fluid and electrolyte imbalance nurse refresher class 2010 by kim uddo rn mn ccrn cne many slides...

Fluid and Electrolyte Imbalance NURSE REFRESHER CLASS 2010 BY KIM UDDO RN MN CCRN CNE MANY SLIDES BORROWED FROM ARLISHA PRATT. MUCH THANKS.

Objectives Review and define concepts related to fluid movement Discuss considerations for older adults in relation to fluid imbalance Correctly interpreting laboratory data and diagnostic testing indicating; fluid and electrolyte imbalances Utilizing laboratory data, and signs and symptoms to determine the presence of fluid and electrolyte imbalances

Objectives (cont) Indentify clients at risk for fluid volume imbalances. Indentify specific assessment findings in electrolyte imbalances. Identify priority nursing diagnosis for clients experiencing fluid and electrolyte imbalance. Describe the therapeutic and nursing management of clients exhibiting fluid and electrolyte imbalances

Overview of Fluid Movement Intracellular Fluid- within the cells Extracellular Fluid- outside the cells (includes the intravascular space) Osmosis-is the movement of water only through a selectively permeable membrane. Osmolality-concentration of particles/kilogram Osmolarity-concentration of particles/liter (does not have to be water)

Overview of Fluid Movement Filtration-Movement of fluid through a cell or blood vessel membrane Hydrostatic pressure-is the pushing force of fluid against the walls of the space it occupies. Diffusion-particles move from a higher concentration to an area of lower-concentration. Oncotic pressure (colloid osmotic pressure)-the pulling force exerted by colloids in a solution

Types of Fluid Replacements Isotonic Hypotonic Hypertonic Serum osmolality 275-295 Colloid

0.9%NS: Sodium Chloride 0.9 Grams per 100 ml 9 Grams per 1000ml (liter) 154 mEq sodium 154 mEq chloride

Hormonal/Chemical Fluid Balance Aldosterone Antidiuretic Hormone (ADH) or Vasopressin Glucocorticoids Atrial Natriuretic Peptides (ANP) Brain Natriuretic Peptides (BNP)

Human serum osmolality Serum Effected by Na, Glu, and BUN 275-295 milliosmoles per kilogram of water (mOsm) If glu and Bun is normal you can roughly multiply Na by 2 to get the osmolality Increases in dehydration and decreases in overload Urine measured for osmolality too

Calculated Osmolality Estimated 2(Na) + BUN/2.8 + Blood Glucose/18 Example 2(135) + 12/2.8 + 110/18 = 280 mOsm Some labs will calculate with the SMA 7 Your calculation my differ from lab

Human urine osmolality Like specific gravity, it is a measure of urine concentration. Unlike specific gravity, it is NOT concerned with the size or weight of the particles in solution, just the number of them. So big glucose and protein molecules in the urine do not raise the osmolality like they do the specific gravity of urine. More sensitive test than specific gravity, temp is controlled, can be compared to the serum osmolality.

Urine osmolality range 500-800 mOsm 800 mOsm = 1.022 specific gravity If the patient has a 14 hour overnight fast, they should have a urine osmolality at least 3 x greater than the serum osmolality. (No intake = more concentrated urine)

Urine specific gravity Measures the density of urine compared to density of water Usually, the higher the number, the more concentrated the urine Normal 1.001 1.040 If glucose or protein in urine, false high. If no glucose or protein in urine and specific gravity is high, urine is concentrated due to dehydration or increased output of ADH which causes a decreased urine volume.

Elevated secretion of ADH Trauma Stress Surgery Drugs Usually means patient needs fluids.

Surgical Diuresis Surgery is major trauma to the body and activates ADH. Urine Specific Gravity gets high as result As stress decreases, post op day 2, ADH and other hormones like glucocorticosteroids decrease, the fluid that was held in reserve to prevent going into shock is released The increase urine output two days after surgery is to be expected. CABG Patient

Serum and Urine mOsm Ratio If urine osmolality goes up and serum is normal or elevated, we know the kidneys are conserving water. Like in dehydration.

Dehydration Urine and Serum Osmolality are HIGH.

Ratios If serum osml is low or dilute and urine osmo is high, we know that this is not a normal response. An increased level of ADH can cause this. Think SIADH: syndrome of inappropriate anti diuretic hormone.

Ratio Urine osmo should always be higher than serum osml unless the patient is putting out dilute urine due to diuretics or due to drinking an excess of fluids. Diuretic use can show a lower urine osmolality with a normal serum osmolality.

Diuretic Use Low urine osmolality and normal serum osmolality What does their urine look like before the diuretic? What does their urine look like after the diuretic?

