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Adult Health Nursing I

Joseph Mariano, RN, MD

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Fluid and Electrolytes

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Fluid and Electrolyte Balance

Dynamic and essential to life

Potential and actual disorders occur

in every setting, with every disorder Changes with conditions that affect

well and ill people

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Fluids: Amount and Composition

Water and electrolytes

60% of body weight

Influenced by age, gender, body fat

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Fluids: Amount and Composition

Intracellular Fluid Compartment(2/3)

Extracellular Fluid Compartment(1/3)

Intravascular (3L)

Interstitial (11-12L)

Transcellular (1L)

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Electrolytes

Cations and anions that are activechemically

Cations Na+, K+, Ca++, Mg++, H+

Anions Cl-, HCO3-, HPO4

--, SO4--,

proteinate

Expressed in mEq/L equivalent tothe electrochemical activity of 1mgH+

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Major Electrolytes

ICF Cations

K 150

Mg 40 Na 10

ICF Anions

PO4, SO4 150

HCO3 10 Proteinate 40

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Fluid Volume Disturbances

Hypovolemia (Fluid Volume Deficit)

ECF loss > intake

Ratio of electrolytes to water isunchanged

Not synonymous with dehydration

which is loss of water alone

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Hypovolemia, Causes

Prolonged inadequate intake

Vomiting, diarrhea, sweating Hemorrhage, diabetes insipidus

Fluid shifts (burns, ascites)

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Hypovolemia, Manifestations

Acute weight loss

Decreased skin turgor Oliguria*

Postural hypotension*

Weak, rapid HR

Cool, clammy skin, increased T

Thirst

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Hypovolemia, Assessment

Elevated BUN Creatinine ratio, Hct

Urine specific gravity is increased

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Hypovolemia, Medical Management

If not severe, oral route is preferred

IV therapy , rate based on severityof loss and hemodynamic response

Fluid challenge test

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Hypovolemia, Nursing Management

I&O monitoring

Daily weights VS monitoring

Skin and tongue turgor

Mental functioning

Inc OFI, considering patientpreferences

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Hypervolemia (Fluid Volume Excess)

Isotonic expansion ofECF

Always due to increased Na

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Hypervolemia, Causes

Fluid overload

Diminished fluid balance regulation Heart, kidney, liver problems

Excessive Na intake

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Hypervolemia, Manifestations

Edema

Distended neck veins Crackles

Increased weight, urine output, BP

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Hypervolemia, Assessment

BUN and Hct decreased

Chest xray may show congestion

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Hypervolemia, Medical Management

Diuretics (HCTZ, loop diuretics)

Fluid and sodium restriction Hemodialysis/Peritoneal Dialysis

Always treat the underlying cause

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Hypervolemia, Nursing Management

I&O, daily weights, VS monitoring

Breath sounds Assess and measure edema

Bed rest

Positioning and turning

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Electrolyte Imbalances: Na

Sodium (Na)

Most abundant in electrolyte in the

ECF (135-145 mEq/L) Primary regulator ofECF volume

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Hyponatremia

< 135 mEq/L

Related to water content

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Hyponatremia, Causes

Vomiting, diarrhea, diuretic use

Dilutional (SIADH, hyperglycemia,tap-water in enemas and GI tubes)

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Hyponatremia, Manifestations

Nausea and vomiting

Muscle twitching and cramps Hypotension

Neurologic changes

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Hyponatremia, Medical Management

Na replacement (diet or IV)

Water restriction (800 ml in 24 hr) Only up to the point of relieving

neurologic signs and symptoms(125 mEq/L)

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Hyponatremia, Nursing Management


GI and Neuro manifestations Dietary intake, fluid restriction

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Hypernatremia

>145 mEq/L

Related to water content

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Hypernatremia, Causes

Fluid deprivation in those who

cannot perceive, respond orcommunicate their thirst

Watery diarrhea

Insensible water loss

Diabetes insipidus

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Hypernatremia, Manifestations

