Fluid and Electrolytes, Balance and Disturbances

By: Ms.

katherina

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Mechanism for fluid and

electrolyte movement

osmosis

diffusion

filtration

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osmosis

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diffusion

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diffusion

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filtration

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Fluid and electrolyte balances

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cations

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sodium potassium

calcium magnesium

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Electrolytes are measured

milliequivalent per litre of water

(mEq / L)

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Equivalent refers to the chemical combining power of a substance or the power of cations to unite with anions to form molecules

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sodium

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most abundant cat ion in the extracellular fluid

sodium is regulated by

Salt intake Aldosterone

Urinary output

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functionsMaintain balance of extracellular fluid,

thereby it controls the movements of the water between fluid compartments

Transmission of nerve impulses

Neuro muscular and myocardial impulse transmission

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Normal concentration of sodium

135 to 145 mEq/L

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POTASSIUM

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Main intracellular cat ionHelps in maintaining fluid

balance of the intracellular fluidPotassium is regulated by

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functionsRegulates neuromuscular excitability and

muscle contraction

Needed for glycogen formation and protein sunthesis

Correction of acid base imbalances. Potassium ion can be exchanged with

hydrogen ion (H+)

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Normal concentration of potassium

3.5 to 5.3 mEq/L

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CALCIUM

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Calcium is the most abundant element in the body

Calcium is extracellular fluid Regulated by the action of Thyroid gland parathyroid

gland

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Parathyroid hormone (PTH) controls the balance among bone calcium, gastrointestinal absorption and kidney excretion of calcium.

Thyrocalcitonin from the thyroid gland inhibits the release of calcium from bones, thus playing a minor role in determining serum calcium levels.

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functionsMaintenance of cell membrane, its integrity

and structure

Conduction of nerve impulses in the skeletal muscle

Stimulation and depolarization and contraction of cardiac muscles

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functionsAids in blood coagulation

Growth and formation of bones

Muscle relaxation

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Normal concentration of calcium

4 to 5 mEq/L

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MAGNESIUM

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Magnesium is the second most important cat ion in the intracellular fluid

It has an inhibitory effect on skeletal muscles.

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functionsPrecipitation of metabolic activities of

cells

Enzyme activity

Neuro chemical activity

Muscular excitability

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Normal concentration of magnesium

1.5 to 2.4 mEq/L

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anions

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phosphate chloride

bicarbonate

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PHOSPHATE

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Phosphate is a buffer anion in extracellular and intracellular fluid

Phosphate absorption is through gastrointestinal tract in a range of 3 to 12 mg/100 ml

Calcium and phosphate are inversely proportional.

When one rises the other falls

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Serum phosphate is regulated by

kidneys

Parathyroid hormone

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Activated vitamin D

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functions

Promotes normal neuromuscular action

Development and maintenance of bones and teeth

Participates in carbohydrate metabolism

Assist in acid base regulation

Maintains levels of ATP ( Adenosine Triphosphate) and thus energy levels

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Normal concentration of phosphate

2.5 to 4.5 mEq/L

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chloride

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Chlorides are found in extracellular and intracellular fluids

The chloride ion balances the cations within the extracellular fluid

The ion exchange helps to maintain the electrical neutrality

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Chloride is regulated through kidneys

The dietary intake of chloride and the amount excreted in urine are closely related

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Normal concentration of chloride

100 to 106 mEq/L

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bicarbonate

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Bicarbonate is found in extracellular and intracellular fluids

It is a major chemical buffer in the body

Regulation is through kidneys

It is an essential component of the carbonic acid-bicarbonate buffering system essential to acid base balance

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Normal arterial bicarbonate value

22 to 26 mEq/L

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Normal venous bicarbonate value

24 to 30 mEq/L

In venous blood, bicarbonate is measured as

carbondioxide content

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FLUID VOLUME DISTURBANCES

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Fluid volume deficit

hypovolemia

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Fluid Volume DeficitMild – 2% of body weight loss

