fluids & electrolyte problems

when to evaluate electrolytes

- any illness that can cause electrolyte derangement

- arrhythmias, cardiac arrest

- use of diuretics

- TPN therapy

what are illnesses that cause electrolyte derangement?

- malnutrition/ GI disorders

- cardiac disorders

- kidney dysfunction

- endocrine disorders

- circulatory disorders

- lung disorders

what is a serum osmolality test?

a measurement to determine the number of solutes present in the blood (serum) that helps determine hydration status

what are serum osmolality tests ordered to evaluate?

hypoantremia: result of sodium lost in the excretion of urine or excess fluid in the bloodstream

what can excess fluid in the bloodstream be caused by?

- water retention

- drinking excessive amounts of water

- decreased ability of the kidneys to produce urine

- presence of osmotically active agents like glucose

what happens to osmolality when someone is overhydrated?

it decreased

what happens to osmolality when someone is dehydrated?

it increases

normal urine specific gravity level

1.010 - 1.030

what can cause urine specific gravity to increase?

- suspected fluid deficit

- dehydration (vomiting, diarrhea, excessive sweating)

- urine is concentrated

what can cause urine specific gravity to decrease?

- suspect well hydrated

- correlate with fluid excess (CHF, renal failure)

- urine is watery, dilute

what is intake?

- fluids taken IN the body

- via routes like mouth, tube, IV

what is output?

fluids that leave the body

insensible loss

- from skin and respiratory system

- can't be measured

insensible loss is estimated to be how much per day?

- 600 mL/day

- depends on patient's activity level, temp etc.

what is the goal for most patients regarding I/O?

euvolemia ( I = O )

what does net negative negative mean?

input < output

output > input

patient is losing more than they take in and is in deficit

input > ouput

patient may be retaining fluid and is in fluid overload

interpreting intake & output

- always correlate with physical assessment, vitals, and labs to "get full picture"

- ask why does my patient have a fluid imbalance?

daily weights

- non-invasive measurement that assists in the diagnosis of fluid issues

- rapid weight gains & losses

- take at same time each day

- can use standing scale or calibrated bed scale

- very important in HF management

rapid weight gains & losses

- can be indicative of a problem

- excellent way to evaluate effectiveness of therapy

edema

a collection of excess fluid in the interstitial space

when does edema commonly present?

when a person is fluid volume overload

- rapid infusion of 3L of NS

- stage III right side CHF

can edema exist on fluid volume deficit patients?

yes, ex: severe protein malnourishment, pt. leaks albumin into interstitial space & fluid follows

what are other causes of edema?

- trauma

- infection

- vascular impairments

what factors influence fluid and electrolyte balance?

- age

- environmental temp

- diet

- stress

- illness

- medical treatment

- medications

- surgery

total body weight

50-70% water, 2/3 is intracellular

how is water divided in the body?

- 2/3 intracellular

- 1/3 extracellular

what are components of extracelluar fluid?

- 80% interstitial fluid

- 20% plasma

extracellular fluid volume deficit

occurs when there is too little isotonic fluid in the extracellular compartment

hypovolemia

decreased vascular volume and often is used when discussing ECV deficit

clinical dehydration

occurs when there is an extracellular fluid volume deficit in combination with hypernatremia

extracellular fluid volume excess

occurs when there is too much isotonic fluid in the extracellular compartment

hypervolemia

increased vascular volume and often is used when discussing FVE

causes of fluid volume deficit

- vomiting, diarrhea, fever, infection

- excessive sweating

- heat-related illness

- excessive urination (renal disease, adrenal insufficiency, overuse of diuretics)

- blood loss from wounds, injuries & bleeding disorders

- severe burns

- decreased or inadequate fluid intake

causes of fluid volume excess

- water intoxication

- too rapid/large volume infusions

- heart failure

- cirrhosis

- kidney failure

- nephrotic syndrome

fluid volume deficit vitals

- increased pulse, weak (1+, thready)

