Ch 52 Fluid/ Electrolites

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cswett
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110559
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Ch 52 Fluid/ Electrolites
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2011-11-12 21:53:56
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52 Fluid Electrolites
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Ch 52 Fluid/ Electrolites
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  1. Fluid & Electrolyte balance
    • }Fluids,
    • electrolytes, & acids & bases need to be balanced within the body to maintain health.

    • }These
    • balances are maintained by the intake & output of water & electrolytes
    • & by the regulation of the kidneys & lungs

    }Homeostatsis is the term we use when this balance exists
  2. Distribution of body fluids
    • 60% of body weight is water
    • Higher % in infants & children
    • Less % >60 years
    • Less in women

    • Intracellular (ICF)
    • Extracellular (ECF)
    • ◦Intravascular (Plasma)
    • ◦Interstitial (Between cells)
    • ◦Transcellular
    • CSF, Synovial, Pericardial, Pleural, Digestive
  3. Composition of Body Fluids
    • }Oxygen
    • }Nutrients
    • }Products of metabolism
    • }Charged particles (ions): electrolytes

    • ◦Cations- positive charge (Ca+)
    • ◦Anions- negative charge (Cl-)
    • ◦Measured as:
    • milliequivalents (mEq/L)
    • mg/100 ml)
    • ◦Although concentration of lytes differ in ICF vs. ECF the balance of cations & anions always exist
  4. Movement of Body fluids and Electrolytes
    F & E constantly shift from compartment to compartment

    • Osmosis
    • Diffusion
    • Filtration
    • Active Transport
  5. Osmosis
    Osmosis- Movement of water across semi-permeable membrane from less concentration to greater concentration

    Solutes- substances dissolved in a liquid

    • ◦Cystalloids- dissolve into solution
    • ◦Colloids- do not dissolve easily in solution
  6. Osmolality & Tonicity
    • Concentration of solutes in the body= osmolality
    • Osmolality of a solution (IV)= tonicity

    • ◦Solutions such as IVs:
    • Isotonic- same osmolality as body fluids (0.9%NS)
    • Hypertonic- higher osmolality than body fluids
    • (3% NaCl)
    • Hypotonic-less osmolality than body fluids
    • (0.45% NaCl)
  7. How Body Regulates Fluids
    Fluid Intake
    • Primarily through drinking fluids
    • Oral fluids- 1500 mL
    • Water in foods- 1000 mL
    • Food metabolism – 200 mL
    • Fluid intake regulated by thirst
    • •Change in plasma osmolality
    • •Hypothalamus
  8. How Body Regulates Fluids
    Fluid Output
    • Urine: 1500 mL/day
    • Skin as sweat: 100 ml/day
    • Feces: 100-200 ml/day
    • Insensible water loss: not measurable
    • ◦Skin: 350-450 mL/day (perspiration)
    • ◦Lungs: 350-400 mL/day (exhalation)
  9. How the Body Regulates Fluids
    Other factors
    • Kidneys- primary regulator
    • ◦Regulates water by reabsorption
    • ◦Regulates lytes by selective retentions & excretion
    • Antidiuretic hormone(ADH)
    • Renin-angiotensin system
    • Aldosterone
    • Atrial natriuretic factor
  10. ADH
    • Hormone made in pituitary
    • Diuresis- secretion & passage of large amts of urine
    • ADH- hormone against diuresis: fluids retained
    • ADH acts on the kidneys
    • ◦Serum osmolality rises- ADH produced
    • ◦Serum osmolality falls- ADH suppressed
  11. Renin-angiotension-aldosterone System
    • Sequence:
    • Blood flow to kidneys is decreased
    • Renin is released
    • Renin converts angiotensin I to angiotensin ll
    • Angiotensin ll release aldosterone from the adrenal gland

    • Result:
    • Kidneys retain sodium & water to restore blood volume
  12. ANF
    • Atrial natriuretic factor
    • Sequence:
    • Excessive blood volume stretches atrial walls & ANF is released
    • Causes sodium wasting & diuresis
    • Result: Reduces vascular volume
    • Thirst inhibited
  13. How the Body Regulates Electrolytes
    }Regulation needed for normal body fuction

