MedSurg Fluid and Electrolytes

What are common risk factors of electrolyte imbalance?

• Elderly

• Diuretic therapy

• Kidney disease

• Dehydration

• GI fluid losses

What are common manifestations of electrolyte imbalances?

• Decreased respiratory muscle function (hypokalemia)

• Changes in cardiac function

• Changes in neurological function

• Changes in GI motility

• Decreased skeletal muscle function

What are common interventions for electrolyte imbalances?

• Address cause of imbalance

• Monitor level of consciousness

• Daily weight

• skin turgor

• Intake and output

• Monitor cardiac status (BP, P, heart sounds, ECG if appropriate)

• Fall risk safety

• Monitor intestinal status (abdominal assessment, N/V/D)

• Monitor labratory values

• Administer appropriate medication to correct imbalance

• Patient education

How do you treat hyponatremia?

• Increase sodium intake (slowly)

• Restrict free water (for dilutional hyponatremia)

• Severe cases: cautiously administer 3% saline

• If caused by FVE: admin diuretics that promote water excretion while maintaing sodium

• If caused by excess diuretics promoting sodium loss: decrease dose of diuretic

• SEIZURE precautions!

How do you treat hyperkalemia?

• Provide IV fluids if imbalance is caused by fluid loss

• Limit sodium intake and/or increase fluid intake (depends on cause)

• Teach to read food lables and use salt substitutes

What are examples of high sodium foods?

• Table salt

• Bouillon cubes/soups

• Soy sauce

• Cheese

• Cottage cheese

• Carrots

• Dried fruits

• Canned foods

• Snack food/pretzels

• Pickled foods

• Spinach

• Lunch meats

• Bacon, Salami

• Dried cereals

• Graham crackers

• Popcorn

• Potato chips

• Ketchup

• Salad dressing

How do you treat hypokalemia?

• Ask about medications (diuretics, digoxin)

• Cardiac monitor!

• Mild: potassium oral supplements (give w/food)

• Severe: IV replacement, max 20meq/hr, tissue irritant (monitor respiratory status)

How do you treat hyperkalemia?

• Avoid salt substitutes, which are high in K+

• Eat low potassium foods

• Use K+ wasting diuretics

• Give IV insulin to bring K+ into cell (in addition to IV D5 to normalize BGL)

• Cardiac monitor!!

What are high potassium foods?

• APricots

• Avocados

• Bananas

• Melons

• Kiwi

• Dates/figs

• Oranges

• Beans

• Potatoes

• Squah

• Tomatoes

• Sweet potato

• Beets

• Yogurt

• Carrot juice

• Milk

• Cantaloupe

• Orange juice

• Spinach

How do you treat hypocalcemia?

• Drug therapy: calcium replacement IV

• Oral replacement: may interfere with absorption of other medications if given at the same time

• Nutrition: high calcium diet

• Injury prevention measures if chronic hypocalcemia

• Cardiac monitor!

• Neuromuscular changes: numbness/tingling and tetany

How do you treat hypercalcemia?

• Stop meds that contain or increase calcium

• Encourage fluids for renal excretion of calcium

• Diuretics such as furosemide excrete calcium

• Cardiac monitor!

• Neurmuscular changes: severe weakness and decreased deep tendon reflex

What are foods high in calcium?

• Cheese

• Yogurt

• Milk

• Sardines

• Dark leafy greens

• Fortified orange juice

• Soybeans

• Tofu

• Salmon

• Enriched breads and grains

What are causes of fluid volume deficit (FVD)/DEHYDRATION?

• Hemorrhage

• Vomiting

• Diarrhea

• Fluid leakage: fistulas

• Ileostomy

• Burns

• Severe wounds

• NPO

• Diuretic therapy

• GI suction

• Diabetes insipidus

• Difficult swallowing

• Fever

What are causes of Fluid Volume Excess (FVE)/FLUID OVERLOAD?

• IV fluids: too much or too fast

• Blood transfusion

• Failure to excrete fluids (kidney failure)

• Heart failure

• Obstructed lymph system

• Long-term corticosteroid therapy

• Syndrome of inappropriate antidiuretic hormone (SIADH)- too much of not diuresing

For Fluid Volume Deficit, what would you assess/see with the different systems?