Something is wrong if The urine osmolality remains dilute while the serum osmolaity starts to climb..remember a dehydrated patient has increased urine and serum levels. We think that the patient cannot activate their ADH DI: diabetes insipidus.pathologic lack of ADH They look like they are unable to concentrate their urine!

DI vs SIADH DI. Im Dry SIADH. I float Which patient gains weight? Which patient looses weight? What does the urine look like?

Sensible & Insensible Fluid Loss OUTPUT Urine Emesis ( only if in liquid form) Feces ( only if in liquid form) Drainage from body cavities ( fistula/wound/ drains ) Perspiration Vaporization through lungs INTAKE Measurable Oral intake Parenteral Fluids Enemas Irrigation fluids Not Measurable Solid foods Metabolism

Hormonal/Chemical Fluid Balance Thirst Mechanism Stimulated by thirst receptors in the hypothalamus Stimulates ADH and aldosterone release, which promotes reabsorption of water. Depressed in older people (> 60y/o)

Consideration for Older Clients Older adults has less total body water than a younger adult. They have decreased thirst sensation Difficulty with walking or other motor skills need for ingesting of fluids They also may take drugs such as diuretics, antihypertensive, and laxatives that increase fluid excretions.

Considerations for Obesity and Females Females have more fat than males Obese have more fat Less water is stored in fat Dehydrate quickly so beware.

Evidence Based Nursing The evidence shows that most hospitalized patients are not offered enough water and become dehydrated. Its a safety concern Offer water! Teach patient and family to record accurately I& O

Fluid Imbalances Fluid Volume Deficit Hypovolemia-Circulating blood volume is decreased and leads to inadequate tissue perfusion. Which can quickly lead to shock. Dehydration- Fluid intake is less than what is needed to meet the bodys fluid needs. Can occur with just water loss or with water and electrolyte loss.

Dehydration What do the labs look like? Who is at risk?

Fluid Imbalance Fluid Volume Overload Fluid overload (overhydration)- is an excess of body fluid; can be either actual excess of total body fluid or a relative fluid excess. Hypervolemia-most common type of fluid overload.

Over hydration What would the labs look like?

Causes, Assessment, Clinical Manifestations Identify who is at risk for fluid and electrolyte disturbances Identify S&S of fluid volume deficit Identify S&S of fluid volume excess Identify S&S of electrolyte disturbances Identify situations that cause disturbances

Laboratory Assessment, Interventions, Patient safety Protocols set for communication of abnormal labs Use SBAR Conduct Physical Assessment include ECG changes Document your actions including phone calls/ time Critical lab value stickers Get follow up lab orders after intervention and evaluate Teach the patient!

Nursing Diagnosis and Case Studies Use your nursing diagnosis list from clinical manila folder

Case Study #1 A 20 y/o client is admitted to the hospital for c/o nausea, vomiting and diarrhea; and has not had an appetite in 3 days. BP 86/42, pulse 124, resp 30; While in the emergency room, one liter of NS has infused and now D5 1/2NS is infusing at 80 mls/hr. What nursing interventions should the nurse perform and monitor while caring for this client?

SBAR the report to the MD Introduce yourself S B A R Any questions for me? How long did it take?

Case Study # 2 A 55 y/o client with Congestive heart failure is receiving D51/2NS at 150cc/hr after surgery. The client reports trouble breathing, and sits up in bed and coughs up moderate amount of clear mucous. What priority nursing action and follow Up actions are needed and why?

SBAR the report to the MD Introduce yourself S B A R Do you have any additional questions for me? How long did it take?

Safety Measures Orient client to the environment (especially the older adult) Monitor for falls Assess the client muscle strengths, gait stability Instruct the client to get up slowly from a lying sitting and standing position Assist the client from the bed to chair Monitor for any skin breakdown Change positions q2 hours

Electrolytes Reference Range 135-145 mEq/L 3.5-5.0 mEq/L 9.0-11 mEq/L 98-106 mEq/L 1.5-2.5 meq/L 3.0-4.5 mg/dl Electrolyte Sodium (Na+) Potassium (K+) Calcium (Ca+) Chloride (Cl-) Magnesium (Mg2+) Phosphorus (P)

Electrolyte Balance and Imbalances Potassium Main cation in the ICF Regulate intercellular osmolarity Maintenance of electrical membrane excitability Maintenance of plasma acid-base balance Sodium Main cation in the ECF Maintenance of plasma & interstitial osmolarity Maintenance of acid-base balance Generation and transmission of nerve impulses

Electrolyte Balance and Imbalances Hyponatremia (< 135mEq/L) Water shift from the ECF to the ICF; resulting in circulating plasma volume & intracellular fluid. Causing cellular swelling Hypernatremia (> 145mEq/L) Water shift from the ICF to the ECF, which result in cellular shrinkage/dehydration

Case Study # 3 The nurse is assigned to a client who is NPO and on prolong intermittent nasogastric suctioning. What will the nurse monitor for and why?

