Fluid, Electrolyte, & acid base regulation

Nurs 330

body fluids are divided between

• intracellular fluid - most body fluid

• extracellular fluid

  • interstitial (between cells of organ/tissue)

  • intravascular (blood plasma)

• fluid is composed of water and solutes

homeostatic mechanics to retain water

• thirst response

• interaction between the brain and kidneys

• osmosis

  • flow of water between the compartments of the body to maintain an equilibrium

Potassium (K+) normal electrolyte values

• 3.5-5.0 mEq/L

Sodium (Na+) normal electrolyte values

• 136-145 mEq/L

Calcium (Ca 2+) normal electrolyte values

• 9-10.5 mg/dL

magnesium (Mg 2+) normal electrolyte values

• 1.3-2.1 mg/dL

Critical lab values

• are life threatening & immediate action is required

  • differentiate abnormal vs critical

• lab calls the primary RN & reports the critical lab value

• RN’s responsibility to act→ notify physician, obtain orders, take appropriate actions to address critical value

  • follow facility policy but these need to be reported to provider ASAP, typically at least within 1 hour

  • document communication with provider & order received

• people may not show symptoms of electrolyte imbalance until a critical value level is reached

Potassium

• helps with nerve & muscle cell function while playing an important role in the muscle cells in the heart

• potassium levels outside of the normal range can cause cardiac arrhythmia which can be an emergency

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what is hypokalemia

• low potassium levels <3.5

what is hyperkalemia

• high potassium levels >5.0

Potassium critical values

• critical value is K+ level less than 3 & greater than 6 in adults

• nursing implication- notify provider for a K+ level that is not WNL and monitor telemetry

Hypokalemia causes

• Medications, some heart conditions, GI losses (diarrhea, vomiting, suctioning, excess laxative use), metabolic alkalosis, excessive alcohol intake, CKD, DKA

Hypokalemia Manifestations

Muscle weakness, cardiac arrythmias, constipation, fatigue

hypokalemia

• Treat cause, K+ supplements (PO & IVPB only), 12-lead EKG, continuous cardiac monitoring, diet rich in K+ (baked potato, sweet potato, yogurt, banana, salmon, avocado, spinach)

hyperkalemia causes

• Renal failure, dehydration, DM, meds, burns, sepsis, trauma, acidosis

Hyperkalemia manifestations

Nausea, vomiting, muscle aches and weakness, decreased DTRs, paralysis, dysrhythmias, palpitations

hyperkalemia treatment

• Treat cause, removing K+ or encouraging K+ excretion, continuous cardiac monitoring, hemodialysis, meds (calcium gluconate, diuretics, insulin, kayexalate). Teach clients about avoiding food high in K+, including salt substitutes

Sodium

• supports the function of nerves & muscles, helps maintain a normal blood pressure & regulates the body’s fluid balance

• critical values occur when NA+ levels are less than 120 greater than 160

hyponatremia

• low sodium levels <136)

Hypernatremia

• high sodium levels >145

Hyponatremia causes

• meds, chronic/severe vomiting or diarrhea, excessive water intake, excessive alcohol, heart/kidney/liver problems, burns

Hyponatremia manifestations

• nausea, general feeling of unwell; fluid shift in brain (cerebral edema); lethargy, confusion, headache, restlessness, irritability

Hyponatremia treatment

• goal is to raise Na+ levels slowly;  treat cause, may give fluids or restrict (depends on cause), monitoring urine (characteristics, output, UA);

Hypernatremia causes

• body water loss, meds, vomiting, prolonged suctioning, excessive sweating, CKD, DM, gastroenteritis, burns

hypernatremia manifestations

• confusion, lethargy, irritability; more severe will manifest with neuro symptoms (muscle twitching, seizing, coma)

• thirst

hypernatremia

• decrease Na+ levels slowly, treat cause; fluid replacement, limiting/eliminating Na+ in diet (high Na+ foods think fast food, canned foods, ham, deli meats, frozen pizza, vegetable juice, shrimp, cottage cheese, puddings)

calcium

• Helps the body maintain strong bones and is mostly stored in teeth and bones to support their hardness. Calcium also helps muscles move, nerves to carry messages between the brain and body, and blood vessels to move blood throughout the body.

