Fluid and Electrolytes

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Prittyrick
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271417
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Fluid and Electrolytes
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2014-04-24 19:56:22
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fluidelectrolytes
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Nursing Fundamentals
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  1. Functions of Water
    • - medium for transportation
    • - transportation of RBC, WBC, glucose
    • - Role in cellular metabolism
    • - Acts as a solvent
    • - Assist in maintaining body temperature
    • - Role in digestion and elimination
    • - Tissue lubricant
  2. Fluid Distribution
    * 50%-60% of the body weight is total fluid in an adult

    • - Influencing factors
    •   * Age (infants 70-75% ECF which u lose easily so they are always at risk for fluid loss and elders have less fluid)
    •   * Gender- males more fluid because of their muscle mass
    •   * Fat distribution
  3. Compartments
    - Intracellular (ICF)

    - Extracellular (ECF)
  4. Intracellular Fluid
    * fluid within the cell

    * 70% (2/3) of the body fluid is in ICF
  5. Extracellular Fluid
    * Fluid found outside the cell

    • * 30% of total body fluid in ECF
    •   - intravascular- liquid portion of the blood (plasma)
    •   - interstitial fluid- liquid that surrounds the tissues
  6. Fluid Balance
    Intake and output should balance out in 2-3 days

    usually 1500-3500 ml/day

    Not all output is measurable
  7. Fluid balance (gains and losses)
    • Fluid Gains
    •   Ingested liquid 1300 ml
    •   Ingested food 1000ml
    •   metabolic oxidation 300ml

    • Fluid Losses
    •   Urine 1500ml
    •   GI 200ml
    •   skin 600ml
    •   lung 300ml
  8. Fluid and electrolytes regulation
    - Maintaining homeostasis of fluid balance and electrolytes is essential to life

    - body produces balance by shifting fluid between the ECF and ICF

    • - There are 4 mechanism used for shifting and transporting fluid are:
    •   diffusion, active transport, filtration, osmosis
  9. Transportation (solvent, solute)
    • Solute:
    •   Substance dissolved in a solution ie salt

    • Solvent:
    •   liquid that holds the substance in a solution ie water

    Cell membrane are semi-permeable, allowing some but not all solutes to pass through
  10. Diffusion
    Movement of molecules thru the solvent from a higher concentration to lower concentration

    downhill

    goal: equilibrium
  11. Active Transport
    It is the process that requires energy for the movement of substance thru a cell membrane from area of lower concentration to an area of higher concentration

    pumping uphill

    energy dependent

    Goal: equilibrium
  12. Filtration
    It is the passage of fluid thru a permeable membrane from an area of higher pressure to an area of lower pressure

    goal: equilibrium
  13. Osmosis
    Major method used for transportation

    it is the movement of water from lesser concentration to higher concentration across a semi permeable membrane.

    Goal: Equilibrium
  14. Osmolarity
    The concentrated particles in a solution, pulling power

    Isotonic- solution has the same osmol as plasma, so fluid remains in the plasma, no shift

    Hypotonic- solution has less osmol than plasma so fluid moves out of the plasma and into the cell (swell)

    Hypertonic- solution has greater osmol than plasma, fluid moves out of the cell into the plasma, causing it to shrink
  15. Fluid balance/homeostasis
    • Works seamless unless there is a problem
    • 1. Kidneys- nephrons- form urine 1-2L per day, selectively retains electrolytes, regioangiotenson- conserving urine

    2. Heart- pumps out blood

    3. Lungs- act of breathing (acid based, O2, CO2)

    4. Adrenal gland- aldetral releasing Na

    5. Thyroid gland- metabolism secretes hormone

    6. Parathyroid- calcium bones and kidneys

    7. GI a lot of fluid absorbed by colon

    8. Thirst Center- ADH anti diructic - retains fluid

    9. Blood Vessel where fluid travels
  16. Electrolytes
    Substance capable of breaking into particles called ions.

    Ion- substance capable of developing an electrical charge when dissolved in water

    Cation- positive charge (Na, K, Ca, Mg)

    Anions- negative charge (Cl, P, HCO3)

    measured in mEq
  17. Sodium (Na)
    Function- aids in fluid balance, assist in nerve transmission, maintains neuromuscular activity

    Levels 135-145 mEq

    most abundant electrolyte in ECF

    Primary regulator of ECF volume. gain/loss of Na leads to gain/loss of water
  18. Hyponatremia (less Na)
    Causes: inadequate intake of Na. losses of GI fluid ie vomiting/diarrhea/suction, use of diuretics, excessive burns, excessive diaphoresis (jogging), excessive administration of IV fluid or drinking too much water.

