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Fluid and Electrolyte Balance-1.13.2010

Fluid and Electrolyte Balance-1.13.2010 - Fluids and...

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Unformatted text preview: Fluids and Electrolytes Nsg. 2041 Nursing Therapeutics: Adult I Curry College 1 1. People who are obese have a higher percent of body fluid than those who are thin. Sodium is important in regulating the volume of body fluid, because sodium concentration affects the overall concentration of extracellular fluid. When treating a patient with water retention, it is safer to administer sodium than restrict fluid intake. 2. 3. 2 1. Mixed acidbase disorders, such as respiratory acidosis and alkalosis, can occur simultaneously with patients. 2. Intravenous (IV) infiltration of any amount of blood product, irritant or vesicant is considered the most severe. 3 1. Body fluid is located in two fluid compartments: ______________space and extracellular space. 2. _________________, the end product of muscle metabolism, is a better indicator of renal function than BUN. 4 Fluid and Electrolyte Balance Necessary for life and homeostasis Nursing role is to help prevent and treat fluid and electrolyte disturbances 5 Approximately 60% of the typical adult weight is fluid Varies with age, body size, and gender Intracellular fluid 40% Extracellular fluid (ECF) 20% Intravascular Interstitial Transcellular "Third spacing": loss of ECF into a space that does not contribute to equilibrium, creates fluid deficit in ECF. Fluid reabsorbs 2472hours. (ascites) 6 Electrolytes Active chemicals that carry positive (cations) and negative (anions) electrical charges Major cations Major anions: Sodium Potassium Calcium Calcium Magnesium Magnesium Hydrogen ions Chloride Bicarbonate Phosphate Sulfate Proteinate ions Electrolyte concentrations differ in the fluid compartments (see Table 141) 7 Electrolytes (cont.) Major cation in ECF Sodium Major cation in ICF Potassium 8 Regulation of Body Fluid Compartments Movement of fluid through capillary walls depends on: Hydrostatic pressure Osmotic pressure Pressure exerted on the walls of blood vessels Pressure exerted by the protein in the plasma The direction of fluid movement depends on the differences of hydrostatic and osmotic pressure 9 Regulation of Fluid (cont.) Osmosis Diffusion Filtration Active transport 10 Osmosis Movement of fluid from an area of lower solute concentration to an area of higher solute concentration 11 Diffusion Movement of molecules and ions from an area of higher concentration to an area of lower concentration 12 Movement of water and solutes from Filtration an area of higher hydrostatic pressure to an area of lower hydrostatic pressure 13 Sodium Potassium Pump Physiologic pump that moves fluid from an area of lower concentration to one of higher concentration Movement against the concentration gradient Sodiumpotassium pump maintains the higher concentration of extracellular sodium and intracellular potassium **Requires adenosine (ATP) for energyACTIVE 14 TRANSPORT** Routes of Gains and Losses Gain Dietary intake of fluid and food or enteral feeding Parenteral fluids Kidney: urine output ~1400cc's Skin loss: sensible & insensible 300400 cc's Lungs: expiration 300400cc's GI tract: reabsorbed from GI tract to ECF. 15 Loss Homeostatic Mechanisms Body has mechanisms to keep composition and volume of fluid within normal limits. Kidneys Lungs Adrenal Glands Parathyroid Glands Pituitary Gland 16 Kidney's Role Filter plasma (180 L) Excrete urine (10002000 mL) Regulate ECF volume and osmolality Spontaneously or in response to aldosterone & ADH Regulate electrolyte levels (retain/excrete) Excreting metabolic wastes/toxins Regulate PH by retaining Hydrogen ions 17 Heart and Blood Vessels' Role Pumping action circulates blood through the kidneys under sufficient pressure to allow for renal perfusion 18 Lung's Role Exhalation Maintain AcidBase Remove H20 Daily (300ml) 19 Pituitary Gland's Role Releases ADH (conserve H20) 20 Adrenal Gland's Role Secrete more Aldosterone to cause NA retention (Water retention & K loss) Secrete less Aldosterone to cause NA loss (Water loss & K retention) 21 Parathyroid Gland's Role Regulate calcium and phosphate balance by PTH 22 23 Role of Atrial Natriuretic Peptide (ANP) in Maintenance of Fluid Balance 24 Gerontologic Considerations Reduced homeostatic mechanisms: cardiac, renal, and respiratory function Decreased body fluid percentage Multiple Medication use Presence of concomitant conditions 25 Fluid Volume Imbalances Fluid volume deficit (FVD): hypovolemia Fluid volume excess (FVE): hypervolemia 26 Fluid Volume Deficit Hypovolemia Loss of extracellular fluid exceeds intake ratio of water, and electrolytes are lost in the same proportion. **H20:Serum Electrolytes ** Causes: fluid loss from vomiting, diarrhea, GI