Fluids and Electrolytes

Atlantic Cape Community CollegeKaren Zaniewski MSN RN

Myra Caplan MSN RN

Class Outcomes

• Describe the distribution and composition of body fluids and mechanisms by which body fluids are regulated.

• Examine the variables that affect fluid and electrolyte balance.

• Interpret laboratory studies associated with fluid and electrolyte balance.

• Describe the major fluid and electrolyte balance disorders.

Class Outcomes

• Evaluate nursing interventions to meet the needs of patients with an alteration in fluid and electrolyte balance.

• Differentiate between common disturbances in fluids and electrolytes.

• Describe how to measure and record intake and output.

Body Fluids

• Water is the primary body fluid with adult body weight 55-60% water.

• Daily fluid intake should equal daily fluid output.

• What is the minimum urine output per hour necessary to maintain renal function?

Functions of Fluids

• Cellular metabolism• Solvent for electrolytes and other

substances• Body temperature maintenance• Aid with digestion and elimination• Lubrication

Normal Fluid Gains and Losses

GAINSFluid intake 1500ml Food intake 1000mlNutrient oxidation 300mlLossesSensible: urine (1500); Sweat (100)Insensible: Skin (500), Lungs (400), Feces (200).

Regulatory Mechanisms

1.Posterior Pituitary: releases ADH (antidiuretic hormone) in response to increased serum Osmolality. ADH causes renal reabsorption of water.

Normal Serum Osmolality is 280-295mosm/kg and reflects the concentration of solutes in the blood. The greater the osmol the greater the pulling force (osmotic pressure)

2. Hypothalmus: Thirst mechanism is triggered in response to increased serum osmolality.

Regulatory Mechanisms• 3. Renal Regulation: Receptors in the nephron

sense decreased serum osmolality and kidney secretes Renin.

Renin converts angiotensinogen to angiotensin I. Then angiotensin 1 is converted to angiotensin II by a converting enzyme.

Angiotensin II causes vasoconstriction sodium (Na) and water retention by the kidneys AND the secretion of Aldosterone from the adrenal cortex which causes the kidneys to excrete potassium (K) and retain NA and water!

Regulation

• Brain Natriuretic Peptide (BNP) Released from brain and right atrium. Causes decrease in Na Increased with CHF

Questions

• Why does a decrease in blood volume cause an increase in Antidiuretic hormone?

• What is the end result of the Renin-Angiotensin mechanism?

• What would a medication that stimulates the Renin mechanism do?

• An angiotensin blocking agent blocks the renin mechanism. What would the result be and what would be the concern of the nurse?

Fluids Distribution

• Body Fluid Compartments: Intracellular (ICF) fluid inside the cell (2/3 body water) Extracellular (ECF): fluid outside the cell (1/3 body water) Interstitial: fluid between cells Intravascular: liquid component of blood Transcellular: Cerebrospinal (CSF), pleural etc.

Specific Populations

• Elderly have a lower percent of body fluid than younger adults.

• Women have a lower percent body fluid then men.

Why???????• Infants have more extracellular fluid than

intracellular fluid. Most of the fluid in an adult is intracellular. This makes infants more prone to what?

Movement of Fluids

• Osmosis: The movement of water from an area of low solute concentration to an area of high solute concentration.

• The greater the concentration (Osmolality) of a solution the greater the pulling force (Osmotic pressure).

Hypertonic Fluids• Hypertonic: have a higher osmolality than ICF.

Higher osmotic pressure pulls the fluid from the cells (cells shrink)

Used to treat hypovolemia; it expands vascular volume and therefore increases blood pressure (BP) and Urine output (U.O.)Contraindicated with Congestive heart failure (CHF). WHY?????

Examples: D5% 0.45NSS D5%LR D5%NSS

Hypotonic Fluids

• Hypotonic fluids have less concentration of particles (low osmolality) than ICF. Low osmotic pressure shifts the fluid into the cells. The cells swell.

