Fluid and Electrolyte Imbalances

Intercellular Space (IFS)

Fluid within the cells (2/3 of water within cells)

Extracellular Space

1. Intercostal: Fluid between cells

2. Intravascular: Plasma (liquid part of blood)

Cations

- Positive Charge

- Na, K, CA, and Mg

Anions

- Negative Charge

- HCO (Bicarbonate), Cl, PO (Phosphate), other proteins

Diffusion

Molecule movement from high to low concentration (neutral)

Facilitated Diffusion

Molecule movement from high to low concentration via a protein carrier

Active Transport

Molecule movement against gradient (low to high concentration)

Osmosis

Movement of H2O from high to low diffusion

Osmolarity

The number of particles that form from a dissolvable substance

Osmolality

Total concentration as a total number of solute particles per Kg

Isotonic Osmotic Movement

Normal (ICF=ECF)

Hypotonic

Cell is big (ICF>ECF)

Hypertonic

Cell shrinks (ICF

Hydrostatic Pressure

Force of fluid pushing against the cell membrane/ vessel

Oncotic Pressure

osmotic Pressure caused by plasma colloids (large molecules)

First Fluid Spacing

Normal distribution of ICF and ECF

Second Fluid Spacing

Abnormal fluid in intercostal space (edema)

Third Fluid Spacing

Excess fluid in nonfunctional areas of the cells (no cells-BV) (EX: dyalysis)

Starling Forces

1. Capillary to Interstitium= hydrostatic pressure (Positive net force=exit the vessel)

2. Capillary to Interstitium= oncontic pressure (negative net force into vessel)

As BP decreases what happens to osmotic pressure?

Osmotic Pressure Increases

Hypovolemia

- Shift from fluid in plasma to intercostal space (EFC defect)

- SE: Vomit, hemorrhage, diarrhea, and polyuria

Hypervolemia

- Shift of fluid from intercostal space to plasma (ECF excess)

- SE: Renal and Heart Failure

NN for Fluid Hypervolemia and Hypovolemia

- Daily Weight

- Input and Output

- Fluid Therapy

- Safety

- Lung, skin, and cardio assessment

Assess signs of: tachycardia, hypoxia, orthostatic HTN, and decreased BP

What are the normal levels of Sodium

135-145mEq/L (mol/L)

What is the role of Sodium

- Maintain concentration and volume in the ECF

- Influence H2O distribution between ECF and ICF

- Nerve Impulse

- Muscle contraction

- Acid-base balance

How do Aldosterone, the kidneys, and GI influence sodium?

- GI absorbs Na

- Kidneys secrete antidiuretic hormone (ADH)

- Aldosterone regulate absorption of Na to the renal tubules

Hypernatremia in the ECF

- Causes hypertonic cells (dehydration)

- Thirst from Hypothalamus

- Na>145mEq/L

Hypernatremia Clinical Causes

- Diabetes Insipidus, aldosteronism, Nephrogenic Diabetes Insipidus

-Due to H20 loss or Na gain

- HYPERTONIC CELLS= DEHYDRATION

Hypernatremia Treatment and S/S

SS: Think Neuro

- Thirst

- Seizures

- Agitation

- Coma

- Dry and swollen tongue

- HTN

- Decreased weight

Treatment:

- Isotonic 9% NaCl (decrease H2O)

- Dextrose or diuretics (Increase Na)

- Monitor Na levels (shouldn't be less than 8-15 in 8 hours)

Hyponatremia in ECF

- fluid shifts from ECF to cells causing an edema (HYPORTONIC CELLS)

- Decrease in NA, Increase in H2O, or Both

- Na<135mEq/L

Hyponatremia Causes and S/S

Causes:

- Vomit

- NG suction

- Draining wound

- adrenal insufficiency

SS:

- Headache

- Difficulty swallowing

- Confusion

Hyponatremia NN and Treatment

NN:

- Monitor SIADH and MENTAL STATUS/ CONSCIOUSNESS (CONFUSION)

- Shouldn't increase greater than 10-12 in first 24 hours or less than 18 in 48 hours

Treatment:

- Mild: fluid retention

- Severe: IV 3% NaCl

Normal Potassium Level

3.5-5mEq/L(mmol/L)

Potassium Roles

- THINK KIDNEYS

- Shift ICF to ECF

- Transmit/conduct nerve and cell function, intercellular osmolality, glycogen in muscles and liver, promote cell growth, acid-base balance

Potassium and the Kidneys

Kidneys= K loss= inverse relationship with K and Na

Causes:

- RF

- Burn

- Crush injury

- intense exercise

- metabolic acidosis

- Tumor lysis

Hyperkalemia S/S

- POTASSIUM FOLLOWS SUGAR

- Weakened or paralyzed skeletal muscle

- Fib or cardio standstill

- Abnormal cramping and diarrhea

What are the signs of Hyperkalemia on an EKG?

