Download Med surge Fluid and electrolyte imbalances

Med surge Fluid and electrolyte imbalances
Always look at labs before giving any fluids
FLUID
About 60% of the adult body is made up of fluids
Infants are at an increased risk for imbalances and are effected most by fluid shifts
Total body H2O decreases from birth to old age
Types of Fluid
1. Intracellular : fluid inside the cell. ( K+ is most abundant) 2/3 of all fluid in the body is
intracellular.
2. Extra cellular: three types of extra cellular fluid
A. Intravascular: capillary blood , 3L Plasma 3L Blood components ( RBC)
B. Fluid around the cell
C. Transcellular: synovial fluid, intraocular fluid, digestive fluid, cerebrospinal fluid.
" Third Spacing"
Loss of extra cellular fluid into space that does not contribute to equalibrium
Example: Edema, pleural edema, blisters, etc...
-Anascara: Edema all over the body.
- third spacing can cause hypovolemia presented by : Low blood pressure, decreased urine
output, increased heart rate.
Routes of gains and losses
-Gaines: dietary intake of fluid, food, enteral feeding, parenteral fluids
-Losses: sweating, kidney and urine output #1, evaporation, breathing, stool.
Gerenterologic considerations
-
they have reduced homeostatic mechanisims: cardiac, renal, respiratory FX
Decreased body fluid percent
They are on more medications that can cause fluid imbalances
They have multiple conditions ( CHF can cause FVE)
{ Assess for dry or thin skin, check turgor on the sternum}
{ they have a decreased ability to concentrate urine, adequate toileting is a must}
{ Average daily urine output is 1.5-2 L , less than 30 ml/ h you should inform the PCP}
Fluid Volume Defecit-Hypovolemia
-loss of extra cellular fluid exceeds intake of water
-Dehydration: loss of water with increased serum sodium levels
- increased altitudes can cause increased fluid loss from respiratory tract
-do not give coffee to a dehydrated person
- FVD can cause hemoconcentration : decrease in plasma volume and increase in RBC count
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Causes of fluid volume Defecit
Vomiting
Diarrhea: especially the very young and the very old
GI suction: loss of gastric fluids can also cause hypocholeremia and metabolic alkalosis
Sweating: can replace electrolytes with a sport drink
Exercise
Decreased intake / inability to get fluids access
3rd space shifts
Diabetes insipidus; Increased uriniation kidneys cant concentrate the urine
Hemorrhage
Symptoms of FVD
1. Postural hypotension : 15mmHG drop in sys. Or 10mmHg drop in diastolic, flat neck
veins , low b/p , orthostatic hypotension
2. Increased respirations : can cause respiratory alkalosis
3. Weak Rapid pulse: easily blocked with light pressure
4. Dry mouth: may have fissures, or cracks or furrows on the tongue{ check meds ,
lisinopril can cause these symptoms also}
5. Oliguria : scanty urine , strong urine, high concentration, strong odor , high specific
gravity
6. Decreased skin turgor
7. Rapid weight loss: 1lb=500 ml of fluid
8. Increased temperature: FVD can cause a fever and fever can cause FVD
9. Cool clammy skin: Hemorrhage
10.Muscle weakness
11. Nausea/cramps
12. Confusion/ lethargy: first s/sx
Managing fluid volume Defecit
-oral fluids
- IV solutions: isotonic NS, lactate ringers
- Medications
-I&O , daily weights, vital signs, measurements, oral care, administer fluids
-monitor for signs od dehydration
!Nursing alert! Do not give K unless kidney FX is good check HR and urine output.
You may also need to give an anti emetic or anti pyretic
Fluid volume excess Hypervolemia
You're retiaining more than you excrete.
Input is greater than output
Can lead to fluid volume overload causing serum to become hypotonic by shutting off ADH ,
causing SIADH thus needing to administer a hypertonic solution.( D5 in 1/2 NS, D5LR, D10 IN
H2O, 3% Saline.