• Treats cellular dehydration• Contraindicated with increased intercranial pressure

(ICP).• Esamples: 0.45 NSS 0.33NSS

Isotonic Fluids

• Isotonic fluids have the same osmolality as the ICF.

• Osmotic pressure is the same inside and outside the cell.

• No cellular changes, and expands the ICF and ECF volume. Often used for excessive vomiting and diarrhea.

• Examples: 0.9 NSS, D5W, Ringer’s Lactate.

Albumin

• Albumin is a serum protein that has what is called colloid osmotic pressure(or oncotic pressure). Albumin pulls water from the interstitial compartments into the intravascular compartment.

• Patients with low serum albumin tend to retain fluids in the interstitial layers, and have edema, and hypotension.

Question

A patient with low albumin levels would probably be prescribed what type of fluid?

ALSO

Albumin binds with many drugs. If albumin level is low then more free drug is available, hence increased risk for toxicity.

Solute

• Diffusion is the movement of solute from an area of high concentration to an area of low concentration.

• Active Transport: movement of solute from a low concentration to a high concentration. (requires energy/ATP).

Solvent and Solute

• Filtration: Passage from an area of high pressure to an area of low pressure. Termed hydrostatic pressure.

• Arterioles have a higher pressure than ICF, so fluid, O2 and nutrients move into cells, whereas venules have lower pressure than ICF so fluid CO2 and water move out of cells.

Nursing Diag.:FVE:Hypervolemia

• Fluid overload= overhydration

• Excess fluid vascular space is hypervolemia.

• Excess fluid interstital space is edema.

Etiology (causes) of FVE

• Excessive intake of water.• Excessive intake of Na• Increased Na/H20 retention.• Syndrome of inappropriate ADH (SIADH)• Heart failure; kidney failure.

Assessment FVE

• Neuro: Altered LOC; muscle twitching.• Cardiac: Increased HR, increased BP;JVD,

bounding pulse.• Respiratory: (SOB or dyspnea), abnormal

lung sounds (fine rales), Increased respiratory rate.

• Gastrointestinal: increased motility, stomach cramps, nausea and vomiting.

FVE

• Renal: weight gain, decreased specific gravity of urine.

• Integumentary: Edema• LABS: Decreased H&H (Hempglobin and

Hematocrit)• HgB men 13-18g/100ml/women 12-16g/100ml• HCT:men 42-50/women 40-48• Decreased Blood Urea Nitrogen (BUN) Normal =

10-20mg/100ml)

Nursing Diagnosis/Planning

• Fluid volume excess related to excessive water intake as evidenced by headache, confusion, increased BP and heart rate, hyponatremia.

• Patient will demonstrate fluid balance by equal intake and output normal serum sodium within………

FVE Interventions

• Diuretics (I.e. Lasix)• Fluid restriction• Sodium restriction• I&O (intake and output)• Daily weights ( most significant determanent

of fluid balance)• Monitor labs (CBC) Complete blood count

(includes H&H); BMP (includes BS, BUN Creatinine, lytes)

Nursing Diag: FVDHypovolemia• Hypovolemia is loss of fluids and lytes.• Dehydration is loss of fluids.• Dehydration most common abn.in the elderly.• Etiology: Increased output (I.e. diabetes insipitus,

hyperglycemia, burns, hemorrhage, vomiting, diarrhea)

• Also third spacing where there is a fluid shift out of the vascular space into the interstitial space (malnutrition, burns,liver disease)

FVD Assessment• Neuro: Decreased LOC, skeletal muscle weakness.• Cardiac: decreased peripheral pulses,BP and

orthostatic hypotension, Increased HR.• Respiratory: Increased rate and depth.• GI: Thirst, decreased bowel sounds• Renal: decrease output, increased SG weight loss,

increased Na• Integumentary: Dry, poor turgor, pitting edema,

sunken eyeballs.

Nursing Diagnosis/Planning

• Fluid volume deficit related to loss of GI fluids/vomiting as evidenced by dry mucus membranes, decreased urinary output, thirst, and increased hematocrit.

• Patient will have moist mucus membranes balanced I&O, and normal hematocrit (HCT) within………..

