FLUIDS & ELECTROLYTESBy; JENITA PILI- DE VERA, RN.MAN

ORGANS INVOLVE IN FLUIDS & ELECTROLYTES:Lungs Heart Pituitary Adrenal Cortex Kidneys Blood Vessels Parathyroid

Water A combination of Oxygen & Hydrogen without electrolytes. It is the most abundant compound that is essential to life

Physical properties of H2O: Colorless Tasteless Odorless liquid It change from liquid to gas It change from liquid to solid

Importance of H2O: Needed for digestion of foods Necessary for circulation of blood Necessary for elimination Form large percentage of plants & animals Essential for many chemical reactions

Water Is the major constituents of the body minus electrolytes 60-70% of water is found in the body

Factors Affecting Volume of Body Water: Age Body Weight Sex

Sources of Body Fluids: Fluid Taken Orally Food Ingested Oxidation of Food

Average Daily Source of Water Intake: 1,200 ml/ day as H2O in beverages 1,100 ml/ day as hidden H20 in foods 300 ml/ day as water oxidation

Average Daily Amount & Sources of H2O output are: 1,500 ml/ day H2O from the kidney urine 1,000 ml/ day H2O from skin & lungs as insensible / evaporated H2O loss 100 ml/ day from gastrointestinal tract - feces

Chemical Reactions H2O: Hydrolysis Hydrates Anhydride

Hydrolysis Process of splitting a substance with the addition of H2O. Hydrates Formation of solid compounds through the combination or formation of H2O & the molecule. Anhydride Hydrate loss the H2O of crystallization

FLUIDS One of the four ultimate states of matter, being composed of molecules that can move about with in limits, permitting change in the shape of the mass without disruptions of the substance. Contain water & electrolytes

Function of Body Fluids: Provide an aqueous medium for cellular metabolism

Maintains physical & chemistry constancy of intracellular or extracellular fluids.

Transport material Aids in regulation to & from the cell of body temperature.

Provides medium for excretion of waste from the body.

Provide lubrication of muscle joints.

Intracellular Fluids Located with in the cells. Provide s the cell with internal aqueous medium necessarychemical function. 2/3-3/4 compromising 70% TBW

Extracellular Fluid Body fluids outside the cells. Serves as body transportation system carrying H2O, electrolytes, nutrients & O2 cell & removing waste product cell metabolism 30% - TBW

Compartment of Extracellular Fluid: Interstitial Compartment Intravascular Compartment Small Fluid Compartment Gastrointestinal Tract

Interstitial Compartment 24-25 % of TBW ECF Located in the space between the vascular space & the cells that provides cell with external aqueous medium necessary cellular metabolism

Intravascular Compartment 4-5% of TBW in ECF Blood Plasma, colloids along with RBC maintain vascular volume.

Small fluid Compartment

Gastrointestinal Tract

Non-electrolytes An electrically neutral solutes. A substance that does not ionize, dissociate in solution or carry an electric charge but necessary to maintain & control the fluid/ H2O between the plasma & interstitial fluid.

Protein Are the tissue builders of the body, inadequate intake will result in negative nitrogen balance.

Proteinate The anion form of protein Major anion with in cells.

Albumin A protein form as it reaches the blood. Important in the development of the plasma colloid osmotic pressure which helps control the flow of water between the plasma & interstitial fluid.

Colloids Macromolecules of protein that are located primarily with in the plasma. Holds water within the blood vessel.

Colloid Osmotic Pressure Pressure exerted by plasma protein. Which: Holds H2O with in the vessel Draws back H2O that escapes from the vessel

Electrolytes Compound substances which when place in solution is being divided or being break up into 2 electrically charge particles known as IONS

IONS An atom or group of atoms having a charge of positive or negative electrically by virtue of having gained or lost electrons. Example; NaCl

Cation Positive charge Sodium Potassium Calcium Magnesium

Anions- Negative Charge Chloride Bicarbonate Phosphate

Milli Equivalent/Liter (mEq/L) Measurement of chemical activity of electrolytes. It is measured in the most accessible portion of Extracellular body fluid namely PLASMA.

Movement of Body Fluids First Phase Blood plasma moves around the body within the circulatory system & nutrients & fluids are picked up from the lungs & the GIT.

Second Phase Interstitial fluid & its component move between the blood capillaries & the cells.

Third Phase Fluids & its components move back from the cells to the interstitial space & then to the intravascular compartment. The intravascular fluid then flows to the kidneys where the metabolic-by-products of the cells are excreted in the form of urine.

Methods of Movement of Fluids & Electrolytes: Diffusion Movements of particles into an area which is increase in concentration to a decrease concentration.

Osmosis Movement of fluids into an area which is lower concentration to higher concentration

Filtration Movements that separate fluids from suspended particles.

Solutions develop after movement: Hypertonic solution - higher concentration of solutes in the solution. Hypotonic solution - Lesser concentration of solutes in the solution.

