Fluid & Electrolytes - Med Surg

Final; Electrolyte Imbalances; Dehydration; Overhydration

Define Electrolytes (3)

• Charged ions in body fluids

• Cations carry a positive charge

• Anions carry a negative charge.

Define Location of Electrolytes (2)

• Distributed between the intracellular (ICF) & extracellular (ECF) compartments

• Their differing concentrations help maintain cell excitability & nerve transmission.

Types of Electrolytes (6)

• Sodium

• Calcium

• Potassium

• Magnesium

• Chloride

• Phosphorus

Sodium Expected Reference Range

136 to 145 mEq/L

Calcium Expected Reference Range

9.0 to 10.5 mg/dL

Potassium Expected Reference Range

3.5 to 5.0 mEq/L

Magnesium Expected Reference Range

1.3 to 2.1 mEq/L

Chloride Expected Reference Range

98 to 106 mEq/L

Phosporus Expected Reference Range

3.0 to 4.5 mg/dL

Define Hyponatremia

Net gain of water or loss of sodium resulting in levels < 136

Patho - Hyponatremia (3)

• Hyponatremia slows membrane depolarization & causes water to move into cells, leading to cellular swelling

• Usually due to fluid imbalance that results in sodium loss

• Compensation includes kidney excretion of sodium-free water

Hyponatremia S/S (8)

• Vitals - Hypothermia, tachycardia, bounding pulse, hypotension, diminished peripheral pulse 

• Headache 

• Confusion  

• Lethargy & fatigue 

• Muscle weakness & Decreased DTRs 

• Seizures 

• Lightheadedness & dizziness 

• GI - Increased GI motility with hyperactive bowel sounds, abdominal cramping & nausea 

Complications of Hyponatremia (4)

• Severe Hyponatremia  

• Coma 

• Seizures 

• Respiratory arrest 

Medications - Hyponatremia (2)

• Conivaptan or tolvaptan

• Promote excretion of excess fluid 

IV Fluids - Hyponatremia (5)

• Hypertonic solutions 

• 5% saline  

• 3% saline  

• 5% dextrose in 0.9% saline (D5NS)  

• 5% dextrose in LR (D5LR) 

Interventions - Hyponatremia (5)

• Client can intake PO – Replace sodium with foods & fluid (beef broth, tomato soup) 

• Administer IV fluids – LRs, 0.9 isotonic saline 

• Replacement of sodium should not exceed 12 mEq/L in 24 hrs (risk of neurological damage due to demyelination; Osmotic Demyelination Syndrome) 

• Fluid overload – restrict water intake 

• Monitor I&Os, daily weight, vitals, level of consciousness 

Osmotic Demyelination Syndrome S/S - Hyponatremia (5)

• Dysarthria – slurred speech 

• Dysphagia  

• Spastic Quadriparesis – Stiff, weak limbs 

• Altered mental status 

• Locked in Syndrome (rare) 

Define Hypernatremia (2)

• Sodium >145

• Severe neuro, endocrine & cardiac disturbances

Patho - Hypernatremia (2)

• Increased sodium causes shift of water out of cells resulting in dehydrated cells

• Fluid loss or excess sodium

Hypernatremia S/S (6)

• Thirst & Dry mucous membranes 

• Vitals – hyperthermia, tachycardia, orthostatic hypotension 

• Restlessness & irritability 

• Muscle twitching, muscle weakness, decreased or absent DTRs 

• Seizures & coma 

• N/V, anorexia, & diarrhea

Complications - Hypernatremia (4)

• Severe hypernatremia 

• Convulsion 

• Seizures 

• Deaths 

IV Treatment - Hypernatremia (6)

• Hypotonic solutions (low salt)  

• Dextrose 5% in 0.45 sodium chloride (hypertonic → hypotonic)  

• D5W & NS (isotonic)  

• 0.45% saline (½ NS)  

• 0.33% saline (1/3 NS)  

• 0.225% saline (¼ NS)  

Treatment - Hypernatremia (2)

• Encourage water intake & decreased sodium  

• Loop Diuretics – clients with poor kidney excretion   

Define Cerebral Edema - Hypernatremia (2)

Occurs in rapid sodium correction

Water rushes into brain cells causing them to swell = cerebral edema  

Cerebral Edema S/S - Hypernatremia (4)

• Headache   

• Increased ICP (pupil changes, decreased LOC, posturing)  

• Confusion & irritability  

• Altered LOC leading to coma 

Interventions - Hypernatremia (6)

• Monitor level of consciousness, vitals, & heart rhythm. 

