Nursing 120 Fluids and Electrolytes

Lewis's Med Surg 12th Edition

Hypovolemia: Causes

Fluid Volume Deficit Causes: Abnormal loss of body fluids- diarrhea, vomiting, hemorrhage, polyuria, inadequate fluid intake, overuse of diuretics, NG Suction, high fever, heatstroke, plasma-to-interstitial fluid shift?

Hypovolemia: S/S

Restlessness, drowsiness, lethargy and confusion =as ess for turgor (should be dec in hypovolemia, tenting=dehydration)

Thirst, dry mucous membranes Gerontologic consideration: Thirst is one of the first signs

Cold Clammy Skin 

dec cap refill 

Dec urine output, dec heart rate, INC RR (bc circulation dec = working harder)

Weakness, dizziness 

Weight loss 

LATE SIGN: Seizures, coma  

Fluid Volume Deficit Diagnostics (check book)

Serum electrolyte values, osmolality, BUN, creatinine, and urine specific gravity.

Hypovolemia: Treatment

Interprofessional Care 

Correct the underlying cause and replacing both water and any needed electrolytes.  

Replacement therapy depends on the severity and type of volume loss.

Mild losses: oral rehydration.

Severe: replace volume with blood products or isotonic IV solutions (0.9% sodium chloride, lactated Ringer’s solution).

Choice of fluid depends on cause and pt’s electrolyte status.

For rapid volume replacement, 0.9% sodium chloride.

Blood is given when volume loss is due to blood loss. 

Hypernatremia: Causes, Normal range

“MODEL”

M: Medications, Meals(too much sodium intake) (Citric acid, aspirin, sodium bicarbonate

O: Osmotic diuretics

D: Diabetes insipidus

E: Excessive H20 loss

L: Low H20 intake

136 mEq/L - 145 mEq/L

**Sodium is responsible for whether fluids are in or out of the cell, has a strong connection with water

Hypernatremia: S/S

“FRIED SALT” F: Flushed skin Restless, irritable, anxious, confused I: Increased BP and fluid retention E: Edema (peripheral and pitting) D: Decreased Urine output and Dry mouth S: Skin Flushed A: Agitation L: Low grade fever T: Thirst

Hypernatremia: Treatment

Treatment: Hypotonic IV solutions: 0.3% Normal Saline, 0.45% Normal Saline or Dextrose 5% in water,

Dec. sodium in diet

Daily Weight

Monitor: Serum Sodium Levels

**Slowly reduce sodium levels 

Sodium should not decrease by more than 8-15 mEq/L in an 8 hour period. Cerebral edema or neurologic complications can occur if reduced to quickly 

Hyponatremia: Causes, Normal Levels

Loss of sodium-containing fluids or water excess: Vomiting, Diuretics, Fasting, **Elderly (unable to excrete free water) Sodium 136-145 mEq/L

Hyponatremia: S/S

“SALT LOSS” S: Stupor/Coma A: Anorexia L: Lethargy T: Tendon reflexes dec. L: Limp muscles O: Orthostatic HypOtension S: Seizures S: Stomach cramping Elderly: Delirium

Hyponatremia: Treatment

**Fluid restriction (if mild hyponatremia from water excess) **Replacement with sodium-containing solutions (if fluid loss) hypertonic saline for trauma or head injury. Diet: include sodium-rich foods: beef broth, tomato juice Lactated Ringer’s IV or high concentration of 0.9% Normal Saline IV Monitor: I&Os, Daily weights, Serum Sodium levels, CNS **Slowly replace sodium  ** Sodium should not increase by more than 6-12 mEq/L per hour in the first 24 hours and 18 mEq/L or less within 48 hours. A quick increase can cause demyelination syndrome with permanent damage to nerve cells in the brain.

Hyperkalemia: Causes, Normal Range

“CARED” C: Cellular Mvmt of K from ICF to ECF (burns) A: Adrenal Insufficiency w/Addison’s Disease R: Renal Failure E: Excessive potassium intake D: Drugs (potassium sparing diuretics) **Potassium: 3.5-5.0 mEq/L

Hyperkalemia: S/S

“MURDER” M: Muscle Weakness U: Urine output=little or none R: Resp. Failure (from muscle weakness) D: Dec. cardiac contractility (weak pulse/low HR) E: Early Sign- twitches/cramps R: Rhythm changes- Tall peaked T waves, prolonged QT interval, wide QRS complexes Nausea, diarrhea, abdominal cramping

Hyperkalemia: Treatment

Diet: restrict intake of potassium-containing foods (Table 17.6) Administration of sodium polystyrene (kayexalate) In emergency situations: administer Calcium gluconate given IV or sodium bicarbonate given IV for dangerous dysrhythmias(?) IV administration of regular insulin and dextrose shifts potassium into cells Administration of Diuretics, Dialysis for clients with renal failure Monitor: ECG to detect fatal dysrhythmias

Hypokalemia: Manifestations, normal lab range

“A SIC WALT”

