Professional Documents
Culture Documents
Electrolyte
NUR 108 - Spring
2014
Learning Outcomes
1.
2.
3.
4.
6.
Fluid Regulation
Fluids move through the body by:
Osmosis
Diffusion
Filtration
Active transport
Diffusion
Osmosis
Active Transport
Filtration
Osmotic Pressure
Osmotic Pressure
Isotonic
Isotonic has same osmolality as
normal plasma
Used to replace extracellula fluids
Expand vascular volume quickly
N.S., Ringers sol., Lactated
Ringers (LR)
D5W: (becomes hypotonic when
Hypotonic
Hypotonic has lower osmolality
0.225% NS
Hypertonic
Hypotonic has higher osmolality than
Colloid Solutions
Colloid large solute (protein), that does
osmosis
Albumin 25%, Dextran, Hetastarch
Manitol or Osmmitrol pulls fluid from
mechanism
Fluid output
Urine
Insensible
loss
Feces
Maintaining
homeostasis
Kidneys
ADH
Renin-
angiotensinaldosterone
system
Atrial natriuretic
intake
*Fluid is lost through 4 routes:
Urine (1400-1500 mL/24 hrs.)
Skin perspiration (350-400 mL)
Lungs (350-400 mL by water vapor)
Intestines (chyme 1500 mL)
Chemical Regulation of
Fluids
ADH
is released when BP or blood
volume decrease (or osmolality inceases)
Results in renal reabsorption of water to
Chemical Regulation of
Atrial
Natriuretic Peptide (ANP) lowers
Fluids
blood volume by:
Causing vasodilation or
Suppressing of the renin-angiotensin
system
Brain Natriuretic Peptide (BNP) decreases
Distribution of Body
Fluids
1. Intracellular
(ICF)
Inside cell
2/3 total body
fluids
2. Extracellular
(ECF)
Outside the cell
1/3 total body
fluids
intravascular
20%
interstitial 75%
Body Fluids
Transcellular fluids:
CSF
Lymph fluid
Biliary fluid
Pancreatic fluids
Intraocular fluid
Peritoneal fluids
Synovial fluid
ECF 15-20%
ICF 40-45%
Infant
ECF 45%
ICF 35%
interstitial fluid
Full-term newborn body wt approx. 80%
Premature infant approx. 90%
Adult (from puberty to age 60) 60%
Elderly (> 60 yrs) 45%
function
A vital medium for metabolic reactions
Transports nutrients, waste products,
absorber
Regulates body temperature
Aids in digestion & peristalsis
of body water
Paracentesis
Burns
Loss of injured
Wound
exudate
Gastric suction
Colitis
Stools
Urine
spaces as edema
Third spacing
intestinal pooling
Draining intestinal
fistulae
Drainage tubes
Clinical Manifestation
of Third-spacing
proteins
starvation
Liver dysfunction Cirrhosis
High vascular hydrostatic pressure from
Clinical Manifestation of
Fluid Volume Deficit (FVD)
volume
Decreased urine volume 30 mL
Postural hypotension
Low central venous pressure
Poor skin turgor and tongue turgor
Dehydration Concept
Isotonic dehydration: involves equal losses
losses of electrolytes
Decreases osmolality, ECF decreases
Assessing Dehydration
Thirst, or excessive thirst
Urine concentration, dark, low urine volume
Specific gravity > 1.030
Dry skin, dry mucous membranes
Decrease turgor & skin elasticity
Sunken eyes, sunken fontaneles < 18 mo.
Hypotension, postural hypotension
Weakness, lightheadedness, syncope
Acute weight loss
Risk Factors
Age: Infants and Elderly
Gender and body fat
Obesity (fat holds less water than muscle)
Acute illness: gastroenteritis (n/v), burns,
Nursing Diagnoses
Fluid volume deficit/excess r/t excessive fluid
dizziness
Risk for impaired skin integrity r/t skin and
of: (etiology)
Nursing Interventions
Monitor VS, & mucous membranes
Monitor lung sounds
Monitor mental status
Monitor I&Os and IV fluids
Monitor urine status
Oral or parenteral replacement of fluids
Monitor IV fluids (prevent overload)
Electrolytes
Regulating Electrolytes
Sodium - Na
Potassium - K
Calcium - Ca
Magnesium - Mg
Chloride - Cl
Phosphate - PO4
Bicarbonate - HCO3
Sodium (Na)
135-145 mEq/L -
Hyper/Hyponatremia
Most abundant electrolyte in ECF
Contributes to serum osmolality
it
adults
High BMR, produce more heat, req. more water
tolerance
diarrhea, NG suction
Burns loss of fl & electrolytes thru tissue
