FLUID AND ELECTROLYTEFUNDAMENTALS Approximately 60% of typical adult weight Influenced by age, gender, body fat Men > Women; Obese < Nonobese Approx 2/3 is Intracellular within cells; Extracellular outside cells ECF: intravascular (3L plasma, 3L erythrocytes, leukocytes, thrombocytes), interstitial (11-12L surrounds cell, lymph), transcellular (1L, includes cerebrospinal, pericardial, synovial, intraocular, pleural fluid, sweat, digestive secretions) Loss can disrupt equilibrium. Loss of ECF into a space not contrib. to equilibrium is called third space shift, third spacingThird Spacing

Occurs inSigns and Symptoms

Ascites, burns, peritonitis, bowel obstruction, bleeding into joint/body cavityDec urine OP despite adequate intake b/c of fluid exiting IV space kidneys receive less blood and compensate, Increased HR, decreased BP, decreased CVP (Central Venous Pressure), edema, increased body weight, imbalance in I&O

Electrolytes Measured in milliequivalents (mEq) per liter (mEq/L)Avg Daily I&O in an Adult

IntakeOutput

Oral Liquids1300 mLUrine1500 mL

Water in food1000 mLStool200 mL

Water produced via metabolism300 mLLungs (Insens)300 mL

Sweat (Insens)600 mL

Approx Total gain2600 mLApprox Total loss2600 mL

Lab Tests for Evaluating Fluid StatusOsmolality: concentration of fluid that affects movement of water b/w fluid compartments by osmosisNormal serum: 280-300 mOsm/kgNormal urine: 250-900 mOsm/kg***Na predominates and holds H2O in this compartment***Comparison of Serum and Urine Osmolality

FluidIncrease OsmolalityDecrease Osmolality

Serum (275-300 mOsm/kg)Free water lossDiabetes InsipidusNa OverloadHyperglycemiaUremiaSIADHRenal FailureDiureticsAdrenal Insufficiency

Urine (250-900 mOsm/kg)Fluid Volume DeficitSIADHHFAcidosisFluid Volume ExcessDiabetes Insipidus

SIADH = Syndrome of Inappropriate Antidiuretic Hormone; HF = Heart FailureRAASRenin angiotensinogen angiotensin IRenin released b/c decrease in renal perfusion. ACE angiotensin I angiotensin IIAngiotensin II vasoconstricts, increased arterial perfusion pressure and stimulates thirst. SNS stimulation aldosterone released in response to increased renin. Volume regulator, also released w/ serum K increase, serum Na decrease, or ADCH increase

Lab Values

Renal FunctionReference RangeIncrease ValueDecrease ValueReason

Blood Urea Nitrogen (BUN)10-20 mg/dLDecreased renal function, GI bleeding, dehydration, increased protein intake, fever, sepsisEnd-stage Liver Disease, low-protein diet, starvation, condition w/ expanded fluid volume (pregnancy)

Creatinine0.7-1.5 mg/dLImpaired renal function, heart failure, shock, and dehydration

Urine Sodium50-220 mEq/24hUsed to asses volume status and diagnosing hyponatremia and acute renal failure

Urine Specific Gravity1.010-1.025

Urine pH4.6-8.2Respiratory alkalosis, potassium depletion, and chronic renal failure. Metabolic acidosis, diabetic ketoacidosis, and diarrhea.

Complete Blood Count (CBC)

HematocritMales: 44%-52%Females: 39%-47%Dehydration, polycythemia, shockOverhydration, anemia, acute massive blood loss, hemolytic reaction to incompatible blood

HemoglobinMales: 13-18 g/dLFemales: 12-16 g/dLHemoconcentration of the bloodAnemia, severe hemorrhage, after hemolytic reaction

Platelets100,000-400,000/mmAn infusion of platelets may be indicated to prevent or treat bleeding associated with deficiencies in the number or function of a patients platelets.

Coagulation Tests

Prothrombin Time (PT)9.5-12 secondsThe PT measures the activity of the extrinsic pathway of the clotting cascade and can be used to monitor the level of anticoagulation. (warfarin)

Activated Partial Thromboplastin Time (APTT)20-45 secondsThe PTT is a measure of the activity of the intrinsic pathway of theclotting cascade; its used to assess the effects of unfractionated heparin.

INR

INR on warfarin therapy1.0

2-3.5The INR is used to monitor the effectiveness of warfarin therapy. The therapeutic range for INR is 23.5, although specific ranges vary warfarin sodium based on diagnosis.

