Fluid and Electrolytes

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Fluid and Electrolytes
2012-04-20 15:23:33
Fluid Electrolytes

Fluid and electrolytes
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  1. Potassium (K+)
  2. Magnesium (Mg2+)
  3. Sodium (Na+)
  4. Calcium (Ca2+)
  5. Fluid Volume Deficit
    • Causes:
    • increase insensible water loss or perspiration (high fever, heat stroke)
    • Diabetes insipidus
    • Osmotic diuresis
    • Hemorrhage
    • GI lossses-vomiting, NG suction, diarrhea, fistula drainage
    • Overuse of diuretics
    • Inadequate fluid intake
    • Third space fluid shifts-burns, intestinal obstruction

    • Manifestions:
    • Restlessness, drowsiness, lethargy, confusion
    • Thirst, dry mucus membranes
    • Decreased skin turgor, decreased capillary refill
    • Postural hypotension, increase pulse, decreased CVP
    • Decreased urine output, concentrated urine
    • Increase respiratory rate
    • Weakness, dizziness
    • Weight loss
    • Seizures, coma

    • Collaborative care:
    • Replace water and electrolytes
    • Balances IV solutions-lactated ringers
    • Isotonic (0.9%) sodium chloride is used when rapid volume replacement is indicated.
    • Blood is administer when volume loss is due to blood loss.
  6. Fluid volume excess
    • Causes:
    • Excessive isotonic or hypotonic IV fluids
    • Heart failure
    • Renal failure
    • Primary polydipsia
    • SIADH
    • Cushing Syndrome
    • Long term use of corticosteroids

    • Manifestations:
    • Headache, confusion, lethargy
    • Peripheral edema
    • Jugular vein distention
    • Bounding pulse, increased BP, increase CVP
    • Polyuria (with normal renal function)
    • Dyspnea, crackles (rales), pulmonary edema
    • Muscle spasms
    • Weight gain
    • Seizures, coma

    • Collaborative care:
    • Removal of fluid without producing abnormal changes in the electrolyte compilation or osmolality of ECF
    • Identify cause and treat it
    • Diuretcis and fluid restriction
    • Restriction of sodium intake
    • If excess leads to ascites or pleural effusion, an abdominal paracentesis or thacentesis may be necessary
  7. Hypernatremia
    • >145mEq/L
    • Causes:
    • Excessive sodium intake-IV fluids (hypertonic NaCl, excessive isotine NaCl, IV sodium bicarbonate)
    • Hypertonic tube feeding without water supplements
    • Near drowning in salt water
    • Inadaequate water intake-unconscuous or cognitively impaired individuals
    • Excessive water loss (increased sodium concentrations)-(increased in insensible water loss, prolonged hyperventilation, heat stroke, diarrhea, osmotic diuretic therapy)
    • Disease states-diabetes insipidus, primary aldosteronism, Cushing Syndrome, uncontrolled DM).

    • Manifestations:
    • Hypernatremia with decreased ECF fluid-Restlessness, agitation, twitching, seizures, coma, intense thirst, dry swollen tongue, sticky mucus membranes, postural hypotension, decreased CVP, weight loss, weakness and lethargy.
    • Hypernatremia with normal/increased ECF volume-Restlessness, agitation, twitching, seizures, coma, intense thirst, flushed skin, weight gain, peripheral and pulmonary edema, increased BP, increased CVP

    • Nursing implementation:
    • Treat underlying cause
    • In primary water deficit, the continued water loss must be prevented and water replacement must be provided.
    • IV solution of 5% dectrose in water or hypotonic saline may be given initially
    • Serum sodium levels must be reduced slowly to prevent too rapid a shift of water back into the cells--->can cause cerebral edema.
    • For sodium excess-dilute the sodium concentration with sodium-free IV fluids, such as 5% dextrose in water and to promote excretion of the excess sodium by admistering diuretics.
  8. Hyponatremia
    • <135mEq/L
    • Causes:
    • Excessive sodium loss-GI losses, diarrhea, vomiting, fistulas, NG suction; Renal losses, diuretics, adrenal insufficiency, Na+ wasting renal disease; Skin losses, burns and wound drainage
    • Inadequate sodium intake-fasting diets
    • Excessive water gain (decreased sodium concentration), excessive hypotonic IV fluids, primary polydipsia
    • Disease states-SIADH, heart failure, primary hypoaldosteronism.