Moderate – 5% of body weight loss

Severe – 8% or more of body weight loss

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Pathophysiologyresults from loss of

body fluids and occurs more rapidly when coupled with decreased fluid intake

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Clinical manifestations

Acute Weight loss

Decreased skin turgor

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Concentrated urine

flattened neck veins

Postural hypotension

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Weak, rapid, heart rate

Oliguria

Increased temperature

Decreased central venous pressure

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Nursing Diagnosis Fluid volume Deficit r/t Insufficient intake, vomiting,

diarrhea, hemorrage, m/b dry mucous

membranes

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Nursing management Restore fluids by oral or IV

Treat underlying cause Monitor I & O at least every 8

hours Daily weight Vital signs Skin turgor Urine concentration

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Fluid volume excess

hypervolemia

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Pathophysiology may be related

to fluid overload or diminished function of the homeostatic mechanisms responsible for regulating fluid balance

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Contributing factors

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Clinical manifestations

Edema

Distended neck veins

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Tachycardia

Increased blood Pressure

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Increased weight

crackles

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Nursing Diagnosis Fluid volume excess r/t CHF, excess sodium intake,

renal failure

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Nursing management

Preventing FVE

Detecting and Controlling FVE

Teaching patients about edema

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Electrolyte Imbalances

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SODIUM

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SodiumNormal range – 135 to 145

mEq/L

Primary regulator of ECF volume (a loss or gain of sodium is usually accompanied by a loss or gain of water)

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HYPONATREMIA

Sodium level less than 135 mEq/L

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causesVomiting Diarrhea

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Sweating Diuretics

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Clinical manifestations

Poor skin turgor

Decreased saliva

production

Dry mucosa

Anorexiavomiting

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Clinical manifestations

Orthostatic hypotension

Altered mental status

Nausea/ abdominal cramping

Confusion & lethargy

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Nursing interventions Assess clinical manifestations

Monitor fluid intake and output, vital signs and lab data.

Encourage food and fluids high in Na

Limit water intake.

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HYPERNATREMIA

Sodium level more than 145 mEq/L

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CAUSESLoss of fluids

Water deprivation

Excessive salt intake

Conditions like Diabetes insipidus, heatstroke

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Pathophysiology- Fluid deprivation in patients

who cannot perceive, respond to, or communicate their thirst

- Most often affects very old, very young, and cognitively impaired patients

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Clinical manifestations- Thirst

- Sticky mucous membranes

- Flushed skin

- Postural hypotension

- Dry, swollen tongue

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Nursing interventions Monitor intake and output

Monitor behavioural changes

Monitor lab findings

Encourage fluids

Monitor diet as ordered(salt restriction)

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POTASSIUM

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Normal serum potassium concentration is 3.5 to 5.5 mEq/L

Major Intracellular electrolyte and 98% of the body’s potassium is inside the cells

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HYPOKALEMIA

Potassium level less than 3.5 mEq/L

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CAUSESLoss of K+ in the form of

vomittings ,GI suction

poor K intake

diuretics

steroid administration

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Clinical manifestations Muscle weakness Leg cramps Fatigue Lethargy Anorexia Nausea, vomitting Decreased bowel sounds Decreased bowel motility Cardiac dysrhythmias Depressed deep tendon reflex

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Nursing interventions

Monitor heart rate and rhythmMonitor clients receiving

DIGITALISAdminister oral K+ as ordered

with food /fluidsAdminister IV K+ as

ordered ,flow rate not more than 10-20 meq/hr

Teach patients about potassium rich diet and to reduce potassium wastage

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HYPERKALEMIA

Potassium level more than 5.5

mEq/L

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Causes Decreased renal potassium

excretion as seen with renal failure and oliguria

High potassium intake Renal insufficiency

Shift of potassium out of the cell as seen in acidosis

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Clinical manifestations

Skeletal muscle weakness/paralysis

ECG changes – such as peaked T waves, widened QRS complexes

Heart block

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Nursing interventions

Monitor ECG changes – telemetry

Administer Calcium solutions to neutralize the potassium

Monitor muscle tone Give Kayexelate Give Insulin and D50W

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CALCIUM

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Normal serum calcium level is 4 to 5 mEq/L

