Fluid & Electrolyte ImbalanceHow to keep things flowing along!

Lisa B. Flatt, RN, MSN, CHPN

Body Fluids

•Body mostly composed of: ▫fluid –water ▫solutes - electrolytes

•Osmolality- the balance between fluid and solutes – This is a delicate balance! Every organ and system reacts differently to an imbalance.

Swollen feet and ankles – water is attracted to sodium!

• Semi-permeable membrane – selected particles move by passive diffusion – that’s how sodium follows water.

• Osmotic pressure is the strength of the solution to draw the water across the SPM.

• Passive diffusion – solutions of greater concentrations moves solutes to solutions of less concentration

• Filtration – fluid and solutes move across a membrane from area higher pressure to lower pressure

• Active transport – substances are moved from low to high concentration areas (metabolic energy & enzymes are used, ie. Sodium potassium pump)

Let’s see… what are the differences….•Osmosis –•Diffusion – •Filtration – •Active transport -

Where you can find Body FluidIntracellular Fluid Extracellular Fluid

• Is 2/3 to ¾ of total body fluid

• Found inside the cells

• Outside the cells• Divided into

compartments▫ Intravascular fluid

Plasma- vascular system▫ Interstitial fluid

Surrounds cells – lymph ▫ Transcellular fluid

Epithelial cells (synovial fluid)

Potassium• Potassium (3.5 – 5.0 meQ/l)• Found and for: intracellular- cardiac, skeletal and smooth muscle

activity• Hyperkalemia- high K

▫ Causes-renal failure & (drug induced) S/S – tetany, irritability, parasthesia, GI hyperactivity, cardiac

arrhythmias Nursing interventions: Kayexelate (po and pr), D50 and

Insulin, dietary intake

• Hypokalemia- low K▫ Causes-drug induced, N&V&D, gastric suctioning, exercise (shin

splints) S/S – weak, fatigued, cardiac arrhythmias

Nursing Interventions: IV and PO K, po and iv fluids, dietary intake

Magnesium• Magnesium (1.5 – 2.5 mEq/l)• Found and For: intracellular metabolism, protein and DNA

synthesis• Hypermagnesia – high Mg

▫ Causes-drug induced, S/S – lethargy, coma, impaired respirations

Nursing Interventions- medication, diet• Hypomagnesia- low Mg

▫ Causes – alcoholism S/S – confusion, disoriented, tremors, irritability

Nursing Interventions – medications, diet

Sodium -- Salt sucks• Sodium (135 - 145meQ/l)• Found and For: intra&extracellular – Na and K balance needed in body – key

electrolyte• Hypernatremia – high sodium

▫ Causes – increased dietary intake, body system imbalances (kidney) – dehydration of the cells, water gets sucked from the cells and into the tissue

S/S – edema, thirst, confusion, dry mucus membranes, mental status changes

Nursing Interventions- fluid restrictions, diet restrictions• Hyponatremia – low sodium

▫ Causes- exercise and too much water “water toxicity” – water gets sucked from the cells into the tissue (how most people die in the Grand Canyon – they need to take salt pills **Thank you Wes for the fun fact**)

S/S – muscle cramping, N&V, postural hypotension, mental status changes, hallucinations of oasis!

Nursing Interventions – medications, iv fluids, electrolytes

Calcium• Calcium (8.5 – 10.5 meQ/l)• For: blood coagulation, neuromuscular activity and bone growth • Found: Located in Bones• Hypercalcemia – high Ca

▫ Causes – cancer with met’s to bone, drugs, parathyroid glandular issue S/S – kidney stones, lethargy, weakness, decreased muscle tone

Nursing interventions: safety, iv fluid

• Hypocalcemia – low Ca▫ Causes-alcoholism, low serum Mg, parathyroid gland removal

S/S – numbness, tremors, cardiac arrhythmia, osteoporosis Nursing Interventions: iv fluids, medications, diet

**Calcium and Phosphate work together – form bone and teeth --- if one is high the other is lower

Phosphates• Essential for function of: muscles, nerves and RBC• Involved in PRO, Fat and CHO metabolism• Hypophosphatemia - TPN, glucose & insulin can cause phosphates to

shift into cells▫ Alcohol withdrawal▫ Antacid use (acid base imbalance)