Case Study # 4 In caring for a client with Hypernatremia, what should the nurse do to help ensure client safety? Note: when sodium levels change, think about how the fluid shift has changed.

Causes of Hypernatremia Dehydration / water loss Too much IV or po saline/salt Many blood bank units of blood Impaired renal function Large increase in sodium intake without proportional water intake (rare cuz this makes you thirsty) Large amount of water loss without salt loss (more commondiarrhea, vomiting) Sometimes one can looses both sodium and water =

Who is at risk for hypernatremia? Elderly Patients on fluid restrictions Diuretic therapy Receiving hypertonic IVs or tube feeding Diabetes Mellitus (HHNKD) Dehydration

Youtube: Dehydration Video http://www.youtube.com/watch?v=rOGS6PhE4wI

Treat hypernatremia Drink water Change IV to isotonic solution Give IV fluids Dialysis Strict I&Os Check Labs

Isotonic dehydration Lose equal parts sodium and water (infants do this with vomiting and diarrhea)

Hypertonic dehydration Loose more water than sodium: Also called- Hyperosmolar dehydration By the time serum sodium is elevated, the compensory shift of water has left the cells and interstitial spaces has entered the blood stream and dehydrated the cells. The patient is dehydrated at the cellular level when we see elevated serum sodium levels. The water exits via the kidneys and the patient is severely dehydrated intracellularlly and intravascularlly.

Symptoms of hypernatremia Thirst Dry membranes, tenting Little or no urine output High specific gravity Hematocrit increased Hyperactivity/ seizures Increase 3meq above normal = I liter fluid loss 1 liter fluid loss = 1 kg in body weight Weight Loss: do daily weights!!!!!!

Edema By the time edema is evident, the patient has already gained 3 liters of fluid Weight gain is the best indicator of fluid retention and weight loss is the best indicator of fluid loss.

Electrolyte Balance and Imbalances Hypokalemia (< 3.5 mEq/L) When K+ moves into the ICF, it causes hypokalemia, in turn hydrogen moves out of the cell. Making the ECF more normalized or acidotic. Hyperkalemia ( > 5.0 mEq/L) Hydrogen moves into the cells, causing the ECF to become more normalized or alkalotic, In turn, K+ and Na+ move out of the cell.

Case Study # 5 A 55 year old client is admitted to the hospital with complaint of diarrhea for three days. The client reports being weak and feels like his/her heart is racing What questions should the nurse ask about the clients medical hx? What other s/s maybe present What labs maybe ordered What orders would the nurse expect this client to receive?

Nursing Diagnosis Decreased cardiac output r/t dysrhythmia 2ndary to electrolyte imbalance (K, Mag, Cal) Impaired physical mobility r/t skeletal muscle Imbalance nutrition r/t decreased renal function or poor dietary intake 2ndary to renal failure anorexia or NPO status or Risk for injury r/t muscle weakness and seizures 2ndary to electrolyte imbalance Impaired safety r/t confusion or altered LOC 2ndary to hyponatremia

Electrolyte Balance and Imbalances Phosphorus Activate vitamins and enzymes Forming ATP Assisting in cellular growth and metabolism. Acid-base balance Calcium homeostasis Calcium Maintain strong bone and teeth Transmission of nerve impulses Allow blood clotting Regulate BP Control by the PTH, Vit D and calcitronin

Electrolyte Balance and Imbalances Hypocalcemia (< 9.0 mg/dl) Abnormally low calcium level or decreased availablity of ionized calcium; any condition that cause a decrease in PTH production. Hypercalcemia (> 11.0 mg/dl) An Anbormally elevated serum calcium level; symptoms may not appear until the serum calcium is >12mg/dl

Case Study # 6 A 54y/o client with a diagnosis of multiple myeloma has been admitted to your unit. The client has a c/o of increasing fatigue, muscle weakness, and bone pain. What do you think is the cause of these symptoms What is the nurse priority nursing intervention How will you evaluate if therapy has been effective. What exactly is multiple myeloma?

