Fluid and Electrolyte Balance Overview

Fluid and Electrolyte Balance, Student Notes Fluid and Electrolyte Balance Overview    Body Fluid Composition o Water  Primary component of body fluids  Provides medium for  Transport and exchange of nutrients and substances to and from cells and metabolic reactions between cells  Assists in regulating temp  Perspire  Don’t want to elevate too quickly  Helps cell maintain shape o Electrolytes  Chemical compound of body fluids that dissociates into particles  Become charged particles:  Cation  Anion  Function of electrolytes  Water balance o Sodium especially cause sodium holds on to water o Too much sodium then too much water  Acid base balance o Kidneys wont function properly  Contributes to enzyme reaction  Necessary for neuromuscular function and cardiovascular Body Fluid Distribution: body fluid is classified by its location o Intracellular: inside the cells o Extracellular: outside the cells (need to know where we are trying to get the water)  Interstitial: in between the cells  CHF or ascites.  Intravascular: in veins arteries or capillaries  Important when talking about blood volume, pressure, and CV  Transcellular: random. Urine, digestive secretion, spinal fluid, pericardial fluids Body Fluid Movement: Four major components (must function properly to maintain balance) o Osmosis: Water movement across a semi-permeable membrane  Osmolarity: the concentration of the solution; the number of solutes per kilogram of water  Drawn to higher solute concentration places  Ex: serum osmolarity or UA Fluid and Electrolyte Balance, Student Notes   Dependent on sodium, glucose, and urea Osmotic Pressure and Tonicity:  Pressure: power of a solution to draw water across membrane o Maintains balance between interstitial and intravascular spaces and keeps water in vascular system  Tonicity: effect solution has on the movement of water o Isotonic: have the same concentration of solutes as surrounding plasma  Description  Example Fluid  Example Scenario  Equal in concentration of solutes as the surrounding plasma  Use this primarily for volume  Cells wont shrink or swell  Ex: normal saline (0.9% sodium chloride) and some others  Ex: use: if there is a bleed. Cause if we lose blood volume we lose blood pressure. Then heart rate will increase o Hemorrhage or GI suctioning o Hypertonic: Greater concentration of solutes than surrounding plasma  Description  When cells are surrounded by hypertonic solution the cells shrink as water is drawn out  Can become dehydrated  Short term  Watch carefully  Example Fluid  3% sodium chloride and there are other things to memorize  Example Scenario  Seizures related to ICP (intracranial pressure) o Hypotonic: have a lower concentration of solutes than plasma  Description: moves water into the cells and causes them to swell  Example Fluid  0.45% sodium chloride  Example Scenario Fluid and Electrolyte Balance, Student Notes  Dehydration Diffusion: process of solutes moving across the membrane from an area of high solute concentration into lower solute concentration through protein channels o Filtration: water and dissolved soluties move from area of increased hydrostatic pressure to and area of lower hydrostatic pressure  Typically occurs in capillary membranes  Hydrostatic pressure: created when the heart pumps and when gravity pushes against capillary membrane  Heart beats pushes water away then when relaxed water comes back o Active Transport: allow molecules to move across the membrane even in areas of high concentration  Ex: sodium-potassium pump Body Fluid Regulation o Thirst  Primary regulator of water intake  Maintains fluid balance and prevents dehydration  Thirst center stimulated with drop in volume or increased serum osmolarity o Kidneys  Prime regulator of fluid volume and electrolyte balance in the body  Selectively reabsorb water and electrolytes o Renin Angiotensin Aldosterone System: helps maintain intravascular fluid balance and blood pressure  Renin stimulates angiotensin 1 angiotensin 2.  Angiotensin 2 increases aldosterone and ADH  Hold on to sodium and water o Antidiuretic Hormone  Fall in bp or increase in serum osmolarity stimulates ADH  Promotes water reabsorption in distal tubule o Atrial Natriuretic Peptide  Blocks RAA system  Promotes sodium wasting and increases urine output Normal Fluid Balance o Intake:2500 ml/day o Urine output: 1500 ml/day o Insensible loss: 1000ml/day  30ml/hour at least (50,60,70 for most people)  These include feces skin(perspire) lungs Factors That Influence Fluid Balance o Age  Young and old.  