Composition of Body Fluids: Intracellular fluid (ICF) Contains: H20 Electrolytes Proteins Nucleic acids Lipids Polysaccharides Extracellular fluid (ECF) Contains: Water Electrolytes Proteins RBC WBC Platelets

Electrolytes Composition of Body Fluids: Contains: Sodium Potassium Chloride Calcium Magnesium Phosphorus bicarbonate

Normal Values: Sodium Potassium Calcium Magnesium Phosphorus Chloride 135-145 mEq/L 3.5-5 mEq/L 8.5-10.5 mEq/L 1.5-10.5 mEq/L 2.5-4.5 mEq/L 100-106 mEq/L

Organs involve in keeping the composition & volume of Body Fluids with in normal: Kidney Heart Blood Vessel Lungs Gastrointestinal tract Hypothalamus Pituitary Gland Adrenal Gland Parathyroid Gland

kidney Vital to the regulation of fluid & electrolyte balance. It normally filter 170L of plasma per day in the adult.

Major Functions of the Kidney: Excretion of metabolic wastes & toxic substances. Regulation of pH of ECF by retention of hydrogen ions Regulation of ECF & osmolality by selective retention & excretion of body fluids. Regulations of electrolytes levels in the extracellular fluid by retention of needed substance & excretion of unneeded substance.

Heart Pumping action of the heart circulates blood through the kidneys under sufficient pressure for urine to form.

Blood Vessels Capillary pressure causing vasodilation & vasoconstriction that influence balance of fluids & electrolytes.

Lungs Hypoventilation & hyperventilation influences loss of carbon dioxide & H2O which effects fluids & electrolytes.

Gastrointestinal Tracts Stomach & intestines help balance the body fluids & electrolytes by absorbing those that are needed & eliminating those that are needed.

Hypothalamus Primary regulator of water intake. It manufactures hormones which is responsible in the retention of H2O in the body & excretion.

Pituitary Gland Stores ADH which is water conserving hormones that causes retention of H2O in the body

Adrenal Glands Adrenal Cortex secreted a hormone known as Aldosterone, a mineralocorticoid which has a profound effect on fluid balance.

Parathyroid glands Embedded in the corners of the thyroid gland, regulate calcium & phosphate balance by means of Parathyroid Hormones.

Hormones that maintain Fluids & Electrolyte balance: Antidiuretic hormone Aldosterone Parathyroid hormone Thyroid hormone

Antidiuretic Hormone (ADH) Also known as vasopressin, hormone release from the posterior lobe of the pituitary gland. Contains water re absorption by the kidney & regulates body fluid osmolality

Factors Stimulating ADH Secretion: Emotional & Physiologic stress Presence of pain Reduced circulating blood volume Administration of morphine sulfate, barbiturate & anesthetic agent Hyperosmolality

Hyperosmolality Decrease in water relative to solute concentration or increase in solute relative to water.

Aldosterone A hormone secreted by zona glomerulosa of the adrenal cortex. It increase renal reabsorption of sodium & water, thus regulating ECF.

Factors Stimulating Release of Aldosterone: Decreasing circulating blood volume Hyperkalemia High ACTH Stress

Parathyroid Hormone Hormone secreted by the parathyroid glands that maintain serum calcium level.

Functions: Increasing the release of calcium from bones Stimulating vitamin D production to increase calcium reabsorption from the GIT Stimulating calcium reabsorption from urine

Thyroid Hormone Thyrocalcitonin Help maintain calcium balance. T3 & T4 * T3 - Triiodothyronine * T4 - Thyroxine Maintain sufficient cardiac output to adequately perfuse the kidney nephron promote glomerular filtration.. maintain urine output.

Four Routes of fluid Output: Kidney Skin Lungs GIT

Kidney Major avenue of fluid output in the form of urine.

Skin In the form of perspiration Stratum corneum - outer layer of the epidermis that control fluid loss in the skin

Content of Sweat: Sodium Chloride Urea Lactic Acid Potassium

Lungs As water vapor in the expired air.

GIT Fluid loss through the intestine in the form of Chyme that passes from the small intestine into the large intestinecontain s H2O & electrolytes.

Factors affecting Fluids & Electrolytes loss: Climate Diet Stress Illness Trauma Medical treatment Medication Surgical procedures

Abnormal Sources of Fluid Intake: Intravenous Solution Total Parenteral Nutrition Blood Volume Replacements Colloids

Colloids Fluids that contains solutes of a higher molecular weight. Examples; Albumin Plasmanate Dextran Hetastarch

Albumin Maintain Colloid Osmotic pressure inside the ECF & cell wall integrity.

Plasmanate Contain Albumin, globulins, & fibrinogen.

Dextran Highly concentrated glucose solution which may interfere with blood coagulation like Hetastarch.

Blood volume replacement Whole blood Plasma Platelets PRBC

Total Parenteral Nutrition An IV fluid providing concentrated glucose, protein, electrolytes, trace elements, & lipids which is used for patients who are unable to take in foods or fluids through the digestive tract.

Intravenous Solution Fluids containing fluids & electrolytes which is used to replace volume & correct abnormalities. Types of IV solution: * Isotonic solution * Hypotonic solution * Hypertonic solution

Isotonic Solution Has the same osmolar concentration or tonicity as plasma.

Hypotonic Solution Contain lower osmolar concentration than serum

Hypertonic Solutions Higher concentration of particles in solution compared with the plasma.

