Fluid and Electrolytes, Balance and Disturbances

1. Fluid and Electrolytes, Balance and Disturbances Larry Santiago, MSN, RN

2. Fluid and Electrolytes • 60% of body consists of fluid • Intracellular space [2/3] • Extracellular space [1/3] • Electrolytes are active ions: positively and negatively charged

3. Fluid and Electrolytes 2

4. Regulation of Body Fluid Compartments • Osmosis is the diffusion of water caused by fluid gradient

5. Regulation of Body Fluid Compartments 2 • Tonicity is the ability of solutes to cause osmotic driving forces

6. Regulation of Body Fluid Compartments 3 • Diffusion is the movement of a substance from area of higher concentration to one of lower concentration • “Downhill Movement”

7. Regulation of Body Fluid Compartments 4 • Filtration is the movement of water and solutes from an area of high hydrostatic pressure to an area of low hydrostatic pressure

8. Regulation of Body Fluid Compartments 5 • Osmolality reflects the concentration of fluid that affects the movement of water between fluid compartments by osmosis

9. Regulation of Body Fluid Compartments 6 • Osmotic pressure is the amount of hydrostatic pressure needed to stop the flow of water by osmosis

10. Sodium-Potassium Pump • Sodium concentration is higher in ECF than ICF • Sodium enters cell by diffusion • Potassium exits cell into ECF

11. Gains and Losses • Water and electrolytes move in a variety of ways • Kidneys • Skin • Lungs • GI tract

12. Fluid Volume Disturbances • Fluid Volume Deficit (Hypovolemia)

13. Fluid Volume Deficit • Mild – 2% of body weight loss • Moderate – 5% of body weight loss • Severe – 8% or more of body weight loss

14. Fluid Volume Deficit • Pathophysiology – results from loss of body fluids and occurs more rapidly when coupled with decreased fluid intake

15. Fluid Volume Deficit 2 • Clinical manifestations • Acute weight loss • Decreased skin turgor

16. Fluid Volume Deficit 3 - Oliguria - Concentrated urine - Postural hypotension - Weak, rapid, heart rate - Flattened neck veins - Increased temperature - Decreased central venous pressure

17. Fluid Volume Deficit 4 • Gerontologic considerations

18. Nursing Diagnosis • Fluid volume Deficit r/t Insufficient intake, vomiting, diarrhea, hemorrage m/b dry mucous membranes, low BP, HR 112-122, BUN 28, Na 152, urine dark amber; Intake 200mL/Output 450mL over 24 hours Goal: Client will have adequate fluid volume within 24 hours AEB: Moist tongue, mucous membranes, BNL WNL, HR WNL, BUN between 8-20, Na 135-145, Urine clear yellow, balanced I/O

19. Fluid Volume Deficit 5 • 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

20. Fluid Volume Disturbances 2 • Fluid Volume Excess (Hypervolemia)

21. Fluid Volume Excess • Pathophysiology – may be related to fluid overload or diminished function of the homeostatic mechinisms responsible for regulating fluid balance • Contributing factors – CHF, renal failure, cirrhosis

22. Fluid Volume Excess 2 • Clinical manifestations – edema, distended neck veins, crackles, tachycardia, increased blood pressure, increased weight

23. Nursing Diagnosis and Goal • Fluid volume excess r/t CHF, excess sodium intake, renal failure AEB: Weight gain of 6 lb. in 24 hours; lungs with crackles in bases bilaterally; 2+ edema in ankles bilaterally Goal: Client will have normal fluid volume within 48 hours AEB: Decreased weight of 1 lb. per day, lung sounds clear in all fields, ankles without edema

24. Fluid Volume Excess 3 • Nursing management • Preventing FVE • Detecting and Controlling FVE • Teaching patients about edema

25. Electrolyte Imbalances Sodium! Normal 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)

26. Hyponatremia • Sodium level less than 135 mEq/L • May be caused by vomiting, diarrhea, sweating, diuretics, etc.

27. Hyponatremia 2 • Clinical manifestations • Poor skin turgor • Dry mucosa • Decreased saliva production • Orthostatic hypotension • Nausea/abdominal cramping • Altered mental status

28. Hyponatremia 3 • Medical management • Sodium Replacement • Water Restriction

29. Hyponatremia 4 • Nursing Management - Detecting and controlling hyponatremia - Returning sodium level to normal

30. Critical Thinking Exercise: Nursing Management of the Client with Hyponatremia • Situation: An 87 year old man was admitted to the acute care facility for gastroenteritis, 2 day duration. He is vomiting, has severe, watery diarrhea and is c/o abd cramping. His serum electrolytes are consistent with hyponatremia r/t excessive sodium loss.