Not developed kidneys or not working as well o    Fluid and Electrolyte Balance, Student Notes environment  How hot or cold is it o diet  how much sodium/protein are you taking in o stress  increases metabolism and tells body to hold onto sodium o illness  Fluid imbalances come with Tests and Indicators of Fluid and Electrolyte Imbalance o Labs:  Osmolality: normal=280-300 mOm  Refers to concentration of solution  Specific gravity of urine: normal =1.010-1.030  Hematocrit: normal = 40%  BUN: normal = 5-20  Sodium: normal =135-145 o Other Indicators  Daily weight: increase/decrease reflects gains and losses  Chf can gain 20-30 pound in a night  Use this to see if treatment is effective  I&O  Low output can be cause holding on to electrolytes  can cause fluid volume excess or be due to dehydration  Edema  Fluid shifts from intravascular to interstitial  Skin turgor  Poor and tenting  Mucous membranes  Dry o  Intravenous Access and Fluids: Nursing Responsibilities  Assessment o Part of your head to toe o Size  Note the color of the catheter to determine the size  Certain things have to use a larger or smaller IV  Insertion date- change every 3  Surrounding area  Color and temp  IV fluids and tubing  Need to match what they are supposed to be getting Fluid and Electrolyte Balance, Student Notes      Fluids are only good for 24 hours Tubing is good for 72 hours unless otherwise specified Complications o Infiltration  Fluid you are giving has gone into the interstitial space. See swelling proximal to insertion site  Cool and pale o Thrombophlebitis  Vein is irritated  Red, swollen, and warm  Meds that are known to cause this the site will be changed often Systemic Complications o Circulatory overload:  BP increases  Respiratory (dyspnea or crackling in lung)  JVD  Edema  Bounding pulse o Air embolism  More common in central line  Central line ends at the heart so there are no nodes to catch an air bubbles  Signs of shock:low BP, tachycardia  Place on left side and in trendelenburg  So that the bubble is stuck in ventricle and will eventually get reabsorbed and wont get into the lung o Allergic reaction Types of lines/access o Peripheral Line  In someones arm  Could also mean lower extremity but someone specially trained puts this in  The cannula is only about an inch or inch and a half under the skin  Clean dressing changes o Central Line  Ends at patients heart  Can have the central line in the chest  Line is tunneled under the skin  Lasts much longer up to months  For cancer patients, the port can be left in for a long time after as long as they maintain it Fluid and Electrolyte Balance, Student Notes o o  You can draw blood from a central line  Sterile dressing changes PICC Line Triple Lumen Catheter (TLC)  A lot of critical care patients need lots of meds at once  Some of these meds cant mix FLUID CLASSIFICATIO N Isotonic Hypotonic NAME AND COMMON USES OF FLUIDS Lactated Ringers (LR): a balance electrolyte formula(puts some electrolytes in us), commonly used for surgical patients. Caution with renal patients because they cant get rid of potassium well. Lactated: helps reverse acidosis after surgery 0.45% Normal Saline (1/2NS): Treats cellular dehydration and promotes waste elimination by kidneys. If BP is really low then give NS first to increase blood volume then the 1/2NS to help with the Normal Saline (0.9%NS): used for vascular volume expansion and fluid resuscitation. Stays in the blood and is used for shock Common in ER and for BP elevation 5% Dextrose (D5W): Can become free water when dextrose metabolizes; expand intracellular and interstitial fluids. Short term only. (can lower the sodium and make the blood cells lyse/eventually washes the cell out) Give when patients need dextrose for blood sugar (diabetic patients) Fluid and Electrolyte Balance, Student Notes dehydration. If you continue to use this, the cells can swell Hypertonic 5% Dextrose and 0.45% Sodium Chloride (D51/2NS):Draws fluid into the vasculature from interstitial and intracellular compartments. 3% Sodium Chloride (3%NS): Prevents seizures from severe hyponatremia.onl y used when at risk of seizures from brain edema . associate with head injury or stroke 5%Dextrose and Lactated Ringers (D5LR): Electrolyte formula used for patients with draining wounds. 