Risk factors
Heart failure
Kidney failure
Cirrhosis of the liver
Contributing factors*
Excess sodium intake
S/SX of FVE
1. Edema: Check feet, legs, hands, sacrum, increased risk of pulmonary edema, check skin for
breakdown
2. Distended neck veins: tachycardia JVD, bounding pulse
3. Abnormal lung sounds: crackles, wheezes, SOB.
4. Increased b/p
5. Increased weight: best indicator
6. Increased urine output
7. Decreased LOC
8. LABS: low BUN, Low CREAT, High sodium, Low hematocrit
NURSING MANAGEMNT
1. I&O / daily weights
2. Monitor response to diuretics
3. Promote fluid and sodium restrictions
4. Avoid sources of excess sodium including meds
5. Promote rest
6. Semi fowlers position for orthopena
7. Skin care/positioning
IV Fluids
HYPOTONIC: contraindicated in brain injury
0.25%
0.45 or 0.5%
HYPERTONIC:
Dextrose 5% in 1/2 NS irritating to the veins
D5LR
Dextrose 10% in water usually given in ICU
3% Saline usually given in ICU
Lab values for fluid monitoring
BUN: 10-20 mg/dl : Urea comes after use of protein from muscles , metabolized in the liver.
Low BUN: end stage liver disease, low protein, starvation, increased fluid volume, and
decreased renal fx
High BUN: dehydration, GI bleed, atkins diet, keto diet, fever & sepsis { infection}
Creatinine: 0.7-1.4 mg/dl : Skeletal muscle tissue, more kidney specific , a better indication of
renal fx than BUN because it dosent effect metabolic state. Creatinine levels increase when
renal fx decreases
Hematocrit: 37-47 % female 42-52% males: Amount of RBC'S concentration in the plasma.
high : hematocrit would indicate hemoconcentration " hypovolemia".
Low: would indicate hemodilution " hypervolemia"
Urine specific gravity: 1.010( dilute) -1.025 ( concentrated) : measures the kidneys ability to
excrete and conserve water.
Sodium: 135(hyponatremic)-145(hypernatremic)
Serum osmoality: 270-300 mOsm: serum NA+ X 2 .
Low: hypervolemia , low hematocrit, hemodilution
High: hypovolemia, hemoconcentration, dehydration
Potassium:3.5-5.0 lost by vomiting
Low: hypokalemia( alkalosis)
High: hyperkalemia (acidosis)
Electrolyte imbalances
Sodium: 135-145
Low: hyponatremia
High: hypernatermia
Potassium: 3.5-5.0
Low: hypokalemia
High: hyperkalemia
Calcium 8.6-10.2
Low: hypocalcemia
High: hypercalcemia
Magnesium: 1.3-2.3
Low: hypomagnesemia
High: hypermagnesemia
Phosporus: 2.5-4.5
Low: Hypophosphatemeia
High: hyperphostate
Chloride: 97-107
Low: hypochloremia
High: hyperchloremia
Electrolyte imbalances
Sodium 135-145: major cation in the ECF, obtained via diet and absorbed in the small
intestines
excreted via kidneys.
-maintains blood volume and blood pressure.
-regulated by aldosterone: conserves sodium
-ADH: thru dilution or retention of h20
-NA+ K+ PUMP: moves in and out of cells via active transport.
NURSING ACTION: Cerebral cells are highly sensitive to changes in sodium level and fluid
volume. Brain cells swell in cases of hyponateremia and shrink in cases of hypernatermia.
These changes may lead to Seizures, coma, and death.
- DO NOT INCREASE SODIUM TOO FAST, IT MAY CAUSE NEUROLOGICAL SYMPTOMS
Hyponatermia: less than 135 men/l
Causes: usually due to a h20 imbalance rather than a sodium imbalance , NPO, low salt diet,
adrenal insufficiancy{ low aldosterone} , water intoxication, SIADH, losses by vomiting, diarrhea
, freshwater drowning, excessive ingestion of hypotonic solutions( fresh water)
Medications that cause HYPONATERMIA: Ace inhibitors, diuretics, ARBS.
Manifestations: nausea, abdominal cramping, general weakness, restlessness, confusion,
seizures, coma
Nursing management: assess and prevention, encourage dietary sodium/fluid intake. Identify
and monitor at risk patients. Evaluate the effects of medications such as lithium ( educate
patients not to decrease sodium intake)
Did you know? : decreased reflexes, as NA levels decrease cellular fluid becomes more
cellular fluid becomes more concentrated , causing fluid to be pulled into the cells, reducing cell
fx and the transmission of impulses.