• Auscultate lung sounds. 

• Provide oral hygiene and other comfort measures to decrease thirst. 

• Monitor I&O & alert the provider of inadequate urinary output. 

• Monitor potassium levels if diuretics are administered. 

• Implement seizure precautions 

Define Hypokalemia

Potassium level < 3.5

Patho - Hypokalemia

Increased loss of potassium from the body or movement of potassium into cells 

Hypokalemia S/S (4)

• Vitals – Thready weak pulse, hypotension, shallow breathing

• Neurologic - Altered mental status, anxiety, & lethargy that progresses to acute confusion & coma. 

• GI - Hypoactive bowel sounds, N/V constipation, abdominal distention; Paralytic ileus can develop. 

• Muscular –Weakness, DTRs can be reduced. 

Complications - Hypokalemia (2)

• Respiratory Failure

• Cardiac Arrest

Respiratory Failure Nursing Actions - Hypokalemia (Complications) (3)

• Maintain open airway

• Monitor vitals, level of consciousness, hypoxemia, & hypercapnia

• Assist with intubation & ventilation

Cardiac Arrest Nursing Actions - Hypokalemia (Complications)

Continuous cardiac monitoring & treat dysrhythmias

Treatment - Hypokalemia (Complications) (3)

• Oral Replacement (food)– Avocados, broccoli, dairy, dried fruit, bananas, juices, melon, lean meats, milk, whole grains, and citrus fruits. 

• IV – Never give bolus, 10 mEq/hr. of no more per 1 mEq per 10 mL 

• Avoid diuretics & laxatives 

Interventions - Hypokalemia (7)

• Administer prescribed potassium replacement; Never give IM or subq (necrosis of tissue) 

• Monitor & maintain adequate urine output. 

• Observe for shallow ineffective respirations & diminished breath sounds. 

• Monitor cardiac rhythm, level of consciousness, SpO2, bowel sounds, & abdominal distension. 

• Monitor clients receiving digoxin (Hypokalemia increases the risk for toxicity) 

• Assess hand grasps for muscle weakness & DTRs. 

• Implement fall precautions 

Define Hyperkalemia (2)

• Potassium > 5.0

• Increased risk of cardiac arrest & rare in clients with normal kidney function

Patho - Hyperkalemia (3)

Due to:

• Increased potassium intake

• Increased movement of potassium out of cells

• Inadequate kidney excretion

Hyperkalemia S/S (4)

• Vitals - Slow irregular pulse, hypotension 

• Neuromusculoskeletal - Restlessness, irritability, weakness, flaccidity, paralysis, paresthesia 

• GI - Increased motility, diarrhea, hyperactive bowel sounds 

• Oliguria 

Complications - Hyperkalemia

Cardiac Arrest

Medications - Hyperkalemia (8)

• Severe hyperkalemia – calcium gluconate  

• IV fluids – D5W (glucose), regular insulin, loop diuretics  

• Sodium bicarbonate – reverses acidosis  

• Sodium Polystyrene (Kayexalate) - Excretes potassium through feces 

• Albuterol 

• Patiromer (valtassa) - Lowers potassium by binding in GI tract; chronic hyperkalemia 

• Sodium zirconium (lokelma) 

• Chronic/severe hyperkalemia – dialysis 

Interventions - Hyperkalemia (6)