Example: Protein solution Hyperalimentation solution of 10% , 50% , 70% Dextrose

Laboratory test Fluid Status: Osmolality Osmolarity Urine Specific Gravity BUN Creatinine Hematocrit Urine Sodium Values

Osmolality Laboratory value defining solute concentration per liter of solvent. It measures the solute concentration per kg in blood & urine Milliosmoles per kg of H20 (mOsm/kg) Serum Osmolality: 280-300mOsm/kg Urine Osmolality: 50-1400 mOsm/kg

Factors increase Osmolality: Urine Fluid Volume Deficit Serum * Diabetes Insipidus * Hyperglycemia * Sodium Overload Uremia

Factors Decrease osmolality: Urine Fluid volume Excess Serum * Renal failure * Diuretics * Adrenal Insufficience

Osmolarity Measurement of the number of solute particles per liter of solution. Most commonly used to express the osmotic pressure of body fluids Measures in milliosmoles per liter (mOsm/L) 270 300 mOsm/L

Urine Specific Gravity Measures the kidneys ability to excrete & conserve H2O Normal Range: 1.001- 1.040 Random : 1.010 1.020 Physiologic Range: 1.025 1.035

BUN Made up of UREA which is an end product of protein metabolism Normal Range: 10-20 mg/dl (3.5 mmol/L)

Factors that increase BUN: GI Bleeding Dehydration Increase protein intake Fever Sepsis

Factors that Decrease BUN: End Stage Liver Disease Low protein Diet Starvation Condition that result in expanded fluid volume

Creatinine End product of muscle metabolism. Normal Range: 0.6 1.5 mg/dl 53 133 mmol/L

Hematocrit Measures the volume percentage of RBC in whole blood Normal Range: Female : 37 47 % Male: 40 54%

Condition that Increase Hematocrit: Dehydration Polycythemia - Abnormal increase in the erythrocytes in the circulating blood.

Conditions that decrease Hematocrit: Overhydration Anemia

Urine Sodium Values: Normal Range:50- 130 mEq/L 50- 130 mmol/L

Clients at Risk for Fluid & Electrolytes: Clients dependent on others to meet their food & fluid needs. Clients who have gained or lost more than 5 lb in a week Clients who are permitted nothing per orem Clients with retention catheters & urinary drainage system

Clients with intravenous infusion Clients with special drainages orr suctions Clients receiving diuretics Clients experiencing excessive fluid losses & requiring increased intake Clients who retain fluids Clients with fluid restrictions

Post operative clients Clients with severe trauma or burns Clients with chronic diseases Confused clients or those who/ with altered level consciousness who may not be able to communicate needs or respond to thirst.

Types of Fluid Imbalance: Isotonic Imbalance = Happen when water & electrolytes are lost or gained in equal proportions. Osmolar Imbalance = Involves the loss or gain of only water.

Four categories of Fluid Imbalances: Isotonic loss of water & electrolytes An osmolar loss of only water An isotonic gain of water and electrolytes Osmolar gain of only water

Disturbances in Fluid & Electrolytes Balance: Fluid Volume Deficit Dehydration (Hyperosmolar imbalance) Fluid Volume Excess Overhydration (Hypo- osmolar imbalance)

Hypovolemia Fluid Volume Deficit Result when fluid loss exceeds fluid intake. Water and electrolytes are lost in the same proportions Causes: * Vomiting* Diarrhea * Gastrointestinal Suctioning

Sweating Decrease Intake Presence of Nausea Drainage of secretions from fistula Inability to swallow Unavailability of fluids Confusion Depression

Risk: Diabetes Insipidus Adrenal Insufficiency Osmotic Diuresis Hemorrhage Coma Burn Ascites with liver dysfunction

Clinical Manifestation: Acute weight loss Decreased skin turgor Oliguria Concentrated urine Postural hypotension Weak, rapid heart rate Flattened neck vein Cool clammy skin

Thirst Anorexia Nausea Lassitude Muscle cramps Muscle weakness

Laboratory Test: BUN Hematocrit CVP Urine Specific Gravity

Assessment Prior to Administration of Fluid Management: Intake & output Weight Vital Sign CVP Level of consciousness Breath sounds Skin color

Management: Prevention Oral fluids at frequent intervals Medications to combat or minimize fluid loss Enteral or Parenteral administration

Fluid Challenge Test: Used to patient with severe FVD To determine whether the depressed renal function is the result of reduced renal blood flow 2 to FVD or acute tubular necrosis due to prolonged FVD

Hypervolemia Fluid Volume Excess Increase blood volume or circulatory overload Isotonic expansion of the ECF caused by abnormal retention of water and sodium in approximately the same proportions Secondary to an increased in the total body sodium content.

Causes: Excessive intake of NaCl Too rapid administration of Na containing infusion particularly to patient with impaired regulatory mechanism Steroid excess Disease process that alter regulatory mechanism

Clinical Manifestation: Edema Distended neck vein Crackles Tachycardia Increase BP Increase CVP Increase weight Increase urine output

Shortness of breath WheezingDiagnostic Test: BUN Decrease Hematocrit Low serum osmolality Decrease Na CXR

Management: Directed at the causative factor

Dehydration Occurs when water & electrolytes are lost in the same proportion. One of the most commonly body fluid disturbances in infancy / childhood Etiology: * Lack of oral intake * Abnormal loss of fluids

Predisposing Factors: Decreases water intake Increased water loss Excess solute intake

Precipitating factor Decreases Water Intake: Unavailability of fluids Impaired thirst mechanism Impaired swallowing Inability to communicate needs Debilitating disorders in which client cannot attend to thirst.