FVD Interventions

• Restore fluid and electrolytes.

• Antiemetic, antidiarrheal medications

• Daily weights/I&O

• Labs: CBC, CMP

Let’s look at Diabetes Insipitus (DI)

• impaired ability to conserve water due to a decrease in ADH.

• Main causes are neurologic and nephrogenic.• Same signs and symptoms as dehydration.• Why is the urine specific gravity decreased with DI?• Would the BUN be increased or decreased with DI.

Electrolytes

• Solutes found in various concentrations and measured in mEq units.

• Positively charged (cations): Sodium (Na+) 135-145 mEq/L (ECF) Potassium (K+) 3.5-5.5 mEq/L (ICF) Calcium (Ca++) 8.5-10.5 mg/100ml or 4.5-5.5

mEq/L Magnesium(Mg++): 1.5-2.5 mEq/L

Electrolytes

• Anions (-)• Chloride (CL-) 95-105 mEq/L• Phosphate (Po4-) 2.5-4.5 mg/dl• Bicarbonate (HCO3- )23-30mEq/L

Electrolytes: Sodium 135-145mEq/L

• Major extracellular cation (135-145)

• Regulates volume of body fluids

• Needed for nerve impulse and muscle fiber transmission.

• Renal and endocrine regulation.

Hyponatremia ↓↓↓ NA

• < 135 mEq/L• Results from excess water loss or loss of

Na+• Sx: confusion, headache, abdominal

cramps, N. V, pitting edema over sternum.• Rx: Diet, IV therapy, Fluid restrictions

Hypernatremia

• > 145 mEq/L• Na+ gained in excess of H20 or water lost

in excess of Na+• Fluid shifts from cells to ECF• Sx: confusion, thirst, flushed skin, dry

mucus membranes, oliguria, increased temperature and heart rate.

• Rx: IV therapy, diet

Potassium 3.5-5.5mEq/L ICF

• Cellular metabolism• Transmission of nerve impulses in nerves,

heart, and skeletal muscles.• Acid base balance• Regulated by diet, renal excretion, and any

condition that increases output decreases potassium. (inverse relationship to sodium).

Hypokalemia

• Less than 3.5 mEq/L• Results from decreased intake, loss via GI/Renal and

potassium depleting drugs such as diuretics.• Sx: muscle weakness, leg cramps, decreased GI

motility, cardiac arrhythmias• Rx: diet: (oranges, peaches, kiwi, prunes, melons,

bananas, raisons, apricots, figs, dates, brocelli, potatoes, beans!)

• Oral Potassium• IV Potassium (NEVER IV PUSH)

Hyperkalemia

• >5.5• Etiologyexcessive intake, trauma, burns, renal failure. • MOST COMMON REASON FOR DIALYSIS!• Sx: Confusion, muscle weakness, cardiac arrhythmias,

N,V,D, paresthesias of hands and feet.• Rx: Temporary: sodium bicarbonate, glucose and

insulin.• Kayexalate, dialysis• K restriction Monitor cardiac status.

Calcium: 8.5.- 10.5mg/100 ml; 4.5-5.5mEq/L

• Most found in bones and teeth.

• Needed for blood clotting, nerve impulse transmission, B12 absorption, myocardial contractility.

• Inverse relationship with Phosphorous

• Needs Vitamin D for absorption

Hypocalcemia: <8.5mg/< 4.3mEq/L

• Etiology: loop diuretics, parathyroid disorders, renal failure.

• Sx: numbness and tingling, tetany, fractures, problems with blood clotting, + Trousseau and Chovek’s signs.

• Trousseau: Inflate BP cuff to 20mm above systolic and note carpal spasms.

• Chovsek:Tap facial nerve 2cm from earlob + = twitching. • Rx: Amphogel(binds phosphate); calcium, seizure

precautions, diet (green leafy, dairy).

Hypercalcemia: > 10.5mg/100ml or > 5.3mEq/L

• Etiology: hyperparathyroidism, some cancers, prolonged immobilization.

