13 Fluids Electrolytes Acid Base CJMM

Major electrolyte in Intracellular Fluid (ICF)

Potassium

Major electrolyte in Extracellular Fluid (ECF)

Sodium

Fluid in blood vessels

intravascular

fluid in tissue spaces

interstitial

Does water follow sodium or does sodium follow water?

water follows sodium

organ that regulates fluid and electrolyte balance

kidneys

common causes of Fluid Volume Deficit (FVD) aka Hypovolemia

vomiting, diarrhea, NG suction, bleeding, NPO or poor intake, too much diuretic

treatment for FVD aka hypovolemia

isotonic IV fluids (first, fluids that replace volume)

common cause of Fluid Volume Excess (FVE) aka Hypervolemia

too much IV fluid or given too fast, heart failure, kidney or liver disease

treatment for FVE aka Hypervolemia

diuretics, fluid and sodium restriction

effects of 0.9% NaCl and Lactated Ringers on cells and fluids

cells stay same size, fluids stay in the blood vessels and tissues

effects of 0.45% NaCl (1/2 NS) and D5W on cells and fluids

water moves into cells, cells swell

effects of 3% NaCl on cells and fluids

water moves out of cells, cells shrink

isotonic crystalloid example

0.9% sodium chloride (Normal Saline, NS; Lactated Ringers)

main use of Isotonic Crystalloid

replace lost extracellular fluid volume and restore circulating volume and perfusion

isotonic crystalloids effects on the body

raises bp, improves perfusion, increase urine output

isotonic crystalloids indications

vomiting, diarrhea, bleeding (FVD), NG suction or wound drainage loss, blood transfusion, mild hyponatremia

isotonic crystalloids contraindications

Heart or kidney failure, existing edema or fluid volume excess, hypernatremia

isotonic crystalloids side effects

IV site discomfort, mild swelling of hands or feet

isotonic crystalloids adverse effects

crackles, JVD, edema, dyspnea (FVE), hypernatremia (with large volumes)

isotonic crystalloids client educations

report shortness of breath, swelling, dizziness when standing, drink fluids as allowed once able

isotonic crystalloids prescription parameters

• sodium _____ to _____ mEq/L

• urine output at least _____ ml/kg/hr

• Rate per perscription; always use a _____

136, 145, 0.5, pump

isotonic crystalloids special instructions: R/T Lactated Ringers

avoid in kidney failure, liver disease, and do not use with blood products

isotonic crystalloids recognize and analyze cues

low BP, fast, HR, dry mouth, low urine output after vomiting

isotonic crystalloids generate solutions & take actions

start NS as prescribed; monitor VS, I&O, weight, lungs

isotonic crystalloids evaluate outcomes

BP and HR stable, urine output at least 30mL/hr, clear lungs

hypotonic crystalloid example

0.45% sodium chloride (1/2 NS and D5W)

main use of hypotonic crystalloid

rehydrate cells and treat dehydration with high sodium

hypotonic crystalloid effects on the body

rehydrates cells, lower serum sodium, circulating volume, and BP

hypotonic crystalloid method of administration

IV pump slowly, used as maintenance fluid

hypotonic crystalloid indications

hypernatremia (over 145), sweating, fever, poor intake (cellular dehydration)

hypotonic crystalloid contraindications and cautions

head injury, stroke (increased ICP), hypovolemia, low BP, burns, trauma, hyponatremia

hypotonic crystalloid side effects

headache, IV site discomfort

hypotonic crystalloid adverse effects

confusion, seizures (cerebral edema), hypotension (from fluid shifting), hyponatremia (from overcorrection)

hypotonic crystalloid client education

change positions slowly and report any headache, confusion, or dizziness

hypotonic crystalloid prescription parameters

• Sodium 136 to 145 mEq/L; recheck often

• Osmolality 275 to 295 mOsm/kg

• Infuse _____ to avoid _____ shifts

slowly, rapid

hypotonic crystalloid special instructions

• D5W: isotonic in bag, hypotonic in body

• D5W: monitor _____ with _____

• Never used to treat _____

glucose, diabetes, shock

hypotonic crystalloid Recognize & Analyze Cues

Sodium over 145, thirst, dry mucous membranes, new confusion

hypotonic crystalloid Generate Solutions & Take Action

Infuse slowly as prescribed, frequent neuro checks and sodium levels

hypotonic crystalloid Evaluate Outcomes

Sodium trending to normal; mentation at baseline; no headache

hypertonic saline example

3% sodium chloride (& 5% sodium chloride)