• Weight: loss

• Cardiovascular: HR- tachycardia, pulses- weak, BP- hypotension (orthostatic, pressure can’t compensate to get fluid up to brain, dizziness/light headed), Veins: neck and hand flat

• Respiratory: RR- increased (need for oxygen)

• Skin: turgor- poor with tenting, mucous membranes (dry, cracks)

• Neurological: confusion

• Organs: Kidney- reduces blood flow to the kidneys, forcing them to conserve water, concentrate urine, and risk a sudden drop in function, Urine- specific gravity >1.030, dark, order, output below 500ml/day

For Fluid Volume Excess, what would you assess/see with the different systems?

• Weight: gain

• Cardiovascular: HR- tachycardia, Pulse- bounding, BP- elevated, Pulse pressure- decreased, Central venous pressure- elevated, Veins- distended, engorged

• Respiratory: RR- increased, shallow, SOB, crackles

• Skin: pitting edema, pale and cool to touch

• Neurological: ALOC, HA, visual changes, muscle weakness

• Organs: GI- increased motility, enlarged liver, Urine- specific gravity depends, output also depends

With FVD what do their lab values look like?

• Hgb: Elevated (hemoconcentration)

• Hct: Elevated

• Serum osmolality: Elevated

• Glucose: Elevated

• Protein: Elevated

• BUN: Elevated

• Electrolyes: Elevated

With FVE what do their lab values look like?

• Hgb: Decreased (hemodilution)

• Hct: Decreased

• Serum osmolality: Decreased

• Glucose: Decreased

• Protein: Decreased

• BUN: Decreased

• Electrolyes: Decreased

With FVD what is the goal, treatment, and priority?

• Goal: prevent further fluid loss, return fluid volume to normal, and prevent complications from FVD

• Fluid replacement: begin with oral fluids (offere every 2hrs), IV fluids (assess cardiac, pulmonary or kidney problems), Do not withhold fluid for incontinence

• Medications: antiemetic, antidiarrheal, antipyretics, antibiotics

• Monitor: VS, I&O, daily weight

• Priority: patient safety (Fall risk, Risk for adverse effects from parental therapy)

With FVE what is the goal, critical rescue, and priority?

• Goal: restore normal fluid balance, prevent complications of FVE, and prevent future fluid overload

• Cirtical rescue: pulmonary edema can occur very quickly and lead to death

  • At risk: elderly or adults with cardiac, kidney, pulmonary or liver problems

• Priority: patienty safety

  • Monitor VS and lungs sounds, accurate I&O/daily weights, at risk for developing AE from treatment of FVE (might do it too well)

With FVE what is the treatment?

• Drug therapy: loop diuretics- furosemide (lasix)

  • Increases urine output, monitor potassium and sodium levels, monitor ECG changes

• Nutrition therapy: restirct water and sodium (2-4 g/day)

• Weight: call HCP if gain more than 3 lbs/week or 2 lbs in 24 hrs

• Assess respiratory and CV status often: administer oxygen as prescribed

• Assess for skin breakdown

FVD evaluation

• No longer experiencing FVD → BP increased, urine output increases, electrolyte balance, skin turgor normal, moist mucous membranes

• AE from treatment → FVE (crackles in lungs, pitting edema, VS changes)

FVE evaluation

• No longer experience FVE → lung sounds normal, decreased edema, decreased SOB, VS improvement, decreased weight

• AE from treatment → FVD

Types of IV Fluids

• Hypotonic

  • Tonicity: <270 mOsm/L

  • Moves water into cells

  • .45% NS

• Isotonic:

  • Tonicity: 270-300 mOsm/L

  • Water neither moves in/out of cells

  • .9% NS, LR, D5W in bag (hypo in body)

• Hypertonic:

  • Tonicity: >300 mOsm/L

  • Moves water out of cells

  • D5LR, D%NS, D5 ½ NS in bag (hypo in body), TPN

What are the different vascular access devices- peripheral IVs?

• Short peripheral catheters: usually inserted into superficial veins of forearm, intended for short term use (<6days)

• Midline catheter: usually inserted into median antecubital vein, catheter tip located in upper arm, intended for vascular access (>6 days)

• Cannot be used for high-osmolarity infusates or vesicants!!