A: Alkalosis

S: Shallow respirations

I: Irritability

C: Confusion/Drowsiness

W: Weakness/Fatigue

A: Arrythmias

L: Lethargy

T: Thready Pulse

Potassium: 3.5-5.0 mEq/L

Severe hypokalemia can cause paralysis

Other symptoms: hyperglycemia, anorexia, N/V, constipation, paralytic ileus, weak periopheral pulses, paresthesia, dec. deep tendon reflexes, **potential for digitalis toxicity

Hypokalemia: Causes, Normal Lab Range

Vomiting, Gastric Suction, Prolonged Diarrhea Diuretics/Steroids, Inadequate Intake, Large urine output Potassium: 3.5-5.0 mEq/L

Hypokalemia: Treatment

Potassium replacement Oral or IV, IV KCL Replacement

**Must be given with a pump

Diet: Increase potassium containing foods: raisins, bananas, apricots etc

Monitor: renal function, resp. status, cardiac rhythm; Risk for digitalis toxicity 

Hypercalcemia: Causes, Normal Lab Range

Hyperparathyroidism (two-thirds of cases) or malignancy (hematologic, breast, or lung cancers). Excess dairy intake, steroids/loop diuretics, inadequate intake, Calcium-containing antacids (Tums), Thiazide diuretics, Vit. A or D overdose, Immobility Calcium: 9.0-10.5 mg/dL

Hypercalcemia: S/S

“BACK ME” B: Bone pain A: Arrhythmias C: Cardiac Arrest K: Kidney Stones M: Muscle Weakness E: Excessive Urination other: dec. memory, dec. reflexes, inc. BP, confusion/psychosis, anorexia/N/V, polyuria/dehydration, seizures/coma

Hypercalcemia Treatment

Stop any medications related to hypercalcemia

Diet: Low calcium, 3000-4000 mL daily fluid intake (decreases kidney stone formation)

Calcitonin-decreases calcium levels

Isotonic fluids: 0.45% Normal Saline or 0.9% Normal Saline

Mobilize client

**Furosemide, Bisphosphates (pamidronate, zoledronic acid) gold standard in treating hypercalcemia particularly when caused by cancer. Dialysis 

Hypocalcemia Causes

Decrease in production of parathyroid hormone. Renal insufficiency, Malnutrition, Low magnesium level, Pancreatitis, Hypoparathyroidism, High phosphate, Loop diuretics, Post-Thyroid Surgery

Hypocalcemia: S/S

“CATS” C: Convulsions A: Arrhythmias T: Tetany S: Spasms/Stridor Muscle cramps/Hyperreflexia, Dec. BP, Numbness/tingling in extremities and around mouth

Hypocalcemia: Treatment

Medications: IV Calcium gluconate, Calcium Chloride and Vitamin D supplements

Diet: Increase calcium

If on loop diuretics, possible change to thiazide diuretics to dec. urinary calcium excretion

**Maintain airway: laryngeal stridor can occur (narrowed airway), Seizure precautions. 

Monitor pts who had neck surgery(thyroidectomy) for signs of hypocalcemia

Hypermagnesemia Causes, Normal Lab Range

Renal insufficiency or failure combined with increased magnesium intake. **Renal failure, hypothyroidism, metastatic bone disease Magnesium: 1.3-2.1 mEq/L

Hypermagnesemia: S/S

“LVDS”

L: Low EVERYTHING (BP, HR, RR, Reflexes)

V: Vasodilation

D: Diaphoresis

S: Skeletal Muscle Weakness

Other: Dec. Deep tendon reflexes, flushed/warm face skin, cardiac arrest

Hypermagnesemia: Treatment

Discontinue oral or IV magnesium

Diet: reduce intake of magnesium enriched foods

Meds: IV Calcium Gluconate (oppose effects of excess magnesium on cardiac muscle), Dialysis (impaired renal function), Diuretics to promote excretion of magnesium

Interventions: Monitor cardiac rhythm, resp. status, support ventilation

Educate: dietary teaching to reduce intake of magnesium enriched foods

Hypomagnesemia: Causes, Normal Lab Range

Malnutrition states (fasting, starvation) or increased GI or kidney losses. Alcoholism, GI suction, diarrhea, malabsorption syndrome, uncontrolled diabetes mellitus, PPI therapy (omeprazole, esmeprazole, pantoprazole) Magnesium: 1.3-2.1 mEq/L

Hypomagnesemia: S/S

“STARVED”

S: Seizures

T: Tetany

A: Anorexia/Arrhythmias

R: Rapid HR

V: Vomiting

E: Emotional lability (**lability=uncontrollable mood)

D: Deep tendon reflexes INCREASED

CHVOSTEK’S AND TROUSSEU’S SIGN

Hypomagnesemia: Treatment

Diet: Inc. intake of magnesium foods

Meds: Magnesium sulfate administration (IV administration use a pump; Rapid administration can cause hypotension and cardiac or respiratory arrest)

Seizure precautions, Monitor vital signs and neuromuscular status

Hyperphosphatemia: Causes, Normal Lab Range

Renl failure, Phosphate enemas (Fleet), Phosphate containing laxatives (bowel prep for colonoscopy), Sickle Cell Anemia, Rhabdomyolysis