- Wide, flat P wave

- Decreased R wave amplitude

- Prolonged PR interval

- Tall, Peaked T wave

- Depressed ST segment

- Widened QRS

Treatment for Hyperkalemia

1. Decrease K intake (diuretics, dialysis, kayexalate)

2. IV insulin or albuterol (beta agonist)

3. IV CaCl or Ca gluconate

4. Increase fluid intake

What is the antidote for hyperkalemia

IV CaCl or Ca gluconate

Hypokalemia Causes and S/S

Causes:

- Shift from K in ECF into ICF

- Vomit, diarrhea, laxative, low mg levels, Mg DEFICIENT OR METABOLIC ALKALOSIS

S/S:

- Cardio Changes

- Skeletal muscle function

- Decrease in Gi mobility

- Weak resp muscles (decreased Breaths/min)

Hypokalemia Treatment and NN

Treatment:

- KCl IV or oral (always dilute and never push)

NN:

- Check IV site for phlebitis and infiltration each hour

- Monitor EKG, serum k levels, and urine output continuously

What does Hypokalemia look like on an EKG?

- slightly peaked P wave

- Slightly prolonged PR interval

- ST DEPRESSION

- SHALLOW T WAVE

- PROMINENT U WAVE

Normal Range for Calcium

9.0-10.5 mg/dL

Calcium roles

- blood clotting

- Nerve impulse

- Myocardial and Muscle contraction

- Found in teeth and bones

What must a patient take when on calcium?

Vitamin D

Hypercalcemia Causes and S/S

Causes:

- Cancer

- Hyperparathyroid

- Vit D Overdose

- Increase Ca intake

- Thiazide Diuretic

S/S:

- fatigue

- weakness

- Confusion

- Seizures

- Lethargic

- HTN

Hypercalcemia Treatment

- Mild: Stop Ca, decrease Ca in diet, and increase weight baring

- Severe: IV isotonic Saline, BISPHOSPHONATES, Calcitonin

What will Hypercalcemia look like on an EKG

Heart block and dysrhythmias

- Short ST and QT

Hypoglycemia Causes and S/S

Causes:

- Low Ca levels

- Decreased PTH production

- Blood transfusion

- Vit D Defect

- Alcohol use

S/S: THINK NEURO AND LUNGS

- Increased nerve excitability

- TROUSSEAU AND CHVOSTEK SIGN (hand freezes and wink. closing of one eye)

- Numbness

- Stridor Lung Sounds

- Dysphagia

What Does Hypocalcemia Look Like on an EKG?

- Vent. Tachycardia

- Prolonged QT and elongated ST

Hypocalcemia Treatment and NN

Treatment:

- Mild: Increase Ca diet and Vit D supplements

- Severe: CALCIUM GLUCONATE

NN:

- Treat pain and anxiety to prevent hyperventilation

Hyperphosphatemia Cause and S/S

Cause: Kidney Disease

S/S:

- Tetany and muscle cramps

- Precipitates in skin, tissue, and BV

Hyperphosphatemia Range Level

>4.5 mEq/L

Hyperphosphatemia Treatment

- Restrict fluid and food intake

- Oral Phosphate binding agent

- loop diuretics, hemodialysis, and volume expansion

Hypophosphatemia Causes and S/S

Causes:

- Decreased intestine absorption

- Increased urine output

- ECF into ICF

S/S:

- CNS depression

- Pain

- Muscle weakness

- Resp and heart failure

Hypophosphatemia Range Level

<3 mEq/L

Hypophosphatemia Treatment

- Oral and dietary supplements

- Severe: IV SODIUM POTASSIUM PHOSPHATE (monitor every 6-12 hrs)

Hypermagnesemia Range Level

>2.1 mEq/L

Hypermagnesemia Cause and S/S

Cause: Increase Mg due to Renal disease/ failure

S/S:

- HTN

- FACE FLUSHING

- decreased urine output

- decreased DTR

- muscle paralysis

Hypermagnesemia Treatment

- Stop Mg intake

- Diuretics if not contraindicated

What is that antidote for Hypermagnesia

IV CALCIUM GLUCONATE

Hypomagnesemia Range Level

<1.3 mEq/L

Hypomagnesemia Causes and S/S

Causes:

- Decreased Mg intake (Increase in GI and Renal loss)

S/S:

- Confusion

- Seizures

- Cramps

- Hyperactive DTR

- V Fib

- Tremors

Hypomagnesemia Treatment and NN

Treatment:

- Increase Mg in diet and supplements

- Mg sulfate

NN:

- Monitor HTN, Resp and Cardio arrest, vitals, consciousness

- REFLEXES

What should you always keep in hand when giving a patient Mg Sulfate

Ca gluconate

What does hypoosmolar normal Imbalance for Na mean

Na loss>H2O loss (isotonic loss)

What does hyperosmolar normal imbalance for Na mean

Na gain>H20 gain (Isotonic gain)

What does hyperosmolar imbalance for Na and H2O mean

H20 loss> Na loss

What does hypoosmolar imbalance for Na and H2O mean

H2O gain> NA gain

How does the Parathyroid Hormone (PTH) regulate calcium

- LOW SERUM calcium stimulates release

- Increase Ca absorption in bone and GI

- Increases renal tubule Ca reabsorption

How does Calcitonin regulate calcium

- HIGH SERUM calcium stimulates release

- Increase Ca deposition into bones

- Decrease GI absorption

- Increase renal Ca excretion