What is the difference from Peripheral IV therapy with Central Vascular Access Devices?

• No limitations on pH or osmolarity of infusate

• Ex’s: Non tunneled catheter, tunneled catheter, PICC line, implanted port

What is the difference between non-tunneled and tunneled?

• Non-tunneled CVAD: inserted by provider, usually into subclavian vein in upper chest or jugular vein in neck, usually inserted in emergent situations only

• Tunneled CVAD: surgical insertion by provider; portion of catheter lies in sub-q tunnel to prevent infection, intended for frequent/long-term infusion therapy (months to years)

What are Peripherally Inserted Central Catheters (PICC)?

• Indications: lengthy courses of antibiotics, chemotherapy agents, parenteral nutrition, vasopressors

• Intended for months of vascular access or when peripheral site is not possible

What are implanted port-a-cath (port)?

• Inserted into subclavian or jugular vein with access port in sub-q pocket in chest/upper extremity

• Intended for vascualr access >1 year

What is a hemodialysis catheter?

• Used for dialysis only

• Very large lumens accommodate hemodialysis

• DO NOT use for adminstering other fluids/medications (except in emergency)

What are complications of peripheral line IV therapy?

• Local Complications: infiltration, extravasation, phlebitis, thrombosis and thrombophlebitis, ecchymosis and hematoma, site infection, venous spasm, nerve damage

What are complications of Central Line IV therapy?

• Central Line Associated Blood Stream Infection (CLABSI) → biggest concern

• Occlusion

• Catheter dislodgment

What are complications of both peripheral lines and central lines?

• Fluid volume overload

• Catheter embolism

How can you prevent complications of peripheral VADs?

• Select appropriate site and catheter size

• Monitor site frequently

• Educate pts about symptoms of complications

• Administer meds into appropriate sites at correct rates

• Adequately secure catheter

• Use aseptic technique for insertion

• Rotate sites per facility policy

What is treatment for complications of peripheral VADs?

• Remove catheter for all complications

• Redness or inflammation → cool compress

• Swollen → elevate

• Cool to touch → warm compress

• Extravasation → administer antidote

• Bleeding → apply pressure

• Infection → clean site, send catheter for culture

How can you prevent complications of CVADs?

• Hand hygiene before and after all contact with the CVAD

• Change tubing at least every 96hrs

• Skin asepsis: daily chlorhexidine (CHG) baths, sterile dressing, CHG-impregnated patch dressing, change dressing 24hrs after insertion, change dressing on a scheduled basis (depending on dressing)

• Daily review of necessity with removal of unnecessary lines

• Scrub the hub for a minumum of 15 sec before accessing

How can you prevent and treat complications of CVADs?

• Catheter dislodgment:

  • Prevent: secure catheter properly, advise the pt to avoid physical exertion

  • Treatment: stop infusion, advise provder

• Occulusion:

  • Prevent: flush before/between/after each med, use positive pressure flush (push, pause)

  • Treatment: may administer thrombotic enzymes

What is Total Parenteral Nutrition (TPN)?

• Daily nutrients given in IV form if GI tract not functional

• May include lipids (only thing that can be y-sided), electrolytes, proteins and dextrose

• Must be given through CVAD

What are SE and AE of TPN?

• Fluid overload- consistency and quantity

• Electrolyte imbalance

• Infection

• Blood glucose imbalance

  • have deficit → hypertonic fluid w/ lots of sugar/electroyltes → causes BG to spike initially → often resolves themselves once body becomes regulated

What is BMP/BMET?

• Why: checks electrolytes, glucose, kidney function, acid-base status

• Assess if: weakness, confusion, dehydration, vomiting/diarrhea, kidney disease, dysrthmias

• Measures: sodium, potassium, chloride, carbon dioxide/bicarbonate, glucose, BUN, creatinie, calcium

• Considerations: blood draw- fasting may be required

• Normal: within ranges, abnormal: high/low values

What is CMP/CMET?

• Why: same as BMP + liver/protein assessment

• Asess if: suspected liver/kidney disease, jaundice, fatigue, abdominal symptoms

• Measures: BMP, albumin, total protein, AST, ALT, ALP, bilirubin

• Considerations: blood draw- fasting may be required

• Normal: within ranges or abnormal: depends on specific value/severity