What is it? Lets check the web. http://www.nlm.nih.gov/medlineplus/multiplemyelo ma.html http://www.nlm.nih.gov/medlineplus/multiplemyelo ma.html Excellent resource http://www.nlm.nih.gov/medlineplus/tutorials/multi plemyeloma/htm/_yes_50_no_0.htm http://www.nlm.nih.gov/medlineplus/tutorials/multi plemyeloma/htm/_yes_50_no_0.htm Awesome movie explaining X-plain.com

Electrolyte Balance and Imbalances Hypophosphatemia (< 2.5 mEq/L) An abnormal decrease in serum phosphorus level. Hyperphosphatemia (> 4.5 mEq/L) An abnormal increase in serum phosphorus level. Phosphorus shifts from the ICF to the ECF which causes serum level to increase

Case Study # 7 Mr. G is a 56 y/o client with newly diagnosed chronic renal failure as a complication of diabetes mellitus. He is receiving hemodialysis 3 times a week and will continue this therapy when discharged. Which electrolyte imbalance the nurse would expect (hypo/hyperphosphatemia) Why? What dietary modifications would be necessary? What role will dialysis play in managing the imbalance? http://www.merck.com/mmhe/sec11/ch143/ch143c.html

Electrolyte Balance and Imbalances Chloride Aids in cellular integrity by maintaining balance. Serves as a buffer in exchange of O2/CO2 Regulates the pH of the stomach Magnesium Powers the sodium- potassium pump Activates enzymes Important for skeletal muscle relaxation Aids in converting ATP for energy release

Electrolyte Balance and Imbalances Hypomagnesemia ( < 1.5 mEq/L) Abnormal secretion of magnesium in the blood. Can cause lethal torsades dysrhythmias Hypermagnesmia ( > 2.5mEq/L) Rare electrolyte imbalance, occur to excessive intake of magnesium and decreased renal excretion.

Case Study # 8 A 25y/o client during a clinic visit reports to the nurse that she has been experiencing; chest pains and frequent cramps in her legs and hands for the past week. Her vital signs are BP 110/72, P 98, resp 18. What other data is necessary to gather? What imbalance may this client be experiencing according to the above data? What collaborate measures should be considered?

Renal function BUN BUN : Creatinine Ratio UUN BUN:Creatinine Ratio Serum Creatinine Creatinine clearance

Blood Urea Nitrogen BUN Urea is a waste product from protein metabolism. It is formed in the liver and travels to the kidneys for elimination from the body. Since the kidneys excrete this, it is a good lab to determine kidney function. Normal 8 25 mg/dL Dehydration, malnutrion with protein wasting, liver failure, and over hydration can mask the renal function on this test.

Elevated BUN Kidney failure Poor perfusion to kidneys due to shock or CHF High protein tube feedings Dehydration Bleeding in the GI tract (blood is protein)

Decreased BUN Over hydration

UUN 1 gram of nitrogen in each 6 grams of protein We loose 4 grams of Nitrogen each day in stool Nitrogen balance= g of pro intake/6.25 (24 hour UUN +4) If the number is less than 0 the patient is not wasting or loosing protein. A patient with a negative protein balance needs extra protein in diet.

Serum Creatinine Waste product of creatinine phosphate from skeletal muscle Normal men 0.6-1.5 mg/dL Normal women 0.6-1.1 mg/dL Elevated in nephron damage

Bun to Creatinine Ratio About 10: 1 is normal 15:1 dehydration or protein breakdown (ratio goes up) Look at together. Kidney failure both will be elevated. If BUN elevated and not creatinine, look for dehydration or protein stores

Uric Acid Proteins and muscle breaks down into purines and are excreted by kidneys as uric acid waste. Feel joint pain. Hyperuricemia: due to renal impairment, drugs, pre- eclampsia, Allopurinol is the medication to correct this.

ALBUMIN Albumin (3.5-5 g/dl) Long half lifeonly get ever two weeks Prealbumin (19.5-35 mg/dl) Shorter half life.more sensitive indicator in changes in nutrition. Hypoalbuminemia= think leaking capillaries in blood vessels and lungs! Loss of colloid pressure.

