Electrolyte Imbalance

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Electrolyte Imbalance
2013-03-29 12:08:49

Electrolyte Imbalance
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  1. Osmosis
    the movement of WATER btwn two compartments separated by a semipermeable membrane.

    Water moves thru the membrane from an area of of low solute concentration to an area of high solute concentration.
  2. Water moves from the more dilute compartment (more water) to the side that is more concentrated (less water)
  3. Diffussion
    movement of molecules from high concentration to low.

    • Stops when concentrations are equal in both areas.
    • (liquids, gases, and solids)
  4. active transport
    molecules moving against the concentration gradient using ATP as it's energy.
  5. Example of active transport
    sodium moves out of the cell and potassium moving in to the cell to maintain a concentration gradient.
  6. Oncotic pressure/Colloid osmotic pressure
    osmotic pressure exerted by colloids (proteins) in a solution.

    Proteins attracting water, pulling fluid from the tissue space to the vascular space.

    Proteins are too large to get out of the vascular space.
  7. ECF is made of

    Consists of interstitial, intravascular and transcellular fluid
  8. ICF is made of

    Consists of fluid within the cell itself
  9. Osmolality
    used to describe fluids inside the body...

    ie-concentration of urine and plasma
  10. Osmolarity
    used to describ fluids outside of the body.
  11. Plasma osmolality
    • normal is btwn 275-295
    • above 295 =high concentration or low water content "water deficit"

    below 275=little solute for the amount of water or too much water "water excess"
  12. Solution in which the solutes are less concentrated than the cell...
  13. Solution in which the solutes are more concentrated than the cells ....
  14. If a cell is surrounded by hypotonic fluid, water moves....
    in to the cell causing it to swell and possibly burst
  15. If a cell is surrounded by hypertonic fluid, water moves....
    out of the cell to dilute the ECF, causing the cell to shring and possible death
  16. Filtration
    transfer of water and dissolved substances thru a permeable membrane from a region of high pressure to low pressure
  17. Insensible losses are from respiration and fever.  They are pure water losses and are __________ losses.  Leaving the body fluids in a ___________state.
    • hypotonic
    • hypertonic
  18. Positively charged ions
    Cations-Ca, K and Na
  19. Negatively charged ions
    Anions-Cl (chloride) and HCO3 (bicarb)
  20. General functions of electrolytes (4)
    • promote neuromuscular irritability needed for proper functioning of nerves and muscles
    • regulate acid/base balance
    • distribute body water btwn fluid compartments
    • maintain body fluid volume and osmolality
  21. Isotonic Solutions
    • Water moves in same proportion as body fluids
    • 0.9% NS
    • D5W (w is water)
    • D5 1/4 NS
    • D5 & 1/4 NS
    • LR (Lactated Ringer)
  22. Hypotonic Solutions
    Causes less movement of body water than body fluids do.

    • 1/2 NS (0.45% sodium chloride solution)
    • 1/4 NS (0.225% sodium chloride solution)
  23. Hypertonic Solutions
    • Causes more movement of water than body fluids do
    • 3% (or greater) Sodium Chloride Sol.
    • 10% (or greater) D/W
    • 5% D 1/2 NS
    • 5% D/0.9% NS
    • 5% D in Ringers Lactate Solution
  24. Increased Osmolarity and Osmolality and Hyperosmolar =
    Increased particles in the solution
  25. Hypertonic, Decreased Osmolality and Osmolarity, and hypo-osmolar and hypotonic=
    Decreased particles in the solution
  26. How much water do the lungs remove daily through exhalation?
    300mL....insensible water loss
  27. What does ADH do?
    • Antidiuretic Hormone
    • Causes the body to retain water by water reabsorption
  28. If the body senses too high of BP...what does it do?
    decreases the amount of ADH released, allowing for water loss
  29. What does the secretion of Aldosterone do?

    causes sodium and water to be retained and the excretion of potassium

    decrease in aldosterone causes sodium and water loss and potassium retention
  30. What does Angiotensin II do?
    stimulates the adrenal cortex to release Aldosterone

    causes vasoconstriction of arterial smooth muscles.....increasing BP
  31. Parathyroid Hormone does what?
    increased PTH causes elevated serum calcium and lowered serum phosphate.

    decreased PTH causes lowered serum calcium and increased serum phosphate.