Neurologic

Subarachnoid hemorrhage Dry, swollen tongue, sticky mucus

membranes

Increased muscle tone and DTRs

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Hypernatremia, Medical Management

Hypotonic or isotonic fluid infusion

Diuretics Desmopressin if insipidus is the

cause

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Hypernatremia, Nursing Management


Monitor thirst Neuro symptoms

Ensure fluid intake

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Electrolyte Imbalances: K

Potassium

Major intracellular electrolyte

The extracellular portion (2%) isimportant in neuromuscularfunction

3.5-5.0 mEq/L

Balance primarily regulated by thekidneys

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Hypokalemia, Causes

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Hypokalemia, Manifestations

Cardiac/respiratory arrest

Muscle weaknesss, leg cramps,decreased bowel motility,paresthesia

Increased sensitivity to digitalis

Decreased BP, reflexes

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Hypokalemia, Assessment

ECG changes

ST segment depression Flat or inverted T-waves

U wave is specific

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Hypokalemia, Medical Management

Oral or IV replacement

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Hypokalemia, Nursing Management

Give fruits, vegetables, legumes,

whole grains, milk and meat Closely monitor patients receiving

digoxin

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Hypokalemia, Nursing Management

Do not give if UO

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Hyperkalemia

>5.0-5.5 mEq/L

Seldom occurs with normal renalfunction

More dangerous than hypo

Major cause is decreased renalexcretion

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Hyperkalemia

Hypoaldosteronism, Addisons dx

Potassium sparing medications acidosis

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Hyperkalemia, Manifestations

Cardiac effects start at >6, almost

always present by 8 mEq/L Skeletal muscle weakness up to

flaccid paralysis

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Hyperkalemia, Assessment

ECG changes

Peaked, narrow T-waves ST-segment depression

Shortened QT interval

Eventually PR interval prolongs and P

waves disappear, QRS prolongs

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Hyperkalemia, Medical Management

Potassium restriction

Kayexalate (cation exchange resin)orally or by enema

Calcium gluconate, NaHCO3

Insulin and hypertonic dextrose

B2 agonist Dialysis

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Hyperkalemia, Nursing Management

Monitor BP and cardiac response

Avoid coffee, cocoa, tea, driedfruits, milk and eggs

Never added to hanging bottle, mixby inverting bottle several times

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Electrolyte Imbalances: Ca

Calcium

Total: 8.5-10.5 mg/dL (2.1-2.6

mmol/L, 4.5-5.5 mEq/L) Ionized (50%), bound, complexed

Ionized: 4.5-5.1 mg/dL (1.1-1.3mmol/L)

Primarily excreted in feces

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Hypocalcemia

Common in renal failure with inc

phosphate levels Hypoparathyroidism, pancreatitis,

glucagon secretion, vitamin D deficit

diuretics

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Hypocalcemia, Manifestations

Tetany

Chvosteks and Trousseaus sign Seizures, alterations in mental

status

ECG: prolonged QT, torsades depointes

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Hypocalcemia, Medical Management

IV administration of Ca

Vit D Aluminum hydroxide antacids

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Hypocalcemia, Nursing Management

IV administration of Ca slow,

diluted Seizure precautions

Watch out for hypotension

Give milk products, green leafyvegetables, sardines

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Hypercalcemia

>5.5 mg/dL

Malignancies, hyperthyroidism Vit A and D intoxication

Cardiac standstill at 18 mg/dL (4.5

mmol/L)

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Hypercalcemia, Medical Management

Isotonic IV to dilute

Furosemide and calcitonin IV phosphate with caution

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Hypercalcemia, Nursing Management

Ambulate

Encourage oral fluid intake Monitor patients on digoxin closely

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Electrolyte Imbalances: Mg

Magnesium

Important in neuromuscular

function Inhibits release of Ach at NMJ

Direct vasodilation

1.5-2.5 mEq/L (1.8-3.0 mg/dL)