    S/s change in mental status, fluid shift into cells leading to cerebral edema, confusion, coma, fatigue, lethargy, muscle weakness, cramps, decrease BP, edema and dry skin

    • Severe- less than 120
    • acute confusion, seizures, CNS changes
    • fluid moves from the ECF to ICF
  19. Hyponatremia nursing implications
    Intervention
    • Intake and output daily
    • monitor CNS, LOC, seizure precautions
    • food increase food with Na, IV solution
    • water restriction diuretics
    • monitor edema, bp, P
    • monitor lab values Na serum
  20. Hypernatremia (too much Na)
    causes- deprived of water, excessive fluid loss ie diarrhea, IV with sodium, intake of too much sodium

    s/s- change in mental status, dry skin, edema, muscle weakness, tachycardia, weight gain, poor skin turgor, oliguria, orthostatic hypotension,

    • S- skin flushed
    • A- agitation
    • L- low grade temp
    • T- thirst

    * fluids shift out of cell and brain cells shrink- agitation, restlessness, disoriented, hallucinations
  21. Hypernatremia Nursing implication
    Intervention
    • intake and output
    • check LOC, behavior changes, safety precaution
    • Na restriction, increase fluids gradually, Po/IV
    • assess thirst
    • monitor VS
    • monitor intake of food with salts, alka seltzer
    • diuretic for Na excretion
    • monitor labs
  22. Potassium (K+)
    Assist in regulating electrical impulses, neuromuscular transmission of nerve impulses, skeletal/cardiac muscle contraction and acid base balance. 

    Levels: 3.5-5 mEq/L

    No mechanism to maintain K+ so defencies happen quickly, eliminated primarily thru the kidneys

    Major cation ion in ICF
  23. Hypokalemia (low K)
    Casues: excessive vomiting, suction of GI tract, prolonged diarrhea, prolonged use of K+ depleted diuretic, poor intake of K+, Excessive sweating, lasix, laxitive abuse, eating disorder, liver disease, digoxin

    • S/S Muscle weakness and leg cramps 1st sign
    • fatigue lethargy, confusion, depressed DTR, cardiac arrythmias, weak pulse, constipation

    Cardiac condition makes pt more sensitive to hypokalemia. cardiac arrest
  24. Hypokalemia Nursing Implications
    • Check K level
    • Administer K supplements
    • encourage K rich foods- OJ, bananas, cantalope
    • closely monitor pt on digoxin
    • monitor cardiac status
  25. Hyperkalemia (too much K)
    Causes: renal failure, excessive intake of K (IV/PO), Cell destruction, burns, crush injuries, trauma, K+ conserving diuretics'

    S/S cardiac arrythmias, bradycardia, EKG changes, paresthesia (tingling), flaccid muscle, paralysis, vague muscle weakness

    most dangerous not putting K out....
  26. Hyperkalemia Nursing implications
    • Monitor cardiac function, slow irregular pulse- contact MD
    • avoid food high in K
    • Avoid administration of K supplements
    • avoid K sparing diurectics, use loop diurectics
    • monitor to digoxin level
    • diuretics

    Severe cases admin kayexelate enemas (to pull K out), IV sodiam bicarbonate, IV calcium, IV insulin, hypertonic dextrose soln as ordered.
  27. Calcium (Ca)
    Cell permability, bone and teeth formation, nerve impulse transmission, muscle contraction, B12 absorption, activation of enzymes, blood coagulation