Hypernatremia: greater than 145 meq/l
Causes: fluid deprivation in unconscious patients , administration of hypertonic solutions w/o
adequate water, supplementation, hypertonic iv solutions, diabetes insipidus, near drowning sea
water, too little sodium excretion ( renal failure, corticosteroids), too much sodium intake,
increased water loss( fever, infection, sweating, diarrhea)
Medications that cause hypernatermia:loop Diuretics, corticosteroids
Manifestation: Thirst is usually the first symptom to appear ( older adults may have decreased
thirst mechanism) , restlessness , confusion, seizures, coma.
Nursing management: alkasletzer , asprin, cough syrups, and cold preparations contain
sodium. Assessment prevention, assess for OTC sources of sodium, offer and encourage fluids,
provide sufficient h20 with tube feedings
- DO NOT DECREASE TOO QUICKLY CAN CAUSE SWELLING IN THE BRAIN DUE TO
RAPID FLUID SHIFTS IN THE BRAIN.
Did you know? : Increased excitability of reflexes increased serum levels of NA can cause fluid
to move out of the cell and into the ECF resulting in cellular dehydration, stimulation or over
stimulation of excitable cells.
POTASSIUM 3.5-5.5 MEQ/L
-
Most common cation in the ECF
Obtained through diet
Absorbed in the small intestine
Excreted in the kidneys
Facilitates : nerve impulse induction, essential for normal electrical conduction in the heart, important for
skeletal muscle contraction.
Regulated: by the sodium /potassium pump and the kidneys
Hypokalemia: less than 3.5 Meq/l
Causes: poor dietary intake, GI losses( vomiting, NG suction, diarrhea) , medications , alterations in acid
base balance / low K alkalosis " your battery is low". Hyperaldosterism: increased aldosterone decreases
the excretion of K. Chronic alcoholism: decreases intestinal absorption of K.
Medications that cause low K: Loop diuretics ( lasix), thiazides(hctz), digitalis preparations, and
corticosteroids. Insulin pushes K back into the cells .
* in patients taking digoxin , hypokalemia increases the hearts sensitivity to the drug possibly resulting in
dig toxicity. Always check dig levels!
Manifestations: causes life threatening dysryhtmias, prominent u waves and flat T waves, muscle
weakness and cramps, decreased DTR, N/V, general weakness.
Did you know? Associate hypokalemia with hypoactivity in the body ( decreased DTR, flat T waves,
hypoactive bowels, constipation,) because low k causes decreased conduction of nerve impulses.
Nursing management: monitor EKG and ABG, encourage dietary potassium, iv potassium
administration
Hyperkalemia: greater than 5.5 meq/l
Causes: usually treatment related ( drugs that increase k or giving too much k) , impaired renal fx or
kidney failure, tissue trauma and crushing injuries, acidosis ( high on acid) . Use of salt/ k supplements ,
cell destruction when drawing blood ( tournaquette on too tight/long) drugs that interfere with secretion of
k ( spirnalactone) , uncontrolled diabetes, not enough insulin to push k back into the cell.
Medications that cause hyperkalemia: spironolactone, ACE inhibitors, ARBS, NSAIDS
Manifestations: life threatening dysrythmeia , elevated T Waves could cause V-fib
Did you know? Associate high potassium with hyperactivity, irritability, elevated T waves, hyperactive
bowel, increased K speeds up nerve impulses.
Nursing management: monitor ECG, limit dietary potassium, administer kayexalate, IV sodium
bicarbonate ( to bring up PH) , iv calcium glutonate, regular insulin and hypertonic dextrose, b2 agonist (
albuterol will push k into cells) dialysis.
-drawing blood above the iv site may cause a false positive
- salt/medications may contain K
- Do not five k sparing diuretics to pts with renal failure/dysfx
Calcium 8.6-10.2 meq/l
-
most abundant cation in the Human body
99% stored in the bones
Primary source is in the bones
Need vit d for absorption
Obtained via diet, absorbed in small intestine , excreted by the kidney
Function: assists in building bones and teeth, facilitates blood clotting, essential for nerve impulses ,
plays a key role in skeletal muscle contraction and relaxation , important for normal heart and muscle fx.
Regulated:
1. Parathyroid hormone: excreted by the parathyroid gland increase CA concentration in the blood.
2. Calcitrol: hormonally active Vit D. Increases CA by aiding in absorption in the small intestine ,
decreases renal transfer from the blood to the kidneys. Increases the release of calcium from the
bones into the blood.