5% Dextrose and Normal Saline (D5NS): provides calories to prevent catabolism when NPO Total Parenteral Nutrition (TPN): Used when patient is NPO more than 5 days or have extensive caloric needs (burns, GI surgery) TPN (Total Parenteral Nutrition)     Large bag of hyperosmolar (hypertonic) solution Contains fats, proteins, glucose, vitamins, and electrolytes Provides items necessary to sustain life Not a tube feeding o Indications  Patient can eat but isn’t getting enough  Bowel system is off limits o Administration  Give via central line  One bag hung daily usually in the evening  So dieticians and docs and can make decisions during the day  Will check blood sugar often  Hanging TPN  Change the entire bag and all tubing with the next TPN ($5000 a bag) o Nursing Care  Hang bag at exact time ordered  Discard old bag and any fluid left in it  Monitor patient’s BS every 6 hours  Two rns must verify before bag is hung  If new bag is not there and old bag is out hang D10 at same rate until new bag comes Fluid and Electrolyte Balance, Student Notes o  Tubing and tpn have 24 hour hang limit Complications  Hyperglycemia: check blood sugar at least qid.  Sepsis: infection in blood stream due to sugar in TPN and central line: change bag and lines accordingly  Fluid overload: due to increase osmolality of solution  Monitor for S/S of overload: lung sounds, resp rate, edema Fluid Imbalances  Fluid Volume Deficit o o o An decrease in intravascular, interstitial, and/or intercellular fluid in the body Causes: excessive fluid loss, insufficient fluid intake, or failure of regulatory mechanisms and fluid shifts within the body Types: Hyperosmolar and Isotonic  Hyperosmolar Volume Deficit:  Description o Blood becomes hypertonic o The water moves out of the cells to dilute the extracellular tissue causing the cells to shrivel and become dehydrated. o Even though water is moving out into the vascular system it is not enough  Causes o Decreased fluid intake  Older people may forget  Cant retain fluids o Increased water loss  Diuretics o Hyperosmolar dietary intake  High amounts of protein and salt they will start losing a lot of fluids  Water is drawn to the salt in the blood o Build-up of solutes due to disease  Renal failure  DKA o Sequestration of body fluids  Major shift. Fluid is going somewhere not acceptable  Pleural effusions or edema  Isotonic Volume Deficit  Description o Loss of water and solutes from extracellular spaces Fluid and Electrolyte Balance, Student Notes  o o o o Causes o o o Balanced loss Balances osmolarity Hemorrhage Excessive sweating GI loss  N/v  NGT drainage  Ileostomy  Higher in bowel so nutrients and water aren’t being absorbed as well Signs and Symptoms:  Skin  Dry, flushed, poor turgor   Mouth  Dry mucous membrane  Eyes  Sunken eyes  May lose ability to make tears  CNS  Wake, restless, confused  CV  Orthostatic or postural hypotension  Pulse pressure will decrease o Difference between systolic and diastolic pressure  Ex: 130/70 then 120/90  Could go into irreversible shock  Other  Thirsty, weight loss  Urine  Decreased uop  Labs  Iso is normal labs  Hyper o Everything increases  BUN creatinine hematocrit, urine osmolality and specific gravity, plasma osmolarity increase Treatment: Fluid replacement and rehydration  Hyperosmolar Replacement  Hypotonic solution is patient normotensive Fluid and Electrolyte Balance, Student Notes  Isotonic solution if patient is hypotensive (so low BP start with iso) Isotonic Replacement  Isotonic solution Nursing Care  Assessment:  Health history, meds (diuretics), exercise  Physical assessment:  Weight, v/s, heart rate (if they become tacchycardic), urine output  Careful I&O Nursing Diagnosis  Deficient fluid volume  Ineffective tissue perfusion  Risk for injury  Orthostatic hypotension  o o Fluid Volume Excess: Typically results from conditions in which sodium and water are retained o o o Types: Hypotonic and Isotonic Hypotonic causes  Renal failure- decreased renal output related to failure or disease  Pump failure- CHF or renal perfusion deficit.  Oral hydration overload- psychogenic polydipsia (no control over how much they drink)  SIADH- syndrome of inappropriate ADH  Retaining water but it is an all over rention.  