• Priority – Prevent falls, assess for cardiac complications, health education 

• Monitor cardiac rhythms, I&O, potassium levels 

• Assess for muscle weakness, GI manifestation (nausea, intestinal colic) 

• Elevated Potassium – report, stop IV infusion of potassium, stop all supplements, restrict potassium food 

• Monitor for hypokalemia while treating hyperkalemia 

• Avoid administering whole blood or packed RBCs in patients with impaired kidney function 

Define Hypocalcemia (2)

• Includes relative & actual calcium deficit

• Calcium levels below 9.0

Define Actual Hypocalcemia (7)

• Inadequate intake of calcium

• Lactose intolerance

• Malabsorption

• Diarrhea

• Inadequate vitamin D

• End-stage kidney disease

• Wound drainage

Define Relative Hypocalcemia (6)

• Alkalosis

• Pancreatitis

• Hyperproteinemia

• Hyperphosphatemia

• Immobility

• Parathyroid removal/drainage

Hypocalcemia S/S (10) Many People Hate People So They Hate

• Tetany 

• Paresthesia of fingers & lips (early manifestation) 

• Muscle twitches & spasms in foot/calf 

• Seizures

• Hyperactive DTRs 

• Positive Chvostek’s sign (tapping on the facial nerve, causing twitching) 

• Positive Trousseau’s sign (hand/finger spasms with BP cuff) 

• GI – hyperactive bowel sounds, diarrhea, abdominal cramps 

Treatment - Hypocalcemia (4)

• Oral or IV calcium supplements

• Vitamin D supplements enhance the absorption of calcium

• Foods high in calcium - Dairy, canned salmon, sardines, fresh oysters, & dark leafy green vegetables.

• Life-threatening Manifestations - Rapid treatment with calcium gluconate or calcium chloride, give slowly (cardiac arrest risk) 

Interventions - Hypocalcemia (2)

• Implement seizure, fall precautions & have emergency equipment on standby. 

• Avoid overstimulation - Keep room quiet, limit visitors, & use soft lighting  

Define Hypercalcemia

calcium > 10.5 mg/dL

Patho - Hypercalcemia (2)

• Excess calcium due to increased bone resorption, increased GI absorption, or decreased renal excretion

• Commonly from hyperparathyroidism or malignancy. 

Hypercalcemia S/S (6)

• Weakness & fatigue 

• Hypoactive DTRs 

• Confusion & lethargy 

• Constipation & nausea 

• Bone pain 

• Renal calculi (kidney stones) 

Complications - Hypercalcemia (4)

• Cardiac dysrhythmias 

• Kidney stones / renal failure 

• Pathologic fractures 

• Coma 

Medications - Hypercalcemia (5)

• IV fluids - NS; dilute calcium 

• Calcitonin 

• Bisphosphonates (alendronate, pamidronate) 

• Loop diuretics (furosemide) to promote Ca²⁺ excretion 

• Glucocorticoids (Vitamin D–related) 

Interventions - Hypercalcemia (5)

• Increase oral hydration (3–4 L/day if tolerated) 

• Monitor cardiac rhythm 

• Mobilize patient to reduce bone calcium release 

• Avoid high-calcium foods & supplements 

• Strain urine for stones 

Define Hypomagnesemia

Magnesium level less than 1.3

Hypomagnesemia S/S (4) Can Nerds Do Homework

• Cardiovascular - Risk for increased BP, dysrhythmias

• Neuromuscular - hyperactive DTRs, paresthesia, muscle tetany, seizures, positive Chvostek’s and Trousseau’s signs 

• Depressed mood, apathy, or agitation 

• Hypoactive bowel sounds, constipation, abdominal distention, paralytic ileus 

Treatment - Hypomagnesemia (3)

• Foods high in magnesium - dark green vegetables, nuts, whole grains, seafood, peanut butter, cocoa 

• Administer oral magnesium sulfate for mild hypomagnesemia 

• IV magnesium sulfate is prescribed if hypomagnesemia is severe; Monitor DTRs hypoactive DTRs = magnesium toxicity (stop ASAP) 

Interventions - Hypomagnesemia (4)

• Correct concurrent imbalance of other electrolytes to prevent worsening of either condition. 