    • Manifestations:
    • Hyponatremia with decreased ECF volume- irritability, apprehension, confusion, dizziness, personality changes, tremors, seizures, coma, dry mucus membranes, postural hypotension, decreased CVP, decreased jugular venous filling, tachycardia, thready pulse, cold an clammy skin.
    • Hyponatremia with normal/increased ECF volume-headache, apathy, confusion, muscle spasms, seizures, coma, n/v, diarrhea, abdominal cramps, weight gain, increase BP, increased CVP

    • Nursing implementation:
    • Water excess-fluid restriction. If severe, small amounts of hypertonic saline solution (3%NaCl) are given to restore serum sodium levels
    • Drugs that block the activity of ADH (vasopressin) are used
  9. Hyperkalemia
    • >5.0mEq/L
    • Causes:
    • Excess potassium intake-Excessive or rapid parenteral administration, potassium-containing drugs (potassium penicillin), potassium-containing salt substitute
    • Shift of potassium out of cells-acidosis, tissue catabolism (fever, sepsis, burn), crush injury, tumor lysis syndrome
    • Failure to eliminate potassium-renal disease, potassium sparing diuretic, adrenal insufficiency, ACE inhibitors.

    • Manifestations:
    • irritability, anxiety, abdominal cramping, diarrhea, weakness of lower extremities, paresthesis, irregular pulse, cardiac arrest if hypokalemia is sudden or severe.

    • ECG changes:
    • ventricular fibrillation, ventricular standstill, dysrhythmias

    • Nursing implementation:
    • Eliminate oral and parenteral potassium intake
    • Increase elimination of potassium-diuretics, dialysis, and use of ion exchange resins such as sodium polystyrene sulfonate (Kayexalate). Increase fluid intake.
    • Monitor with ECG to detect dyshythmias and monitor the effect of therapy
    • If experiencing dysrhythmias, the patient should receive IV calcium gluconate
  10. Hypokalemia
    • <3.5mEq/L
    • Causes:
    • Potassium loss-
    • GI losses-d/v, fistulas, NG suction
    • Renal losses-diuretics, hyperaldosteronism, magnesium depletion
    • Skin losses-diaphoresis
    • Dialysis
    • Shift of potassium into cells -
    • Increased insulin (IV dextrose load), Alkalosis
    • Tissue repair, increase in epinephrine (stress)
    • Lack of potassium intake-Starvation, diet low in potassium, failure to include potassium in parenteral fluids in NPO.

    Manifestations: Fatigue, muscle weakness, leg cramps, n/v, paralytic ileus, soft flabby muscles, paresthesias, decreased reflexes, weak irregular pulse, polyuria, hyperglycemia

    ECG changes: Bradycardia, enhance digitalis effect, ventricular dysrhythmias.

    • Nursing implementation:
    • give potassium chloride-must always be diluted, NEVER give in IV push or in concentrated amounts, NEVER add to hanging IV bag to prevent giving bolus dose. Invert several times to ensure even distribution. Preferred max concentration is 40mEq/L. Rate of IV administration should not exceed 10-20mEq/L per hour and should be administered via infusion pump to ensure administration rate.
    • Central IV lines shoud used when rapid correction of hypokalemia is necessary.
  11. Hypercalcemia
    • >10.2mg/dL
    • Causes:
    • Increased total calcium-multiple myeloma, malignancies with bone metastasis, prolonged immobilization, hyperparathyroidism, vitamin D overdose, thiazide diuretics, milk-alkali syndrome
    • Increased ionized calcium-acidosis.

    • Manifestations:
    • lethargy, weakness, depressed reflexes, decreased memory, confusion, personality changes, psychosis, anorexia, n/v, bone pain, fractures, polyuria, dehydration, nephrolithiasis, stupor, coma

    • ECG changes:
    • ventricular dyshrthmias, increased digitalis effect

    • Nursing implementation:
    • promotion of the excretion of calcium in urine by administration of loop diuretic (Lasix) and hydration of patient with isotonic saine infusion.
    • Drink 3000-4000ml of fluid daily to promote renal exretion and decrease the possibility of kidney stone formation
    • Synthetic calcitonin can also be administered to lower serum calcium levels.
    • Low calcium diet
    • Mobilization with weight bearing activities is also encouraged.
  12. Hypocalcemia
    • <8.6mg/dL
    • Causes:
    • Decreased total calcium-chronic kidney disease, elevated phosphorus, primary hypoparathyroidism, Vitamin D deficiency, Magnesium deficit, acute pacreatitis, Loop diuretics, chronic alcoholim, diarrhea, decrease serum albumin
    • Decreased ionized calcium-alkalosis, excess administration of citrated blood.