Precipitating factor Increase Water loss: Diabetes Insipidus Severe Burn Osmotic diuresis Increased respiratory rate

Precipitating factor - Excess Solute Intake High protein diet or tube feeding without adequate fluid intake Excessive IV infusion of hypertonic solution

Sign & Symptoms: Thirst Weight loss Decrease urine output Elevated body temperature Dry or cracked mucous membrane & tongue Poor skin turgor Depressed fontanelle

Sunken eyeball Decrease or absence of tears Alteration in CNS Manifestation of decreases circulating blood volume : * Postural hypotension * Rapid thready pulse * Decreased vein prominence * Increased vein refill time

Complications: Fever Dilutional Hypernatremia Renal Failure Shock Coma

Implementation: Assess for sign & symptoms of dehydration Monitor vital sign & I & O Check peripheral circulation Check specific urine gravity Administered IV therapy as ordered.

Monitor Sign of Water Intoxication: Polyuria Decreases Na & Osmolarity CNS Alteration

Edema Excess in fluids in interstitial space, which maybe localized or generalized. It forms in: * Peritoneal Cavity * Pleural Space * Pericardial Cavity * Subcutaneous

Predisposing factors: Increased Capillary hydrostatic pressure Increased Capillary permeability Decreased Plasma Colloid Osmotic Pressure Lymphatic Obstruction

Precipitating Factors Increased Capillary Hydrostatic pressure: Condition causing venous obstruction Conditions causing arteriolar dilation Increases extracellular fluid volume * Renal Failure * Excessive fluid administration * Endocrine disorder or compensatory mechanism: Cushings disease Liver disease Renal ischemia

Precipitating factors - Increased capillary permeability: Inflammation Allergic Reaction Burn Mechanical Injury

Precipitating factors Decreased Plasma Colloid Osmotic Pressure: Conditions causing loss of albumin Condition causing decreased albumin production

Precipitating factors Lymphatic Obstruction: Malignant invasion of lymph nodes Surgical removal of lymph nodes Infection & inflammation

Sign & Symptoms: Weight gain Elevated BP Skin alteration Alterations in body contours: * Pitting edema * Dependent Edema * Weeping Edema * Brawny Edema

Dependent Edema Gravitational flow of edema fluid to most dependent portion of the body.

Pitting Edema Indentation PIT that forms over edematous area under pressure from examiners fingers.

4 POINT SCALE: 1+ = edema barely detectable with slight pitting 2+ = deeper pit but fairly normal contours 3+ = deep pit & puffy appearance 4+ = excessive fluid accumulation with deep pit & frankly swollen appearance

Brawny Edema Caused by trapping of fluid by coagulated proteins in tissue spaces; skin become thick & hardened with an orange- peel appearance due to severe stretching.

Weeping Edema A very severe form of edema Fluid leaks out of skin pores when pressure exerted over area

Treatment: Specific depends on the cause of edema: Pharmacology & nutrition

Management: Monitor I & O Administer prescribed drugs Restrict fluid & sodium intake Instruct client to read food labels for sodium content Elevate body parts prone to edema avoid pressure / sharp bends Use elastic support stocking & sleeves

Keep skin over edematous tissue clean & lubricated Change client position frequently Monitor electrolytes for sign of hypokalemia or hyponatremia & administer prescribed electrolytes supplements if needed.

Renal failure Acute Renal failure Abrupt reversible cessation of renal function Urine output 400ml/24 hours Chronic Renal failure * Irreversible slow or progressive failure of the kidneys to function that result in death unless treatment is instituted.

Etiology; Pre- renal failure Intra- renal failure Post- renal failure

Pre- renal failure Refer to those factors which causes decreased blood flow to kidneys e.g. decrease of cardiac output , hypotension, hypovolemia such as: Severe hemorrhage Shock Severe burn Severe loss of body fluids

Severe dehydration Circulatory collapse Hemorrhage during maternal cycle Hepatorenal syndrome Septic shock

Intra- Renal Refers to those factors which cause damage to the parenchyma of the kidneys like; AGN Acute Pyelonephritis Due to: Carbon Tetrachloride Sulfonamides Gentamycin

Poison Mushroom Mercury Radiographic contrast agent Transfusion reaction Complication of Pregnancy Hypercalcemic crisis Acute interstitial nephritis Severe crushing injuries

Post Renal Factors which cause obstruction of the ureters or bladders outlets E.g. Tumor Scar tissue Calculi Trauma

Clinical Manifestation: Subjective symptoms: Irritability & confused Headache Anorexia Circumoral numbness Tingling of extremities Lethargy Drowsiness Stupor - Coma

Objective Symptoms: Sudden dramatic drop in urinary output Restlessness, twitching, convulsion Nausea & vomiting Skin pallor, anemia & increased bleeding time Ammonia odor breath & perspiration

Generalized edema, hypovolemia, hypertension & increased venous pressure Deep rapid respiration Elevated serum level BUN, Crea, K, Na, pH, CO2 (+) Albumin in urine, decreased specific urine gravity

Therapeutic Intervention: Correct the underlying cause of renal failure Complete bed rest Diet therapy - Restrict sodium, Protein intake Monitor v/s, I & O Administer diuretics

Monitor urine specific gravity Report for sign of oliguria Report sign of Respiratory infection Prepare client for dialysis; Hemodialysis Peritoneal Dialysis

Peritoneal Dialysis Dialyzing solution is introduced via a catheter inserted in the peritoneal cavity, the peritoneal membrane is used as a dialyzing membrane.