    Elevation of one means a decrease in the other
  32. Third spacing
    When plasma proteins are lowered, by colloid osmotic pressure, the fluids are shifted from the intravascular compartments in to the interstitial space.  These fluids are not available for use by the body. (ascites)
  33. How much urine should we expel in 24hrs or per hour?
    • 1500mL
    • 60mL

    • 30mL's for 2 hours....call Dr.
    • minimal amount is 400-600mL/day
  34. Fluid loss in stool, respiration and perspiration
    • Stool-200mL
    • Respiration-300mL
    • Perspiration-600mL
  35. Isotonic Dehydration
    an equal loss of fluids and electrolytes from the ECF

    NO shift of fluid from intracellular space-lose sodium and water in = amounts
  36. What causes isotonic dehydration?
    • Sport/marathon runner
    • Hemorrhage
    • Vomiting/Diarrhea
    • NG Suctioning
    • Burns
  37. Hypotonice Dehydration
    losing more solutes from the ECF than water

    Causing ECF to have a lower osmotic pressure than ICF so fluid shifts from ECF to ICF causing vascular swelling
  38. What causes hypotonic dehydration?
    • Anorexia/Severe malnutrition
    • Chronic renal failure
    • Over admin of hypotonic IV fluids (0.45 NS or D5)
  39. Hypertonic Dehydration
    a greater loss of EC Fluid than electrolytes

    Causes a shift of fluid from ICF to ECF, resulting in cellular dehydration and shrinking
  40. What are serum sodium levels in hypotonic dehydration and hypertonic dehydration?
    hypotonic sodium is low

    hypertonic sodium is high
  41. What causes hypertonic dehydration?
    • decreased water intake
    • excess loss of water without loss of elctrolytes
    • increased solute intake without sufficient water
    • excess accumulation of solutes due to disease process
  42. Example of decreased water intake that causes hypertonic dehydration
    NPO for a procedure....procedure may get pushed back to NPO for all day!
  43. Example of excess loss of water without loss of elctrolytes causing hypertonic dehydration
    • watery diarrhea
    • fevery
    • cough
    • pneumonia
    • increased respiratory rate
  44. Example of increased solute intake without sufficient water that causes hypertonic dehydration
    • TPN
    • Tube Feedings
    • Ensure
  45. Example of excess accumulation of solutes due to disease process causing hypertonic dehydration
    diabetes mellitus
  46. S/S of deficient fluid volume
    Subjective-c/o dry mouth, dysphagia, weakness, hx of vomiting, diarrhea, polyuria

    • Objective-output greater than intake
    • dry skin-tenting turgor
    • Increased HR, RR and depth, temp, but decreased BP
    • Decreased urine output
    • Elevated specific gravity-above 1.0125
  47. When you have deficient fluid volume what happens to H&H?
    it will increase but you dont have more blood cells
  48. What happens first when a person has deficient fluid volume?
    decreased urine output
  49. Where do you assess skin turgor in the elderly?
  50. S/S of fluid volume excess:
    Subjective-SOB, weight gain, fatigue, HTN, Hx of cardiac or renal disease, steroid therapy, history of use of excessive tap water enemas
  51. S/S of fluid volume excess:
    • pedal or sacral edema (+1-+4)
    • Shiny taut skin
    • Increased BP, bounding pulse
    • Decreased urinary output
    • Change in behavior-confused and lack of coordination
  52. What's anasarca?
    accumulation of fluid in all body tissues-can hear as fluid in lungs
  53. What causes fluid volume deficienty?
    • vomiting
    • diarrhea
    • polyuria
    • fever
  54. What causes Isotonic fluid volume excess?
    • causes ECF excess and edema
    • fluid overload
    • CHF
    • Renal failure
    • Increased secretion of Aldosterone
    • Steroid therapy
    • inflammatory rxns
    • 3rd spacing
  55. What causes hypo-osmolar volume excess aka water intoxication?
    • causes Cellular edema....
    • excess intake of electrolyte free fluids-athelete drinking pure water
    • SIADH
    • Renal failure
    • Sodium deficit
  56. Interventions for fluid volume deficiency
    • Control vomiting/diarrhea/reduce fever
    • daily weights
    • replace fluid loss as order by MD(IV or parentally)
    • monitor vs
  57. BP test to see if a pt has fluid volume deficiency....
    • Orthostatic
    • BP taken laying, sitting and standing with 2 min. btwn each. 