- decreased BP

- orthostatic hypotension

- increased temp. unless in shock

fluid volume deficit symptoms

- changes in awareness & mental state

- weakness & tiredness

- thirst

- weight loss (rapid)

- dark urine or low urine output

- dry mucous membranes

- reduced skin turgor or elasticity

- capillary refill of > three seconds

fluid volume deficit labs

- increased urine specific gravity

- increased Hct (hemoconcentrated)

- increased BUN (hemoconcentrated)

-increased osmolality

fluid volume deficit treatment

- identification of vulnerable patients

- oral fluids

- IVFs

- protect from injury due to decrease in BP

fluid volume excess vitals

- increased pulse ( > 3+, bounding)

- increased RR, dyspnea

- increased BP

fluid volume excess symptoms

- peripheral edema

- weight gain (rapid)

- JVD

- moist crackles in lungs, SOA

- intake > output

- headache

fluid volume excess labs

- decreased urine specific gravity

- decreased Hct (hemodiluted)

- decreased BUN (hemodiluted)

- decreased osmolality

fluid volume excess treatment

- identify and treat underlying pathology

- administer diuretics

- restrict fluids

why are electrolytes important?

water balance, acid-base balance, nerve conductivity and muscle contractility, and many other cellular functions

what does sodium play a primary role in?

- body's fluid balance

- impacts functioning of bodily muscles & CNS

normal sodium levels

135-145 mEq/L

hyponatremia level

< 135

hypernatremia level

> 145

hypovolemic hyponatremia

body loses sodium and water

hypovolemic hyponatremia causes

- vomiting

- diarrhea

- NG suction

- diuretic therapy

- burns

- sweating

- drugs (laxatives, diuretics, corticosteroids)

hypervolemic hyponatremia

where the body has increased in fluid & sodium but sodium decreases due to dilation

hypervolemic hyponatremia causes

- CHF

- kidney failure

- IV infusion of saline

- liver failure

s/s of hyponatremia: SALT LOSS

- Seizures

- Abdominal cramping

- Lethargic

- Trouble concentrating

- Loss of urine & appetite

- Orthostatic hypotension

- Shallow respirations

- Spasms of muscles

hyponatremia assessment

- cardiac

- respiratory status

- neuro

- GI

hyponatremia monitor

- cardiac monitor/telemetry

- vitals

hyponatremia treatment options

- increase oral sodium intake

- restrict fluid intake

- administer diuretics to excrete extra water rather than sodium to help concentrate sodium

- critical? hypertonic IV solution given in ICU in a central line

hyperantremia causes

- endocrine disorders

- loss of fluids (dehydrated)

- infection (fever)

- sweating

- diarrhea

- diabetes insipidus

- thirst impairment

hypernatremia s/s: FRIED

- fever, flushed skin

- restlessness & confusion

- increased fluid retention

- edema

- decreased urine output, dry mouth/skin

hypernatremia assessment

neuro, oral cavity

hypernatremia monitor

neuro, vital signs

hyperantremia treatment options

- force fluids

- sodium restriction

- hypotonic IV fluids

why do you need to give hypotonic IV fluids slowly in someone with hypernatremia?

brain tissue is at risk due to shifting of fluids back into the cell & pt. is at risk for cerebral edema

what does potassium do?

promotes & facilitates electrical impulses that are necessary for muscle contractions & also for normal functioning of brain & heart

normal potassium levels

3.5-5.0 mEq/L

hypokalemia levels

< 3.5

hyperkalemia levels

> 5.0

hypokalemia causes

- heavy fluid loss (NG suction, vomiting, diarrhea, wound drainage, sweating)

- drugs (laxatives, diuretics, corticosteroids)

hypokalemia s/s: the 7 L's

- lethargy (confusion)

- low, shallow respirations

- lethal cardiac dysrhythmias

- lots of urine

- leg cramps

- limp muscles

- low BP & heart

hypokalemia assessment

- cardiac

- respiratory status

- neuro

- GI

- urinary output & renal status (BUN/creatinine)

hypokalemia monitor

- cardiac monitor/telemetry

- vitals

- magnesium levels

PO potassium can cause what?

