NU 352 - Exam 2 - PP1 (INT. FOR FLUID & ELECTROLYTE IMBALANCE)

FLUID BALANCE REVIEW

The body requires balance in:

•Volume

•Acidity (pH)

•Composition (electrolyte concentration)

•Concentration (Osmolality)

Balance through Intake/Output:

-Intake

• Thirst

• Personal habits (drinking, eating)

-Output

• Kidneys

• Skin

• Lungs

• GI Tract

lower osmolality

fewer particles

high osmolality

more particles

FLUID MONITORING

-Head to toe includes fluid status assessment

-Monitor vital signs

-Measurements:

• Weight is the most accurate measurement

• 1 kg (2.2 lbs) = 1 liter of fluid

• 1 gram diaper weight = approximately 1 mL urine

• IF ascites is present, include abdominal girth measurement

-Intake & output:

• Minimum acceptable volume of urine output:

• Adult: 30 mL/hour

• Child: 1 mL/kg/hour

HYPOVOLEMIA CAUSES (fluid volume deficit FVD)

-Excessive GI losses

• Nausea/vomiting

• NG suctioning

-Excessive skin and GU losses

• Diaphoresis

• Diuretic therapy

• Kidney disease

-Third spacing, burns

-Hemorrhage or plasma loss

-Altered intake

DEHYDRATION CAUSES:

•Hyperventilation

•Prolonged fever

•Diabetic ketoacidosis

•Diabetes insipidus

•Excessive intake of salt orhypertonic IV fluids

•Altered intake

Dehydration is not the same as FVD–

•Loss of water alone

•Increased serum sodium level

ASSESSMENTS FOR FLUID VOLUME DEFICIT (FVD) (HYPOVOLEMIA

What you could see:

• VS changes: Tachycardia (thready pulse), hypotension, tachypnea,

↑ temp

• Neuromusculoskeletal: Dizziness, syncope, confusion, weakness

• GI: Thirst, nausea/vomiting, acute weight loss

• GU: Oliguria

• Labs: Hgb, Hct, & BUN increased due to hypovolemia and hemoconcentration, increased urine specific gravity

INTERVENTIONS FOR FLUID VOLUME DEFICIT (FVD) (HYPOVOLEMIA

-Promote oral intake/replacement

-Provide fluid replacement per IV if oral insufficient/unable

-Frequent vital signs

-Frequent intake & output

-Daily weight

-Ensure patient safety (possible orthostatic hypotension, weakness, gait instability, increased fall risk) and educate on slowly repositioning/sit to stand

HYPERVOLEMIA CAUSES

•Heart failure

•Kidney disease

•Liver cirrhosis

•Fluid overdose per oral, IV, or enteral route

•Fluid shift from burns

•Prolonged use of corticosteroids

•Severe stress

•Hyperaldosteroneism

OVERHYDRATION CAUSES

•Excessive water intake

•Replacing fluids without electrolytes

•Excessive use of D5W for IV administration or hypotonic irrigation

•Syndrome of inappropriate antidiuretic syndrome (SIADH)

Overhydration is not the same as FVE–

•Excess of fluid only

•Water intoxication

ASSESSMENTS FOR FLUID VOLUME EXCESS (FVE) (HYPERVOLEMIA)

What you could see:

• VS changes: Tachycardia (bounding pulse), hypertension, tachypnea

• Resp: Crackles, cough, dyspnea

• Neuromusculoskeletal: Weakness, visual changes, paresthesia, altered level of consciousness (LOC)

• GI: Ascites, ↑ motility

• Peripheral/vascular: Distended neck veins, peripheral edema, cool skin, acute weight gain

• Labs: Decreased Hgb, Hct, BUN, and urine specific gravit

INTERVENTIONS FOR FLUID VOLUME EXCESS (FVE) (HYPERVOLEMIA)

-Anticipate orders for decreased IV rate, fluid/sodium restrictions, diuretic administration