suctioning, sweating, decreased intake, and inability to gain access to fluid, diabetes insipidus, adrenal insufficiency, osmotic diuresis, hemorrhage, coma, and third space shifts 27 Clinical Manifestations Acute weight loss Oliguria Decreased skin turgor Orthostatic hypotension Weak, rapid HR Thirst Muscle weakness and cramps 28 Examining the skin turgor of an elderly client 29 Assessment Findings Increased BUN (in proportion to Creatinine) Increased HCT (decreased plasma volume) Serum electrolyte changes **Elderly need closer monitoring** 30 Management Medical Not severePO route SevereIV route May need Fluid Challenge Isotonic solutions for hypotensive (expand plasma volume) Hypotonic solution for normotensive ( provide electrolytes and h20) 31 Management Nursing Monitor I & O, urine concentration Daily wgts (1 lb=500ml) Vital Signs (weak, rapid HR, Orthostatic Hypotension) Skin Turgor Mucous Membranes Mental Status 32 Hypervolemia Fluid volume excess Pathophysiology Isotonic expansion of the ECF caused by abnormal NA & H20 retention. Serum concentration of NA remains normal Simple fluid overload Diminished function of homeostatic mechanisms 33 Clinical Manifestations Edema Distended neck veins Tachycardia Crackles in lungs/SOB/Wheezing Increased BP Increased wgt. Increased U/O 34 Assessment Findings Decreased BUN (plasma dilution) Decreased HCT (plasma dilution) CXRpulmonary congestion Low Na & osmolality (excess H20) 35 Management Medical Management Directed at alleviating cause Symptomatic treatment Nursing Management Diuretics, fluid restriction & NA restriction I & O, Daily wgts. Edema (pitting, measure) Asses Respiratory status Effect/Side Effects of Diuretics Teaching regarding FR & NA restriction Promote Rest SemiFowlers position 36 Electrolyte Imbalances Sodium: hyponatremia and hypernatremia Potassium: hypokalemia and hyperkalemia Calcium: hypocalcemia and hypercalcemia Magnesium: hypomagnesemia and hypermagnesemia Phosphorus: hypophosphatemia and hyperphosphatemia Chloride: hypochloremia and hyperchloremia 37 Serum sodium less than 135 mEq/L Hyponatremia Causes: adrenal insufficiency, water intoxication, SIADH, and losses by vomiting, diarrhea, sweating, and diuretics Manifestations: poor skin turgor, dry mucosa, headache, decreased salivation, decreased BP, nausea, abdominal cramping, and neurologic changes 38 Hyponatremia (cont.) Medical management: Water restriction and sodium replacement Nursing management: Assessment and prevention, monitoring of dietary sodium and fluid intake, identification and monitoring of atrisk patients and the effects of medications (diuretics and lithium) 39 Hypernatremia Serum sodium greater than 145mEq/L Manifestations: thirst; elevated temperature; dry, swollen tongue; sticky mucosa; neurologic symptoms; restlessness; and weakness Thirst may be impaired in the elderly or ill 40 Causes: excess water loss, excess sodium administration, diabetes insipidus, heat stroke, and hypertonic IV solutions Hypernatremia (cont.) Medical management: Hypotonic electrolyte solution or D5W Nursing management: Assessment and prevention, assess for overthe counter (OTC) sources of sodium, offer and encourage fluids to meet patient needs, and provide sufficient water with tube feedings 41 Hypokalemia Belownormal serum potassium (<3.5 mEq/L) may occur with normal potassium levels in alkalosis due to shift of serum potassium into cells Causes: GI losses, medications, alterations of acidbase balance, hyperaldosteronism, and poor dietary intake Manifestations: fatigue, anorexia, nausea, vomiting, dysrhythmias, muscle weakness, cramps, paresthesias, glucose intolerance, decreased muscle strength, and deep tendon reflexes (DTRs) 42 Hypokalemia (cont.) Medical management: Increased dietary potassium, potassium replacement, and IV for severe deficit Nursing management: Assessment (severe hypokalemia is life threatening), monitoring of electrocardiogram (ECG), arterial blood gases (ABGs), and dietary potassium, and providing nursing care related to IV potassium administration 43 Hyperkalemia Serum potassium greater than 5.0 mEq/L Causes: usually treatmentrelated, impaired renal function, hypoaldosteronism, tissue trauma, and acidosis Manifestations: cardiac changes and dysrhythmias, muscle weakness with potential respiratory impairment, paresthesias, anxiety, and GI manifestations 44 Hyperkalemia (cont.) Medical management: Monitor ECG, cation exchange resin (Kayexalate), IV sodium bicarbonate, IV calcium gluconate, regular insulin and hypertonic dextrose IV, and 2 agonists; limit dietary potassium; and perform dialysis Nursing management: Assess serum potassium levels, mix well IVs containing K+, monitor medication effects, and initiate dietary potassium restriction and dietary teaching for 45 patients at risk Effect of Potassium on ECG 46 Hyperkalemia