Week 11: Fluid & Electrolyte Imbalance

True or false: fluid circulates in both the blood and lymph vessels

TRUE

True or false: fluid surrounds the cells

TRUE - interstitial space

True or false: fluid inside the cells slows chemical reactions

FALSE - fluid inside the cells promotes chemical reactions (metabolism)

What are electrolytes?

body ions

True or false: fluid and electrolytes are essential to life

TRUE

What is fluid and electrolyte balance called?

homeostasis

_______, _______, and _______ of the fluid in the body influence function at all levels from the cell to the whole person.

amount, concentration, and composition

What is the primary fluid in the body?

water

What are the functions of water?

• transporting

• facilitation (metabolism, chemical functions, digestion, elimination)

• acts as solvent for electrolytes and tissue lubricant

• maintain body temperature

What percentage of body weight is total body water?

50-60% in a healthy person

• muscle holds the most water in the body

True or false: as the percentage of muscle in the body decreases (aging), the total body water percentage decreases.

TRUE

True or false: body fat contains very little water

TRUE → obesity can impact total body water percentage

What process type is fluid and electrolyte balance?

a process of regulation

What are different characteristics of fluid?

• volume

• osmolality (degree of ion concentration)

• pH

What 3 processes regulate fluid & electrolyte balance?

• intake and absorption (movement into blood)

• distribution (intracellular or extracellular)

• output (removal of fluid & electrolytes from the body) → lungs, sweat

True or false: only urine contains electrolytes

FALSE - all bodily fluids contain electrolytes (sweat)

True or false: body fluids are in different locations and contain different concentrations of electrolytes depending on optimal function needs

TRUE

When does optimal fluid & electrolyte balance occur?

• intake & absorption matches the output of fluid and electrolytes

• volume, osmolality, and electrolyte concentration of fluid are within their normal ranges

What are the 3 fundamental causes for fluid and electrolyte imbalance?

• output is greater than intake & absorption

• output is less than intake & absorption

• distribution is altered

Output is greater than intake and absorption - F&E imbalance

• normal output with deficient intake or absorption

• increased output not balanced with increased intake

Output is less than intake and absorption - F&E imbalance

• output is less than excessive/rapid intake

• decreased output not balanced by decrease intake

may see edema in these cases

Distribution is altered - F&E imbalance

• shift vascular fluid into interstitial (3rd spacing → rapid)

• electrolyte shift from ECF (extracellular fluid) into electrolyte pool

• electrolyte shift from electrolyte pool into ECF (extracellular fluid)

How can F&E imbalances impact the physiologic state?

• impaired perfusion & oxygenation

• impaired brain function

• impaired neuromuscular function

Impaired perfusion & oxygenation

• imbalances in extracellular volume → edema presents

• imbalances in plasma potassium, magnesium, and calcium → dysrhythmias

Impaired brain function

imbalance in osmolality (sodium) → swelling or shrinking of brain cells → seizures or LOC

Impaired neuromuscular function

• potassium has ability to generate skeletal muscle contraction

• calcium & magnesium ability to generate neuromuscular excitability

What is the normal level of sodium?

135-145

What is the normal level of potassium?

3.5-5

What is the normal level of chloride?

98-106

What is the normal level of magnesium?

1.8-2.6

What is the normal level of calcium?

8.8-10.5

What is the normal level of phosphorus?

2.5-4.5

What are the focuses of nursing care in relation to F&E imbalances?

• identify high risk FEA-B imbalances

• identify the nature of the imbalances (severity, S/S, cause)

• plan of care

• evaluate effectiveness

What is important history assessment for general F&E imbalance?

focus on renal, endocrine, or other conditions that may cause F&E issues

• normal I&Os, N/V, diarrhea, meds

What is important physical examination for general F&E imbalance?

part of a larger picture and unless specific symptoms are assessed for, the imbalance may be missed

What are physical assessment objective data cues for F&E imbalance?

• turgor & tongue appearance (furrow?)

• moist oral cavity

• tearing, saliva

• skin

• facial appearance (sunken eyes)

• edema

• body temp (low, high → fluid replacement)

• pulse & respiration

• BP → decrease systolic or diastolic indicate deficiency

• mental status changes/reflexes

mind behind TEMP FE(eyes/tearing/saliva)BB

Fluid intake & output - objective data

• recorded every 8 hours with a 24-hour total

• intake: all fluids (oral, IV, enteral) and foods that are liquid at room temperature

• output: urine, vomit, diarrhea, fistula drainage, wounds, ulcers, suctioning device drainage

Daily weights - objective data

• monitor for increase or decrease

• same time with same type of clothing on same scale

What lab studies are important to monitor for F&E imbalance?

• CBC: fluid volume status (hgb, hct)

• Serum electrolytes: acid-base and fluid status

• BUN & creatinine levels: fluid status & renal function

• Urine pH & specific gravity: acid-base & hydration

What are normal BUN levels? Common causes for low vs high levels?