• Absorption depends on adequate levels of Vitamin D.

• Hypoparathyroidism, low parathyroid hormone levels, is a common cause of low calcium levels.

• Hypercalcemia is most commonly caused by overactive parathyroid glands, or hyperparathyroidism.

hypercalcemia

• high calcium levels >10.5

hypocalcemia

• low calcium levels <9

Hypocalcemia causes

• meds (laxatives; glucocorticoids, diuretics), inadequate intake of vit D, menopause (low estrogen), hypoparathyroidism (decreased PTH), renal disease, blood transfusions, mag or phos imbalance, sepsis, low albumin levels

Hypocalcemia manifestations

• dysrhythmias, syncope, numbness/tingling, muscle cramping/spasms, confusion, lethargy, seizures, wheezing/spasms of larynx, hair loss/coarseness, brittle nails, dry/itchy skin,

  + Chvostek sign, +Trousseau sign

hypocalcemia treatment

• calcium & vit. D supplements, Ca2+ rich foods (cheeses, yogurt, milks (various kinds), orange juice)

hypercalcemia causes

• hyperparathyroidism (high PTH), cancer, vit D toxicity, meds, renal failure

hypercalcemia manifestations

Constipation, abd pain, n/v, anorexia; as it worsens, you may see confusion & behavioral changes, thirst, polyuria, bone pain, muscle weakness

hypercalcemia treatment

• lab work, phosphate (to block Ca2+ absorption), IVF, diuretics, limiting/eliminating Ca2+ rich foods in diet

hypocalcemia - Chvosteks sign

• Use the fingertips to tap the facial nerve, which is located 2 cm in front of the tragus of the ear.

• A twitching of the facial muscles on the same side being tapped is a positive Chvostek sign.

Trousseau Sign

• Place a blood pressure cuff on the client’s arm and inflate it 20 mm Hg above the client’s systolic blood pressure for 3 to 5 minutes, which will cause irritability of the nerves in the arm.

• A positive result occurs with flexion of the wrist, thumb, and first joints of the fingers, combined with hyperextension of the fingers.

Magnesium

• assists in the regulation of nerve and muscle function, blood pressure and blood sugar levels as well as making bone protein and DNA

Hypomagnesemia

• low magnesium levels (<1.3)

hypermagnesesmia

• high magnesium levels (>2.1)

Critical Mg2+ levels

• <0.5 & >3

Hypomagnesemia causes

meds (diuretics, PPIs, abx), excessive etoh use, severe burns, DM2, crohn’s & celiac disease, diarrhea, pancreatitis, increased exc. by the kidneys, undernutrition, low K+ & Ca2+ levels

hypomagenesmia manifestations

• n/v, decreased appetite, fatigue, weakness; muscle cramps/spasticity, numbness/tingling, seizures, tetany, personality changes when more severe

hypomagnesemia treatment

Cardiac monitoring, admin of Mag sulfate IV, potentially correcting other electrolyte imbalances, increase Mg2+ rich foods in diet (cooked spinach, pumpkin seeds, black beans, soybeans, cashews, dark chocolate, avocados, tofu, salmon, and bananas)

hypermagnesemia causes

kidney disease, excessive intake, meds, trauma, acidotic states, hypothyroidism, chronic alcohol use

Hypermagnesemia manifestations

• nausea, dizziness, weakness, confusion, blurred vision, headache, decreased or loss of DTR, flushing, constipation

hypermagnesemia

• continuous cardiac monitoring if cardiac symptoms present; IV calcium gluconate or chloride, diuretics; limiting/eliminating Mg2+ rich foods from diet, DTR

assessment

• Health history

  • Recent changes in fluid intake, diet, and other lifestyle habits

• Vital signs

  • Pay particular attention to prolonged fever, tachycardia, changes in respirations, and alterations in blood pressure.

• Intake and output

  • Oral intake

    • All fluids and foods that become liquid at room temperature

  • Output

    • Body fluids and drainage that can be measured

  • 24 hour balances

    • Document intake and output each shift

    • Daily the shift totals are added to obtain the 24 hour balances

    • Note trends over subsequent days

    • Weight

      • A change of 1 kg (2.2 lb) is equivalent to 1 L (1000 mL) of fluid.