    + sign is 15mmhg drop in systolic or 5 mmhg drop or +10 in diastolic
  58. How do you treat isotonic dehydration?
    replace with isotonic iV solution
  59. How do you treat hypertonic dehydration?
    replace with isotonic or hypotonic solutions (solutions that contain less electrolytes or solutes than the bloodstream)
  60. How do you treat hypotonic dehydration?
    replace with isotonic or hypertonic solutions (solutions that contain more electrolytes or solutes than the bloodstream
  61. Interventions for fluid excess...
    • Encourage pt. to decrease salt intake
    • keep edematous extremity elevated above heart
    • TEDs
    • Fluid restriction as ordered
    • Diuretics
    • Monitor I&O
  62. Normal Serum Na levels
    135-145 mEq/L
  63. Normal serum Potassium levels
    3.5-5 mEq/L
  64. Normal serum calcium levels
    • 4.5-5.5mEq/L or
    • 8-10mg/dl
  65. S/S of hyponatremia
    • headache
    • apprehension/apathy
    • delussions and hallucinations
    • muscle weakness
    • abdominal cramps/anorexia/NV
    • Postural Hypotension
    • Convulsions/coma....death
  66. Biggest symptoms of hyponatremia are brain issues...why?
    it causes brain cells to swell....cerebral edema and ICP
  67. S/S of hypernatremia
    • Dry, sticky mucous membranes
    • low urinary output
    • rubbery tissue turgor
    • Manic excitement
    • tachycardia
  68. S/S of hypokalemia
    • weakness/fatigue
    • anorexia/NV
    • apathy, confusion, coma
    • muscle weakness
    • abdominal distention/cramping
    • shallow breathing
  69. S/S Hyperkalemia
    No clinical symptoms in mild cases

    • Initially-skeletal muscle spasms
    • Nausea
    • Colic
    • Diarrhea

    • Later-muscles become weak
    • cardiac arrhythmias
  70. S/S of hypocalcemia
    • muscle spasms and rigidity
    • Tingly lips, nose and fingertips
    • Tetany
    • Anxiety, irritability, seizures
  71. Where do you first notice muscle spasms for hypocalcemia?
    • hands and feet
    • Chvostek sign-cheek spasm
    • Trousseau's sign-blood pressure cuff tightened and muscle contraction occurs at hand and wrist
  72. S/S of hypercalcemia
    • Severe thirst
    • Polyuria
    • GI upset-anorexia, NV and constipation
    • Respiratory weakness
    • Lethargy, confusion, coma
    • Bone and flank pain (kidney stones)
  73. What causes hyponatremia?
    • Potent diuretics
    • Diarrhea
    • GI Suctioning
    • Decreased aldosterone
  74. What should you irrigate GI tubes and body cavities with?  Why?
    • NS only
    • Using water will deplete Na
  75. What can you use normal water with when it comes to NG tubes?
    flushing tubes, before, between and after medication administration
  76. Disease processes that cause hyponatremia
    • Renal disease
    • SIADH
    • Cirrhosis fo the liver
    • CHF
    • Hyperglycemia
  77. What's SIADH
    • Syndrome of Inappropriate Antidiuretic Hormone
    • Excess secretion of ADH causing hyponatremia
  78. If a person uses plain water enemas, or replenishes after sports with plain drinking water....what will happen?
  79. What causes hypernatremia?
    • Hyperaldosteronism
    • Renal failure/Cushings
    • Use of corticosteroids
    • Diabetes Insipidus
    • Fever, infection, excessive diaphoresis, dehydration
  80. What will happen if a person is NPO without IV replacement and the person has no access to H2O?
  81. How do  you get hypokalemia?
    • Hyperaldosteronism
    • Chronic Steroid use
    • Potent loop diuretics
    • Loss of gastric/intestinal juices
  82. What happens with hyperaldosteronism?
    over secretion of aldosterone, which causes the kidneys to hold on to water and excret K+
  83. How does admin of insulin cause hypokalemia?
    insulin causes K+ and glucose to move in to the cell and lowers serum K+
  84. What causes hyperkalemia?
    • decreased secretion of aldosterone (adrenal insufficiency)
    • Excessive admin of parenteral K+
    • Respiratory acidosis
    • Renal failure
    • Tissue trauma
    • Medication with K+ sparing diuretics
  85. How does respiratory acidosis cause hyperkalemia?
    H+ moves in to the cell and K+ moves in to the ECF
  86. What causes hypocalcemia?
    • Hypoparathyroidism
    • Acute pancreatitis
    • Renal failure
    • Malabsorption syndromes (Crohns/Celiac)
    • Diarrhea/GI wound drainage
    • Lack of sunlight
  87. What causes Hypercalcemia?
    • Hyperparathyroidism
    • Excessive calcium intake
    • V. D intoxication
    • Metastatic cancer of the bone
    • Prolonged immobilization
  88. How does acute pancreatitis cause hypocalcemia?
    when pancrease is inflamed, it releases an enzyme that reacts on fatty tissue to release fatty acids...which combine with Ca+ and inactives it
  89. How does renal failure cause hypocalcemia?
    serum phosphate levels rise in renal failure...two have an inverse relationship, if phospherous rises, calcium decreases and vice versa
  90. How does hyperparthyroidism cause hypercalcemia?
    it causes excessive amounts of CA+ to be released from the bone
  91. How does prolonged immobilization cause hypercalcemia
    disuse causes increased bone resorption...CA+ moves from the bones in to the ECF
  92. Interventions for hyponatremia
    • IV 0.9% NS
    • Monitor VS
    • Monitor for ICP/seizure precuations
    • Watch for fluid overload
    • Treat whatever is causing imbalance
  93. Interventions for hypernatremia
    • Water replacement orally or D5W
    • Monitor for fluid overload
    • Diuretics
    • Reduce salt intake
  94. Best interventions for hypokalemia
    • K+ replacement-orally is best:
    • KLyte
    • Ktabs
    • KDur
    • KCL
  95. Other interventions for hypokalemia
    IV...but watch for hyperkalemia and cardiac arrest!!

