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Fluid & Electrolyte Imbalance. How to keep things flowing along!. Lisa B. Flatt, RN, MSN, CHPN. Body Fluids. Body mostly composed of: fluid –water solutes - electrolytes

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Fluid & Electrolyte Imbalance


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fluid electrolyte imbalance

Fluid & Electrolyte Imbalance

How to keep things flowing along!

Lisa B. Flatt, RN, MSN, CHPN

body fluids
Body Fluids
  • Body mostly composed of:
    • fluid –water
    • solutes - electrolytes
  • Osmolality- the balance between fluid and solutes – This is a delicate balance! Every organ and system reacts differently to an imbalance.
swollen feet and ankles water is attracted to sodium
Swollen feet and ankles – water is attracted to sodium!
  • Semi-permeable membrane – selected particles move by passive diffusion – that’s how sodium follows water.
  • Osmotic pressure is the strength of the solution to draw the water across the SPM.
  • Passive diffusion – solutions of greater concentrations moves solutes to solutions of less concentration
  • Filtration – fluid and solutes move across a membrane from area higher pressure to lower pressure
  • Active transport – substances are moved from low to high concentration areas (metabolic energy & enzymes are used, ie. Sodium potassium pump)
let s see what are the differences
Let’s see… what are the differences….
  • Osmosis –
  • Diffusion –
  • Filtration –
  • Active transport -
where you can find body fluid
Where you can find Body Fluid

Intracellular Fluid

Extracellular Fluid

  • Is 2/3 to ¾ of total body fluid
  • Found inside the cells
  • Outside the cells
  • Divided into compartments
    • Intravascular fluid
      • Plasma- vascular system
    • Interstitial fluid
      • Surrounds cells – lymph
    • Transcellular fluid
      • Epithelial cells (synovial fluid)
potassium
Potassium
  • Potassium (3.5 – 5.0 meQ/l)
  • Found and for: intracellular- cardiac, skeletal and smooth muscle activity
  • Hyperkalemia- high K
    • Causes-renal failure & (drug induced)
      • S/S – tetany, irritability, parasthesia, GI hyperactivity, cardiac arrhythmias
        • Nursing interventions: Kayexelate (po and pr), D50 and Insulin, dietary intake
  • Hypokalemia- low K
    • Causes-drug induced, N&V&D, gastric suctioning, exercise (shin splints)
      • S/S – weak, fatigued, cardiac arrhythmias
        • Nursing Interventions: IV and PO K, po and iv fluids, dietary intake
magnesium
Magnesium
  • Magnesium (1.5 – 2.5 mEq/l)
  • Found and For: intracellular metabolism, protein and DNA synthesis
  • Hypermagnesia – high Mg
    • Causes-drug induced,
      • S/S – lethargy, coma, impaired respirations
        • Nursing Interventions- medication, diet
  • Hypomagnesia- low Mg
    • Causes – alcoholism
      • S/S – confusion, disoriented, tremors, irritability
        • Nursing Interventions – medications, diet
sodium salt sucks
Sodium -- Salt sucks
  • Sodium (135 - 145meQ/l)
  • Found and For: intra&extracellular – Na and K balance needed in body – key electrolyte
  • Hypernatremia – high sodium
    • Causes – increased dietary intake, body system imbalances (kidney) – dehydration of the cells, water gets sucked from the cells and into the tissue
      • S/S – edema, thirst, confusion, dry mucus membranes, mental status changes
        • Nursing Interventions- fluid restrictions, diet restrictions
  • Hyponatremia – low sodium
    • Causes- exercise and too much water “water toxicity” – water gets sucked from the cells into the tissue (how most people die in the Grand Canyon – they need to take salt pills **Thank you Wes for the fun fact**)
      • S/S – muscle cramping, N&V, postural hypotension, mental status changes, hallucinations of oasis!
        • Nursing Interventions – medications, iv fluids, electrolytes
calcium
Calcium
  • Calcium (8.5 – 10.5 meQ/l)
  • For: blood coagulation, neuromuscular activity and bone growth
  • Found: Located in Bones
  • Hypercalcemia – high Ca
    • Causes – cancer with met’s to bone, drugs, parathyroid glandular issue
      • S/S – kidney stones, lethargy, weakness, decreased muscle tone
        • Nursing interventions: safety, iv fluid
  • Hypocalcemia – low Ca
    • Causes-alcoholism, low serum Mg, parathyroid gland removal
      • S/S – numbness, tremors, cardiac arrhythmia, osteoporosis
        • Nursing Interventions: iv fluids, medications, diet

**Calcium and Phosphate work together – form bone and teeth --- if one is high the other is lower

phosphates
Phosphates
  • Essential for function of: muscles, nerves and RBC
  • Involved in PRO, Fat and CHO metabolism
  • Hypophosphatemia - TPN, glucose & insulin can cause phosphates to shift into cells
    • Alcohol withdrawal
    • Antacid use (acid base imbalance)
      • S/S – weakness, pain, mental changes, seizures