    • Manifestations:
    • Easy fatigability, depression, anxiety confusion, numbness and tingling in extremities and region around mouth, hyperreflexia, muscle cramps, Chvostek's sign, Trousseau's sign, laryngeal spasm, tetany, sizure.

    ECG changes: ventricular tachycardia

    • Nursing implementation:
    • Treating the cause
    • Oral or IV calcium supplements, not given IM bc it may cause severe local reations such as burning and necrosis.
    • Calcium gluconate givn in severe hypocalcemia
    • Diet high in calcium with Vitamin D supplements
    • Calcium carbonate in people who are unable to consume dietary calcium.
    • Monitor persons who have had thyroid or neck surgery
    • treat pain and anxiety especially in people with hypocalcemia due to hyperventilation-induced respiratory alkalosis.
  13. Hyperphosphatemia
    • >4.4mg/dL
    • Causes:
    • Renal failure, chemotherapeutic agents, enemas containing phosphorus (fleet enemas), excessive ingestion (milk, phosphate containing laxatives), large vitamin D intake, hypoparathyroidism

    • Manifestations:
    • Hypocalcemia, muscle problems (tetany), deposition of calcium-phosphate precipitates in skin, soft tissue, cornea, viscera and blood vessels.

    • Management:
    • Identify and treat the cause
    • Restrict foods high in phosphorus-such as dairy products
    • Adequate hydration and correction of hypocalcemic conditions can enhance renal excretion
    • Increase calcium levels to increase renal excretion of phosphorus
  14. Hypophosphatemia
    • <2.4mg/dL
    • Causes:
    • Malabsorption syndrome, nutritional recovery syndrome (reversal or treatment of starvation), glucose administration, total parenteral nutrition, alcohol withdrawal, phosphate-binding antacids, recovery from diabetic ketoacidosis, respiratory alkalosis

    • Manifestations:
    • CNS dysfunction (confusion, coma), muscle weakness, including respiratory muscle weakness and difficulty weaning, renal tubular wasting of Mg2+, Ca2+ and HCO3-, cardiac problems (dysrhythmias, decreased stroke volume), osteomalacia, rhabdomyolysis

    • Management:
    • oral supplementation (Neutra-Phos), and ingestion of foods high in phosphates.
    • Severe-may require IV sodium phosphate or potassium phosphate.
    • Monitory frequently
    • Sudden symptomatic hypocalcemia, secondary to increased calcium phopshorus is a potentioal complication of IV administration of phosphorus.
  15. Hypermagnesemia
    • Causes:
    • increase in magnesium intake accompanied by renal insufficiency or failure.
    • Adrenal insufficiency
    • A patient with chronic kidney disease who ingests products containing magnesium will have a problem with excess magnesium.
    • could also occur in pregnant women who receive MgSO4 for the management of eclampsia.

    • Manifestations:
    • lethargy, drowsiness, and n/v. Deep tendon reflexes are lost, somnolence, and then respiratory and cardiac arrest can occur with severe hypermagnesemia

    • Management:
    • Prevention
    • People with CKD should not take magnesium-containg drugs and must review all OTC drugs for magnesium content.
    • Emergency treatment is Calcium Chloride or calcium gluconate.
    • Promote excretion with fluid.
    • Persons with renal impairment will require dialysis.
  16. Hypomagnesemia
    • Causes:
    • diarrhea, chronic alcoholism, impaired GI absorption, malabsorption syndrome, prolonged malnutrition, large urine output, NG suctioning, poorly controlled DM, hyperaldosteronism

    • Manifestations:
    • confusion, hyperactive deep tendon reflexes, seizures. Cardiac dysrhythmias. Resembles hypocalcemia and may contribute to the development of hypocalcemia as a result of decreased action of PTH. Can also be associated with hypokalemiathat does not respond well to potassium replacement. This occurs bc intracellular magnesium is critical to normal function of he sodium-potassium pump.
    • Management:
    • Mild forms can be treated with oral supplements and increased dietary intake of foods high in magnesium (green vegetables, nuts, bananas, oranges, peanut butter, chocolate).
    • Severe conditions are treated with parenteral IV or IM magnesium (MgSO4).
    • Too rapid administration can lead to cardiac or respiratory arrest.