Wont notice distinct edema  Sodium levels start to drop o When drop below 120 the CNS symptoms will come o Intracranial pressure increases o Give 3% (noted from above) Isotonic causes  Increased venous pressure  Obstruction from DVT  Increased aldosterone  Cushings disease: salt and water reabsorption  Cirrhosis- decreases in aldosterone metabolism  Decreased capillary oncotic pressure  Loss of protein- burns, liver disease, nephrotic syndrome o Excess protein is in the urine  Increased interstitial oncotic pressure  Blocked lymphocytes Fluid and Electrolyte Balance, Student Notes o o Symptoms:  Skin  Dependent edema, tight and cool skin  CNS  Lethargy and confusion  Respiratory  Sob crackles, increased respiration dyspnea at rest  CV  Full bounding pulse, hypertension, distended neck weins, tachycardia  Labs  Normal with isotonics. Hypotonic: decreased sodium, hct, osmolality, and BUN. UA decreased osmolality and specific gravity Type of edema  Increased hydrostatic pressure: pressure in blood causes fluid to shift into tissues  Pitting edema o Ankle/dependent edema, CHF, pregnancy o Pregnant women cause baby is putting pressure on the vena cava  Pulmonary edema o Blood isn’t pumping out fast enough and is in lungs  Ascites: cirrhosis o Liver scarring prevents portal blood from going into liver  Edema caused by electrolyte imbalance: cerebral edema  Where we start giving 3%  Steroids to decrease inflammation  Mannitol  Fluid shifts from blood into brain  Low protein edema  Non pitting  Caused by low albumin  Often seen with burn victims and malnourished o Just increase protein  Edema caused by lymphatic problems  Lymph nodes have been removed  Congential defect that impairs one’s ability to filter and move fluids appropriately o Say axillary lymph nodes was blocked, the whole arm could swell Fluid and Electrolyte Balance, Student Notes Another example could be people with breast cancer who have had those nodes removed Treatment of fluid volume excess  Diuretics: potassium sparing vs non potassium sparing  Fluid restriction  Divided up throughout the day  Sodium restriction  No added sodium on meal trays plus high sodium foods removed from diet  Elevation of HOB/FOB depending on symptoms  Lymphedema  Elevation of extremity, jobst sleeve (like spanx for arm or leg), ted hose Nursing Care  Health assessment: history, recent weight gain, diet. Complaints of SOB, dyspnea at rest, coughing, or edema  Physical assessment: weight, vital signs, lung sounds, urine output, level of consciousness Nursing Diagnosis  Fluid volume excess  Risk for impaired skin integrity  Impaired gas exchange o o o o Electrolyte Imbalance: Sodium, Normal Range: 135-145.      Primary regulator of volume, osmolality, and distribution of extracellular fluid Helps in maintaining neuromuscular activity Imbalance affect osmolality of ECF and water distribution between fluid compartments Low sodium=water drawn into cells of the body, causing them to swell High sodium=water drawn out of cells, causing them to shrink Hyponatremia o Causes:  Diuretics  Causing them to lose sodium with water  Kidney disease  Adrenal insufficiency  Vomiting  Severe will start out at an isotonic situation but then turns to an electrolyte issue  Diarrhea Fluid and Electrolyte Balance, Student Notes o o o  GI suctioning  Excessive sweating Symptoms  BP decrease  Cause no sodium to hold onto volume  Could go into shock  Muscle cramps  Weakness  Headache  Typically cause of brain edema  Brain edema: lethargy, stupor, coma  Very extreme confusion  Ex: 40 yr old man who sat on floor and cried Treatment  If dilution is the cause, restrict intake and give diuretics  If Hypotensive give NS to balance that out  Patient has CNS symptoms: give 3% saline and or mannitol  3% has to be given very slowly  If too fast it demyelinizes the myelin shift  Should be scared when giving this and be very careful  Loop diuretics  for people with normal pressure  ignore the thiazide diuretics cause you will just lose more sodium Nursing Care  High sodium diet if it is a true loss  Monitor neuro status and pad rails  Weigh daily  Accurate I&O  Monitor VS  Monitor electrolytes Hypernatremia o Causes  Hypertonic dehydration  Fluid loss with electrolyte loss  Certain diuretics  Water is drawn out of cells  Serious in brain cells because the cells shrink and cause neurological issues  Brain vessels contract and they can tear  Medication related to sodium rention : cortisone, PCN  Increased intake of salt Fluid and Electrolyte Balance, Student Notes o o o Symptoms  Excessive thirst  Lethargy, weakness, irritability  Coma, seizures, death  Weight gain  Dry mucous membranes Treatment  Hypotonic fluids1/2 NS  Or D5W  Diuretics (thiazide)  To get rid of fluid and sodium Nursing Care  Fluid replacement  Assessment of neurological function  Safety precautions Electrolyte Imbalance: Potassium (Normal Range: 3.5-5.3)    Primary intracellular cation Vital in cell metabolism, cardiac and neuromuscular