main use of hypertonic saline

sever hyponatremia

hypertonic saline indications

brain swelling/increased ICP

hypertonic saline administration

central line preferred (irritates veins), slow infusion (via pump only)

hypertonic saline nursing safety precautions

frequent sodium and neuro checks, watch for crackles, JVD, edema (FVE)

potassium replacement example

Potassium chloride (KCl - IV or PO)

main use of potassium replacement

hypokalemia

potassium replacement effectso on the body

stabilizes heart rhythm, improves muscle strength, reduces cramps

true or false: potassium replacement can be given via IV push

false

potassium replacement indications

hypokalemia (K below 3.5), loop or thiazide diuretic therapy, vomiting, diarrhea, NG suction (losses)

potassium replacement contraindications

hyperkalemia, kidney failure, low urine output

potassium replacement cautions

ACE inhibitors, K-sparing diuretics

potassium replacement side effects

nausea, vomiting, diarrhea, stomach pain, burning at IV site

potassium replacement adverse effects

bradycardia, dysrhythmias (hyperkalemia), GI ulceration or bleeding (tablets), phlebitis, IV infiltration

potassium replacement client education

swallow ER tablets whole (do not crush), take with food and full glass of water, beware of salt substitutes (contain potassium), report black stools or irregular heartbeat

potassium replacement prescription parameters

• Potassium 3.5 to 5.0 mEq/L

• Urine output at least 0.5ml mL/kg/hr before IV K

• Mild (3.0 to 3.4): often _____

• Below 3.0: often _____

PO, IV

potassium replacement special instructions

never IV push or IM, peripheral rate 10 (mEq/hr) or less, low Mg makes low K hard to correct

potassium replacement Recognize & Analyze Cues

hypokalemia (K below 3.5), muscle cramps, irregular pulse, taking furosemide

potassium replacement Generate Solutions & Take Action

check urine output and kidney labs, give diluted KCl by pump

potassium replacement Evaluate Outcomes

K normal (3.5 to 5.0), regular rhythm, cramps resolved, IV site intact

hyperkalemia agents example

Calcium gluconate + insulin + dextrose (all IV)

sodium zirconium cyclosilicate (Lokelma)

sodium polystyrene sulfonate (Kayexelate)

• patiromer (Valtessa)

main use of hyperkalemia agents

protect heart and lower potassium

hyperkalemia agents mechanism of action

_____: protects heart; does NOT lower K

_____: shifts K into cells

_____: binds to K leaves the body in stool

calcium, insulin + dextrose, Kayexalate (SPS)

hyperkalemia agents effects on the body

protects against dysrhythmias and lowers serum K (except calcium)

hyperkalemia agents methods of administration

• Calcium: _____ IV

• Insulin: IV regular insulin + IV _____

• Kayexalate: PO or _____ enema

slow, dextrose, rectal

if patient hyperkalemic, what should you stop/hold?

K supplements and K rich foods

if patient hyperkalemic, you notice major ECG changes and very high serum potassium, what can you give to protect the heart but doesn’t lower serum K?

calcium gluconate

if patient hyperkalemic, what can you give to shift K into cells?

insulin and dextrose (and also sodium bicarbonate)

if patient hyperkalemic, what can you give to remove the K out of their body?

SPS (Kayexelate), patiromer, dialysis

hyperkalemia agents indications

hyperkalemia (K above 5.0), ECG changes (give calcium first), Kidney failure with K buildup

hyperkalemia agents contraindications & cautions

• Calcium: caution with _____

• Kayexalate: _____

• Kayexalate: caution in _____ (sodium)

digoxin, bowel obstruction or slow bowel, heart failure (HF)

Calcium gluconate (hyperkalemia agents) side effects

• Calcium: warmth, tingling, IV site irritation

• Kayexalate: constipation or diarrhea, nausea

warmth, tingling, IV site irritation

Kayexalate (hyperkalemia agents) side effects

constipation or diarrhea, nausea

hyperkalemia agents adverse effects

Insulin: _____ (MAJOR)