CBC RBC Count (4.7-6 males/ 4.2-5.4 females) Hematocrit (42-52% males/ 37-47 %) Hemoglobin (14-18 g/dl males / 12-16 g/dl females) WBC Count with differential (5-10 x 10 to the 9 th )

WBC Neutrophils and bands :neutrophilia (bact. Infec) Nomal bands less than 3% decreased neutrophil count: neutropenia (viral infec) Increased eosinophil count: eosinophilia (asthma) Decreased eosinophil count: (steroid use) Basophil count changes (infec and steriods) Increased lumphocyte count: lymphocytosis (CD numbers)(infections lymphocytic leukemia) Decreased lymphocyte count: lymphopenia (HIV)

Coagulation Tests Activated clotting time (180-570 sec) D-dimer Screen (less than 500 ng/ml)(high w clot) Fibrinogen(200-400mg/dl) (2-4 g/liter)(low in DIC) Fibrinogen Degradation Products(fsp)(high in DIC) Partial Thromboplastin time (PTT)(therapy 1.5-2x) Activated PTT (30-40 sec) Platelet count (150-400 x 10 9 th per liter) (20 severe) Prothrombin time (PT)(10-14sec)(therapy 1.5-2.5x) International Normalized Ratio (INR)

DIC Disseminated intravascular clotting in microcirculationuse up all the clotting factors.bleedsee a drop in platelets Ddimer positive = clot somewhere Abruptio placentae D dimer negative = r/o pulmonary embolus

Therapeutic Levels On heparin drip post op MVR (PTT 1.5 2x normal) 60 x 2.5 = 150 On Coumadin by mouth for chronic afib (1.5-2.5 normal) so 10 x 2.5 = 25 sec INR: 2-3 for chronic afib INR: 2.5-3.5 for mechanical heart valve replacement

Acid Base Balance ABGs Anion gap Serum CO2 Electrolytes shift Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

ABGs Great online tutorials pH 7.35 7.45

Anion Gap (8-16 +/- 4) Acid base lab Think of conditions that create acid DKA Lactate lactic acidosis from shock and sepsis Gap = higher number Differentiates the types of acidosis Lactic acid = gap High chloride no gap

Serum Co2 High levels think high base binding ability Carbon dioxide binding power or total CO2 is an indirect measurement of serum bicarbonate. If anion gap is high, this will be low And vice versa

CO2 Base Excess Extra buffering base on board to compensate for losses of H ions, K, and Cl Common cause: GI suctioning induced loss of gastic contents. COPD compensation

CO2 Base Deficit Less buffer binding availability Compensation to acidosis buffers used up Or due to Chloride elevated Or due to kidneys loosing bicarbonate

Electrolyte Shift What happens to K during acidosis event? What happens to K during alkalosis event? Chloride Elevated acidosis (no anion gap)

Relationships We rarely ever just look at one lab value. We look at relationships between the labs. Inverse relationships Proportional relationships.

Inverse Relationship Acidic Environment Alkaline Environment Serum co2 decreases Potassium increases Serum co2 increases Potassium decreases

Proportional Relationship Calcium Albumin Calcium travels on albumin If albumin levels are low calcium will be low. Expect this finding Indicates nutritional status If you want to improve the calcium level, think about feeding the patient protein. Normal 3.5 5.2 g/dl

Corrected Calcium For every gram decrease in albumin calcium will decrease 0.8. This is our coeffiencient. Mid normal Albumin is 4.0 0.8 (4.0 current albumin) = x X + calcium level= corrected calcium level

Example Lab report shows calcium level to be 7.5 The nurse knows that if albumin is low, calcium will also probably be low. But how low? Albumin is 3.0 0.8 (4.0-3.0)= 0.8 0.8 + 7.5 = 8.3 The corrected calcium is low. If the patient is showing physical symptoms, they probably will be given IV calcium gluconate Trousseaus and Chvostecks sign classic & tremors

Example Calcium is 7.5 Albumin is 2.8

Patient Populations Pancreatitis Diabetes/ DKA/ DI Hemorrhage/ thrombocytopenia Post op CABG Liver Failure/ ETOH Abuse Malnutrition Homework: Post on Wiki

Each population What labs should you follow? What do the labs look like in this condition? What is the goal (expected outcomes) for our labs? What interventions do we do?

Questions

Lipoprotein panel A lipoprotein panel gives information about your: Total cholesterol. LDL ("bad") cholesterol. This is the main source of cholesterol buildup and blockages in the arteries. (For more information about blockages in the arteries, go to the Diseases and Conditions Index Atherosclerosis article.)Atherosclerosis HDL ("good") cholesterol. This type of cholesterol helps decrease blockages in the arteries. Triglycerides. Triglycerides are a type of fat in your blood. A lipoprotein panel measures the levels of LDL and HDL cholesterol and triglycerides in your blood. Abnormal cholesterol and triglyceride levels may be signs of increased risk for CHD. Most people will need to fast for 9 to 12 hours before a lipoprotein panel

fluid and electrolyte imbalance nurse refresher class 2010 by kim uddo rn mn ccrn cne many slides...

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