More than 99% of the body’s calcium is located in the skeletal system

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HYPOCALCEMIA

Calcium level less than 4 mEq/L

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Causes- Vitamin D/Calcium

deficiency- Primary/surgical

hyperparathyroidism- Pancreatitis- Renal failure

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Clinical Manifestations

Tetany and cramps in muscles of extremities

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Trousseau’s sign – carpal spasms

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Chvostek’s sign – cheek twitching

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Seizures, mental changes

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ECG shows prolonged QT intervals

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Nursing interventions- IV/PO Calcium Carbonate or

Calcium Gluconate- Encourage increased dietary

intake of Calcium- Monitor neurlogical status- Establish seizure precautions

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HYPERCALCEMIA

Calcium level more than 5 mEq/L

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Causes- Hyperparathyroidism- Prolonged immobilization- Thiazide diuretics- Large doses of Vitamin A and D

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Clinical manifestations

- Muscle weakness, nausea and vomiting

- Lethargy and confusion- Constipation- Cardiac Arrest

(high level)

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Nursing interventions

- Eliminate Calcium from diet- Monitor neurological status- Increase fluids (IV or PO)- Calcitonin

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MAGNESIUM

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Normal serum magnesium level is 1.5 to 2.4 mEq/L

Thought to have a direct effect on peripheral arteries and arterioles

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HYPOMAGNESEMIA

magnesium level less than 1.5 mEq/L

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Causes- Chronic Alcoholism

- Diarrhea, or any disruption in small bowel function

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- TPN

- Diabetic ketoacidosis

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Clinical manifestations

- Neuromuscular irritability- Positive Chvostek’s and

Trousseau’s sign- EKG changes with prolonged

QRS, depressed ST segment, and cardiac dysrhythmias

- May occur with hypocalcemia and hypokalemia

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• Starved – possible cause of hypomagnesemia

• Seizures• Tetany• Anorexia and arrhythmias• Rapid heart rate• Vomiting• Emotional lability• Deep tendon reflexes

increased

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Nursing interventions

- IV/PO Magnesium replacement, including Magnesium Sulfate

- Give Calcium Gluconate if accompanied by hypocalcemia

- Monitor for dysphagia, give soft foods

- Measure vital signs closely

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Foods high in Magnesium:

Green leafy vegetables

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Nuts

Legumes

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Seafood

Chocolate

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HYPERMAGNESEMIA

magnesium level more than 2.4

mEq/L

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Causes- Renal failure- Untreated diabetic

ketoacidosis- Excessive use of antacids

and laxatives

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Clinical manifestations- Flushed face and skin warmth

- Mild hypotension

- Heart block and cardiac arrest

- Muscle weakness and even paralysis

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RENAL• Reflexes decreased (plus

weakness and paralysis)• ECG changes (bradycardia and

hypotension)• Nausea and vomiting• Appearance flushed• Lethargy (plus drowsiness and coma)

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Nursing interventions- Monitor Mg levels- Monitor respiratory rate- Monitor cardiac rhythm- Increase fluids- IV calcium for emergencies

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PHOSPHORUS

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Normal serum phosphorus level is 2.5 to 4.5 mg/100 ml

- Phosphate levels vary inversely to calcium levels

- High Calcium = Low Phosphate

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HYPOPHOSPHOTEMIA

Phosphorus level less than 2.5 mEq/L

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Causes- Most likely to occurs with

overzealous intake or administration of simple carbohydrates

- Severe protein-calorie malnutrition (anorexia or alcoholism)

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Clinical manifestations

- Muscle weakness- Seizures and coma- Irritability- Fatigue- Confusion- Numbness

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Nursing interventions- Prevention is the goal- IV Phosphorus for severe - Prevention of infection- Monitor phosphorus levels- Increase oral intake of

phosphorus rich foods

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Foods rich in phosphorus

- Milk and milk products- Poultry- Whole grains- Organ meats- Nuts- Fish

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HYPERPHOSPHOTEMIA

Phosphorus level more than 4.5

mEq/L

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Causes- Renal failure

- Chemotherapy

- Hypoparathyroidism

- High phosphate intake

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Clinical manifestations

- Tetany- Muscle weakness- Similar to Hypocalcemia because

of reciprocal relationship

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Nursing interventions- Treat underlying cause

- Avoid phosphorus rich foods

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