Calcium: _____; tissue injury if infiltrates

Kayexalate: _____; rare bowel injury

hypoglycemia, bradycardia, hypokalemia

(not part of the blueprint ;-;)

main use of magnesium replacement

• Magnesium sulfate (IV)

• Magnesium oxide (MagOx) (PO)

hypomagnesemia, correcting potassium that will not rise

(not part of the blueprint ;-;)

magnesium replacement Effects on the Body

Calms overexcitable nerves and muscles

Stabilizes heart rhythm

(not part of the blueprint ;-;)

magnesium replacement Method of Administration

IV: diluted, slowly via pump

IM (painful); PO forms for mild deficits

(not part of the blueprint ;-;)

magnesium replacement Indications

Hypomagnesemia (Mg below 1.3)

Alcohol use disorder, malnutrition, diarrhea

Low K that does not correct with KCl

(not part of the blueprint ;-;)

magnesium replacement Contraindications & Cautions

Kidney failure (Mg builds up)

Heart block

(not part of the blueprint ;-;)

magnesium replacement Side Effects

Flushing, warmth, sweating

Pain at IV or IM site

(not part of the blueprint ;-;)

magnesium replacement Adverse Effects

Toxicity: loss of deep tendon reflexes

Respiratory depression, hypotension

Cardiac arrest at very high levels

(not part of the blueprint ;-;)

magnesium replacement Client Education

Report weakness, drowsiness, trouble breathing

Eat Mg-rich foods: greens, nuts, whole grains

(not part of the blueprint ;-;)

magnesium replacement Prescription Parameters

Magnesium 1.3 to 2.1 mEq/L

Respirations at least 12/min

Urine output at least 0.5ml/kg/hr

Check DTRs before and during infusion

(not part of the blueprint ;-;)

magnesium replacement Special Instructions

Antidote for toxicity: calcium gluconate

Absent reflexes: stop infusion, notify provider

Also used in OB for seizure prevention

(not part of the blueprint ;-;)

magnesium replacement Recognize & Analyze Cues

Mg 1.1, tremors, hyperactive reflexes, K will not rise

(not part of the blueprint ;-;)

magnesium replacement Generate Solutions & Take Action

Infuse by pump; check DTRs, respirations, and urine output

(not part of the blueprint ;-;)

magnesium replacement Evaluate Outcomes

Mg 1.3 to 2.1; reflexes normal; respirations at least 12/min

(not part of the blueprint ;-;)

Opioids & benzodiazepines Nursing Connection

Monitor RR; naloxone reverses opioids

(not part of the blueprint ;-;)

Loop and thiazide diuretics Nursing Connection

Monitor K; replace with KCl

(not part of the blueprint ;-;)

Antacid overuse Nursing Connection

Teach safe antacid use

(not part of the blueprint ;-;)

Severe diarrhea & laxative overuse Nursing Connection

Replace fluid and K; sodium bicarbonate

(not part of the blueprint ;-;)

Insulin (treating DKA) Nursing Connection

Monitor K; replace as prescribed

(not part of the blueprint ;-;)

alkalinizing agent example

sodium bicarbonate

(not part of the blueprint ;-;)

main use of alkalinizing agent

metabolic acidosis

(not part of the blueprint ;-;)

alkalinizing agent effects on the body

(not part of the blueprint ;-;)

alkalinizing agent Method of Administration

• PO tablets for _____ acidosis

• IV for _____ acidosis

mild or chronic, severe

(not part of the blueprint ;-;)

alkalinizing agent indications

Metabolic acidosis: severe diarrhea, kidney failure

Hyperkalemia with acidosis

(not part of the blueprint ;-;)

alkalinizing agent contraindications & cautions

Metabolic or respiratory alkalosis

Hypokalemia (lowers K further)

Heart failure or sodium restriction

(not part of the blueprint ;-;)

alkalinizing agent side effects

PO: belching, gas, bloating

Thirst

(not part of the blueprint ;-;)

alkalinizing agent adverse effects

Metabolic alkalosis from overcorrection

Hypokalemia; fluid overload

Tissue injury if IV infiltrates