Phosphate: 3.0-4.5 mg/dL

Hypophosphatemia: Causes, Normal Lab Range

Malabsorption syndromes, malnutrition, chronic diarrhea, Vit D deficiency, Parenteral Nutrition, Phosphate-binding antacids

Phosphate: 3.0-4.5 mg/dL

Hyperphosphatemia: S/S

“MADS”

M: Muscle Spasms and tetany

A: Arrhythmias

D: Dry nails/skin

S: Seizures

*can be asymptomatic unless calcium binds w phosphate and leads to signs of hypocalcemia

Hyperphosphatemia: Treatment

Treat underlying condition

Diet: Restrict intake of high phosphate foods (dairy products)

Calcium carbonate, Dialysis in severe cases, Loop diuretics to promote excretion

**If hypocalcemia is present institute measures to correct calcium levels 

Hypophosphatemia: S/S

“ALOW”

A: Arrhythmias

L: Loss of appetite

O: Osteoporosis

W: Weakness, fatigue

other: confusion/coma/seizures, resp. muscle weakness, dysrhythmias, Osteomalacia, Rickets (poor bone growth, soft/weak bones), Rhabdomyolysis

Hypophosphatemia: Treatment

Diet: Increase dairy intake

phosphate supplements, IV sodium phosphate or potassium sulfate (During IV administration monitor serum calcium and phosphate levels ever 6 to 12 hours)

**During IV therapy monitor for hypocalcemia, hyperkalemia, hypotension and dysrhythmias. 

Define: Chvostek’s sign

contraction of facial muscles in response to a light tap over facial nerve in front of ear.

Tests for Hypocalcemia - nerve hyperexcitability

Define: Trousseau’s sign

carpal spasm induced by inflating a BP cuff above the systolic pressure for a few minutes

Tests for Hypocalcemia - latent tetany

Hypervolemia: Causes

Abnormal retention of fluids: heart failure, renal failure, long-term corticosteroid use, excess isotonic or hypotonic IVF

Hypervolemia: S/S

Headache, confusion, lethargy 

Peripheral Edema 

Jugular vein distention 

Bounding pulse, increased blood pressure 

Polyuria with normal renal function 

Dyspnea, crackles, pulmonary edema 

Muscle spasms 

WEIGHT GAIN: the most consistent manifestation  

Seizures, coma 

Hypervolemia: Treatment

Interprofessional Care 

Treat underlying cause, remove fluid w/o causing abnormal changes in electrolyte composition or osmolality of ECF.  

Therapies: Diuretics and fluid restriction 

**Some patients also need sodium restrictions. 

 If the fluid excess leads to ascites or pleural effusion, an abdominal paracentesis or thoracentesis may be needed.  

**Careful assessment and management of fluid volume changes are needed 

 

Hypotonic: Describe, Types, Reasons, Nursing Considerations

1. Lower osmolality than plasma. Dilutes ECF lowering serum osmolality. Osmosis moves water from ECF to interstitial spaces and cells, causing cells to swell. 

2. 0.45% Saline

3. Used to treat hypernatremia and uncontrolled hyperglycemia. Used as a maintenance solution due to normal daily losses being hypotonic. 

4. They are not good for replacement as they can deplete ECF and lower BP. Monitor for changes in mentation because it may signal cerebral edema (due to potential for cells to swell) 

Hypertonic: Describe, Types, Reasons, Nursing Considerations

1. Higher osmolality than plasma. Draws water out of the cells into the ECF. 

2. 3.0% Saline, 10% Dextrose in Water

3. 3.0% Saline - Used to treat symptomatic hyponatremia and trauma patients with head injury. 

   10% Dextrose in Water - Higher osmolality than plasma. Draws water out of the cells into the ECF. Used with Parenteral Nutrition

4. Give slowly because it can cause pulmonary edema. 

   Contains Na and Cl more than plasma levels. Monitor through frequent lab draws. 

   Hypertonic solutions need frequent monitoring of BP, lung sounds and serum sodium levels due to the risk of intravascular fluid volume excess. 

Isotonic: Describe, Types, Reasons, Nursing Considerations

1. Osmolality is like plasma. It expands only the ECF and fluid does not move into cells Ideal for fluid replacement for patients. 

2. 0.9% nacl, Lactated Ringer’s

3. 0.9% Saline - ONLY solution given with blood products!!! 

   Used for both fluid and sodium losses.   

   Lactated Ringer’s -Similar in composition to plasma except it does not contain Mg. It contains sodium, potassium, chloride, calcium, and lactate. Does not provide free water or calories, used to treat hypovolemia, burns, and GI fluid losses. 

4. 0.9% Saline - Giving too much can increase sodium and chloride levels. 

   Lactated Ringer’s - Cannot be used in patients with liver problems, severe hypovolemia, or hyperkalemia because they cannot convert lactate to bicarbonate. Also, cannot give to patients with alkalosis or lactic acidosis.