Protein

Total Protein6-8 g/dLProteins influence the colloid osmotic pressure.

Albumin3.5-5 g/dLChanges in serum albumin affect total serum calcium. Very low levels of albumin can lead to edema, ascites, and pulmonary edema.

Major Fluid & Electrolyte Imbalances

ImbalanceContributing FactorsS/S and LabsNursing Interventions

Hypovolemia (FVD)Vomiting, diarrhea, fistulas, fever, excess sweating, burns, blood loss, GI suction, 3rd space shifts, anorexia, nausea, inability to access fluid. DI and uncontrolled DM contribute to depleted ECF volume.Acute weight loss, decreased skin turgor, oliguria, weak rapid pulse, capillary filling time prolonged, low CVP, BP, flattened neck veins, dizziness, weakness, thirst and confusion, pulse, muscle cramps.Labs: hemoglobin and hematocrit, serum and urine osmolality and specific gravity, urine Na, BUN and creatinine. Check urinalysis, oxygen saturation (SaO2), and CBC and electrolytes. Administer supplemental oxygen as prescribed. Monitor vital signs and heart rhythm. Auscultate lung sounds. Initiate and maintain IV access. Place the client in shock position (on back with legs elevated). Fluid replacement Administer IV fluids as prescribed (isotonic solutions, such as lactated Ringers, normal saline, blood transfusions). Monitor intake and output. Alert the provider for urine output less than 30 cc/hr. Monitor level of consciousness, and maintain client safety. Assess level of gait stability. Encourage client to use call light and ask for assistance. Initiate fall precautions. Encourage the client to change positions, slowly rolling from side to side, or standing up.

Hypervolemia (FVE)Renal failure, HF, cirrhosis, overzealous admin. Of Na-containing fluids. Prolonged corticosteroid therapy, severe stress, and hyperaldosteronism augment FVE.Acute weight gain, edema, distended jugular veins, crackles, and elevated CVP, SOB, BP, bounding pulse, cough.Labs: hemoglobin and hematocrit, serum and urine osmolality, urine Na and specific gravity. Check ABGs, SaO2, CBC, and chest x-ray results. Position the client in a semi-Fowlers position. Obtain daily weight. Monitor intake and output. Administer supplemental oxygen as prescribed. Reduce IV flow rates. Administer diuretics (osmotic, loop) as prescribed. Limit fluid and sodium intake as prescribed. Monitor and document presence of edema (pretibial, sacral, periorbital). Reposition the client at least every 2 hr. Support arms and legs to decrease dependent edema as appropriate. Monitor vital signs and heart rhythm. Auscultate lung sounds (listen for crackles)

Hyponatremia Na < 135Loss of Na thru diuretics, loss of GI fluids, renal disease, adrenal insufficiency. Gain of H2O thru excessive D5W and H2O supplements for pts receiving hypotonic tube feedings; disease states associated w/ SIADH such as head trauma and oat-cell lung tumor; meds associated w/ H2O retention. Also hyperglycemia and HF.Anorexia, nausea, vomiting, headache, lethargy, confusion, muscle cramps and weakness, muscular twitching, seizures, papilledema, dry skin, pulse, BPLabs: serum and urine Na, urine specific gravity and osmolality.Report abnormal laboratory findings to the provider.Fluid overload: Restrict water intake as prescribed by the provider.For clients who have heart failure and hyponatremia, provide loop diuretics and ACE inhibitors as prescribed.Acute: Administer hypertonic oral and IV fluids as prescribed. Administer 3% sodium chloride slowly, and monitor sodium levels frequently. Encourage foods and fluids high in sodium (cheeses, milk, condiments). Restoration of normal ECF volume: Administer isotonic IV therapy (0.9% sodium chloride, lactated Ringers). Monitor intake and output, and daily weight. Monitor vital signs and level of consciousness; report abnormal findings to the provider. Encourage the client to change positions slowly.

Hypernatremia Na > 145H2O deprivation, hypertonic tube feedings w/o adequate H2O supplements, DI, heatstroke, hyperventilation, watery diarrhea; excess corticosteroid, NaHCO3, and NaCl admin. And salt water near-drowning victims.Thirst, body temp, swollen dry tongue and sticky mucous membranes, hallucinations, lethargy, restlessness, irritability, focal or grand mal seizures, pulmonary edema, hyperreflexia, twitching, nausea, vomiting, anorexia, pulse, BP.Labs: serum Na, urine Na, urine specific gravity and osmolality.Report abnormal laboratory findings to the provider.Fluid loss: Based on serum osmolarity and hemodynamic stability. Administer hypotonic IV fluids (0.45% sodium chloride). Administer isotonic IV fluids (0.9% sodium chloride).Excess sodium: Encourage water intake, and discourage sodium intake. Administer diuretics (loop diuretics) for clients who have poor kidney excretion. Monitor level of consciousness, and ensure safety. Monitor the clients vital signs and heart rhythm. Auscultate lung sounds. Provide oral hygiene and other comfort measures to decrease thirst. Monitor intake and output, and alert the provider of inadequate renal output.