Hyperphosphatemia – Phosphates shift out of cell (trauma, chemo, malignant tumor), at risk – infants fed cow milk ((Fleets phosophosoda))

S/S – numbness, tingling **Around mouth and fingers** muscle spasm, tetany

Nursing interventions: Diet, Medications, IV Fluids, Education

chloride
Chloride
  • Imbalances occur with Na imbalances
  • Hypochloremia – low Chloride
    • Causes: sweating, kidney loss, GI tract losses
      • S/S – twitching, tremors, tetany
  • Hyperchloremia – high Chloride
    • Causes: Na retention or high potassium
      • S/S – tremors, acidosis, weakness, lethargy, arrhythmias, coma
      • NURSING INTERVENTIONS: Medication, IV Fluids
electrolyte imbalances universality
Electrolyte Imbalances Universality
  • Nursing Interventions: diet, med’s, iv fluids, education, assessment, labs
  • Causes: Diet, Medication issues, metabolism (cancers, diseases)
  • S/S – muscle tremors, twitches, LOC, Mental status, cardiac affects
look at your patient be a spy
Look at your patient- be a spy
  • Previous history? Alcoholic = mg or K
  • Malnourished?
  • Objective and Subjective findings?
  • Labs – the blood
  • EKG
homeostatic mechanisms
Homeostatic Mechanisms
  • Control the levels of fluids and electrolytes
  • Found throughout the body
    • _kidneys________
    • __endocrine_______
    • __cardiovascular_______
    • ___GI______
    • _____Lungs____
kidneys not kidney beans
Kidneys (not kidney beans!)
  • Regulate what?
    • __water____
    • __electrolytes____
    • __acid/base content of blood____
    • __all body fluids____
  • Adjust what? Reabsorption of water
  • Excrete what? Water and waste == pee pee
antidiuretic hormone adh
Antidiuretic Hormone ADH
  • ADH regulates water excretion
  • Increases in response to increased serum (blood) osmolality
  • Ducts become more permeable to water and it is reasborbed easier into the blood and urine output will decrease
renin angiotensin aldosterone system
Renin-angiotensin-aldosterone system
  • Renin (enzyme) splits Angiotensinogen into angiotensin I and this transforms to angiotensin II (with the help of an ACE inhibitor).
  • Angiotensin II – stimulates vasoconstriction and secretes aldosterone
  • Aldosterone – increases Na reabsorption to regulate BP and electrolyte levels
put it together
Put it together
  • Increased osmolality – need more water in blood so: ADH secretion increases and water travels to the blood
  • R-A-A system – renin excreted to make angiotensin II and secrete aldosterone
  • Aldosterone causes vasoconstriction increase bp

Give ACE inhibitor – stops angiotensin I to II and aldosterone (thereby lowers BP). This may also affect the ability of the body to maintain extracellular fluid (without edema).

atrial natriuretic factor anf
Atrial Natriuretic Factor ANF
  • Secreted from atrial heart tissue
  • Increases sodium and water elimination (urine)
  • Lowers the blood volume and decreases cardiac output
  • Decreases the workload of the heart
  • OPPOSITE EFFECT OF ADH
ph acids and bases
pH acids and bases
  • Acid = substance that releases Hydrogen ion in a solution
  • Base = low hydrogen ion concentration
  • Buffers prevent excessive ph changes by: adjusting the ions
  • **Major buffer is H2CO3***
    • Kidneys and Lungs play a key
factors that affect fluid and electrolyte balance
Factors that affect fluid and electrolyte balance
  • Sex
  • Body size
  • Age
  • Diet
  • NPO
  • General adaption syndrome (GAS) hehe
  • Altered LOC
more factors
More factors…….
  • Body temperature
  • Renal, cardiac, pulmonary system
  • Medications
    • Steroids
    • NSAIDs
    • Diuretics
    • Laxatives
    • Electrolyte supplements
more factors just when you thought you were done
More factors…… just when you thought you were done!
  • Dehydration
  • Surgical procedures
  • Vomiting
  • Diarrhea
  • Exercise
  • Culture and traditional foods MSG
  • Religious practices
  • Socioeconomic
  • Emotional
definitions and conditions
Definitions and conditions
  • Fluid volume deficit is__hypovolemia_______
  • Fluid volume excess is__hypervolemia____
  • Ascites__fluid in the abdominal cavity______
  • Edema _fluid in the interstitial space_______
hypovolemia
Hypovolemia
  • Define: low fluid volume
  • Causes: increased sodium chloride intake (po, iv), dehydration, CHF, Renal failure, Cushing’s, trauma
  • Nursing ramifications: identify cause and educate, medications, iv’s, etc…
  • S/S: weak, nausea, low pulse, SOB, low BP
hypervolemia
Hypervolemia
  • Define: increased volume in vascular system
  • Causes: water toxicity, iv fluids, disease states
  • Nursing ramifications: medication, educate
  • S/S: elevated BP, moist crackles in lungs, bounding pulse, SOB
ascites
Ascites
  • Define: serous fluid in peritoneal cavity (3rd spaced)
  • Causes: liver – cardiac dx, sodium retention, some cancers
  • Nursing ramifications: educate, diet, fluids, albumin (pulls fluid from 3rd space, interstitially back into the blood stream). Albumin has high osmolality.
  • S/S: swelling, fluid shift – the wave~~~~~~~
  • Treatment: Albumin and Pericentesis
edema
Edema
  • Define: fluid in the tissues
  • Causes: increased sodium, electrolyte imbalances, poor cardiac output, kidney failure, hypervolemia, diseases
  • Nursing ramifications: fluid restrictions, educate & elevate body parts, sodium restrictions, medications
  • S/S: swelling (LOL), weeping skin, pain, numbness, cool skin, bruised/discolored
edema29
Edema