• 5-25 → product of protein metabolism

• low: overhydration, malnutrition, low protein

• high: dehydration, kidney issues, high protein

What are normal creatinine levels? Common causes for low vs high levels?

• 0.5-1.5 → muscle breakdown; excreted in urine

• low: pregnancy

• high: kidney issue, cancer, heart disease

What are normal osmolality levels? Common causes for low vs high levels?

• 280-300 → serum concentration

• low: excess fluid volume

• high: deficient fluid volume

What are normal albumin levels? Common causes for low vs high levels?

• 3.5-5 → major plasma protein; liver

• low: liver failure, malnutrition, kidney

• high: dehydration, diarrhea, vomiting

What are nursing diagnoses when F&E disturbance is the problem?

• excess fluid volume

• deficient fluid volume

• risk for deficient fluid volume

What are nursing diagnoses when F&E disturbance is the cause?

• ineffective breathing pattern r/t compensatory mechanism by lungs

• impaired oral mucous membrane integrity r/t fluid volume deficiency

• risk for impaired skin integrity r/t deficient or excess fluid volume

True or false: when creating an outcome related to F&E imbalance, we want to focus on a 24-hour timeframe.

FALSE - 48-72 hours

Urine specific gravity normal range

1.005 - 1.030

General nursing interventions for F&E imbalance

• adequate fluid intake & well-balanced diet

• med admin

• iv therapy admin & maintenance

• reduction of anxiety

• patient & family education → diet

If needed: blood & blood products, parenteral nutrition

Independent nursing interventions for F&E imbalance

• provide safety & comfort

• oral intake if appropriate

• administer collaborative interventions → adjust I&Os, treat underlying cause

• monitor for complications

• teach how to prevent imbalances or when to seek help (chronic)

Collaborative interventions for F&E imbalances

• fluid & electrolyte support → correct deficits, patient teaching

• medication management → treat cause, increase output, shift electrolytes into their pools, counter life threatening effects of imbalance, HOLD MED ADMINISTRATION if imbalance present & collab with prescriber

What are some causes of fluid volume deficit?

• vomiting

• diarrhea

• sweating / hyperthermia

• GI suction

• diuretics

• decreased intake / alcohol / caffeine

• elderly → inability to regulate sodium & water + decreased thirst

What are signs and symptoms of fluid volume deficit?

• thirst (1st sign) + dry mucous membranes

• increased temp

• rapid & weak pulse, increased RR, low BP

• pale, clammy, poor skin turgor

• flattened neck veins

• dizzy, nausea, weak

• concentrated urine, oliguria

• increased HCT, HGB, BUN, Na+

What are potential nursing interventions for fluid volume deficit?

• encourage oral intake or IV fluids

• monitor I&Os closely

• assess skin turgor

• daily weights

• monitor vital signs → pulses

• monitor LOC

• assess urine specific gravity → >1.020

Isotonic - IV fluid

Used in hypovolemia, shock, resuscitation

• 0.9% NACL or lactated ringers

• similar osmolality to blood plasma

Hypotonic - IV fluid

Provides Na+ & CL & free water

• 0.45% NACL

• provides more water than electrolytes

Hypertonic - IV fluids

Decrease cellular swelling

• 3% NaCl

• Provides more electrolytes than water

Colloid - IV fluids

volume/plasma expander

• D5W (dextrose 5% water)

• provides free water & calories

What are causes of fluid volume excess?

• heart failure

• renal failure

• liver cirrhosis

• excessive Na+ intake

• excessive IV infusion

What are signs and symptoms of fluid volume excess?

• edema

• JVD

• increased BP; bounding pulses

• crackles, SOB, increased RR

• weight gain

• increased urine output

• decreased HCT, BUN

What are nursing interventions for fluid volume excess?

• administer diuretics

• restrict fluids

• sodium restricted diet

• monitor I&Os

• daily weights

• skin care

• edema assessment

• position semi-fowler or greater if dyspneic

Loop diuretics - potassium wasting

Ex: furosemide, bumetanide

• most potent

• common adverse effects: dehydration, hypotension, hypokalemia

• nursing considerations: monitor I&Os, monitor lytes (K+)

Thiazide diuretics - potassium wasting

Ex: hydrochlorothiazide

• common adverse effects: hypokalemia

• nursing considerations: monitor I&Os, monitor lytes (K+)

Potassium-sparing diuretics

Ex: spironolactone

• common adverse effect: hyperkalemia

• nursing consideration: monitor I&Os, monitor lytes (K+)

What electrolytes are found in the ICF?

potassium, calcium, magnesium, phosphate, bicarbonate

What electrolytes are found in the ECF?

sodium, chloride, bicarbonate

What is the purpose of electrolytes and their balance?