    Levels 8.5-10.5 mg/dl
  28. Hypocalcemia (low Ca)
    Causes: inadequate intake of vit D, excessive loss of intestinal secretions, alcohol abuse, malabsorption, renal inefficiency, medications

    S/S muscle tremors, cramps, tetany, weakened bone structure, positive trousseau's sign and chvostek sign, numbness and tingling, MS changes- confusion, memory impairment, cardiac arrythmias
  29. Hypocalcemia nursing implications
    Mild cases- high ca intake, ca supplements along with vit d. monitor labs

    severe- safety precaution, seizure precautions, monitor airways, admins IV Ca gluconate or Ca chloride
  30. Hypercalcemia (too much Ca)
    causes: prolonged immobilization and non weight bearing, malignancy of the bone, meds- large doses of Vit d and Ca

    S/s Bones, groans, stones, moans (pain, anorexia, N/V, constipation, muscle weakness, confusion, arrythemias, kidney stones
  31. Hypercalcemia nursing implication
    • Increase mobility to keep Ca in bones
    • increase PO hydration, IV hydration
    • monitor labs/ekg
    • strain urine for calculi 
    • check cardiac status, digoxin leve
    • decrease ca intake
    • medication- diuretics, neutrohos
    • safe enviroment
    • dietary restriction
  32. Magnesium (Ma)
    Function- metabolism of CHO, proteins, muscle and nerve transmission, aids in movement of Na, K, Ca. RNA/DNA synthesis

    Levels 1.5- 2.5 mEq/L
  33. Hypomagnesemia (low Mg)
    causes: excessive lose from the gi tract, meds, renal disease, alcohol abuse, malaborption

    S/S neuromusclar irritability, changes in mental status, increase DTR, cardiac arrythemia, postive trousseau (inflate bp cuff to see if hand bends adn), positive chvostek sign touch face to see if it twitches
  34. Hypomagnesemia nursing implication
    • monitor labs
    • increase intake of food with it (seafood)
    • teach healthy use of diuretics and laxatives
    • assess for changes in mental status and nerve muscle irritability
    • seizure precaution
    • assess breathing 
    • assess cardiac status, VS
    • neducation- IV/PO
  35. Hypermegnesemia (too much mg)
    causes: advance renal diseas, excessive aborption of Mg (antacid) not putting out alot of urine

    s/sn warm, flushed skin, bradycardia, hypotension, nausea, vomiting, generalized weakness, change in mental status, decrease DTR, decrease respirations
  36. hypermagnesemia nursing implication
    • monitor labs, assess vs and dtr
    • assess for flushed skin, diaphoresis
    • assess for urine output, change in ms
    • adequate intake, diuretics
    • avoid products that have Mg ie antacids
    • emergency- Ca gluconate, renal dialysis (temp)
  37. Types of fluid imbalances
    Fluid Volume Deficit (FVD)- dehydration, hypovolemia

    Fluid Volume Excess (FVE)-  hypervolemia
  38. Fluid Volume Deficit (FVD) hypovolemia
    causes
    both water and electrolyte deficiencies in ECF

    Cause- insufficient fluid intake, excessive fluid loss, med therapy (diuretics), disease processes- DI, renal failure, prolonged fever, or diarrhea, hypoglycemia, psychiatric disorder (thinking someone posioned your food), third space shifting
  39. FVD hypovolemia 
    S/S
    • Tachycardia
    • pulse rate increase
    • weight loss in short time frame
    • weakness, fatigue, thirst, fever
    • decrease urinary output and tearing
    • hypotension (postural)
    • intake less than output
    • decreased bowel sounds
    • slow cap refill
  40. diagnostic test for FVD
    • check electrolytes
    • BUN
    • U/A, urine osmolarity 
    • serum osmolarity
    • H&H- concentration would go up
    • urine concentration would go up
  41. Nursing interventions/treatments for FVD
    • 1. assessment- look for sunken facial features, skin turgor, cap refill
    • 2. IV therapy and electrolytes
    • 3. push oral fluids and mouth care (dry mucous membrane, crack if we don't check)
    • 4. Monitor I/O daily weights, VS
    • 5. safety needs- monitor LOC
    • 6. Interventions to prevent skin breakdown
    • 7. treat cause
  42. Fluid Volume Excess (FVE/hypervolemia)
    Excessive retention of sodium and water