    }Concentration differs between fluid compartments but a balance always exists

    • }Electrolytes mostly obtained through dietary intake
    • }Some lytes not stored in body- Na & Cl
    • }Some stored- K & Ca
  14. Factors Affecting Fluid & Electrolyte balance
    • }Age
    • ◦Young & old have different % of fluid in body
    • ◦Older people – Ca+ lose & osteoporosis

    • }Gender- men have more water
    • }Body size
    • }Environmental temperature
    • ◦Lost through sweating esp. Na & Cl

    • }Life style
    • ◦Diet
    • ◦Exercise
    • ◦Alcohol consumption
  15. Disturbances in Fluid Volume
    • }2 basic types:
    • }Isotonic imbalances:
    • ◦loss or gain of fluid & lytes are in equal proportion

    • }Osmolar Imbalances:
    • ◦loss or gain of water only
  16. Fluid volume deficit (FVD)-
    know this
    • isotonic loss: water & lytes lost in same amount
    • }Risk factors
    • ◦Vomiting
    • ◦Diarrhea
    • ◦Sweating
    • ◦Fever
    • ◦Drainage- wound or NGT
    • ◦Bleeding
    • ◦Insufficient intake
    • ◦Third spacing

    • }Symptoms:
    • }Weight loss
    • }Decreased BP & T
    • }Orthostatic hypotension
    • }Flat veins
    • }Hypovolemia
    • }Dry skin & mucous membranes
    • }Nonelastic skin turgor
    • }Decreased urine output
    • Sunken eyeballs
  17. FVE Labs
    • Decreased:
    • }Hematocrit
    • }Specific gravity in urine
    • }BUN
  18. FVD Labs
    • }Increased:
    • ◦Hematocrit
    • Normal: Men- 40-54%
    • Women- 37-47%

    • ◦◦Urine specific gravity
    • Normal: 1.005-1.030

    • ◦Blood Urea nitrogen (BUN)
    • Normal: 5-20 mg/dL
    • 8-23 if >60 years old
  19. Fluid volume excess (FVE)-
    isotonic gain: water & lytes gained in same amount

    • }Risk factors
    • ◦Too much Na IV fluids
    • ◦Excess ingestion of diet or meds with water & NA
    • ◦Medical Dx: heart, kidney, or liver failure
    • ◦Meds: steroids

    • }Symptoms
    • ◦Wt gain
    • ◦Increased BP
    • ◦Distended neck & peripheral veins
    • ◦Hypervolemia
    • ◦Fluid in lungs, short of breath
    • ◦Mental confusion
    • ◦Edema
    • ◦Pitting edema
  20. Osmolar Imbalances
    • }Hyperosmolar
    • }Water lost
    • }Dehydration
    • }Serum osmolality & serum Na increased
    • }SX: cell dehydration
    • }Cause:
    • ◦Elders- decreased thirst
    • ◦Enteral feeding without water

    • }Hypoosmolar
    • }Water gain
    • }Overhydration
    • }Serum osmolality & serum Na decreased
    • }SX: cerebral edema

    • }Cause:
    • ◦Fluid replacement w/o lytes
    • ◦ADH imbalances
  21. Nsg Interventions for Fluid Volume Imbalances
    • }Assess for sx of FVD or FVE
    • }Daily weights
    • }Assess VS
    • }Monitor I & O
    • }Assess skin turgor
    • }Assess veins
    • }Assess lung sounds
    • }Assess for edema
    • }Restrict or provide fluids
    • }Provide mouth care
    • }Assess labs
  22. Electrolytes
    • }Function:
    • }Maintaining fluid balance
    • }Acid-base balance
    • }Enzyme reactions
    • }Neurotransmission & muscle contraction

    • }Sodium- most abundant cation in ECF
    • •135-145 mEq/L

    • }Potassium
    • - most abundant cation in ICF
    • 3.5-5 mEq/L

    • }Calcium- Stored in bone mostly
    • •8.5- 10.5 mg/dL
  23. Hyponatremia
    • Risk Factors:
    • Loss of sodium
    • GI fluids
    • diuretics
    • Sweating
    • Gain of water:
    • Hypotonic tube feedings, oral ingestion, IV-D5W