Types: CIPD - Chronic Intermittent Peritoneal Dialysis

CAPD Continuous Ambulatory Peritoneal Dialysis

CCPD Continuous Cycler Assisted peritoneal Dialysis

Automatic PD Cycling machine.1964

Drake- Willock PD Cycler machine1970

Automated Peritoneal Dialysis Cycler

Peritoneal Catheter

Nursing Care: Prior: Explain procedure, equipment, & care Obtained consent Weigh Measure abdominal girth Monitor serum electrolytes, BUN, CREA Make the patient void

Warm dialysate to body temperature Shave abdomen Administer sedatives as prescribed Assist physician with insertion of peritoneal catheter

During: Make sure outflow line is clamped Open inflow line & allow dialysate to flow into peritoneum

Clamp inflow line after dialysate has flowed into the peritoneum Allow dialysate solution to remain in peritoneal cavity for specified time Unclamped outflow line after dwell time is completed Allow solution to drain by gravity Record type of dialysate used

Measure amount of fluid that flowed in & amount that flowed out Report any deficit or excess Record color of outflow drainage.

Management Drainage Ceases: Turn client from side to side Elevate head of bed Check line for kink, clots or leaks Notify physician to reposition catheter if necessary

Hemodialysis The client is attached to a machine that pumps the blood along a semipermeable, dialyzing solution is on the other side of the membrane & osmosis and/or diffusion of waste, toxins & fluids from the client occur.

Kolff Rotating drum 1943, 1st dialysing machine

Kolff Brigham Dialysis machine:1948

Milton- Roy Model A, First machine use for Nocturnal Home Hemo: 1964

Travenol RSP: 1967

Cordis Dow Seratron Dialysis Machine:1979

Purpose: Remove the end product of protein metabolism from blood Maintain safe level of electrolytes Remove excess fluid from the blood Correct acidosis & replenish blood bicarbonate system

Access line: Subclavian catheter Anteriovenous shunt Bovine graft Gortex graft Arteriovenous fistula Saphenous vein graft External shunt - Exanguination

Nursing Care: Secure consent Have client void Assess v/s before & every 30 mins. During procedure With hold anti HPN, sedatives, & vasodilators, diuretics Ensure bed rest Change position frequently

Assess insertion site Maintain patency of femoral or subclavian catheter Assess for patency of shunt, fistula or graft by listening to bruit & feeling thrills or pulsation Determine client response for dialysis

Post Dialysis Complication: Dialysis Disequilibrium syndrome: * Nausea & vomiting * Hypertension * confusion * Seizures Hypovolemia (Hypovolemic shock)

Shock Failure of circulatory system to provide tissue perfusion necessary for normal cellular function & failure to remove waste products of metabolism that accumulate due to inadequate venous return

Types: Hypovolemic shock Vasogenic shock Cardiogenic shock Shrill shock

Hypovolemic shock Result from decreased intravascular volume of at least 1525 % causing decreased venous return

Predisposing factor: Hemorrhage Dehydration Third space of fluid

I Hemorrhage due to: Injury/ trauma Surgery GIT bleeding Delivery of baby Bleeding disorder Defect in coagulation Liver disease Hemophilia DIC

Sign & Symptoms- DIC: Tissue Hypoxia Infarction

Common Cause DIC: Abruptio Placenta Retained Dead Tissue Amniotic fluid Embolism Ca pancrease, lungs, stomach, prostate

II- Dehydration due to: Prolonged vomiting Excessive diarrhea Excessive GIT drainage Overuse of diuretics Endocrine disorder

III- Third Space- fluid: Burn Peritonitis Bowel obstruction Liver disease

Clinical manifestation: Changes in vital sign Changes in the level of consciousness Changes in the skin & mucous membrane Changes in urine output

Diagnostic Measures: CXR CBC Electrolytes BUN/ CREA

Management: Maintain adequate fluid volume Insert foley catheter Monitor I & O Fluid therapy

Fluid Replacement Therapy: Whole blood or blood products Plasma expander Crystalloid Solution

Monitor Sign Fluid overload: Rales Peripheral edema Jugular venous distention

Na - Sodium Normal serum concentration: 136-145 mEq/L Minimum daily intake requirements:2gm/day Sources: * Processed & canned foods * Fish & smoked & sausage type foods * Processed cheese * Snack type foods

Function: Conduction of neural impulses Muscular contraction Regulates osmotic pressure & therefore volume of ECF

Hyponatremia A sodium deficit in the blood plasma Na level below 135 mEq/L Predisposing factor: Increased Na loss Decreased Na intake Dilutional Hyponatremia

Precipitating factor: Increased Na loss Renal lossed Gastrointestinal losses Endocrine imbalance Skin loss Decreased sodium intake