damage
Brain trauma CVA, tumors, cerebral edema,
electrolytes
DM osmotic changes in hyper-hypoglycemia
Potassium (K)
Serum: 3.5 5.0 mEq/L
Hper/Hypokalemia
salt substitutes
syndrome
Increase aldosterone: heart failure,
Treatment:
Potassium replacement in hypokalemia
Medication: black
box
Monitor labswarning
Monitor V.S, cardiac status (teley or monitor)
IV infusion: K is a vesicant; causes phlebitis
Hyperkalemia > 5
mEq/Lof K as a result of
Retention
decreased or inadequate urine
output
Excessive release of K from the cells
containing K
Various drugs
Causes of Hyperkalemia
Blood transfusions
Drugs
Beta-blockers, K sparing diuretics, NSAIDs,
Aminoglycosides, Chemotherapy
output
injuries
S/Sx of Hyperkalemia
Neuromuscular alerts
Muscle weakness in lower extremities
Flaccid paralysis
Muscle hyperactivity or Irritability,
Cardiac Alerts
cramping
Arrhythmias
ECG changes:
Tall,
tented T wave
Flattened
P wave
Prolonged
Widened
PR interval
QRS complex
Depressed
ST segment
Treatment
In Mild cases
Loop diuretics;
Restricted dietary K
Emergency measures
Monitor ECGs
Treat acidosis
Use IV regular insulin therapy
Administer IVs
Nursing Actions
Assess vital signs
Anticipate cardiac monitoring
Monitor I & O -- report output < 30 mL/hr
Adm. a slow IV infusion of Calcium
Gluconate
Assess for clinical signs of hypoglycemia
Muscle weakness
Syncope
Hunger
Diaphoresis
Calcium (Ca)
Serum: 8.5 10.5 mg/dL
hyper/Hypocalcemia
99% body Ca stored in skeletal system
Essential for muscle contraction, nerve
Deficiencies in Vit. D
transfusions
Citrate toxicity leading to hypocalcemia
Alcoholism
inflation
Chvosteks sign facial nerve tapping causes
twitching
Post-menopausal women
Osteoporosis, osteopenia; Ricketts disease
Post- thyroidectomy, parathyroidectomy
Chrons disease; Hypothyroidism
Immobility: clients in prolong bedrest
Hypocalcemia
Total serum Ca < 8.9 mg/dL
Ionized serum Ca < 4.5
mg/dL
Causes
Severe burns,
Infections
Alcoholics with
poor nutritional
intake
Renal alerts
Diuretics
Especially loop
diuretics
Drugs;
Cisplatin,
Gentamycin
insufficiency
tetany
Hyperactive deep tendon reflexes
Decreased cardiac output and arrhythmias
Diarrhea
Treatment
Acute hypocalcemia requires IV Ca
Mag replacement may also be needed
Chronic hypocalcemia needs vitamin D
supplement
Dietary changes
Diagnostic tests: ECG, labs
Nursing Actions
Assess for risk of hypocalcemia
Monitor vital signs, respiratory status
Cardiac monitor
Check Chvostek's and Trousseaus signs
Assess and monitor IV line and IV meds
Monitor labs
Client teaching
Hypomagnesemia
< 1.5 mEq/L
Hypermagnesemia
> 2.5 mEq/L
GI and GU systems regulate Mag levels
Must measure along with serum albumin
Must also consider Ca, K, PO4 levels and Ph
Most common risk factor of
hypermagnesemia is
Renal insufficiency
Causes of Hypomagnesemia
Poor dietary intake of magnesium
Chronic alcoholism
Prolonged IV fluids in clients on TPN
Absorption problems
Malabsorption syndromes, steatorrhea
Ulcerative colitis, Crohns disease, Bowel
resection
Pancreatic insufficiency, cancer
GI problems
Prolonged diarrhea, fistulas, laxative abuse,
Causes of
Urinary
Problems
Hypomagnesemia
Primary aldosteronism, hyperparathyroidism
Diabetic ketoacidosis
Use of amphotericin B, cisplatin,
aminoglycosides
Loop or thiazide diuretics
Other causes
Sepsis
Serious burns
Wounds requiring debridement
Cardiovascular
Seizures
Tachycardia
Altered LOC
Hypertension
Confusion
ECG changes
Delusions
GI tract
Depression
Anorexia
Hallucinations
Nausea
Emotional lability
Vomiting
Dysphagia
stridor; Respiratory
difficulties
Paresthesia
Diagnostic Tests
Evaluate serum levels < 1.5 mEq/L
Decreased serum albumin level
Decreased K or Ca
ECG changes
Elevated serum levels of cardiac
Treatment
Varies with cause and degree of severity
Usually involves replacement therapy
Real important to read the label on the Mag.