Hypokalemia K < 3.5Diarrhea, vomiting, gastric suction, corticosteroid admin., hyperaldosteronism, carbenicillin, amphotericin B, bulimia, osmotic diuresis, alkalosis, starvation, diuretics, and digoxin toxicity.Fatigue, anorexia, nausea, vomiting, muscle weakness, polyuria, bowel motility, ventricular asystole or fibrillation, paresthesias, leg cramps, BP, ileus, abd. distention, hypoactive reflexes.ECG: flattened T waves, prominent U waves, ST depression, prolonged PR interval.Report abnormal findings to the provider.Replacement of potassium: Encourage foods high in potassium (avocados, broccoli, dairy products, dried fruit, cantaloupe, bananas). Provide oral potassium supplementation.IV potassium supplementation: Never administer by IV bolus (high risk of cardiac arrest). The maximum recommended rate is 5 to 10 mEq/hr.Assess for phlebitis (tissue irritant). Monitor and maintain adequate urine output. Observe for shallow ineffective respirations and diminished breath sounds. Monitor the clients cardiac rhythm, and intervene promptly as needed. Monitor clients receiving digoxin (Lanoxin). Hypokalemia increases the risk for digoxin toxicity. Monitor level of consciousness, and maintain client safety. Monitor bowel sounds and abdominal distention, and intervene as needed. Monitor kidney function (BUN, GFR, creatinine). Monitor magnesium, calcium, and phosphorus. Provide assistance with ADLs (weakness is usually pronounced if the client has a K+ less than 2.5)

Hyperkalemia K > 5.0Pseudohyperkalemia, oliguric renal failure, use ofpotassium-conserving diuretics in pts with renalinsufficiency, metabolic acidosis, Addisons disease,crush injury, burns, stored bank blood transfusions,and rapid IV administration of potassiumVague muscular weakness, tachycardia bradycardia,dysrhythmias, flaccid paralysis, paresthesias, intestinalcolic, cramps, irritability, anxiety. ECG: tall tentedT waves, prolonged PR interval and QRS duration,absent P waves, ST depression.Report abnormal findings to the provider.Cardiac protection: Prepare to administer calcium gluconate or calcium chloride.Decrease potassium intake: Stop the infusion of IV potassium. Withhold oral potassium. Provide a potassium-restricted diet (avoid foods high in potassium [avocados, broccoli, dairy products, dried fruit, cantaloupe, bananas]).Promote movement of potassium from ECF to ICF: Administer IV fluids with dextrose and regular insulin. Administer sodium bicarbonate to reverse acidosis. Monitor the clients cardiac rhythm, and intervene promptly as needed. Administer loop diuretics (furosemide [Lasix]) if kidney function is adequate. Administer cation exchange resins (sodium polystyrene sulfonate [Kayexalate]). Can be used with renal disorders.

Hypocalcemia Ca < 8.5Hypoparathyroidism (may follow thyroid surgery orradical neck dissection), malabsorption, pancreatitis,alkalosis, vit. D deficiency, massive subcutaneousinfection, generalized peritonitis, massive transfusionof citrated blood, chronic diarrhea, decreased parathyroidhormone, and diuretic phase of renal failureNumbness, tingling of fingers, toes, and circumoral region;positive Trousseaus sign and Chvosteks sign; seizures,carpopedal spasms, hyperactive deep tendon reflexes, irritability, bronchospasm, anxiety, impaired clotting time, prothrombin.ECG: prolonged QT interval andlengthened ST. Administer oral or IV calcium supplements. Implement seizure precautions. Have emergency equipment on standby. Encourage foods high in calcium, including dairy products and dark green vegetables.