Hemolysis of blood specimen or drawing of blood above IV site may result in false laboratory result Salt substitutes and medications may contain potassium Potassiumsparing diuretics may cause elevation of potassium and should not be used in patients with renal dysfunction 47 Hypocalcemia Serum level less than 8.5 mg/dL must be considered in conjunction with serum albumin level Causes: hypoparathyroidism, malabsorption, pancreatitis, alkalosis, massive transfusion of citrated blood, renal failure, medications, other Manifestations: tetany, circumoral numbness, paresthesias, hyperactive DTRs, Trousseau's sign, Chovstek's sign, seizures, respiratory symptoms of dyspnea and laryngospasm, abnormal clotting, and anxiety 48 Medical management: IV of calcium gluconate; calcium and vitamin D supplements; diet Nursing management: assessment as severe hypocalcemia is lifethreatening, weightbearing exercises to decrease bone calcium loss, patient teaching related to diet and medications, and nursing care related to IV calcium administration Hypocalcemia (cont.) 49 Palmar flexion--positive Trousseau's sign in hypocalcemia 50 Trousseau's Sign 51 Positive Chvostek's sign in hypocalcemia 52 Hypercalcemia Serum level above 10.5 mg/dL Causes: malignancy and hyperparathyroidism, bone loss related to immobility Manifestations: muscle weakness, incoordination, anorexia, constipation, nausea and vomiting, abdominal and bone pain, polyuria, thirst, ECG changes, and 53 dysrhythmias Medical management: treat underlying cause, administer fluids, furosemide, phosphates, calcitonin, and biphosphonates Nursing management: assessment as hypercalcemic crisis has high mortality, encourage ambulation, fluids of 3 to 4 L/d, provide fluids containing sodium unless contraindicated and fiber for constipation, and ensure safety 54 Hypercalcemia (cont.) Hypomagnesemia Serum level less than 1.8 mg/dL; evaluate in conjunction with serum albumin Causes: alcoholism, GI losses, enteral or parenteral feeding deficient in magnesium, medications, rapid administration of citrated blood; contributing causes include diabetic ketoacidosis, sepsis, burns, and hypothermia Manifestations: neuromuscular irritability, muscle weakness, tremors, athetoid movements, ECG changes and dysrhythmias, and alterations in mood and level of consciousness 55 Hypomagnesemia (cont.) Medical management: diet, oral magnesium, and magnesium sulfate IV Nursing management: assessment, ensure safety, patient teaching related to diet, medications, alcohol use, and nursing care related to IV magnesium sulfate Hypomagnesemia is often accompanied by hypocalcemia Monitor and treat potential hypocalcemia Dysphagia is common in magnesiumdepleted patients; assess ability to swallow with water 56 before administering food or medications Hypermagnesemia Serum level more than 2.7 mg/dL Causes: renal failure, diabetic ketoacidosis, and excessive administration of magnesium Manifestations: flushing, lowered BP, nausea, vomiting, hypoactive reflexes, drowsiness, muscle weakness, depressed respirations, ECG changes, and dysrhythmias Medical management: IV calcium gluconate, loop diuretics, IV NS of RL, hemodialysis Nursing management: assessment, avoid administering medications containing magnesium, and provide patient teaching regarding magnesiumcontaining OTC 57 medications Hypophosphatemia Serum level below 2.5 mg/dL Causes: alcoholism, refeeding of patients after starvation, pain, heat stroke, respiratory alkalosis, hyperventilation, diabetic ketoacidosis, hepatic encephalopathy, major burns, hyperparathyroidism, low magnesium, low potassium, diarrhea, vitamin D deficiency, and diuretic and antacid use Manifestations: neurologic symptoms, confusion, muscle weakness, tissue hypoxia, muscle and bone pain, and increased susceptibility to infection Medical management: oral or IV phosphorus replacement Nursing management: assessment, encourage foods high in phosphorus, and gradually introduce calories for malnourished patients receiving parenteral nutrition 58 Serum level above 4.5 mg/dL Hyperphosphatemia Causes: renal failure, excess phosphorus, excess vitamin D, acidosis, hypoparathyroidism, and chemotherapy Manifestations: few symptoms, softtissue calcifications, symptoms occur due to associated hypocalcemia Medical management: treat underlying disorder; use vitamin D preparations, calciumbinding antacids, phosphate binding gels or antacids, loop diuretics, NS IV, and dialysis Nursing management: assessment, avoid highphosphorus foods, and provide patient teaching related to diet, phosphatecontaining substances, and signs of hypocalcemia 59 Hypochloremia Serum level less than 96 mEq/L Causes: Addison's disease, reduced chloride intake, GI loss, diabetic ketoacidosis, excessive sweating, fever, burns, medications, and metabolic alkalosis Loss of chloride occurs with loss