    • Edema

    • skin turgur & mucous membranes

Skin turgor & mucous membranes assessment

• Skin turgor

  • Normal fluid balance: pinched skin returns to normal quickly

  • Fluid volume deficit: skin remains tented after release

• Mucous membranes

  • Normal: moist and pink

  • Severe fluid volume deficit: dry and sticky, furrows in the tongue; dry, cracked lips

Intake & output

• Intake refers to the amount taken in by a client (PO, intravenously, or any feeding tubes)

• Output is the amount produced by the body of a client (urine, bowel movements, and vomiting)

• Should be recorded at least every 8 hours or per a facility’s protocol.

• Net I & O is the difference. Either + or –

Dehydration

• occurs when there is a loss of water (or lack of water intake) without loss of sodium

  • what are potential causes of dehydration

  • what are potential symptoms of dehydration

  • labs may indicate hypernatremia, elevated serum osmolality, concentrated urine (w/ increased specific gravity)

  • treatment/care: PO fluids, IVF

Hypovolemia

• fluid volume deficit

• occurs when there is a decrease in blood volume within the body due to loss of body fluids or blood

• loss of water and electrolytes

causes of hypovolemia

• excessive sweating , large burns, diuretics, inadequate fluid intake, and increased urination

clinical manifestations of hypovolemia

• dry mucous membranes, tenting, decreased UOP

  • what will vital signs look like?

hypovolemia interventions

• increased fluids, administer meds as ordered, I & O, daily weight, oral care

untreated hypovolemia

if hypovolemia goes untreated, serious symptoms may develop including

• Blue discoloration of lips and nail beds

• Change in alertness or level of consciousness

• Chest pain, tightness, or pressure

• Palpitations

• No urine production or decreased urine production

• Tachycardia – increased heart rate

• Tachypnea – rapid breathing

• Decreased blood pressure

• Weak pulse

Hypervolemia

• fluid overload, is a condition where the body has too much fluid

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What patients may be at risk for hypervolemia

• heart failure, patients with hypertension, patients with excessive sodium intake

sign & symptoms of hypervolemia

• peripheral edema

• shortness of breath (dyspnea)

• ascites or abdominal swelling

hypervolemia interventions

• fluid restriction

• ice chips instead of water

• oral hygiene

• avoid salty & sweet foods

• diuresis (using diuretics such as furosemide)

• daily weight

• I & O

Rehydration

• the process of restoring water that has been lost back into the body tissues & fluids

oral rehydration

• assess ability to swallow

• record I & O hourly

intravenous (IV) rehydration

• prescribed IV solution depends on the purpose of therapy

peripheral IV

• Single-lumen plastic catheters that are inserted into a peripheral vein.

• Fluids, medications, and blood products are administered through the peripheral IV directly into the bloodstream for quick absorption.

• Range from 14 gauge to 24 gauge, with the catheter becoming narrower as the number increases.

What determines the IV catheter size?

• determined by the type and amount of fluid or medication being administered, how quickly it needs to infuse, and the patient's vein size and condition.

Peripheral IV access - intravenous sites

• Location

• Condition of vein

• Purpose and duration of therapy

Peripheral IV Access - types of peripheral catheters

• Over-the-needle (ONC) catheter (Angiocath)

• Winged infusion needle (butterfly needle)

• Midline catheter

IV insertion

IV complications

• infection

• phlebitis

• fluid overload

• infiltration

• extravasation

• air embolism-obstruction of vessel by air

IV tubing & pumps

• Flow rate, infusion time, and total volume based on the provider’s prescription.