Hypercalcemia Ca > 10.5Hyperparathyroidism, malignant neoplastic disease, prolonged immobilization, overuse of calcium supplements, vitamin D excess, oliguric phase of renal failure, acidosis, corticosteroid therapy, thiazide diuretic use,increased parathyroid hormone, and digoxin toxicityMuscular weakness, constipation, anorexia, nausea,vomiting, polyuria and polydipsia, hypoactive deep tendon reflexes, lethargy, deep bone pain, pathologic fractures,flank pain, and calcium stones. ECG: shortened QT interval, bradycardia, heart blocks. Monitor level of consciousness for safety. Encourage patient movement and exercise. Assist patient with movement to decrease pain. Monitor for ECG changes Teach patient to decrease calcium intake and increase fiber Encourage oral intake of acid-ash fluids to decrease deposit of calcium salts. Monitor for symptoms of digitalis toxicity; calcium enhances the action of digitalis

Hypomagnesemia Mg < 1.8Chronic alcoholism, hyperparathyroidism, hyperaldosteronism, diuretic phase of renal failure, malabsorptive disorders, diabetic ketoacidosis, refeedingafter starvation, parenteral nutrition, chronic laxativeuse, diarrhea, acute myocardial infarction, heart failure, decreased serum K+ and Ca++ and certain pharmacologic agents (such as gentamicin, cisplatin, and cyclosporine)Neuromuscular irritability, positive Trousseaus andChvosteks signs, insomnia, mood changes, anorexia,vomiting, increased tendon reflexes, and BP.ECG: PVCs, flat or inverted T waves, depressedST segment.- Monitor level of consciousness and breathing for laryngeal stridor- Administer magnesium sulfate- Monitor for ECG changes and assess the patient for digitalis toxicityTeach patient to each magnesium-rich foods and to avoid excessive use of laxative and diuretics

Hypermagnesemia Mg > 2.7Oliguric phase of renal failure (particularly when magnesium-containing medications are administered), adrenal insufficiency, excessive IV magnesium administration, and DKAFlushing, hypotension, drowsiness, hypoactive reflexes, depressed respirations, cardiac arrest and coma, diaphoresis.ECG: tachycardia bradycardia, prolonged PR interval and QRS.- Monitor level of consciousness- Assess patellar reflexes; if absent notify practitioner- Monitor vital signs q15-30 minutes until stable and for ECG changes- Encourage fluids unless contraindicate to dilute the serum level of magnesium- Teach patient over-the-counter drugs with magnesium content

HypophosphatemiaP < 2.5Refeeding after starvation, alcohol withdrawal, diabeticketoacidosis, respiratory alkalosis, magnesium, potassium, hyperparathyroidism, vomiting, diarrhea, hyperventilation, vitamin D deficiency associatedwith malabsorptive disorders, burns, acidbase disorders, parenteral nutrition, and diuretic useParesthesias, muscle weakness, bone pain and tenderness,chest pain, confusion, cardiomyopathy, respiratory failure, seizures, tissue hypoxia, and increased susceptibilityto infection- Monitor patients level of consciousness.- Institute safety measures for seizures- Administer pain medication and other comfort measures- Monitor for bleeding and respiratory failure- Teach patient about phosphorus-rich foods and over-the-counter drugs that contain aluminum hydroxide- Administer IV phosphate with caution: dilute and infuse slowly to avoid phlebitis; infiltration at the IV site may cause tissue sloughing; do not infuse with calcium

HyperphosphatemiaP > 4.5

Acute and chronic renal failure, excessive intake of phosphorus, vitamin D excess, respiratory acidosis, hypoparathyroidism, volume depletion, leukemia/lymphoma treated with cytotoxic agents, increasedtissue breakdown, rhabdomyolysisTetany, tachycardia, anorexia, nausea and vomiting, muscleweakness, signs and symptoms of hypocalcemia- Monitor for tetany and other signs of hypocalcemia- Monitor heart rate and assess for ECG changes- Administer calcium replacement- Monitor urinary output; 108Excessive sodium chloride infusions with water loss,head injury (sodium retention), hypernatremia, renal failure, corticosteroid use, dehydration, severe diarrhea (loss of bicarbonate), respiratory alkalosis, administration of diuretics, overdose of salicylates, Kayexalate,acetazolamide, phenylbutazone and ammonium chloride use, hyperparathyroidism, metabolic acidosisTachypnea, lethargy, weakness, deep rapid respirations,decline in cognitive status, decreased cardiac output, dyspnea, tachycardia, pitting edema, dysrhythmias, comaLabs indicate: increased serum chloride, increased serumsodium, decreased serum pH, decreased serum bicarbonate,normal anion gap, increased urinary chloride level- Hypotonic Iv solutions may be given to restore balance.-Lactated Ringers solution may be prescribed to convert lactate to bicarbonate in the liver, which increases the base bicarbonate level and corrects the acidosis.- IV sodium bicarbonate may be administered to increase bicarbonate levels, which leads to the renal excretion of chloride ions as bicarbonate and chloride compete for combination with sodium.- Diuretics may be administered to eliminate chloride.-Sodium, chloride and fluids are restricted.