• maintain electrical neutrality in cells

• generate & conduct action potential in the nerves and muscles

What are S/S of hyponatremia?

impaired cerebral function → decreased LOC (drowsy or coma), nausea, seizures (severe)

What is treatment for hyponatremia?

• correct underlying condition

• replace sodium

• restrict water

• adjust meds

What are nursing actions for hyponatremia?

• monitor I&Os

• daily weight

• monitor Na+ level

• monitor for LOC changes

• encourage dietary sodium intake

• monitor and restrict fluid intake

• monitor meds

What are S/S of hypernatremia?

impaired cerebral function → decreased LOC (drowsy to coma), thirst, seizures (severe)

What are treatments for hypernatremia?

• lower sodium levels gradually → infuse hypotonic solution

• administer diuretics

What are nursing actions for hypernatremia?

• monitor for CNS changes

• assess for abnormal water loss or low water intake

• assess for OTC sources of sodium

48!!

What are the S/S of hypokalemia?

• bilateral ascending flaccid muscle weakness

• abdominal distension

• constipation

• postural hypotension

• polyuria

• cardiac dysrhythmias

Treatment for hypokalemia

• potassium replacement → oral, iv, dietary

• only give IV if adequate urine output has been determined

Nursing actions for hypokalemia

• assess for early S/S

• monitor extent of loss → K+ levels

• monitor ECG, acid/base, digitalis toxicity

• teach about potassium-rich foods

What are S/S of hyperkalemia?

• bilateral ascending flaccid muscle weakness

• cardiac dysrhythmias → cardiac arrest if severe

Treatment for hyperkalemia

• administer cation exchange resins → kayexalate

emergent -

• IV calcium gluconate, IV sodium bicarbonate

• infusion of hypertonic dextrose

• beta-2 agonists

• dialysis

Nursing actions for hyperkalemia

• monitor ECG

• assess and monitor K+

• I&Os

• apical pulse

• restrict dietary potassium

What is first nursing action if K+ imbalance?

telemetry monitoring of heart

What are S/S of hypocalcemia?

• increased neuromuscular excitability → threshold potential is lowered

• positive Chvostek & Trousseau signs

• muscle cramps & twitching

• hyperactive reflexes, carpal & pedal spasms

• cardiac dysrhythmias

• seizures

• if severe: tetany & laryngospasm

Treatment for hypocalcemia

• oral calcium with vitamin D supplement

emergent -

• IV calcium gluconate

Nursing actions for hypocalcemia

• seizure precautions → bedside are padded, suction

• exercises to decrease bone calcium loss

• increase calcium diet

What are S/S of hypercalcemia?

• decreased neuromuscular excitability

• anorexia, nausea, constipation

• muscle weakness, diminished reflexes

• decreased LOC

• cardiac dysrhythmias

Treatment for hypercalcemia

• treat underlying cause

• administer IV fluids

• administer furosemide, phosphates, calcitonin, bisphosphonates to push Ca+ out

Nursing actions for hypercalcemia

• increase mobility

• encourage fluids

• diet & fiber for constipation

• ensure safety

What are S/S of hypomagnesemia?

Hyperexcitability

• positive Chvostek’s & Trousseau signs

• insomnia

• hyperactive reflexes, cramps, twitching

• nystagmus

• cardiac dysrhythmias

• seizures

Treatment for hypomagnesemia

• oral magnesium supplement

• IV magnesium sulfate → monitor VS & urine output

Nursing actions for hypomagnesemia

• monitor for dysphagia (swallowing)

• seizure precautions

• dietary teaching

What are S/S of hypermagnsemia?

Hypoexcitability

• flushing, diaphoresis

• diminished reflexes, muscle weakness

• hypotension

• decreased LOC

• respiratory depression, bradycardia, cardiac dysrhythmias

Treatment for hypermagnesemia

• IV calcium gluconate

• loop diuretics & IV infusion (isotonic(

• avoid magnesium meds

• hemodialysis

Nursing actions for hypermagnesemia

• assess and monitor deep tendon reflexes (hammer to knee)

• monitor for changes in LOC

Causes of hypophosphatemia

• alcoholism

• pain

• heat stroke

• respiratory alkalosis

S/S of hypophosphatemia

• neurologic symptoms: confusion

• muscle weakness & pain

• tissue hypoxia

• increased infection risk

Treatment of hypophosphatemia

oral or IV phosphorus replacement

Nursing actions of hypophosphatemia

• encourage foods high in phosphorus

• gradually introduce calories for malnourished patients

Causes of hyperphosphatemia

• kidney injury

• excess vitamin D

• acidosis

• hypoparathyroidism

• chemo

S/S of hyperphosphatemia

• soft-tissue calcification

• symptoms occur due to associated hypocalcemia

Hyperphosphatemia treatment

• vitamin D prep

• calcium-binding antacids

• phosphate-binding antacid

• loop diuretics

• dialysis

Hyperphosphatemia nursing actions

• avoid high phosphorus foods

• teach about signs of hypocalcemia