function Maintenance of nerve impulses, normal cardiac rhythms, and muscle contraction Hypokalemia o o Causes  Inadequate intake  Excessive losses, intestinal, or skin losses  Redistribution between the ICF and ECF  Diabetic ketoacidosis  Secondary loss from medications: loop diuretics, corticosteroids, certain antibiotics  GI/GU losses  Diarrhea ,suction Symptoms  Confusion, lethargy  Dysrhythmias, irregular pulse, ECG abnormalities, cardiac arrest  Nausea/vomiting, diarrhea  Fatigue, muscle cramps, muscle weakness, parathesia (numbness and tingling)  Paralytic ileus due to decreased muscle activity in smooth muscle  When hypokalemic muscle activity decreases including in your bowels Fluid and Electrolyte Balance, Student Notes o o Treatment  Medications  IVF with potassium added, oral and or parenteral supplements  If potassium is going as a secondary IVF it can cause pain in veins  Potassium rich foods  Bananas, oranges, avocados, spinach, potatoes, tomatoes, meat, seafood, milk, yogurt Nursing Care  Urine output  Monitor for decreasing/normalizing output  Monitor patients taking digoxin  Hypokalemia potentiates the digozin  Evaluate serum labs  Dilute potassium given intravenously Hyperkalemia o o o o Causes  ICF to ECF redistribution: burns, acidosis, chemo  Has to do with cell destruction  Total body excess from increased intake  Renal retention from failure (ARF or CRF) Symptoms  Oliguria  If related to renal failure  Will be on dialysis  Intestinal colic, diarrhea  EKG changes: peaked T waves and wide QRS  Muscle twitching, weakness, irritability  Potassium is given with lethal injection Treatment  Kayexalate  Binds to potassium and gets it out of the bowels  Binds to stool so if given lots then poop a lot  Insulin with D50: shifts potassium back into the cells  Don’t wanna make the patient hypoglycemic  Dialysis  Low potassium diet  lasix Nursing Care  High serum levels need to be called ASAP  Assess heart sounds and pulse irregularity Fluid and Electrolyte Balance, Student Notes   Monitor heart via ECG monitor; ask if potassium is above 6 and not ordered Monitor muscle tone and deep tendon reflexes  These things will be decreased Electrolyte Imbalance: Calcium/Phosphorus: Normal Range: 8.5-10 Has distinct relationship to phosphate     Phosphorus is mainly ICF o Phosphorus binds to calcium to lower the calcium o When one goes up the other goes down Calcium regulated by PTH and Calcitonin PTH: When calcium levels fall, PTH increases Calcitonin secreted by the thyroid gland when calcium levels are high Hypocalcemia o o o o Causes  Decreased intake from poor nutrition; decreased vitamin D  Decreased absorption from loss of parathyroid gland Risk factors  Parathyroidectomy  Older adults, especially women  Lactose intolerance  Alcoholism  PTH will decrease with alcoholism Symptoms  Numbness and tingling, especially around the mouth  Tetany  Spasm of feet and hand  Deep tendon reflex hyperactivity  Trousseau’s sign  Increase BP cuff 2-3 minutes and handles flexers  Chvosteks sign  Tap facial nerve, lip contracts  Laryngeal spasms  When calcium levels get so high  This is looking at respiratory symptoms o Will lead to stridor Treatment  Oral or IV calcium  Calcium gluconate if tetany Calcium rich diet Fluid and Electrolyte Balance, Student Notes o  Dairy, canned salmon, broccoli, spinach, tofu Nursing Care  Health history: current manifestations  Physical assessment: musculoskeletal and respiratory status  Monitor airway and respiratory status, report stridor (high pitched, harsh inspiratory sound in the upper airway) sounds like sucking in balloon  Tetany  Provide safe, quiet environment with raised bedrails and keeping an oral airway at bed o When tetany, you increase chance for the laryngeal spasms Hypercalcemia o o o o Causes  High dietary intake of calcium or vitamin D  Not very common  Diseases that cause calcium to be released  Fractures or long term immobility cause calcium to be released  Thiazide diuretics increase calcium reabsorption in renal tubules and cause calcium to be released Symptoms  GI Nausea vom diarrhea anorexia  MS  Weakness fatigue  CNS  Lethargy, confusion, personality changes  CV  Dysrhythmia, ecg changes Treatment  IVF  Normal saline to enhance calcium excretion  Loop diuretics flush out calcium  Calcitonin with immediate needed: quickly absorbs calcium into bones Nursing Care  Physical assessment: bowel sounds, muscle strength, level of consciousness  Increase mobilization to drive calcium back into bones  Encourage fluids