-monitor intake & output

-Frequent respiratory and edema assessments

-Daily weights

-Promote proper positioning for respiratory and skin care, encourage rest

-Monitor labs

-Patient education on low NA diet

FLUID COMPARTMENTS

o Intracellular fluid (fluid in the cells)

o Extracellular fluid (fluid outside the cells)

• Interstitial (fluid that surrounds the cell)

• Intravascular (fluid within blood vessels)

• Transcellular (CSF, pericardial, synovial)

IV FLUID THERAPY

-Crystalloid solutions

• Isotonic

• Hypotonic

• Hypertonic

-Colloid solutions

• Dextran or hetastarch (Hespan)

• Volume expanders

• Contraindicated in renal disease

-Blood products

• Packed RBCs

• Platelets

• Fresh frozen plasma

• Cryoprecipitate

• Whole blood

CRYSTALLOIDS & FLUID MOVEMENT

-Isotonic solution: Has the same osmolality as blood/serum

-Hypotonic solution: Has lower osmolality than blood/serum

-Hypertonic solution: Has higher osmolality than blood/seru

COMPARING IV FLUIDS - hypotonic

Hypotonic:

•0.45% NaCl (NS)

•*D5 ½ NaCl (NS)

•*D5W

-Used for hypertonic dehydration, Na+ and Cl- depletion, & gastric fluid loss

COMPARING IV FLUIDS - isotonic

•0.9% NaCL (Normal Saline, NS)

•Lactated Ringers (LR)

•*D5W

• Expands ECF volume

• Used for hypovolemia, shock, resuscitation, diabetic ketoacidosis, & metabolic acidosis

COMPARING IV FLUIDS - hypertonic

•3% NaCl (NS), 5% NaCl (NS)

•Solutions initially

hypertonic: D5 0.9% NS,

D5LR, *D5 ½ NS, D10W, D50W

•Used to increase ECF volume, decrease cellular swelling

•Used to treat hyponatremia

•Give slowly as can cause pulmonary edema

ELECTROLYTE IMBALANCES: GENERAL INTERVENTIONS

1. Prevent occurrence (be alert to causes)

2. Monitor for signs/symptoms

3. Monitor labs, cardiac status (place on cardiac monitor), daily weights

4. Replace with appropriate foods if low or limit foods if high

5. Administer oral or IV supplements if low

6. Promote safety (assess for weakness, fall risk, seizure precautions

HYPONATREMIA (low sodium) 135 - 145

CAUSES

• Can be acute or chronic

• Loss of sodium-containing

-fluids:

• Vomiting, diarrhea

• Sweating

• Diuretics

-Water excess dilutes sodium:

• Adrenal insufficiency, SIADH

• Inappropriate administration of hypotonic iv fluids

MANIFESTATIONS

-CNS/neuro changes due to increased fluid in brain cell

• muscle cramps/ weakness

• lethargy

• N/V

• headaches

• confusion, other mental changes

• seizures

HYPONATREMIA INTERVENTIONS

• Assess: I&O, daily weight, lab values, CNS changes, patient safety

• Replace fluid losses with solute solutions, not just water

-Replace NA+ in oral food/fluids or IV (avoid overcorrection too rapidly)

-If severe/symptomatic: IV hypertonic saline (3% NaCl) infused slowly

• Fluid restriction

• Seizure precaution

*Na+ is important for skeletal, cardiac, and nerve function. Plays critical role in fluid balance

HYPERNATREMIA (high sodium) 135 - 145

CAUSES (6 D’S)

1. Diuresis

2. Dehydration

3. Diabetes insipidus

4. Docs (treatments– baking soda intake, excess sodium chloride administration per IV)

5. Diarrhea

6. Disease (e.g., kidney disease, sickle cell)

MANIFESTATIONS (FRIED SALT)

• Flushed skin, fever

• Restlessness, irritable, anxious, confused

• Increased BP & fluid retention

• Edema

•Decreased urine output, dry mouth

• Skin flushed

• Agitation

• Low-grade fever

• Thirst

HYPERNATREMIA INTERVENTIONS

-Prevention:

• Tube feedings: Need supplementary H2O

• Impaired LOC or inability to obtain fluids: Provide water

• Elderly with impaired thirst mechanism: Encourage fluid intake

-Assess: I&O, daily weight, lab values, CNS changes, patient safety

• Gradual lowering of serum sodium with IV hypotonic solution

• Sodium restriction

• Diuretic administration

• Oral care for thirst

IMBALANCES THAT TEND TO HAVE S/S RELATED TO NEUROMUSCULAR IRRITABILITY

↑ NM irritability

(s/s most likely):

1. Hypocalcemia

2. Hypomagnesemia

↓ NM irritability:

1. Hypercalcemia

2. Hypermagnesemia

3. Hypokalemia

S/S OF INCREASED NM IRRITABILITY

• Irritability

• Abdominal cramps

• Diarrhea

• Circum-oral numbness & tingling

• Muscle cramps

• Tetany

• Seizures

• Tremors

• Hyper-reflexes

• Anxiety

• + Chvostek sign (tapping on cheek Infront of ear = twitching of facial muscles)

• + Trousseau sign (BP cuff, inflate to 20 mmhg above pt normal systolic, maintain pressure for 2-3 min, if pt is in severe pain/ strong spasm = positive sign)

S/S OF DECREASED NM IRRITABILITY

• Fatigue

• Muscle weakness (some cramping could occur)

• Lethargy--confusion

• Respiratory depression

• Hypotension

• Hypo-reflexes

• Decreased GI motility; constipation, decreased bowel sounds, abdominal distention, anorexia, nausea, vomiting, paralytic ileus

• Paralysis if severe

HYPOKALEMIA (low potassium) 3.5 - 5

CAUSES

• GI tract losses:

• Vomiting/diarrhea

• Prolonged NG suction

• NPO status

• Hyperaldosteronism

• Excessive dieting/starvation

• Meds; thiazide and loop diuretics, digitalis, corticosteroids

• Kidney disease/renal insufficiency

MANIFESTATIONS

• Fatigue, lethargy

• ECG changes (especially ↓ T wave), cardiac dysrhythmias

• ↓ blood pressure, thready pulse

• Muscle weakness, hypoactive DTRs

• Polyuria

• Decreased bowel motility

• Anorexia

HYPOKALEMIA INTERVENTIONS

• Prevention if possible

• Assess: I&O, daily weight, lab values, CNS changes, DTRs

• Increased dietary intake, oral supplements, IV supplementation (cautiously– diluted and never by IV push)

• Continuous cardiac monitoring

• Monitor bowel function

• Patient safety (fall precautions

*K+ is important for cardiac, lung, and muscle function. Renal function is required for NA+ & K+ balance.

HYPERKALEMIA (high potassium) 3.5 - 5

CAUSES

• Rarely occurs with patients with normal renal function

• Older adults at increased risk

• Impaired renal function/renal insufficiency

• Hypoaldosteronism

• Tissue injury/trauma (and think vigorous exercise)

• Acidosis

• Meds; ACE inhibitors, NSAIDS, spironolactone (K+ sparing diuretic

MANIFESTATIONS

• Cardiac dysrhythmias (especially peaked T waves)

-HIGH RISK for cardiac arrest!

• Muscle weakness, paresthesia

• Increased bowel motility/cramps

• Irritability

• Anxiety

• Metabolic or respiratory acidosis

HYPERKALEMIA INTERVENTIONS

• Prevention if possible

• Assess: I&O, daily weight, CNS changes, patient safety

• Cardiac monitoring (ECG), apical pulse, blood pressure, monitor labs

• Hold K+ sparing diuretic (spironolactone) and ACE inhibitors

• Administration of Patiromer (K+ binder), cation exchange resin (sodium polystyrene sulfonate)

• Emergent care: Reversal with medications or procedures:

• IV calcium gluconate

• IV sodium bicarbonate

• IV Regular insulin and IV dextrose

• Albuterol (beta-2 agonist)