    Eat foods rich in K+
  96. What shouldn't the infusion rate exceed when administering Potassium?
  97. 20mEq/hr
  98. Foods rich in K+
    • bananas
    • spinach
    • avocado
    • oranges
    • fruits
  99. Interventions for hyperkalemia
    • Hold K+ admin
    • Kayexalate admin
    • IV infusion of dextrose and insulin (if ordered)
    • Dialysis
  100. What does Kayexalate do?
    • treats hyperkalemia by:
    • exchanging K+ for Na+ in the bowel, so K+ is excreted in the stool

    Must retain enema for 45 minutes!!!
  101. How does IV infusion of dextrose and insulin correct hyperkalemia?
    by tricking K back in to the cell and out of the vasculature
  102. How do you treat hypocalcemia?
    • Admin of calcium-IV calcium gluconate
    • admin of v. D
    • Ca supplements
  103. What do you need to watch when giving a patient calcium by IV?
    EKG changes
  104. When should a person take calcium supp?
    After meals
  105. Foods rich in calcium
    • dairy
    • yogurt
    • green leafy vegetables
  106. Calcium has a strong effect on neuromuscular mechanisms.  What nursing measures can be taken to prevent tetany and convulsions?
    • decrease stimulation by:
    • lights out
    • speak calmly
    • seizure precuations
  107. What does long term calcium loss place a pt at high risk for?
  108. Interventions for hypercalcemia
    • hydration to prevent kidney stones
    • admin of meds to inhibit CA resorption
    • Lasix
    • assess bowel activity and treat constipation
  109. Example of drugs that inhibit calcium resorption
    • phospherous (soda)
    • NSAIDS
  110. What are the effects of potassium imbalance on patients receiving digitalis preparations?
    people taking digoxin experience increased digoxin toxicity if their serum potassium is low

    Skeletal muscle weakness and paralysis may occur
  111. What are the actions of medications used to lower serum potassium levels?
    Increase elimination of potassium by diuretics

    Force potassium from the ECF to the ICF by admin of IV insulin or IV sodium bicarb

    Admin of IV calcium gluconate to reverse the membrance excitability (membrane potential)
  112. What are the implications of fluid and electrolyte imbalances in the elderly client?
    • physiologic changes increase their susceptability to this:
    • renal fxn changes-excretion of  problems
    • hormonal changes-decreased/increased release
    • Skin changes
    • Decrease in thirst mechanism
    • Musculoskeletal changes-cant hold cup
  113. If you see a foley bag with a lot of urine....what do you assume?
    the person has excreted lots of K+, if it is low....then they are holding on to K+
  114. Describe pitting edema scale
    +1 is barely perceptible...when push on skin the pit is lasting up to 5 seconds

    +4 is edema when the pit lasts 20-30 seconds  and is 1 inch deep
  115. Name some food sources that are high in sodium
    • salt shaker
    • Processed meats
    • Ketchup
    • Cheese
  116. Most important NANDA for electrolyte imbalances
    Risk for injury
  117. How do you administer K-Lyte
    it is an effervescent tab that must be DISSOLVED in water
  118. Normal magnesium levels
    1.5-2.5 mEq/L
  119. What IV solution is compatible with most meds and blood?
  120. Which hypertonic solutions change to hypotonic once it enters the blood stream?
    • 5% D 1/2NS
    • 5% D 0.9%
    • 5% D in Ringers Lactate Solution
  121. Colloid osmotic pressure does what?
    pulls in
  122. Hydrostatic pressure does what?
    pushes out
  123. osmolality vs. osmolarity
    osmolality is concerned with weight (kg)

    osmolarity is concerned with fluids (litres)
  124. With water intoxication what are 2 key nursing interventions?
    • change positions every 2 hours
    • watch for SKIN BREAKDOWN, especially in edematous areas