Dilutional Hyponatremia Excessive ingestion of H2O Water retention

Diagnostic Test History & physical examination Serum Na Concentration Serum osmolarity

Sign & Symptoms:1.Decrease BP 2. Weak thready pulse 3. Oliguria 4. Postural hypotension 5. Weight gain 6. Increase BP 7. Pulmonary edema 8. Altered level of sensorium

9. Weakness 10. Cramps 11. Muscle twitching 12. Convulsion 13. Anorexia 14. Diarrhea 15. Abdominal cramps.

Complications: Shock Coma Co- existing electrolytes deficiencies

Prevention: Advise client working in hot environment to drink sodium containing fluids or add salt- diet/ ingest salt tablets. Monitor clients on diuretics Na depletion Teach client/ outpatients to recognize & report S/s of hyponatremia

Management: Administer prescribed NaCL Restrict H2O intake Administer prescribed diuretic Relieve CNS alteration from cellular swelling

Hypernatremia Serum level higher than 145 mEq/l Predisposing factor: Primary hypernatremia Decreased Extracellular H2O resulting in increased serum Na

Precipitating factor- primary Hypernatremia: Infusion of saline Excessive ingestion of sodium salt in diet/ drugs Salt water drowning Renal disease Hyperaldosteronism Cushing syndrome/disease Excessive Na intake in client with renal failure

Precipitating factor of decreased H2O in ECF- increased serum Na Excessive H2O loss Decreased water intake

Sign & Symptoms:1. 2. 3. 4. 5. 6. 7. 8. Thirst CNS alteration Dry flushed skin Dry fissured mucous membrane Weight loss Decrease BP Weak, thready pulse Increased temperature

Sign of severe Hypernatremia: Agitated Restlessness Disorientation Hallucination

Diagnostic Test: History & physical examination Serum osmolarity Serum Na concentration Laboratory test Urine specific gravity

Complication: Manic excitement Hypovolemia Coma

Prevention: Restrict Sodium intake Placed on regular schedule of H2O administration Check for adequacy of renal function prior to administration of IV electrolytes.

Management: Diuretics to remove Na Discontinue Na containing IV fluids Renal dialysis Liberal administration of water Monitor electrolytes Assess for manifestation of fluid overload-H2O replacement therapy Assist client while ambulating

Potassium Normal serum K: 3.5-5.0 mEq/L Daily requirements: 0.5-1.5 gm Sources: * Meats * Fish * Milk products * fruits/ vegetables

Functions: Regulates intracellular osmotic pressure & fluid volume Participate in acid base balance Co- factor in metabolic reactions Critical in neuromuscular excitability of skeletal, cardiac, & smooth muscle

Hypokalemia Decreased serum K below 3.5 mEq/L Predisposing factors: Inadequate K intake Increase K loss from body K shift into cells

Precipitating factors-Inadequate K intake: Diet or IV solution deficit in K Inability to eat

Precipitating factors-Increase K loss from body: Renal losses GI losses Skin losses

Precipitating factors-K shift into cells: Alkalosis or alkalinizing drugs Insulin & glucose therapy

Sign & Symptoms: CNS alteration Altered neuromuscular activity ECG alteration Postural hypotension Shallow breathing Respiratory muscle paralysis Metabolic alkalosis

Arrhythmias

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Prolonged interval widening QRS

Diagnostic: History & physical assessment Serum K concentration Serum pH

Complication: Ventricular fibrillation Respiratory Arrest Potentiation for digitalis toxicity

Ventricular fibrillation

Management: Prevention depends on the situation Nursing history & assessment Replenish K preferably by oral route Food high in K K supplement: KCL K-lyte K gluconate Cena K

Monitor client for sign & symptoms of K toxicity Assess adequacy of renal function Monitor ECG & pulse, muscle strength Assist client while ambulating & observe client frequently

Hyperkalemia Increased serum K above 5.5 mEq/L Predisposing factor: Excessive K intake Decreased K excretion K shift out of the cells

Precipitating factor- Decreased k excretion: Decreased renal excretion Decreased fecal excretion

Precipitating factor-K shift out of cells: Cell injury Acidosis or acidifying drugs

Diagnostic test: History & physical examination Serum k concentration

Sign & symptoms: Manifestation of altered cell polarization, which affect neuromuscular activity Neural & skeletal muscle alterations Cardiac alteration Smooth muscle alterations

Peaked T-wave

Wide QRS complex

Cardiac fibrillation

Cardiac arrest

Complication: Ventricular fibrillation Cardiac arrest Respiratory arrest

Management: Monitor serum K in patient receiving K containing medications & in client in acidosis Avoid transfusion of old, stored blood Check adequacy of urine output prior to administration of IV solution containing K Monitor ECG

Increase K excretion with prescribed dialysis /ion exchange resins Decrease K release from cell Increased cellular uptake of K Monitor client for sign & symptoms of hypokalemia Safety precaution K reducing medication: * Kayexalates (Sodium Polystyrene Sulfonate)

Mg -Magnesium Normal serum: 1.5-2.5 mEq/L Daily requirements: Non-pregnant -250 mg Absorption: GIT Excretion: Normal kidneys

