Composition Every fluid compartment contains a balance of cations and anions The concentration of an electrolyte in a solution or body compartment is measured in mEq/L Electrolytes can move from one compartment to another

7. Intra vs. Extra Potassium Calcium Phosphate Magnesium Sodium Chloride Calcium Bicarbonate

8. Nonelectrolytes Other substances that dissolve in H2O Urea, protein, glucose, creatinine, bilirubin Measured in mg/dl

9. Osmolality Concentration of a solution Determined by the # of particles/Kg of H2O changing osmolality of one compartment affects the osmolality of another compartment

10. Osmolarity The concentration of particles in a body of water Measured per liters of fluid

11. Fluid Regulation Kidneys control extracellular fluid by adjusting concentration of electrolytes, the osmolality of body fluids, volume of extracellular fluid, blood volume, and pH nephron is fixing unit of kidney, made of glomerulus (filtering) and tubules (reabsorption)

12. Kidney Controlled by hormones and processes Filtration - blood enters via renal artery. 20% because filtrate and enters the glomerular capsule, goes thru the tubules and is transformed into urine by reaborption. Other 80% leaves thru renal vein.

13. Kidney Reabsorption - occurs in the tubules. Important of adjusting volume and decomposition of filtrate preventing excessive fluid loss. Secretions - last phase, filtrate transformed to urine. Substances pass from blood into tubules and eliminated to maintain fluid and electrolyte balance.

14. Hormones Aldosterone - released by adrenal glands, increases reaborption of Na+ and decreases reaborption of K+ Antidiuretic Hormones - produced by hypothalamus and secreted by the posterior pituitary. Causes the kidney tubules to reabsorb more H2O, so urine is more concentrated and there is less fluid loss

15. Thirst Regulates fluid intake Increased osmolality stimulate osmoreceptors in the hypothalamus to start the sensation of thirst Kidneys are alerted to conserve H2O

16. Fluid Gains/Losses Healthy individuals have = I/O Urine output is 1-2L/day Seating causes H2O and electrolyte losses H2O loss in lung via evaporation approximately 300-400 ml/day GI tract loses 100-200ml/day via reabsorption in the small intestine

17. Age-Related Changes Kidney functioning slower Reduced sense of thirst Total body H2O declines Chronic conditions which contribute to imbalances Decreased need for fluid

18. Basic Principles of IV Fluid Replacement Iso-osmolar - has the same amount of particles (sodium, glucose, urea, or protein) and water Hypo-osmolar - has fewer particles than water Hyper-osmolar - has more particles than water 4 major categories of IV fluid replacement crystalloids colloids lipids blood products

19. Crystalloids and Colloids Crystalloids - dextrose, saline, and lactated Ringer’s solutions Used for replacement and maintenance of body fluids Colloids - amino acids, plasmanate, and dextran solutions Used as volume expanders

20. Crystalloids Isotonic Solutions sodium chloride 0.9% lactated Ringer Hypotonic Solutions (hydrating) dextrose 2.5%, 5%, 10% dextrose 2.5% in 0.45 NaCl dextrose 5% in 0.45 NaCl

21. Crystalloids (cont.) Maintenance Solutions Plasmalyte 56 Plasmalyte 148 Isolyte Hypertonic Solutions sodium chloride 3% sodium chloride 5%

22. Colloids Protein Solutions Aminosol 5% Aminosol 5% with dextrose 5% Plasma Expanders Dextran 40 10% in normal saline or 5% dextrose in water Dextran 70 6% in normal saline or 5% dextrose in water

23. Assessment Health History kidney disease, diabetes, vomiting, diarrhea, salicylate poisoning, CHF, burns, cerebral injuries, ulcerative colitis, hormone imbalances risk factors: diuretics, cathartics, gastric suctioning complaints: fatigue, palpitations, dizziness, edema,dyspnea, confusion

24. Assessment Vital Signs fever causes fluid and electrolyte loss pulse will increase in response to volume loss electrolyte changes can affect conduction of impulses in the heart respiration is minimally affected blood pressure directly related to blood volume

25. Assessment Intake and output Body weight: same scale, same time, same clothes. 1L=2.2lbs Skin: color, moisture, temperature, facial characteristics, edema Mucous membranes Veins: neck vein distension

26. Diagnostic Tests Urine pH (4.6 - 8.0) specific gravity (1.010 - 1.025) osmolality creatinine clearance sodium protein

27. Diagnostic Tests Blood hematocrit % blood urea nitrogen(BUN) osmolality electrolytes

28. Electrolyte Imbalances Major Electrolyte Categories Sodium and Potassium Calcium and Magnesium Electrolyte Conditions Hyponatremia and hypernatremia Hypokalcemia and hyperkalcemia Hypocalcemia and hypercalcemia Hypomagnesemia and hypermagnesemia

29. Hyponatremia Serum levels drop below 135 mEq/L C/M headache, muscle weakness,fatigue, abdominal cramping, postural hypotension,confusion Treatment Fluid restriction Sodium chloride 0.9% (Isotonic) Ringer’s solution (Isotonic) Sodium chloride 3% - if severe

30. Hypernatremia Serum level is above 150 mEq/L C/M thirst, flushed skin, dry mucous membranes, restlessness, increased HR, low urine output, postural hypotension, convulsions Treatment Reduced salt intake Increase PO and IV replacement Dextrose 5% in water (Hypotonic)

31. Hypokalemia Serum level is below 3.5 mEq/L C/M anorexia, nausea and vomiting, neurological disturbances, muscle cramps, polyuria, dyspnea, shallow respirations,confusion, dysrhythmias Treatment Oral potassium replacements: Potassium chloride, Slow-K, K-Dur, Micro-K, K-Tab Parenteral potassium replacements Nursing alert Over correction resulting in hyperkalemia

32. Hyperkalemia Blood level is above 5.8 mEq/L C/M explosive diarrhea, muscle cramps, weakness, paresthesias, irritability, anxiety, decreased urine output, abdominal cramps, dysrhythmias Treatment Sodium polystyrene sulfonate (Kayexalate) Potassium-sparing diuretics Dextrose solutions with insulin IV Calcium gluconate 10%

33. Hypocalcemia Serum level is below 4.5 mEq/L C/M numbness and tingling around mouth, hyperreflexia, tetany, seizures Treatment Oral and IV calcium salt supplements : carbonate, chloride, lactate, citrate, gluconate Vitamin D supplements IV lipids

34. Hypercalcemia Blood level is above 5.5 mEq/L C/M lethargy, confusion, N/V, depressed reflexes,bone pain, polyuria, stupor, coma Treatment Sodium chloride 0.9% (Isotonic) Biophosphonates: pamidronate (Aredia) Corticosteroids: Predisone Antibiotic: mithramycin IV magnesium sulfate

35. Hypomagnesemia Blood level is below 1.5 mEq/L C/M confusion, hyperreflexia, tremors, seizures Treatment Oral and enema magnesium salt supplements: hydroxide (MOM), sulfate (Epsom), citrate IV magnesium sulfate

36. Hypermagnesemia Blood level is above 2.5 mEq/L C/M lethargy, N/V, depressed reflexes, cardiac arrest Treatment Diuretics: Mannitol Corticosteroids: Predisone IV Calcium gluconate

37. Complications of IV and Electrolyte Replacement Infiltration Thrombosis Thrombophlebitis Pain at insertion site Necrosis Pulmonary edema Pyrogenic reactions Air emboli