GI upset

IV potassium

- never give PUSH

- IVPB over 1 hr

- watch for infiltration

- must be on telemetry

what do you avoid with hypokalemia?

- Lasix

- thiazides

hypokalemia diet

potassium rich foods: broccoli, bananas, dark green leafy veggies, fortified cereals, raisins

hyperkalemia causes

- renal failure

- excessive potassium intake

- drugs (potassium-sparing drugs: spirnolactone, triamterene, ACE inhibitors, NSAIDs)

hyperkalemia s/s: MURDER

- muscle weakness

- urine (oliguria/anuria)

- respiratory failure

- decreased cardiac contractility

- early signs of muscle twitches/cramps... late profound weakness, flaccid

- rhythm changes (EKG)

hyperkalemia assessment

- cardiac

- respiratory

- neuromuscular

- renal

- GI status

hyperkalemia monitor

- cardiac monitor/telemetry

- vitals

what do you need to avoid with hyperkalemia?

potassium sparing drugs

hyperkalemia treament options

- kayexalate: promotes GI sodium absorption which causes potassium excretion

- potassium wasting drugs: lasix or HCTZ

- glucose & regular insulin: pulls the serum

- dialysis, if indicated

what does magnesium do in the body?

- plays important role in enzyme activity & brain neuron activity,

- contraction of skeletal muscles & relaxation of respiratory smooth muscles

- metabolism of Ca, K, Na

normal magnesium levels

1.3-2.1 mg/dL

hypomagnesemia levels

< 1.3

hypermagnesemia levels

> 2.1

hypomagnesemia causes

- hypokalemia, hypocalcemia

- alcohol dependence

- malabsorption/insufficient dietary intake

hypomagnesemia s/s: TWITCHING

- trouesseau's

- weak respirations

- irritability

- torsades de pointes (abnormal heart rhythm that leads to sudden cardiac death), tetany (seizures)

- cardiac changes (EKG)

- hypertension, hyperreflexia

- involuntary movements

- nausea

- GI issues

hypomagnesemia assessment

- cardiac

- respiratory

- neuro

- GI

hypomagnesemia monitor

- cardiac monitor/telemetry

- vitals

- other electrolytes

what do you need to caution/avoid with hypomagnesemia?

PO magnesium (diarrhea)

hypomagnesemia treatment options

- administer magnesium sulfate IV route

- place pt. on seizure precautions

what do you need to monitor closely after giving magnesium sulfate IV?

monitor MG+ level closely because patient can become magnesium toxic

what sign shows magnesium toxicity?

depressed or loss of deep tendon reflexes

hypermagnesemia causes

over correction with Mg+ IV/PO supplements

hypermagnesemia s/s: LETHARGIC

- lethargy (profound)

- EKG changes

- Tendon reflexes absent or diminished

- hypotension

- arrhythmias (bradycardia, heart blocks)

- respiratory arrest

- GI issues (N/V)

- impaired breathing (due to skeletal weakness)

- cardiac arrest

hypermagnesemia assessment

- cardiac

- respiratory

- neuro

- GI

- renal

hypermagnesemia monitor

- cardiac monitor/telemetry

- vitals

- other electrolytes

hypermagnesemia treatment options

- ensure safety

- monitor cardiac rhythm, breathing

- assess for hypermagnesemia during IV infusions of magnesium sulfate for hypomagnesemia (early: diminished/absent deep tendon reflexes)

phosphate & calcium

- stored mainly in the bones. the kidneys and parathyroid play a role in the regulation of calcium and phosphate

- calcium and phosphate influence each other in opposite way. for example, when calcium levels increase in turn phosphate levels decrease (vice versa)

normal phosphate levels

3.0-4.5 mg/dL