Functions: Regulation of synaptic transmission at neuromuscular junction & in CNS Co-factor in variety of enzymatic reactions in metabolic pathways

Magnesium rich foods: Green vegetables Nuts Sea foods Whole grains Dried beans Cocoa Banana Legumes Oranges

Hypomagnesemia Decreased serum Mg level below 1.5 mEq/L Predisposing factor: Inadequate intake Decreased absorption of mg Excessive excretion or fluid loss

Precipitating factor-Inadequate Mg intake: Malnutrition Increased dietary intake of Calcium without increasing Mg intake Prolonged IV infusion of Mg free IV solutions without oral Mg intake

Precipitating factors-decreased absorption of Mg: Diarrhea Genetic Mg absorption defect Mal absorption syndromes Presence of high Ca, fat or phosphorus in GIT

Precipitating factors-Excessive excretion or fluid loss: Diuretics Diabetic Ketoacidosis Prolonged GI suction Hypoaldosteronism

Sign & Symptoms: Manifestation of increased CNS & neuromuscular excitability resulting from increased acetylcholine release A. CNS alterations B. Neuromuscular alterations Cardiovascular alterations

Positive Chvosteks sign Consist of twitching of muscles supplied by the facial nerve when the nerve is tapped

Trousseaus sign Carpo pedal spasm will occur as ischemia of the ulnar nerve develops

Diagnostic Test: History & Physical examination Serum Magnesium level

Complication: Convulsion Cardiac arrhythmias

Management: Prevention depends on situations Nursing history & assessment Monitor client for manifestation of Mg excess Have Calcium Gluconate available Safety & seizures precautions

Hypermagnesemia Increased serum Mg greater than 2.5 mEq/L associated sign & symptoms appear if Mg exceeds 4 mEq/L Predisposing factors: Decreased renal excretion Increased Mg intake or absorption

Sign & Symptoms: CNS alteration Skeletal muscle alterations Cardiovascular alterations

Flaccid Paralysis

Diagnostic Test; History & Physical Exam Serum Mg level

Complications: Over sedation Respiratory depression Cardiac arrhythmias Coma Arrest

Management: Prevention: Do not administer Mg containing medication if renal function is inadequate Teach proper use of antacids/ cathartics Decrease intake of food rich in Mg

Intervention: Provide adequate fluid adequate excretion of urine With hold medication containing Mg Conduct prescribe dialysis procedure Administer prescribed Calcium Gluconate Monitor client for manifestation of Mg deficit / Calcium toxicity

Calcium & Phosphate 75% - Ca & PO4 , derived from milk & milk product 30% - ingested Ca absorbedintestine & excreted - feces 70% - ingested PO4 absorbedintestine & excreted- urine Vitamin D- increase Ca absorption & renal excretion of PO4

Function: Ca & PO4 essential component of bone & teeth PO4 involved in metabolic reactions & cellular energy production PO4 functions in acid- base balance Ca regulates membrane permeability & nerve transmission

Ca triggers muscle contractions Ca involves in blood coagulations Ca essential for hormone secretion NORMAL VALUE: Ca : 9-11mg/dl or 4.5-5.8 mEq/L PO4: 3-4.5 mg/dl or 1.7- 2.6 mEq/L

Phosphate Function in cellular energy metabolism combines with calcium ions in bones, providing hardness. Involve in structure of genetic material DNA & RNA

Sources : Milk Milk products Green leafy vegetables Sardines Clams Oyster

Diagnostic test: History & P.E Serum Ca concentration HYPOCALCEMIA decrease serum Ca below 9mg/ dl or 4.5 mEq/L

Predisposing factors/ Precipitating factors: Decrease intake of Ca Decrease Ca absorption Vitamin D deficiency Overuse of antacids Increase Ca losses GI losses Loss in exudates

Decrease availability of physiologically active free Ca Alkalosis Massive transfusion with citrated blood Hypothyroidism

Sign & Symptoms: Manifestation of increased neuromuscular excitability; Numbness & tingling Muscle spasm Tetany Cramps Convulsion (+) trousseaus & Chevosteks sign Laryngospasm

Manifestation of depressed cardiac contractility; Weak cardiac contractions Cardiac arrhythmias

Complications: Convulsion Respiratory arrest CHF Cardiac arrest Pathological fracture

Management: Oral increase dietary intake of Ca & Vitamin D Administer prescribed Ca supplement- IV/ IM Ca CL Ca gluconate Calcium lactate

Hypercalcemia Increased serum Ca above 11mg/ dl Predisposing/Precipitating factors: Excess Ca or Vitamin D Hyperthyroidism Increased availability of physiologically active free Ca

Increased Ca mobilization from bone; Multiple fractures Prolonged immobilization Tumors (breast/ lungs/ kidney etc) Bone tumors

Sign & Symptoms CNS depression, altered level of sensorium Decrease deep tendon reflexes Muscle weakness Decrease GI mobility Nausea & vomiting Constipation Cardiac arrythmias

Diagnostic Test: History & P.E Serum Calcium COMPLICATIONS: Renal failure Cardiac arrest Pathological fracture Potentiation of digitalis toxicity

Management: Restrict dietary intake of Ca Hydrate client- promote renal excretion of Ca Maintain acid urine increase Ca solubility Prevent UTI Administer prescribed Mithramycin Avoid vitamin D supplement