of other electrolytes, potassium, and sodium Manifestations: agitation, irritability, weakness, hyperexcitability of muscles, dysrhythmias, seizures, 60 and coma Hypochloremia (cont.) Medical management: replace chloride--IV, NS, or 0.45% NS Nursing management: assessment, avoid free water, encourage highchloride foods, and provide patient teaching related to highchloride foods Serum level more than 108 mEq/L Causes: excess sodium chloride infusions with water loss, head injury, hypernatremia, dehydration, severe diarrhea, respiratory alkalosis, metabolic acidosis, hyperparathyroidism, and medications 61 Hyperchloremia Manifestations: tachypnea, lethargy, weakness, rapid, deep respirations, hypertension, and cognitive changes Normal serum anion gap Medical management: restore electrolyte and fluid balance, LR, sodium bicarbonate, and diuretics Nursing management: assessment, provide patient teaching related to diet and hydration 62 Needleless IV Access Device 63 Complications of IV Therapy Fluid overload Air embolism Septicemia and other infections Infiltration and extravasation Phlebitis Thrombophlebitis Hematoma Clotting and obstruction 64 Solution Isotonic Solutions 0.9% NaCl (isotonic, also called normal saline [NS]) Na+ 154 mEq/L Cl- 154 mEq/L (308 mOsm/L) Also available with varying concentrations of dextrose(the most frequently used is a 5% dextrose concentration) Lactated Ringer's solution concentrations of dextrose (the most common is 5% dextrose) Comments An isotonic solution that expands the extracellular fluid (ECF) volume, used in hypovolemic states, resuscitative efforts, shock, diabetic ketoacidosis, metabolic alkalosis, hypercalcemia, mild Na+ deficit Supplies an excess of Na+ and Cl-; can cause fluid volume excess and hyperchloremic acidosis if used in excessive volumes, particularly in patients with compromised renal function, heart failure, or edema Not desirable as a routine maintenance solution, as it provides only Na+ and Cl- (and these are provided in excessive amounts) Only solution that may be administered with blood products An isotonic solution that contains multiple electrolytes in roughly the same concentration as found in plasma (note that solution is lacking in Mg++): provides 9 cal/L Used in the treatment of hypovolemia, burns, fluid lost as bile or diarrhea, and for acute blood loss replacement Lactate is rapidly metabolized into HCO3- in the body. Lactated Ringer's solution should not be used in lactic acidosis because the ability to convert lactate into HCO3- is impaired in this disorder. Not to be given with a pH > 7.5 because bicarbonate is formed as lactate breaks down, causing alkalosis Should not be used in renal failure because it contains potassium and can cause hyperkalemia Similar to plasma 5% dextrose in water (D 5W) No electrolytes 50 g of dextrose An isotonic solution that supplies 170 cal/L and free water to aid in renal excretion of solutes Used in treatment of hypernatremia, fluid loss, and dehydration Should not be used in excessive volumes in early postop (when ADH secretion is increased due to stress reaction) Should not be used solely in treatment of fluid volume deficit, because it dilutes plasma electrolyte concentrations Contraindicated in head injury because it may cause increased ICP Should not be used for fluid resuscitation because it can cause hyperglycemia Use with caution in patients with renal or cardiac disease risk of FVE Electrolyte-free solutions may cause peripheral circulatory collapse, anuria in patients with sodium deficiency, and increased body fluid loss. Hypotonic Solutions 0.45% NaCl (half-strength saline) Na+ 77 mEq/L Cl- 77 mEq/L (154 mOsm/L) Also available with varying concentrations of dextrose (the most common is a 5% concentration) Provides Na+, Cl-, and free water Free water is desirable to aid the kidneys in elimination of solute. Lacking in electrolytes other than Na+ and ClUsed to treat hypertonic dehydration, Na+ and Cl- depletion, and gastric fluid loss Administer cautiously, because it can cause fluid shifts from vascular system into cells, resulting in cardiovascular collapse and increased icp. Hypertonic Solutions 3% NaCl (hypertonic saline) Na+ 513 mEq/L Cl- 513 mEq/L (1026 mOsm/L) Used to increase ECF volume, decrease cellular swelling Highly hypertonic solution used only in critical situations to treat hyponatremia Must be administered slowly and cautiously, it can cause intravascular volume 65 Lab Values Urine Osmolality Urine Specific Gravity BUNurea 1020 HCT M= 4452% 1.0051.030 F= 3947 % Best indicator of urine concentration Ability of kidney to conserve or excrete water Increases with decreased kidney function and *dehydration or Increase protein intake RBC's in whole bld Increase with dehydration, decrease with overhydration 66 ...
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