2/3 is ionized form

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Hypomagnesemia

< 1.5 meq/L

Alcohol withdrawal Diarrhea, citrate administration

insulin

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Hypomagnesemia

Neuromuscular irritability

Torsades de pointes Arrhythmias

Chvosteks and Trousseaus

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Hypomagnesemia ECG:

prolonged PR and QT Widened QRS Depressed ST Flattened T Prominent U

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Hypomagnesemia, NursingManagement

Green leafy vegetables, nuts,legumes, seafoods

Monitor for dysphagia and DTRchanges

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Hypermagnesemia

>3.5 mEq/L

Commonly due to renal failure DKA, Addisons, antacid use

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Hypermagnesemia, Manifestations

CNS depression

Sensations of warmth Loss of DTRs

>10 mEq/L depresses therespiratory center

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Hypermagnesemia, Manifestations

ECG:

Prolonged PR Tall T waves

Widened QRS

Prolonged QT, AV Blocks

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Hypermagnesemia, MedicalManagement

Ventilatory support IV calcium

Loop diuretics

Dialysis

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Hypermagnesemia, NursingManagement

Monitor for hypotension and shallowbreaths

Check DTRs

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Electrolyte Imbalances: HPO4

Phosphorus

Essential to muscle and RBC

Essential in ATP and nutrientmetabolism

2.5-4.5 mg/dL (0.8-1.5 mmol/L)

Primary anion of the ICF

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Hypophosphatemia

With severe protein-calorie

malnutrition, alcohol withdrawal,poor intake, vit D deficiency

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Hypophosphatemia, Manifestations

Irritability, numbness, seizures to

coma Respiratory alkalosis

Ms weakness, pain

Rickets, osteomalacia

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Hypophosphatemia, MedicalManagement

Oral phosphate replacement IV not more than 10 mEq/hr

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Hyperphosphatemia

Commonly due to renal failure

Hypoparathyroidism

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Hyperphosphatemia, Manifestations

Tetany

Muscle weakness, hyperreflexia Skeletal changes on xray

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Hyperphosphatemia, MedicalManagement

Restrict intake Dialysis

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Hyperphosphatemia, NursingManagement

Avoid hard cheese, cream, nuts,whole-grain cereals, milk products

Avoid laxatives

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Electrolyte Imbalances: Cl

Chloride

Major ECF anion

Changes along with Na andbicarbonate

96 mEq/L-106 mEq/L

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Hypochloremia

Metabolic alkalosis

Hyperexcitable neuromuscularsystem

Dysrhythmias

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Hypochloremia, Medical Management

Ammonium chloride

Isotonic solution

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Hypochloremia, Nursing Management

Provide tomato juice, fruits,

processed meat Monitor ABGs

Assess neuro and respiratoryfunctions

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Hyperchloremia

Due to bicarbonate losses in the

kidney or GI tract Consequences: Hypernatremia,

bicarbonate loss, metabolic acidosis

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Hyperchloremia, Medical Management

LR to increase bicarbonates

Diuretics to eliminate chloride

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Hyperchloremia, Nursing Management

Monitor VS and I&O

Diet changes (avoid tomato juice,fruits, processed meat)

Monitor for signs and symptoms

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Acid-Base Imbalances

Normal Values

pH = 7.35-7.45

paCO2 = 35-45 mm Hg HCO3 = 22-26 mEq/L

Base excess/deficit = +/- 2 mmol/L

O2 Sat =93-98

%

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Respiratory Acidosis

pH 42 mm Hg,

HCO3 elevated Hypoventilation, COPD

Sx: Dyspnea, rapid shallowbreathing, weakness

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Respiratory Acidosis Tx: ventilation, encourage coughing

and deep breathing Monitor VS and ABGs

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Respiratory Alkalosis

pH >7.45, paCO2

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Metabolic Acidosis

pH

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Metabolic Alkalosis

pH >7.45, HCO3 >26 mEq/L,

paCO2 normal or slightly increased Hypokalemia, vomiting,

hyperaldosteronism

Sx: hypoventilation

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For all of these:

Treat the underlying cause

The compensatory mechanism isthe reverse

Monitor VS and ABGs

Monitor cardiovascular andneurologic status

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The End

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