• Peritoneal or hemodialysis

graph for heart waves

HYPOCALCEMIA (low calcium) 8.8 - 10.4

CAUSES

• Relatively common imbalance

• Malabsorption

• Vitamin D deficiency

• Pancreatitis

• Burns

• Peritonitis

• Hypoparathyroidism

• Serum calcium level is controlled by parathyroid hormone and calcitonin

MANIFESTATIONS

• Tetany (most common)

• Numbness/tingling of fingers, toes, and circum-oral region

• Hyperactive DTRs

• + Chovstek & Trousseau signs

• Impaired clotting time

• Anxiety, confusion

• Dyspnea and laryngospasm

• Seizures

HYPOCALCEMIA INTERVENTIONS

• Acute symptomatic hypocalcemia (emergency)

• IV administration of calcium gluconate

• Diluted and administered per pump; monitor patient d/t high

risk of bradycardia/cardiac arrest if administered too quickly

• Seizure precautions

• Oral calcium supplements (antacids)

• Vitamin D supplements and therapy

• Dietary supplementation

• Exercises to decrease bone calcium loss

*Ca+ is Important for neuromuscular, cardiac, and bone function

HYPERCALCEMIA (high calcium) 8.8 - 10.4

CAUSES

• Relatively common imbalance

• Malignancy and hyperparathyroidism

• Prolonged immobilization

• Overuse of calcium supplements

• Oliguric phase of acute kidney injury (AKI)

• Diuretics

MANIFESTATIONS

• Polyuria

• Thirst

• Muscle weakness

• Constipation, nausea

• ECG changes, dysrhythmias

• Anorexia

• Lethargy, fatigue, headache

• Hypoactive DTRs

HYPERCALCEMIA INTERVENTIONS

• Treat underlying cause (parathyroid cancer)

• Cardiac monitoring

• IV fluids to dilute serum Ca+ level

• Furosemide, phosphates, calcitonin

• Encourage fluid intake

• Encourage ambulation

• Patient safety precaution

HYPOMAGNESEMIA (low magnesium) 1.8 - 2.6

CAUSES

• Diuretic phase of acute kidney injury (AKI)

• Diabetic ketoacidosis (DKA)

• Chronic alcoholism

• GI losses

• Often occurs along with hypokalemia & hypocalcemia

MANIFESTATIONS

• Neuromuscular irritability

• Muscle weakness, tremors, tetany

• + Chvostek and Trousseau signs

• Increased DTRs

• Apathy, depression, insomnia, confusion, agitation, psychosis

• ECG changes

• Flat/inverted T waves

• Depressed ST segment

• Prolonged PR interval

• Widened QRS

HYPOMAGNESEMIA INTERVENTIONS

• Mild; dietary supplements (oral magnesium)

• Moderate to severe; administer magnesium sulfate IV

• Frequent vital signs

• Seizure precautions

• Patient education for dietary sources of magnesium (green leafy vegetables, beans, lentils, almonds, peanut butter)

*Mg+ is Important for neuromuscular and cardiac function

HYPERMAGNESEMIA (high magnesium) 1.8 - 2.6

CAUSES

• Oliguric phase acute kidney injury (AKI)

• Diabetic ketoacidosis (DKA)

• Administration of magnesium sulfate

• Extensive soft tissue injury

MANIFESTATIONS

• Flushing/diaphoresis

• Depressed respirations

• Hypoactive DTRs

• Muscle weakness

• ECG Changes

• Prolonged PR interval

• Prolonged QRS

• Peaked T waves

HYPERMAGNESEMIA INTERVENTIONS

• Assess: Frequent vital signs, DTRs, changes in LOC

• IV calcium gluconate (antidote for mag toxicity)

• Administration of loop diuretics, sodium chloride, and Lactated Ringers (LR)

• Extreme cases:

-For respiratory depression; airway/breathing support

-Hemodialysis with magnesium-free dialysate