    Causes: excessive Na or fluid intake. fluid or Na retention, medication therapy steriods, pathological disorders- CHF, RF, liver disease, water intoxication- polydypsia: not thirsty but you continuously keep drinking
  43. FVE (s/s)
    • acute weight gain over a short period of time
    • peripheral edema
    • SOB, increase respiration, orthoapnea, cough, dyspnea, changes in lung sounds, increase bp, increase pulse and pulse bounding*, change in LOC, lethargy, confusion, cool pale skin, ascites, 

    edema 5-10lbs increase, pitting edema
  44. Dx tests for FVE
    • Chest x-ray
    • BUN
    • H&H decrease? diluted
    • Serum Sodium
  45. Nursing Intervention (FVE)
    • 1. Assessments
    • 2. D/C or slow down IV fluids
    • 3. fluid/sodium restriction
    • 4. assess I/O, weight, edema, e-lytes, VS
    • 5. assess lung sounds, respiratory status
    • 6. encourage rest period with activity
    • 7. diuretics if ordered
    • 8. skin assessment and care
  46. Nursing assessment/interventions for patients with impaired fluid and electrolyte balance
    1. assess risk factors- age, people with handicaps may not be able to recognize thirst, diuretics, NPO, fluid restrictions, IV, burns, trauma, crush injuries

    2. Assess VS- pulse, temp (fever-dehydration), pink forthy septum because of fluid in lungs

    3. assess I/O- check this over several days, assess risk for FVE/FVD

    4. Assess weight each day (more accurate than I/O)

    5. Physical exam: skin turgor, mucous membrane, decrease tears, salivation, cards arrythmias, edema, pitting edema > 10lbs

    6. mental status- confused, irritiable, dizzy

    7. IV fluids and replacements

    8. Monitor labs- BUN, electrolytes, CBC

    9. Safety- seizures, confused irritatable 

    10. patient teaching
  47. IV therapy
    • Goal/purpose
    • Maintain or restore fluid balance
    • electrolyte balance
    • means to admins medication
    • provide nutrition while resting the GI
    • acid base balance
    • admin blood components

    Solutions: isotonic, hypotonic, hypertonic
  48. Isotonic solution
    solution has the same concentration as the body's plasma

    action- no fluid shift, expand circulating volume, replace actual fluid loss (vascular expansion)*, electrolyte replacement

    Tx: FVD from hemorrhage, GI loss, draining wounds, fistulas, burns, peri-op fluid replacement

    • ex: 0.9% sodium chloride (saline), lactated ring
    • * closely monitor pts for FVE, esp HF, HTN
  49. Hypotonic Solution
    Solution has a lower concentation than the body's plasma- causes the water to be pulled out of the plasma into the cell (intestitional) which can cause it to burst

    Action/use: cellular dehydration from excessive diuresis, gastric fluid loss, fluid shifts out of blood vessels into the intravascular and interstitual space, hydration occurs

    ex. 0.45% NS

    Contraindicated: pt at risk for ICP, not for rapid rehydration, note: DO Not use on pt with stroke, head trauma, neurosurgery, or risk for 3rd space shift
  50. Hypertonic Solution
    • Solution is greater than the plasma in the blood causing the fluid to leave the cell and go into the plasma causing the cell to shrink
    • if too much, cellular dehydration can occur

    tx- short term hypovolemia, correct electrolytes and acid base imbalance, suppressed inflammation, cerebral edema

    special consideration- do not administer to pt with impaired cardiac and renal function, monitor for circulation overload, admin by IV pump

    ex. D5NS, D5 .45%NS, DRLR
  51. Other types of solutions
    - Blood and blood products- reciepent has to match the donor