31. Critical Thinking Exercise: Nursing Management of the Client with Hyponatremia 2 • 1. What is the relationship between vomiting, diarrhea, and hyponatremia? • 2. What s/s should the client be monitored for that indicate the presence of sodium deficit? • 3. In addition to examining the client’s serum electrolyte findings, how will the nurse know when the client’s sodium level has returned to normal?

32. Hypernatremia • Sodium level is greater than 145 mEq/L - Can be caused by a gain of sodium in excess of water or by a loss of water in excess of sodium

33. Hypernatremia 2 • 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

34. Hypernatremia 3 • Clinical manifestations • Thirst • Dry, swollen tongue • Sticky mucous membranes • Flushed skin • Postural hypotension

35. Hypernatremia 4 • Medical Management • Nursing Management • - Preventing Hypernatremia • - Correcting Hypernatremia

37. Critical Thinking Exercise: Nursing Management of the Client with Hypernatremia • Situation: A 47 year old woman was taken to the ER after she developed a rapid heart rate and agitation. Physical assessment revealed dry oral mucous membranes, poor skin turgor, and fever of 101.3 orally. The client’s daughter stated her mother had been very hungry recently and drinking more fluids than usual. Suspecting DM, the practitioner obtained serum electrolytes and glucose levels, which revealed serum sodium of 163 mEq/L and serum glucose of 360 mg/dL.

38. Critical Thinking Exercise: Nursing Management of the Client with Hypernatremia 2 • 1. Interpret the client’s lab data. • 2. Why are clients with DM prone to the development of hypernatremia? • 3. What precautions should the nurse take when caring for the client with hypernatremia? • 4. List 4 food items this client should avoid and why. • 5. Identify 3 meds that could have an increased effect on the client’s sodium level.

39. All About Potassium • Major Intracellular electrolyte • 98% of the body’s potassium is inside the cells • Influences both skeletal and cardiac muscle activity • Normal serum potassium concentration – 3.5 to 5.5 mEq/L.

40. Hypokalemia • Serum Potassium below 3.5 mEq/L Causes: Diarrhea, diuretics, poor K intake, stress, steroid administration

41. Hypokalemia 2 • Clinical manifestations: Muscle weakness, cardiac arrythmias, increased sensitivity to digitalis toxicity, fatigue, EKG changes (like ST elevation)

42. SUCTION • Skeletal muscle weakness • U wave (EKG changes) • Constipation, ileua • Toxicity of digitalis glycosides • Irregular, weak pulse • Orthostatic hypotension • Numbness (paresthesia)

43. Hypokalemia 3 • Nursing interventions: • Encourage high K foods • Monitor EKG results • Dilute KCl! – can cause cardiac arrest if given IVP

44. Hypokalemia 4 • Administering IV Potassium • Should be administered only after adequate urine flow has been established • Decrease in urine volume to less than 20 mL/h for 2 hours is an indication to stop the potassium infusion • IV K+ should not be given faster than 20 mEq/h

45. Critical Thinking Exercise: Nursing Management of the Client with Hypokalemia • Situation: A 69 year old man has a history of CHF controlled by Digoxin and Lasix. Two weeks ago he developed diarrhea, which has persisted in spite of his taking OTC antidiarrheal meds. His partner transported him to the ER when she found him lethargic and confused. Initial assessment of the client reveals heart rate at 86 bpm, respiratory rate 10, and blood pressure 102/56 mmHg.

46. Critical Thinking Exercise: Nursing Management of the Client with Hypokalemia 2 • 1. An electrolyte panel shows the client’s serum potassium is 2.9 mEq/L. Does the nurse have cause to be concerned about the client’s serum potassium? Why or why not? • 2. What data supports the presence of hypokalemia in this client? • 3. What, if anything, should the nurse do? • 4. What foods should the client be advised to eat that are high in potassium?

47. Hyperkalemia • Serum Potassium greater than 5.5 mEq/L • More dangerous than hypokalemia because cardiac arrest is frequently associated with high serum K+ levels

48. Hyperkalemia 2 • 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

49. Hyperkalemia 3 • Clinical manifestations: • Skeletal muscle weakness/paralysis • EKG changes – such as peaked T waves, widened QRS complexes • Heart block

50. Hyperkalemia 4 • Medical/Nursing Management: • Monitor EKG changes – telemetry • Administer Calcium solutions to neutralize the potassium • Monitor muscle tone • Give Kayexelate • Give Insulin and D50W