S/S – weakness, pain, mental changes, seizuresHyperphosphatemia – Phosphates shift out of cell (trauma, chemo,

malignant tumor), at risk – infants fed cow milk ((Fleets phosophosoda))S/S – numbness, tingling **Around mouth and fingers** muscle

spasm, tetany

Nursing interventions: Diet, Medications, IV Fluids, Education

Chloride• Imbalances occur with Na imbalances•Hypochloremia – low Chloride

▫ Causes: sweating, kidney loss, GI tract losses S/S – twitching, tremors, tetany

•Hyperchloremia – high Chloride▫ Causes: Na retention or high potassium

S/S – tremors, acidosis, weakness, lethargy, arrhythmias, coma

NURSING INTERVENTIONS: Medication, IV Fluids

Electrolyte Imbalances Universality•Nursing Interventions: diet, med’s, iv

fluids, education, assessment, labs•Causes: Diet, Medication issues,

metabolism (cancers, diseases) •S/S – muscle tremors, twitches, LOC,

Mental status, cardiac affects

Look at your patient- be a spy

•Previous history? Alcoholic = mg or K•Malnourished?•Objective and Subjective findings?•Labs – the blood•EKG

Homeostatic Mechanisms

•Control the levels of fluids and electrolytes

•Found throughout the body▫_kidneys________▫__endocrine_______▫__cardiovascular_______▫___GI______▫_____Lungs____

Kidneys (not kidney beans!)

•Regulate what?▫__water____▫__electrolytes____▫__acid/base content of blood____▫__all body fluids____

•Adjust what? Reabsorption of water•Excrete what? Water and waste == pee

pee

Antidiuretic Hormone ADH

•ADH regulates water excretion•Increases in response to increased serum

(blood) osmolality•Ducts become more permeable to water

and it is reasborbed easier into the blood and urine output will decrease

Renin-angiotensin-aldosterone system•Renin (enzyme) splits Angiotensinogen

into angiotensin I and this transforms to angiotensin II (with the help of an ACE inhibitor).

•Angiotensin II – stimulates vasoconstriction and secretes aldosterone

•Aldosterone – increases Na reabsorption to regulate BP and electrolyte levels

Put it together•Increased osmolality – need more water in

blood so: ADH secretion increases and water travels to the blood

•R-A-A system – renin excreted to make angiotensin II and secrete aldosterone

•Aldosterone causes vasoconstriction increase bp

Give ACE inhibitor – stops angiotensin I to II and aldosterone (thereby lowers BP). This may also affect the ability of the body to maintain extracellular fluid (without edema).

Atrial Natriuretic Factor ANF

•Secreted from atrial heart tissue•Increases sodium and water elimination

(urine)•Lowers the blood volume and decreases

cardiac output•Decreases the workload of the heart•OPPOSITE EFFECT OF ADH

pH acids and bases

•Acid = substance that releases Hydrogen ion in a solution

•Base = low hydrogen ion concentration•Buffers prevent excessive ph changes by:

adjusting the ions•**Major buffer is H2CO3***

▫ Kidneys and Lungs play a key

Factors that affect fluid and electrolyte balance•Sex•Body size•Age•Diet•NPO•General adaption syndrome (GAS) hehe•Altered LOC

More factors…….

•Body temperature•Renal, cardiac, pulmonary system•Medications

▫Steroids▫NSAIDs▫Diuretics▫Laxatives▫Electrolyte supplements

More factors…… just when you thought you were done!•Dehydration•Surgical procedures•Vomiting•Diarrhea•Exercise•Culture and traditional foods MSG•Religious practices•Socioeconomic•Emotional

Definitions and conditions

•Fluid volume deficit is__hypovolemia_______

•Fluid volume excess is__hypervolemia____•Ascites__fluid in the abdominal

cavity______•Edema _fluid in the interstitial

space_______

Hypovolemia

•Define: low fluid volume•Causes: increased sodium chloride intake

(po, iv), dehydration, CHF, Renal failure, Cushing’s, trauma

•Nursing ramifications: identify cause and educate, medications, iv’s, etc…

•S/S: weak, nausea, low pulse, SOB, low BP

Hypervolemia

•Define: increased volume in vascular system

•Causes: water toxicity, iv fluids, disease states

•Nursing ramifications: medication, educate

•S/S: elevated BP, moist crackles in lungs, bounding pulse, SOB

Ascites• Define: serous fluid in peritoneal cavity (3rd

spaced)• Causes: liver – cardiac dx, sodium retention,

some cancers• Nursing ramifications: educate, diet, fluids,

albumin (pulls fluid from 3rd space, interstitially back into the blood stream). Albumin has high osmolality.