• Discontinue magnesium-depleting medications - loop diuretics, osmotic diuretics, medications that contain phosphorus. 

• Monitor clients taking digitalis closely if magnesium is low (digitalis toxicity risk) 

• Have calcium gluconate readily available to reverse hypermagnesemia. 

Define Hypermagnesemia

Magnesium levels > 2.1 

Patho - Hypermagnesemia

Excess magnesium from renal failure, excessive Mg-containing antacids/laxatives, or overcorrection of hypomagnesemia

Hypermagnesemia S/S (4) How Lame Man Really

• Vitals - hypotension, bradycardia

• Lethargy, drowsiness 

• Muscle weakness & Decreased DTRs  

• Respiratory depression 

Complications - Hypermagnesemia (4)

• Cardiac arrest 

• Respiratory failure 

• Severe hypotension/shock 

• Coma 

Reversal/Treatments - Hypermagnesemia (3)

• Calcium Gluconate IV (antidote) - antagonizes magnesium effects on heart & muscle (arrhythmias/respiratory depression)  

• IV fluids & loop diuretics  

• Dialysis – severe hypermagnesemia  

Priority Nursing Actions - Hypermagnesemia (3)

• Stop magnesium source immediately

• Encourage fluids

• Monitor airway, RR, & BP

Define Fluid Balance Homeostasis

Homeostasis is maintained when body fluid volume, concentration (osmolality), composition, & pH remain in balance 

Fluid Movement (2)

• Fluid moves between compartments via diffusion, active transport, filtration & osmosis to maintain homeostasis 

• Compartments - ICF & ECF

Fluid Balance is Maintained Through… (2)

• I&O

• Fluid output = kidneys (major regulator), skin, lungs, GI  

Define Fluid Imbalances

Too little/too much isotonic fluid 

Define Osmolality Imbalances

Fluid becomes hypertonic/hypotonic 

Define Dehydration

A lack of fluid from insufficient intake or excess loss

Patho - Dehydration

Includes actual & relative & hypovolemia/isotonic dehydration

Define Actual Dehydration

Lack of fluid in the body

Define Relative Dehydration

Shift of water from blood (plasma) to the interstitial space

Define Hypovolemia/Isotonic Dehydration (2)

• Lack of both water & electrolytes decreasing blood volume

• Fluid volume deficit

Dehydration S/S 1 of 2 (13)

• Vitals - Hypothermia, Fever, Tachycardia, Thready pulse, Hypotension, Tachypnea, Hypoxia

• Decreased central venous pressure 

• Syncope

• Confusion

• Weakness & Fatigue

• Thirst

• Dry furrowed tongue, dry mucous membranes, poor skin turgor

• N/V, Anorexia, & acute weight loss

• Oliguria & dark urine

• Diminished capillary refill

• Cool clammy skin & diaphoresis

• Sunken eyes

• Flattened neck veins

Dehydration - Urine Specific Gravity

> than 1.030

Complications - Dehydration

Hypovolemic Shock

Define Hypovolemic Shock

Mean arterial pressure decreases > slows blood flow & perfusion to body tissues > cells can no longer carry oxygen to blood (loss of RBCs)

Hypovolemic Shock - Nursing Actions (5)

• Administer O2

• Monitor SpO2

• Stay with client

• Monitor vitals every 15 min

• Hemodynamic monitoring

Hypovolemic Shock - Treatment

Fluid replacement with Colloids & Crystalloids

Vasoconstrictors

Positive Inotropic Meds

Colloids (Hypovolemic Shock) (3)

• Whole blood

• Packed RBCs

• Plasma

Crystalloids (Hypovolemic Shock) (2)

• LRs

• NS

Vasoconstricters (Hypovolemic Shock) (3)

• Dopamine

• Norepinephrine

• Phenylephrine

Positive Inotropic Medications (Hypovolemic Shock) (2)

• Dobutamine

• Milrinone

Treatment - Dehydration

• Oral or IV rehydration therapy (saline) 

Interventions - Dehydration (4)

• Monitor I&O, vitals (BP & HR), changes in mentation/confusion 

• Monitor weight every 8 hr while fluid replacement is in progress. 