Chloride Most abundant anion in extracellular fluid Help balance Na Major component of gastric secretions. Sources:Salt

Chloride FUNCTION: Help maintain osmotic pressure & fluid volume - ECF Essential for production of HCL by gastric parietal cells Participate in regulations of acid/ base balance

Hypochloremia Decreased serum Cl level below 96 mEq/L Predisposing factor: * Loss commonly parallel to Na loss or dilution by excess H20 * Independent loss * Decrease intake of Cl

Sign & Symptoms: Edema Distended neck vein Tachycardia Increased urine output Increased BP Crackles, wheezing, shortness of breathing Thirst

CNS alterations Dry flushed skin Weight loss Decreased BP Weak thready pulse Increased temperature

Management: Monitor electrolytes Specific depend on the underlying cause Safety & seizure precautions

Hyperchloremia Increased serum level above 106 meq/L Prediposing factors: Excessive ingestion or infusion of Cl containing compounds such as KCl , NaCl, ammonium chloride

Acid Base Balance Acid Compound that yields hydrogen ions when dissociated in solution. Properties: Acts as an electrolytes in H20 Reacts with base to form H20 & salt Destroy body tissues

Common Acids: Hydrochloric acid Carbonic acid Acetic acid Lactic acid

Hydrochloric acid Secreted by the parietal cells of the stomach , transform pepsinogen into pepsin. Carbonic acid - one form in which CO2 is transported in the blood - part of the bicarbonate buffer system

Lactic acid Builds up in muscle tissue during exercise & it is transported to the liver via the circulatory system where it is completely oxidized into Co2, H20 , & energy

Bases A compound that combines with an acid to form H20 & a salt properties: * Acts as an electrolyte in H20 * Destroy body tissue

Common base: Magnesium Hydroxide Aluminum Hydroxide Ammonium Hydroxide

Salts Compound formed when an acid is neutralized by a base Properties: * Acts as an electrolyte in H20 * Crystalline in nature * Salty taste

Common Salts: Sodium chloride Potassium chloride Silver nitrate Barium sulfate Ferrous sulfate Sodium bicarbonate

Organs responsible in acid base balance: Lungs - maintain acid-base balance by controlling CO2 in the body. Kidneys - it maintain acid-base balance by controlling HC03

Process of Ventilation:Ventilationrespiration hypoventilation Excretion of CO2 Retention of CO2 H2CO3 Respiratory Acidosis respiration hyperventilation Excretion of CO2 Retention of CO2 H2CO3 Respiratory Alkalosis

Respiratory Acidosis H2CO3 Kidney to retain HCO3 HCO3 Metabolic Alkalosis

Respiratory Alkalosis H2CO3 Excretion HCO3 HCO3 Metabolic Acidosis

Parameters of Acid-Base Balance: pH - denotes the power strength of hydrogen ions in a solution Normal value: 7.35 7.45

pC02 - partial pressure of CO2 measurement of respiratory function normal value: 35-45 mmHg

HCO3 - measurement of metabolic function Normal Value: 22-26 mEq/L

Example:pCO2 - 60 = respiratory acidosis HCO3 - 32 = metabolic alkalosis pH - 7.43 = normal

Different acid- base imbalance: Uncompensated type Compensated type * Partially compensated type * Fully compensated type

Uncompensated type Example: pCO2 - 31 = Respiratory alkalosis HCO3 - 25 = Normal pH - 7.52 = Alkalosis

pCO2 - 39 = Normal HCO3 - 18 = Metabolic acidosis pH - 7.31 = Acidosis

Partially compensated type Example:pCO2- 50 = Respiratory acidosis HCO3- 30 = Metabolic alkalosis pH- 7.5 = Alkalosis

Fully compensated Example:pCO2- 55 = Respiratory Acidosis HCO3- 31 = metabolic alkalosis pH- 7.37 = Normal

Metabolic acidosis State of excess acid accumulation & deficient base HCO3. Symptoms result from the bodys attempt to correct the acidotic condition through compensatory mechanism in the lungs, kidneys & cells. ABG reveals: pH below 7.35 HCO3 below 24 meq/L

Cause: Cellular breakdown Chronic alcoholism Diabetic ketoacidosis Diarrhea or Intestinal malabsorption Renal insufficiency & failure

Sign & symptoms: Headache Lethargy Drowsiness CNS depression Stupor Kussmauls respiration

Treatment: IV fluid administration& insulin administration Na bicarbonate IV or orally Endotracheal intubation & mechanical ventilation Oral hygiene Insulin or oral anti diabetic therapy

Metabolic alkalosis Decrease amount of acid or increased amount of base (HCO3) ABG reveals: pH greater than 7.45 HCO3 above 29 mEq/L

Causes: Loss of gastric juices Fistula Excessive intake of bicarbonate of soda or other antacid Excessive intake of alkaline Use of steroid & certain diuretics Hyper adrenocorticism

Sign & Symptoms Hypoventilation Irritability Carphology Nausea & Vomiting Diarrhea Cyanosis Atrial tachycardia Twitching Apnea

Treatment: Ammonium chloride Potassium supplement

THE END GOOD LUCK