• S/S: swelling, fluid shift – the wave~~~~~~~• Treatment: Albumin and Pericentesis

Edema• Define: fluid in the tissues• Causes: increased sodium, electrolyte

imbalances, poor cardiac output, kidney failure, hypervolemia, diseases

• Nursing ramifications: fluid restrictions, educate & elevate body parts, sodium restrictions, medications

• S/S: swelling (LOL), weeping skin, pain, numbness, cool skin, bruised/discolored

Edema

•Pitting – leaves a small depression or pit •Areas of edema: body parts, periorbital

edema, axillary, groin, generalized

▫Note how many seconds it takes for pit to disappear (normally 10-30seconds)

What’s the Difference?Dehydration Overhydration

• Define: loss body fluid, normal electrolytes

• Causes: decreased fluid intake

• Nursing ramifications: IVF, educate, diet, assessment

• S/S: jugular vein distention, tachycardia, mental status changes, confusion, weight loss, dry skin, poor skin turgor, dry mucus membranes, increased thirst

• Define: water intake is greater than electrolyte intake

• Causes: increased fluid intake

• Nursing ramifications: education, diet, medications, assessment

• S/S: altered mental status, edema, SIADH (water toxicity), possible decreased urine output

Acid-Base Balance

•Normal pH of blood:_7.35-7.45____•Acidic pH of blood: __<7.35_____•Alkaline pH of blood (basic):_>7.45___•Blood is acidotic if the pH is __low__•Blood is alkalitic if the pH is __high__

Metabolic conditionMetabolic Alkalosis Metabolic Acidosis

• HCO3 – high• Causes: excess intake of

baking soda (antacid) or alkalitic substances; lots of puking

• The body compensates:▫ CO2 is retained and

carbonic acid levels increase to help balance the excess HCO3

• HCO3 – low• Causes: starvation, renal

impaired, DM• The body compensates:

▫ Stimulates respiratory system and eliminates CO2

Respiratory conditionRespiratory alkalosis Respiratory acidosis

• HCO3 – high• Causes: hyperventilation,

fever, anxiety, pulmonary infections

• The body compensates: kidneys excrete HCO3 (or stop hyperventilation ASAP)

• HCO3 – low• Causes: hypoventilation,

lung dx, asthma, COPD• The body compensates:

▫ Kidneys retain NAHCO3 **may take hours or days to restore pH

Intrepretation practice!

Nursing Interventions Include:

• Dietary education▫Menus▫Special diets

• Oral fluid/food intake▫Restrictions

• Administering medications as ordered▫IVF▫Diuretics▫Electrolyte supplements

• Education on medication uses/side effects and complications

Educating on Diuretics

•Loop diuretic – Lasix/Furosemide•Thiazide sparing – HCTZ•Potassium sparing - Aldactone

Educating on Electrolyte supplements•Potassium•Magnesium•Sodium Bicarbonate•Others? Gatorade, Power waters, Coconut

water•What do we recommend if you are exercising

in the heat? Water and Power/Gatorade, etc…•Babies who have diarrhea need? Pedialyte•We use __kayexelate, D50 and Insulin_to

reduce Potassium

Intravenous Fluids - Types• Hypotonic solutions: .45%NS, .33%NS, 2.5%Dextrose –

lower osmotic pressure than plasma –DO not give if at risk for IICP

• Hypertonic solutions:D5NS, D51/2NS, D5LR D5W – higher osmotic pressure than plasma – kidney, cardiac and dehydration

• Isotonic solutions:0.9 NS, LR – expand vascular volume – LR has extra ingredients, treats metabolic acidosis

• Electrolyte replacement: Potassium, KCL, MG, Banana bags!

Ethical consideration with IVF

•Life sustaining?•Religious and/or cultural issues?•Comfort measure?•Emotional?

Calculations (oh no….not math!)

Assessing the patient

•Urine•Skin•Mental state•MS•Bowel status

Further Assessment

•Labs▫BUN 7-18 mg/dl

Increased indicates- renal failure Decreased indicates - malnutrition, over

hydration, liver damage▫Creatinine 0.6 – 1.5 mg/dl

Increased indicates – renal failure, CHF, shock

Decreased indicates – fluid status, dehydration

Let’s do a care plan! CHF Patient See pg 98-100