• Sx: muscle weakness, decreased reflexes, renal calculi, fatigue, sedation, slurred speech cardiac changes, constipation.

• Rx: Parathyroidectomy (as needed), steroids, mithromycin, calcitonin.

Intake and Output

• Measurement of fluid in and out.• Patients who need I&O = IV therapy, Fluid restriction,

blood administration, cardiovasular disorders, critically ill.• Intake Includes:• Oral liquids (includes Jello, ice cream, popcicles, broth) • IV’s• IVPB• Tube Feedings/Tube Flushes• Blood and blood products

Fluids and Electrolytes – Group Exercise

1. Floyd Fluid is in the hospital with Congestive Heart Failure. His physician initially ordered Furosemide (Lasix) 80 mg IV BID. Now that he is going home, the order was changed to Furosemide 40 mg po BID. He is also on Digoxin 0.25 mg daily and nitro-dur patch BID. What fluid and electrolyte imbalances would you assess for and what nursing interventions would you initiate? (Lasix is a diuretic; digoxin increases cardiac contractility and nitro-dur is a vaso-dilator)

You would assess for hypokalemia due to diuretics. Assess for weakness, malaise, fatigue, ECG changes. Monitor potassium level. Teach pt about potassium containing foods at discharge as well as side effects of the medications.

2. Mrs. Emanuele is an 81 year old admitted with a 3 day history of vomiting and diarrhea. She

has only had ice chips since the first episode of vomiting and is now complaining of malaise, cramping muscles and a temp of 101. Which lab findings would you expect to be abnormal and what interventions would you be expecting?

Dehydration – elevated BUN, H&H. Assess for confusion, weakness, decreased skin turgor hypotension, tachycardia, Needs fluids. Monitor for cause, skin breakdown, change in VS,confusion.. Make sure to monitor for safety. 3. Darlene Malone, age 42, comes to the ED with weakness, fatigue and heart palpitations. She

has not seen a health care provider for 10 years. She goes into cardiac arrest and is resuscitated. Her lab results are: a. Potassium (K) = 7 mEq/L b. BUN = 102 mg/dL c. Creatinine = 5 mg/dL

Acute renal failure is diagnosed. Which lab results are abnormal? Which lab result directly reflects her renal failure? What do you think is causing her hyperkalemia? Which lab result is the most dangerous?

All the lab results are abnormal. They are all elevated. The lab result that most directly reflects her renal failure is the creatinine Most likely she went into acute renal failure from the cardiac arrest and the hyperkalemia is from the renal failure because the kidneys cannot excrete the potassium. The elevated potassium is the most dangerous result because of the potential to cause cardiac arrest.

1. Match the following fluid and / or electrolyte disorder with its appropriate characteristic. ___D_ 1. hyperkalemia d. frequent cause of death in patients with renal failure ___E_ 2. dehydration e. dry skin, oliguria, thirst. >>dehydration __B___3. hypokalemia b. frequent complication of diuretics (lowK) ____F__ 4. hypocalcemia f. tetany; increased reflexe __C___ 5. diabetes insipitus c. may be seen after cranial surgery; Increase in urine output ___A__ 6. third spacing a. caused by decreased plasma proteins 2. Determine the following intake and output in milliliters

Intake Output ½ cup of jello - 120 1 cup of coffee - 240 2 cups of cornflakes Toast ½ cup of milk - 120 2 cups water - 480

Urine – 480 ml Wound drainage 120 ml

Total = 960 Total = 600 What fluid and electrolyte abnormalities would you suspect with the following clients? List 2 important assessments for each.

Client Condition Suspected Abnormality

Assessment

An 80 year old living alone with diminished appetite and thirst

Dehydration BP, HR, confusion

A 42 year old female with bone cancer

Hypercalcemia Hypotonicity, kidney stones, slurred speech, decreased reflexes

A 53 year old female with renal failure

Hyperkalemia Overhydration

ECG changes, diarrhea, mental changes, paresthesia (tingling)

A 73 year old male taking large amounts of diuretics for heart failure

Hypokalemia ECG changes, nausea and vomiting, weak pulse