    • Disease:
    • SIADH: head injury, tumor

    • Signs & Symptoms:
    • Serum Na <135
    • Serum osmolality <280
    • Neuromuscular: Confusion, headache, muscle twitching, seizures, lehtargy
    • GI: abdominal cramps, N/V, anorexia
  24. Hyponatremia
    Nursing Interventions
    • }Monitor I/O
    • }Monitor labs
    • }Restrict water intake
    • }Increase oral sodium intake
    • }Assess closely if receiving hypertonic solutions
  25. Hypokalemia
    • Risk factors
    • }Potassium loss:
    • ◦GI- low K intake, vomiting, gastric suction, diarrhea
    • Meds- K wasting diuretics
    • Steroid Administration
    • ◦Disease- Hyperaldosteronism
    • Anorexia or bulemia

    • Signs & Symptoms
    • Serum K < 3.5
    • ECG changes
    • Neuromuscular: Muscle weakness
    • leg cramps
    • Fatigue
    • GI: Anorexia, Nausea/vomiting
    • Decreased bowel sound
    • Cardiac: dysrhythmias
  26. Hypokalemia
    Nursing interventions
    • }Administer prescribed K supplements
    • }Monitor HR and rhythm
    • }Assess digitalized clients for symptoms of digitalis toxicity (hypokalemia increases risk of digitalis toxicity)
    • }Prevention: encourage K rich foods for at risk clients
  27. Hyperkalemia
    • Risk Factors
    • }Decrease potassium excretion:
    • ◦Renal failure
    • ◦Potassium sparing diuretics
    • ◦Hypoaldosteronism
    • }High K intake:
    • ◦ improper use of supplements
    • ◦Salt subst. containing K
    • }Shift of K out of cells: acidosis, burns, tissue trauma

    • Signs & Symptoms
    • Serum K >5
    • Neuromuscular:First sign is vague muscle weakness
    • Irritability, apathy, confusion, absent reflexes
    • GI: Diarrhea, GI hyperactivity
    • Cardiac: ECG changes, dysrhythmias
  28. Hyperkalemia
    Nursing interventions
    • ◦Monitor K levels
    • ◦Hold K supplements
    • ◦Monitor EKG
    • ◦Administer diuretics, glucose and insulin as ordered
    • ◦Hyperkalemia is life threatening-it must be detected early
    • ◦Teach at risk clients to avoid foods high in K
  29. Hypocalcemia
    • Risk factors
    • }Neck surgery:
    • ◦Hypoparathyroidism
    • ◦Thyroid cancer
    • }Acute pancreatitis
    • }Vitamin D deficiency:
    • ◦Malabsorption
    • ◦Alcohol abuse

    • Signs & Symptoms
    • Total serum Ca <8.5
    • Neuromuscular:
    • Numbness
    • Tingling of fingers and toes
    • Muscle cramps
    • Convulsion, seizures
    • Laryngeal spasms
    • ECG changes
    • Positive signs
    • Chvostek’s sign
    • Trousseau’s sign
  30. Hypocalcemia
    Nursing interventions
    • ◦Monitor serum calcium
    • ◦Monitor airway
    • ◦Seizure precautions
    • ◦Administer parenteral calcium as ordered
    • ◦Educate women about calcium supplements
  31. Hypercalcemia
    • Risk factors
    • }Lost from bone:
    • }Prolonged immobility
    • }Bone cancer
    • }Hyperparathyroidism
    • }Excessive ingestion
    • } Calcium
    • }Supplements
    • }Antacids
    • }Vitamin D-megadoses

    • Signs & Symptoms
    • Serum Ca >10.5
    • Neuromuscular:
    • Muscle weakness
    • Changes in behavior
    • Cardiac- slow heart
    • GI:
    • Constipation
    • Anorexia, N&V
    • Kidney stones
  32. Hypercalcemia
    Nursing interventions
    • ◦Keep client well hydrated
    • ◦Discourage excessive dietary milk products
    • ◦Fiber in diet
    • ◦Safety precautions for confusion, weakened bones
    • ◦Eliminate calcium supplements & avoid calcium based antacids
    • ◦Prevention: Encourage mobility to the extent possible
  33. Electrolytes- other
    • Magnesium
    • •Found in bone & ICF
    • •1.5- 2.5 mEq/L
    • •Foods: grains, nuts, dried fruit, legumes, green leafy veges
    • •Alcoholism leads to low levels

    • Chloride
    • •Bound to other ions
    • ◦95-108 mEq/L
    • ◦Regulates osmolality & blood volume