HypochloremiaCl < 96Addisons disease, reduced chloride intake or absorption,untreated diabetic ketoacidosis, chronic respiratoryacidosis, excessive sweating, vomiting, gastric suction, diarrhea, sodium and potassium deficiency, metabolic alkalosis, loop, osmotic, or thiazide diuretic use, overuse of bicarbonate, rapid removal of ascetic fluid with a high sodium content, intravenous fluidsthat lack chloride (dextrose and water), draining fistulas and ileostomies, heart failure, cystic fibrosisAgitation, irritability, tremors, muscle cramps, hyperactivedeep tendon reflexes, hypertonicity, tetany, slow, shallow respirations, seizures, dysrhythmias, comaLabs indicate: serum chloride, serum sodium, pH, serum bicarbonate, total carbon dioxide content, urine chloride level- Normal saline (0.9% sodium chloride) or half strength saline (0.45% sodium chloride) solution is administered by IV to replace the chloride- the physician may reevaluate whether the patient receiving a diuretic (loop, osmotic or thiazide) should discontinue the medications or change to another diuretic.- Foods high in chloride are provided: tomato juice, bananas, eggs, cheese, milk, canned vegetables and processed meats.- avoid to drink free water (water without electrolytes) or bottled water because they excrete large amount of chloride.

Hypovolemia (Fluid Volume Deficit) Loss of ECF > Intake of fluid Loss of fluid AND electrolytes equally. NOT dehydration, which is fluid only.Pathology: Abnormal fluid losses (vomiting, diarrhea, GI suctioning, sweating, decreased intake (nausea, inability to gain access to fluids), diabetes insipidus, adrenal insufficiency, osmotic diuresis, hemorrhage, coma, third space fluid shiftsManifestations: Acute weight loss, decreased skin turgor, oliguria, concentrated urine, postural hypotension, weak and rapid HR, flattened neck veins, increased temp, decreased CVP, cool and clammy skin r/t peripheral vasoconstriction, thirst, anorexia, nausea, lassitude (weariness, exhaustion), muscle weakness and crampsAssessment: BUN elevated out of proportion to serum creatinine (> 20:1) It can be elevated r/t dehydration or decreased renal perfusion/function. Hematocrit elevated r/t decreased plasma volume. Urine specific gravity increases r/t kidneys attempt to conserve water and decreased with diabetes insipidus. They try to compensate! Hypokalemia w/ GI and renal losses Hyperkalemia w/ adrenal insufficiency Hyponatremia w/ increased thirst and ADH release Hypernatremia w/ increased insensible losses and diabetes insipidusInterventions: Monitor I&O, monitor weights daily (1L fluid equals approx. 1kg), monitor VS, skin and tongue turgor, urine specific gravity, mental functionPrevention: Minimize fluid loss, antidiarrheals, replacement fluidsCorrection: Oral fluids, frequent mouth care, small volumes of fluids frequently, anntiemetics if nausea, enteral or parenteral therapy if neededHypervolemia (Fluid Volume Excess) Abnormal retention of H2O and Na in approx. the same proportions in which they normally exist Always secondary to an increase in total body Na, which increases total body H2O Isotonic retention of substances means Na concentration remains normalPathology: Fluid overload, diminished function of homeostatic mechanisms r/t fluid balance. Contributing factors: HF, renal failure, liver cirrhosis, excessive consumption of Na in patient with impaired regulation.Manifestations: Edema, distended neck veins, crackles, tachycardia, increased BP, pulse pressure, and CVP, increased weight, increased urine OP, SOB and wheezing.Assessment: BUN and hematocrit normally decrease r/t plasma dilution; also low protein intake and anemia. In CRF, serum osmolality and Na are decreased r/t excessive H2O retention. Urine Na increased if kidneys attempting to excrete excess. CxR may show pulmonary congestion. Hypervolemia occurs when aldosterone chronically stimulated (cirrhosis, HF, and nephrotic syndrome; Na will not rise w/ these)Interventions: Promote rest, restrict Na, monitor parenteral therapy, diuretics, semi-Fowlers if dyspnea or orthopnea present, turn q2h b/c edema promotes skin breakdown, teach patient to monitor I&O and importance of adherence