3. Calcitonin: produced by the thyroid gland , decreases blood CA and increases reabsorption into the
bones.
Did you know? Serum calcium moves the same as magnesium
Hypocalcemia: less than 8.6 meq/l
Causes:
1. hypoparathyroidism: absence or deficiency of PTH secretion
PTH Increase serum calcium levels .
2. Pancreatitis: inadequate pth secretion prevents reuptake of calcium of bones resulting in
hypocalcemia.
3. Massive transfusion of citrated blood: the calcium binds to citrate leading to low calcium serum.
4. Renal failure, medications , alkalosis because ca binds to albumin.
5. Severe hypomanesemia can lead to hypocalcemia that cant be fixed by administration of ca and VIT D.
6 . Malabsporption: celiac, crohns , alchohol
7. Defecit to vit d
Medications that cause low CA: Antiseizure meds ( dilantin) phenobarbitol , loop diuretics promote
exertion of ca by the kidneys. Corticosteroids in large doses or prolonged use can cause reduced CA
absorption. Some cholesterol lowering drugs. Phosphate enemas will increase phostpate and decrease
calcium.
Manifestations: THINK muscle and nerve excitability, tetany, muscle spasms of the face , hand, and feet,
Cirumoral numbness( numbness around the mouth) parasethis ( numbness and tingling) , hyperactive
DTR, positive trossous sigh, positive chovsteks sign. Seizure , dyspnea, laryngospasm, abnormal
clotting
EKG: prolong QT interval and ST segment.
Nursing management: calcium glutonate( never push) calcium and vit d suppliments, severe
hypocalcemia is life threatening, weight bearing exercise to decrease bone loss, PT teaching r/t diet and
meds, IV calcium administration
Hypercalcemia: greater than 10.2 meq/l
Causes:
excessive release of calcium from the bone or decreased calcium excretion by the kidneys
Hyperparathyroidism: main cause of hypercalcemia , too much PTH is produced causing increased
calcium in the bloodstream.
Malignancies: cancer cells can release substances that destroy osteoclasts( bone cells) increasing the
release of calcium into the blood stream.
Medications that cause high CA: excessive ingestion of VIT D , excessive ingestion of calcium
containing antacids, thiazide diuretics.
Manifestations: decreased excitability of muscle and nerve, severe muscle weakness, decreased DTR
w/o parathesis. Ekg: heart block, short qt, wide T waves, spastic contraction of heart muscles. Poly uria
and bone pain, thirst.
Nursing management: high mortality, encourage ambulation, encourage 3-4 l of fluids a day, provide
fluids containing sodium unless contraindicated. , fiber for constipation, ensure saftey. Treat underlying
causes, administer fluids, diuretics furosemide, lasix, phosphates, calcitonin, biphosphonates.
Magnesium: 1.3-2.3 mg/dl
-second most abundant cation in the body
-50-65% found in bone , the rest is in ICF and intravascuar system
-primary source is diet
-absorbed in the ileus, excreted in stool and urine
Function :Maintaines normal muscle fx , nerve fx, and heart rythm,
Required for calcium and vit b absorption, stimulates parathyroid hormone which regulates ICF calcium
levels. Fights tooth decay by binding calcium to tooth enamel . Has a sedative effect of the
neuromuscular system causing decrease ach release causing smooth muscle relaxation.
Regulated: kidneys
Did you know? Older adults may be at risk hypermagnesima because of decreased renal fx and
increased use of OTC laxatives that increase magnesium.
Hypomagnesemia : less than 1.3 mg/dl
Causes:
Alcoholism: inhibits absorption and causes increased urinary excretion of magnesium
GI loss: NG suction, enteral or parenteral feedings low in magnesium,
DKA: hyperglycemia causes diuretic osmosis, and polyuria, which increases the excretion of magnesium
in the urine . Insulin shifts mag into the cells.
Medications that cause hypomagnesemia: aminoglycosides, loop diuretics, thiazides
Manifestations: initially by hyperexcitability, increased DTR, APATHY, confusion, agitation. Ataxia ( poor
coordination) EKG changes: torsades ( twisting) trossus/ chvosteks signs because usually low
mag low calcium.
Nursing management: diet, oral magnesium, mag sulfate IV., educate pt on alcohol use; nursing are r/t
iv mag sulfate.