    • Phosphate
    • •Bound with calcium in teeth and bones; inverse relationship

    • Bicarbonate
    • •Regulated by kidneys to maintain acid-base balance
  34. Assessment
    • }Nursing History
    • ◦Environmental factors- temperature
    • ◦Diet-intake of fluids & foods containing lytes
    • ◦Lifestyle- exercise, alcohol consumption
    • ◦Medications
    • Diuretics, Steroids, Potassium supplements, Respiratory center depressants, Antibiotics

    • }Physical Assessment – Table 52-8 pg 1446
    • ◦Skin, mucus membranes, cardiovascular, respiratory & neurological systems

    • }Clinical measurements
    • ◦Vital signs
    • ◦I/O’s
    • ◦Weights

    • }Lab values: Electrolytes, CBC (hematocrit), BUN,
    • Creatinine, Urine specific gravity, Serum osmolality
  35. Nursing Diagnosis
    • }Deficient fluid volume
    • }Excess fluid volume
    • }Risk for imbalanced fluid volume
    • }Impaired oral mucous membranes
    • }Impaired skin integrity
    • }Acute confusion
  36. Implementation
    • Preventing Fluid & Electrolyte Imbalances
    • Promoting Wellness
    • ◦Client teaching: Promoting Fluid & Electrolyte
    • Balance, p. 1453
    • Dietary Changes
    • ◦Potassium- box 52-1
    • Oral Electrolyte supplements- K, Ca
    • Fluid Intake modifications
    • ◦Facilitating Fluid Intake- pg 1454
    • ◦Facilitating Fluid Restriction- pg 1454
    • Enteral Replacement
  37. Practice Guidelines Facilitating Fluid Intake
    • }Explain reason for required intake and amount needed
    • }Establish 24 hour plan for ingesting fluids
    • }Set short term goals
    • }Identify fluids client likes and use those
    • }Help clients select foods that become liquid at room temperature
    • }Supply cups, glasses, straws
    • }Serve fluids at proper temperature
    • }Encourage participation in recording intake
    • }Be alert to cultural implications
  38. Implementation
    • }Parenteral Replacement
    • ◦Isotonic- expand ECF volume

    • ◦Hypertonic- osmolality > body fluids-
    • pulls fluid from ICF & interstitial into vascular compartment. Check kidneys 1st

    ◦Hypotonic- osmolality < body fluids- IV fluid pushed into cells for rehydration
  39. Administration Of IV Fluids
    • }Type of solution
    • ◦0.9% NS
    • ◦D5W
    • ◦D5 1/2NS

    • }Vascular Access – pg 1456-7
    • ◦Peripheral
    • ◦PICC
    • ◦Central

    }Pumps
  40. Parental Replacement
    • Side Effects to be aware of
    • }Infiltration
    • ◦Localized swelling,
    • pallor,
    • ◦coldness,
    • ◦pain around infusion site

    • }Phlebitis
    • ◦Localized redness,
    • ◦warmth,
    • ◦mild edema of the vein above insertion site

    }Air embolism
  41. Potassium-rich foods
    • Avacado
    • Spinach
    • Raw carrot
    • baked potato
    • Raw tomato

    • banana
    • dried fruits
    • apricot
    • cantalopue
    • orange

    • been
    • cod
    • pork
    • veal

    • milk
    • OJ
    • apricot necter
  42. Elder considerations for Fluid and Electrolyte imbalance
    • decrease in thirst sensations
    • decrease in ability of kidneys to concentrate urine
    • decrease in ICF and total body water
    • decrease in response to body hormones that help regulate fluid & lyte balance

    • Increase use of diuretics for hypertension & heart disdease
    • Decrease intake of food & water
    • Prep for tests that have client NPO for long periods of time or diarrhea from laxative preps
  43. Hypernatremia
    • Risk Factors
    • Loss of water:
    • profuse sweating
    • diarrhea
    • water deprivation
  44. Gain of sodium:
    • high salt intake
    • hypertonic tube feedings with inadequate water
    • Excess administration of hypertonic saline, sodium bicarb
  45. Hypernatremia
    Nursing interventions
    • ◦Monitor I/O
    • ◦Assess for abnormal water loss or low water intake
    • ◦Increase water intake
    • ◦Restrict dietary sodium
    • ◦Prevention: if using tube feedings, give enough water to keep Na and BUN levels in normal limits
    • ◦Medical: hypotonic IVs

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