fluids

Concept: Fluid and Electrolytes

Risk factors for impaired fluid and electrolyte imbalances
- Infants
  - High metabolic rate
  - Immature kidneys
  - More rapid respiration
  - Proportionally greater body surface
- Very Old
  - Thirst sensation blunted
  - Kidneys less able to respond to ADH
  - Impaired ability to conserve water of fluid and electrolyte imbalances
Recognize cues of fluid or electrolyte imbalances
- Fluid volume deficit
  - Restlessness, drowsiness, lethargy, confusion
  - Thirst, dry, mucous membranes
  - Cold clammy skin
  - Decreased skin turgor
  - Decreased capillary refill
  - Postural hypotension
  - Increased pulse
  - Decreased central venous pressure
  - Decreased urine output, concentrated urine
  - Increase respiratory rate
  - Weakness, dizziness
  - Weight loss
  - Seizures
  - Coma
  - Increased serum osmolality
  - Increased BUN
  - Increased hematocrit
- Fluid volume excess
  - Headache, confusion, lethargy
  - Peripheral edema
  - Jugular vein distention
  - S3 heart sounds
  - Bounding pulse
  - Increased bp and cvp
  - Polyuria with normal renal function
  - Dyspnea, crackles, pulmonary edema
  - Muslce spasm
  - Weight gain
  - Seizures, coma
  - Lowered serum osmolality
  - Lowered BUN
  - Diluted electrolytes
  - Decreased protein concentration
  - Increased BNP
Sodium - 136-145 mEq/L
- Balances acid base levels
- Regulates chloride
- Influences renal excretion of water
- Initiates neuromuscular reactions
- Opposition of potassium for membrane potentials
- Hypernatremia
  - Causes
    - Dehydration
    - NGT suction
    - Drains
    - Fever
    - Burns
    - Diarrhea
  - Cues
    - Altered mental status
    - Seizures
    - Agitation
    - Twitching
    - Thirst and dry membranes
    - Decreased cardiac contractility
  - Interventions
    - Cardiac monitoring
    - Seizure precautions
    - I’s and O’s
    - Vitals signs
    - IV D5%W
  - Complication risks
    - Seizure
- Hyponatremia
  - Causes
    - Hypervolemia
    - Psychogenic polydipsia
    - Diuretics
    - Burns
    - Poor sodium intake
    - SIADH
  - Cues
    - Altered level of consciousness
    - Confusion
    - Seizures
    - Weakness
    - Abdominal cramps
  - Interventions
    - Is and Os
    - Seizure precautions
    - Normal saline
    - 3% saline
    - Monitor vital signs, cardiac activity, and electrolytes
    - Withholding diuretics
  - Complications
    - Seizure risk
Potassium - 3.5-5 mEq/L
- Transmits nerve impulses
- Cardiac and skeletal muscle contraction
- Activates enzymes
- Acid base balance
- Regulates insulin and storage
- Hyperkalemia
  - Causes
    - Renal failure
    - Adrenal insufficiency leading to potassium retention
    - Acidosis
    - Excessive intake
    - ACE inhibitors
    - Burns
    - Fever
    - Crushing injury
  - Cues
    - Irritability
    - Abdominal cramps
    - Weakness
    - Cardiac arrhythmias
    - Peaked t waves
  - Interventions
    - Regular insulin and dextrose 50%IV
    - Kayexalate
    - Cardiac monitoring
    - Diuretics
    - Monitor vital signs and electrolytes
    - Possible renal dialysis
  - Risks
    - Cardiac arrest

Hypokalemia
- Causes
  - Nausea
  - Vomiting
  - Diarrhea
  - Diuretics
  - NG tubes
  - Diaphoresis
  - Alkalosis
  - Poor intake
  - Insulin
  - Low magnesium can stimulate potassium excretion
- Cues
  - Fatigue
  - Weakness
  - Bradycardia
  - Irregular pulse
  - Paresthesias
- Interventions
  - Potassium
  - Cardiac, electrolyte and vitals monitoring
- Risks
  - Abnormal heart rhythms
    - *KCL orally or IV, always diluted
    - Never give as IV push or bolus
    - Should not exceed 10mEq/L
    - Use infusion pump*

Calcium 9-10.5 mg/dL
Magnesium 1.3 - 2.1 mEq/L

Isotonic Solutions
- No ECF and ICP movement
- Used to treat hypovolemia
- Normal Saline
  - .9% saline
  - Used when both sodium and fluid is needed
  - Only solution used with blood
- Lactated Ringers
  - Contain sodium, potassium, chloride, calcium and lactate
  - Expands ECF - treats burns and GI fluid loss
  - Contraindicated with liver dysfunction, hyperkalemia, and severe hypovolemia
Hypotonic IV fluids
- More water then electrolytes
- Water moves from ECF to ICF
- Maintenance fluids
- 5% dextrose injection
- .45% saline solution
  - Contains free water and sodium chloride
  - Treats hypernatremia and uncontrolled hyperglycemia
  - Maintenance solution
Hypertonic IV fluids
- Expands and raises osmolality of ECF
- Draws water our of ICF to ECF
- Requires frequent BP, lung sound, and serum sodium level monitoring
- 10% dextrose and .9% sodium chloride
- 3% sodium chlorideis a hypertonic solution used to treat severe hyponatremia by pulling excess water out of cells and into the extracellular fluid.

Fluid and Electrolytes

Risk Factors for Imbalances:

Infants: High metabolic rate, immature kidneys, rapid respiration, larger body surface area.
Very Old: Blunted thirst sensation, less responsive kidneys, impaired water conservation.

Cues of Imbalances:

Fluid Volume Deficit: Restlessness, confusion, dry mucous membranes, cold clammy skin, decreased skin turgor, hypotension, increased pulse, decreased CVP & urine output, weakness, seizures, weight loss, increased serum osmolality, elevated BUN & hematocrit.
Fluid Volume Excess: Headache, lethargy, edema, jugular vein distention, bounding pulse, hypertension, dyspnea, muscle spasms, weight gain, decreased serum osmolality, diluted electrolytes.

Electrolytes:

Sodium (136-145 mEq/L): Regulates fluid balance, influences renal excretion of water.
- Hypernatremia Causes: Dehydration, NGT suction, burns, diarrhea.
- Hyponatremia Causes: Hypervolemia, diuretics, poor sodium intake.
Potassium (3.5-5 mEq/L): Important for nerve impulses and muscle contractions.
- Hyperkalemia Causes: Renal failure, adrenal insufficiency, excessive intake.
- Hypokalemia Causes: Vomiting, diarrhea, diuretics.

IV Solutions:

Isotonic Solutions: Normal Saline (.9% saline) for hypovolemia.
Hypotonic Solutions: .45% saline for hypernatremia.
Hypertonic Solutions: 3% saline for severe hyponatremia.