• Assess level of gait stability; Encourage client to use call light & ask for assistance because of fall risk. 

• Encourage client to change positions, rolling from side to side or standing up slowly

Define Overhydration

Too much fluid in the body from excess intake or ineffective removal.

Define Fluid Overload (4)

• Excess fluid or water

• Water intoxication

• Hemodilution

• Lowers blood components (blood cells, electrolytes)

Define Hypovolemia/Fluid Volume Excess (2)

• Excess of water & electrolytes

• Excess sodium causes water retention

Overhydration S/S (11)

• Vitals - Tachycardia, bounding pulse, hypertension, tachypnea

• Increased central venous pressure 

• Weakness 

• Visual changes 

• Paresthesia 

• Altered level of consciousness 

• Seizures  

• Peripheral edema & weight gain 

• Distended neck veins 

• Increased urine output, clear urine 

• Pallor & cool skin 

Fluid Volume Overload S/S (7)

• Vitals – Hypertension, tachycardia, tachypnea, increased RR, decreased O2 sat 

• Altered Mental Status 

• Increased Jugular Venous Pressure 

• Hepato Jugular Reflux 

• Increased Body Weight 

• Orthopnea 

• Pitting Edema 

Pitting Edema Grades (4)

• 1+ - < 2 mm depression barely detectable & immediate rebound 

• 2+ - 2-4 mm deep pit, few seconds to rebound 

• 3+ - 5-7 mm deep pit, 10 to 12 seconds to rebound 

• 4+ - > 7 mm very deep pit, 20 seconds to rebound 

Fluid Overload Interventions (5)

• D – diuretics 

• R- restrict fluids & sodium 

• A – assess daily weight 

• I – I & O 

• N – Na+ levels monitored & other electrolytes 

Weight Gain - Overhydration (6)

• Monitor weight daily  

• Notify provider if there is 1-2 lb. weight gain in 24 hrs. OR 3 lb. weight gain in 1 week 

• Excess weight gain = heart failure/pulmonary edema 

• 2 lbs. a day = STABLE in heart failure 

• > 2 lbs. a day or 5 lbs. in a week = fluid overload 

• 1kg (2.2 lbs) = 1 L of fluid 

Complications - Overhydration (2)

• Pulmonary Edema  

• Congestive Heart Failure 

Pulmonary Edema S/S - Overhydration (8)

• Vitals - tachycardia, dyspnea at rest

• Anxiety

• Increased neck/hand vein distention

• PVCs

• Change in level of consciousness

• Restlessness

• Lethargy

• Crackles & productive frothy pink sputum cough  

Pulmonary Edema Nursing Actions - Overhydration (4)

• Position in high fowler’s

• Administer O2

• PAP

• Intubation & mechanical ventilation if needed

Pulmonary Edema Medications - Overhydration (3)

• Morphine

• Nitrates

• Diuretics

Treatment - Overhydration (3)

• Sodium-restricted diet - indicated for isotonic/fluid volume excess 

• Fluid Restrictions

• Diuretics

Interventions - Overhydration (7)

• Monitor I&O, peripheral edema, breath sounds, daily weight (weight gain or loss of 1 kg (2.2 lb) in 24 hr. is equivalent to 1 L of fluid) 

• Encourage rest. 

• Monitor clients receiving diuretics. 

• Encourage clients to discuss the use of OTC medications, as some of these contain sodium. 

• Position - Semi-Fowler’s or Fowler’s position & reposition to prevent tissue breakdown in edematous skin. 

• Use a pressure-reducing mattress & assess bony prominence on a regular basis. 

• Monitor sodium & potassium levels.