- hypomagnesemia is often accompanied by hypocalcemia
- Dysphasia is common in magnesium depleted patients : assess ability to swallow before administering
food or meds orally.
Hypermagnesemia: greater than 2.3 mg/dl
Causes:
Renal failure: cant excerete magnesium
DKA: profound fluid depletion, so not excreted
Excess admin of magnesium
Medications that cause hypermagnesemia:
Mag containing antacids
Mag supplements
Manifestations:
Decreased or absent DTR are the primary sign
Central nervous system depression increases as mag levels increase
Heart block, cardiac arrest. Depressed respiration , muscle weakness.
Nursing management:
- IV calcium glutonate, loop diuretics, IV NS of RL, hemodialysis.
-do not administer meds with magnesium
-pt teaching regarding OTC meds that contain mag.
PHOSPHORUS: 2.5-4.5
-Major anion in the ICF
-phosphorus is found in the body in combination with 02
-approx. 85 % is bound with calcium in teeth
-obtained via diet
-Absorbed in intestines
-excreted by urine and stool
Function:
- essential for bone and teeth formation
- Helps regulate calcium
- Assists in muscle contraction, maintenance of heart rhythm, and kidney fx
Regulated
Parathyroid and calcitrol
Did you know?: Calcium and phosporus have an inverse relationship? High ca low phosporus .
Hypophosphatemia: less than 2.5 mg/dl
Causes
- most dangerous problems are related to hypercalcemia , which can lead to severe cardiac and
neuromuscular problems.
-
Heatstroke
Respiratory alkalosis
Hyperventilation
Hepatic encephalopathy , major burns, low mag, low potassium
Use of diuretics and antacids
Manifestations:
-tissue hypoxia
-neurologic symptoms
-muscle and bone pain
-susceptibility to infection
Medications that cause hypophosphatemia
-calcium containing antacids
-phosphate binders ( amphogel)
Nursing actions: oral or iv phosphate replacement, encourage food high in phosphate, gradually
introduce calories to a malnourished pt receiving parenteral nutrition
Hyperphosphatemia: greater than 4.5
Causes: excess vit d, hypoparathyroidism, symptoms associated with hypocalcemia, decreased excretion
by the kidneys.
Medications causing hyperphosphatemia: decreased excretion by the kidneys
- causes related to hypocalcemia
Manifestations ;
- soft tissue calcifications
- Symptoms occurs due to hypocalcemia
Nursing management;
Give vit D preparations
-calcium binding antacids, phosphate binding gels
-
loop diuretics
Iv, NS, Dialysis
Avoid high phosphorus food
Manage signs of hypocalcemia
Teach about phosphate containing substances
Chloride 97-107 meq/l
-the major ANION in the ECF , functions primarily with sodium and chloride to maintain a balance
between intra and extracellular fluid.
- when sodium is retained so is chloride.
- Chloride is retained continuously in the intestines along with sodium, kidneys are responsible for
reabsorption and excretion of sodium and chloride.
Function: combines with hydrogen in the stomach to produce hydrochloric acid
-works with magnesium and calcium to maintain nerve transmission and normal muscle
contraction/relaxation
-imbalance never occurs alone , always check bicarbonate, k , and sodium as well.
Regulation
Primarily by the kidneys
Did you know? Serum chloride levels increased in the presence of acidosis
Wherever sodium goes chloride follows
Hypochloremia: Less than 97 meq/l
Causes: hyponatermia, excess chloride loss from vomiting, diharrea or NG suction. , addisons disease,
DKA, excess sweating, fever, burns, metabolic alkalosis.
Medications that cause hypochloremia: diuretics ( loop and thiazide) increase excretion of chloride by
the kidneys.
Manifestations: agitation, irritability, weakness, hyperexcitability of muscles, dysrythmia, seizure, coma. ,
hypotension, confusion " sodium imbalance"
Nurse management: replace chloride with IV NS or 0.45% NS , avoid free water, high chloride foods.
Hypercholeremia: greater than 107 meq/l
Causes: hypernatermia, excess sodium chloride infusions with water loss, head injury, dehydration,
severe diarrhea, metabolic acidosis , hyperparathyroidism , respitory alkalosis,
Manifestations: tachypnea , lethargy, weakness, rapid deep respirations, hypertension, cognitive
changes.
Nursing management: restore electrolyte and fluid balance, LR, Sodium Bicarbonate diuretics.