Pitting – leaves a small depression or pit

Areas of edema: body parts, periorbital edema, axillary, groin, generalized

Note how many seconds it takes for pit to disappear (normally 10-30seconds)

what s the difference
What’s the Difference?

Dehydration

Overhydration

  • Define: loss body fluid, normal electrolytes
  • Causes: decreased fluid intake
  • Nursing ramifications: IVF, educate, diet, assessment
  • S/S: jugular vein distention, tachycardia, mental status changes, confusion, weight loss, dry skin, poor skin turgor, dry mucus membranes, increased thirst
  • Define: water intake is greater than electrolyte intake
  • Causes: increased fluid intake
  • Nursing ramifications: education, diet, medications, assessment
  • S/S: altered mental status, edema, SIADH (water toxicity), possible decreased urine output
acid base balance
Acid-Base Balance
  • Normal pH of blood:_7.35-7.45____
  • Acidic pH of blood: __<7.35_____
  • Alkaline pH of blood (basic):_>7.45___
  • Blood is acidotic if the pH is __low__
  • Blood is alkalitic if the pH is __high__
metabolic condition
Metabolic condition

Metabolic Alkalosis

Metabolic Acidosis

  • HCO3 – high
  • Causes: excess intake of baking soda (antacid) or alkalitic substances; lots of puking
  • The body compensates:
    • CO2 is retained and carbonic acid levels increase to help balance the excess HCO3
  • HCO3 – low
  • Causes: starvation, renal impaired, DM
  • The body compensates:
    • Stimulates respiratory system and eliminates CO2
respiratory condition
Respiratory condition

Respiratory alkalosis

Respiratory acidosis

  • HCO3 – high
  • Causes: hyperventilation, fever, anxiety, pulmonary infections
  • The body compensates: kidneys excrete HCO3 (or stop hyperventilation ASAP)
  • HCO3 – low
  • Causes: hypoventilation, lung dx, asthma, COPD
  • The body compensates:
    • Kidneys retain NAHCO3 **may take hours or days to restore pH
nursing interventions include
Nursing Interventions Include:
  • Dietary education
    • Menus
    • Special diets
  • Oral fluid/food intake
    • Restrictions
  • Administering medications as ordered
    • IVF
    • Diuretics
    • Electrolyte supplements
  • Education on medication uses/side effects and complications
educating on diuretics
Educating on Diuretics
  • Loop diuretic – Lasix/Furosemide
  • Thiazide sparing – HCTZ
  • Potassium sparing - Aldactone
educating on electrolyte supplements
Educating on Electrolyte supplements
  • Potassium
  • Magnesium
  • Sodium Bicarbonate
  • Others? Gatorade, Power waters, Coconut water
  • What do we recommend if you are exercising in the heat? Water and Power/Gatorade, etc…
  • Babies who have diarrhea need? Pedialyte
  • We use __kayexelate, D50 and Insulin_to reduce Potassium
intravenous fluids types
Intravenous Fluids - Types
  • Hypotonic solutions: .45%NS, .33%NS, 2.5%Dextrose – lower osmotic pressure than plasma –DO not give if at risk for IICP
  • Hypertonic solutions:D5NS, D51/2NS, D5LR D5W – higher osmotic pressure than plasma – kidney, cardiac and dehydration
  • Isotonic solutions:0.9 NS, LR – expand vascular volume – LR has extra ingredients, treats metabolic acidosis
  • Electrolyte replacement: Potassium, KCL, MG, Banana bags!
ethical consideration with ivf
Ethical consideration with IVF
  • Life sustaining?
  • Religious and/or cultural issues?
  • Comfort measure?
  • Emotional?
assessing the patient
Assessing the patient
  • Urine
  • Skin
  • Mental state
  • MS
  • Bowel status
further assessment
Further Assessment
  • Labs
    • BUN 7-18 mg/dl
      • Increased indicates- renal failure
      • Decreased indicates - malnutrition, over hydration, liver damage
    • Creatinine 0.6 – 1.5 mg/dl
      • Increased indicates – renal failure, CHF, shock
      • Decreased indicates – fluid status, dehydration