    • -TPN/PPN- hypertonic, glucose solution (why in large vein), provides calories, electrolytes, fluids, 
    • TPN- needs to be infused from the central line
    • PPN needs to be infused thru the picc line
    • - multiples electrolyte solutions
  52. Vascular Access Devices
    Standard Peripheral IV access
    • Short term
    • heplock or saline lock
    • peripheral catheter- 1-1 1/2 inch length 
    • site change every 72 hours
  53. VAD (PICC)
    • Can be single or multiple lumen
    • usually inserted thru antecubital region
    • tip rest in the SVC (superior vena cava)
    • Can be inserted by a trained nurse

    more invasive, more infection prone can last for months
  54. More on PICC line
    • Intended for long term therapy
    • maybe used for pt with poor venous access
    • suitable for pt who PPN or vesicant solutions
    • PPN lumen should be only for that
    • cost effective, fewer complications
    • chest x-ray for placement prior to use (always wait for radiology to see it is placed right..
  55. Central line cathetrs
    • what is this? 
    • a venous catheter inserted in the vein to go into the vena cava or right atrium
    • allows concentration solutions to be infused with complications
    • permits administration of IV fluids, blood components, meds, nutrition solution
    • dangerous cause could puncture lung
  56. Complication of IV therapy: INFILTRATION
    Escape of fluid into the subcutanous tissue (asso with perpheral IV)

    cause cannula dislodges and goes into the tissue

    s/s cold clampy cool, complaints of pain and burning, blanched

    TR: stop the IV, change sites, warm compress, elevate
  57. Phlebitis
    Inflammation of vein 

    cause- cannula in too long, irritating solution, sepsis can lead to thrombus formation

    s/s red, hot swollen, pain, may have red line inflammation

    TR: stop IV, move site, identify cause, warm compress.
  58. Infection bacterial contamination
    causes: bacterial invasion which can spread to the bloodstream, older pts are more prone. 

    s/s drainage at the IV site, fever, chills, nausea, headache elevated WBC

    TR: stop the IV, remove the cannula, send tip to the lab for testing, notify the MD, 

    prevention- use a sterile technique for tubing changes
  59. Factors that contribute to infections
    • loss of skin integrity- 1st line of defense
    • multiple invasive procedures,
    • malnutrition
    • antibiotic therapy
    • age- older pts poor circulation
  60. extravasation
    infiltration/leakage of a irritating (vesicant) solution (ie chemo, dopamine, vancomycin, gentamycin) into the tissue which can lead to tissue damage, nerve damage, or death of a cell. trauma

    s/s swelling, edema, pain, changes, tissue slough, tissue necrosis

    • tr: remove IV, use syringe to attempt to aspirate the solution, notify the MD, inject 
    • antidote, elevate, apply cool/warm compress depending on solution, apply corticosteriod cream, assess and document
  61. circulatory overload (too much fluid or too fast)
    s/s bounding pulse, tachycardia, increase bp, SOB, orthopnea, cough, changes in lung sounds, crackles, distended neck veins, edema

    tr: slow or stop IV, monitor IV infusion, assess vs and s/s, notify md, raise the HOB, admin O2. admin diuretic, prevention
  62. Air Embolus
    air in the blood stream can be life threatening since it could stop the blood from flowing to where it needs to go. seen in stroke and MI pts

    s/s CP, SOB, weak rapid pulse, decrease bp, change in mental status, respiratory distress

    TR: accurate assessment, notify MD, place pt in trendelenberg position (head down left side so the air doesn't go into the lung), apply O2, admin anticoagulant therapy, 

    prevention- prime all IV tubing carefully
  63. Hematoma
    leakage of blood into surrounding tissues caused by break in blood vessels

    s/s bruising, tenderness, small edema

    tr: assess the site, elevate the extremity, cold compress, apply pressure, prevention

    closely monitor pts on anticoagulant (heparin, coumadin) 
  64. RN responsibility with IV adminstration
    • verify:
    • COrrect pt
    • correct fluid
    • correct rate
    • admin using sterile technique

    • assess IV site/infusion every hour
    • assess for sign and symptoms of fluid overload
  65. Nursing Dx related to fluid and electrolyte imbalance
    • fluid volume excess
    • fluid volume deficient
    • fluid volume, risk for imbalanced

    • breathing patterns ineffective
    • cardiac output decrease
    • risk for injury

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