• Infection Control

acidic pH

← 7.35

alkaline pH

→ 7.45

CO2 normal values (on Arterial Blood Gas)

• 35-45 mmHg

HC03 normal values (on Arterial Blood Gas)

• 22-26 mEq/L

PaO2 normal values (on Arterial Blood Gas)

• 80-100

O2sat normal values (on Arterial Blood Gas)

• 95-100%

Normal Values (on Arterial Blood Gas)

• These values will be found in an Arterial Blood Gas (ABG) which is drawn from the arterial blood in the radial or brachial artery

• This is not a nursing duty (you will be responsible for interpretation of results)

• You will consult your respiratory therapist for this test

pH

• examine the pH and determine if the values falls within the normal ranges

acidotic

• if the pH t is less than 7.35

alkalotic

• if the pH is greater than 7.45

what contributes to alkalosis

• if the PaCO2 is less than 35, carbonic acid (an acid) is being lost

what contributes to acidosis

• if the PaCO2 is greater than 45, carbonic acid (an acid) is being retained

HCO3^- contribution to acidosis

• if the HCO3^- is less than 22 bicarbonate (a base) is being lost

HCO3^- contribution to alkalosis

• if the HCO3^- is greater than 26, bicarbonate (a base) is being retained

Respiratory acidosis

• pH: 7.26 decrease

• PaCO_2: 48 increase

• HCO₃ : 24

Respiratory alkalosis

• pH: 7.48 increase

• PaCO₂: 31 decrease

• HCO_3: 24

Metabolic Acidosis

• pH: 7.28 decrease

• PaCO₂: 36

• HCO₃: 20 decrease

Metabolic Alkalosis

• pH: 7.49 increase

• PaCO₂: 36

• HCO₃: 29 increase

respiratory acidosis causes

• Airway diseases such as COPD and asthma

• Diseases that affect the chest and breathing ability such as scoliosis

• Diseases of the lung tissues

• Medicines that suppress breathing such as narcotics

• Severe obesity

• Obstructive sleep apnea

respiratory acidosis manifestations

• Anxiety and confusion

• Fatigue

• Shortness of breath

• Lethargy

• Sleepiness

Respiratory acidosis treatment

• Identifying the underlying cause

• Supplemental oxygen administration

• Medications (bronchodilators and corticosteroids)

• Nursing interventions: monitoring respiratory effort, lung sounds, and the airway; monitoring vital signs, I&O, and subsequent ABGs or other laboratory results

Respiratory Alkalosis causes

• Breathing too fast or too deep

• Hyperventilation, or over breathing (ridding the body of too much carbon dioxide)

• Pain

• Anxiety

• Stroke

• Hyperthyroidism

Respiratory Alkalosis manifestations

• Hyperventilation

• Lightheadedness

• Dizziness

• Confusion

• Chest discomfort/ tachycardia

• Altered mental status.

Respiratory Alkalosis treatment

• Treat the cause/ decrease respiratory rate

• Breathing into a paper bag or applying oxygen using a partial rebreathing mask 

• Nursing interventions include monitoring the client’s respiratory status including effort, depth, and rate; vital signs; I&O; neuromuscular status; and subsequent ABGs or other laboratory results

• Fall precautions

metabolic acidosis causes

• Renal or hepatic failure

• Pancreatitis

• Dehydration

• Diarrhea

• Starvation

• Diabetic ketoacidosis

• Lactic acidosis (cancer, alcohol toxicity, cardiac arrest)

• Salicylate intoxication

metabolic acidosis manifestations

• Long and deep breaths (Kussmaul respirations)

• Confusion

• Headache

• Tachycardia

• Lethargy

• Loss of appetite, and nausea and vomiting.

metabolic acidosis treatment

• Aimed at correcting the underlying cause

• Sodium bicarbonate (a base) is often given

• IV fluids

• Nursing interventions: monitoring respiratory effort, lung sounds, and the airway; monitoring vital signs, I&O, and subsequent ABGs or other laboratory results; and administering medications and treatments as prescribed.

metabolic alkalosis causes

• Prolonged vomiting

• Gastric suctioning

• Excessive use of diuretics or antacids

• Renal impairment

• Hypokalemia, or hypovolemia.

metabolic alkalosis manifestations

• Muscle twitching or spasms

• Lethargy, lightheadedness

• Nausea and vomiting

• Tremors or numbness of the hands

• Tingling of the face or feet

• Headache

• With severe metabolic alkalosis, confusion, seizures, agitation, and coma; arrhythmias

metabolic alkalosis treatment

• Reversing the underlying cause.

• Nursing interventions: monitoring the client’s respiratory status including effort, depth, and rate; vital signs; I&O; neuromuscular status; and subsequent ABGs or other laboratory results

• Fall precautions