Nursing Actions
Assess mental status, neuromuscular status,
and dysphagia
Especially check DTRs, tremors, tetany,
Chvosteks Facial twitching when the facial
nerve is tapped
Trousseaus signs - Carpal spasm when the
Memory Jogger
S = seizures
T = tetany
Chloride (Cl)
Hypochloremia:
< 95 mEq/L
Hyperchloremia:
Hypochloremia
Causes:
Na, K imbalances, metabolic alkalosis
Diabetic acidosis, SIADH, CHF
Acute infections
Metabolic stress conditions: burns, fevers
heat exhaustion
Vomiting, bulimia, diarrhea, tap water enemas
Treatment
Replacement therapy: appropriate foods, oral
conditions
Dietary changes
Obtain ABGs - maintain acid-base balance
Panic value: < 80 mEq/L
Nursing Interventions
Assess for:
Hyperchloremia
Causes:
Na, K, CO2 imbalances, metabolic acidosis
Injections of drugs: salicylates,
Treatment
Decrease chloride intake
Withdraw chloride-containing
agents
Diuretics excretes chloride
Nursing Intervention
Monitor acid-base, respirations, cardiac status
Monitor VS and I&O
changes
Maintain adequate hydration
IV sol. 0.45% NaCL or D5W (act as
hypotonic)
Client education: avoid foods high in chloride,
Phosphate (PO4)
A major component of ATP in cellular
metabolism
Newborns have twice the adult level
Essential for RBC, NS and muscle function
Needed for bone and teeth formation
Helps regulate calcium and renal acid-base
Role in metabolism of CHO, Proteins, fats
Foods: organ meats, meat, fish, poultry,
Hypophosphatemia
< 2.5 4.5 mg/dL or
< 1.7 to 2.6 mEq/L
Causes
Adm. Of glucose, insulin and TPN can shift
aluminum)
DKA, alcoholism, severe burns, resp.
alkalosis
Treatment
Labs: PO4 levels, mag, calcium
ABGs watch for metabolic acidosis
X-rays: may show skeletal changes
Replacement therapy
Avoid phosphate binders
Monitor cardiac function
Monitor for other electrolyte imbalances
Assess for:
Levels < 2.0
Anemia, bruising, bleeding
Slurred speech, confusion, seizures, coma
Muscle weakness, tremors, tetany
Chest pain, dysrhythmias r/t decreased O 2,
hypoxemia
Decreased GI functions: gastric atony, ileus
Will lead to acid-base imbalance, cardiac
arrest
Hyperphosphatemia
> 4.5 mg/dL
or
Causes
Shifting from cells into ECF
Respiratory or lactic acidosis
Rhabdomyolysis muscle dysfunction r/t
Renal insuficiency
Excess vit. D; infants fed cows milk
Nursing Management
Nursing history
Physical assessment
Clinical measurement
Review of laboratory test results
Evaluation of edema
Nursing diagnosis
Planning
Implementation & Evaluation
(etiology)
Desired Outcomes
Maintain or restore normal fluid balance
Maintain or restore normal balance of
electrolytes
Prevent associated risks
Tissue breakdown, decreased cardiac
needed
Practice Guidelines
Restricting Fluid Intake
Explain reason and amount of restriction
Help client establish ingestion schedule
Identify preferences and obtain
Set short term goals; place fluids in small
containers
Offer ice chips and mouth care
Teach avoidance of ingesting chewy, salty,
Evaluation of Edema
Nursing Interventions
Monitoring
Fluid intake and output
Cardiovascular and respiratory status
Results of laboratory tests
Assessing
Clients weight
Location and extent of edema, if present
Skin turgor and skin status
Specific gravity of urine
Level of consciousness, and mental status
Nursing Interventions
Fluid intake modifications
Dietary changes, dietary consult
Parenteral fluid, electrolyte, and blood
replacement
Other appropriate measures such as:
Administering RX medications and
oxygen
Providing skin care and oral hygiene
Positioning the client appropriately
strenuous exercise
Replace lost electrolytes
of medications
Recognize risk factors
Seek professional health care for notable
balance
help
Correcting Imbalances
Oral replacement
If client is not vomiting or experiencing
fluid retention
Vary from NPO to precise amt. ordered
Dietary changes
Oral Supplements
Potassium (KCL)
Calcium
Multivitamins
Sports drink
Documentation
Vital signs, I & O, rhythm strips
Assessment findings
Lab results, x-rays
Interventions and client responses
Safety measures
Client teaching
Question 1
1.
2.
3.
4.
Rationales 1
1.
2.
Chapter
Acid-Base
Balance
52
Regulation Acid-Base
pH Balance
Huma
n
Blood
7.4
Copyright 2012
by Pearson
Buffers
Body fluids are maintained between pH of
7.35 and 7.45 by:
Buffers
Respiratory system
Renal system:
Prevent excessive
changes
in pH
Lungs
Regulate acid-base balance by eliminating or
respirations
Kidneys
Regulate by selectively excreting or
Age
Balance
Gender
Acute conditions
Body size
Medications
Environmenta
Treatments
l temperature
Lifestyle
Extremes of age
Inability to
food
access
and fluids
Imbalances
Burns
Drug Therapy
Diuretics
Steriods
Aldactone, aldosterone inhibiting
agents
Gastroenteritis
Nasogastric suctioning
Fistulas
IV Therapy - TPN
Acid-Base Imbalances
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
Nursing History
Current history & past medical history
Diabetes mellitus
Chronic lung diseases
Medications
Functional & socioeconomic factors
Developmental factors
Fluid and Nutritional intake
Fluid output
Nursing History:
Chronic Diseases
Nursing History:
Acute Conditions
Acute gastroenteritis
Bowel obstruction
Head injury or decreased LOC
Trauma: burns, crushing injuries
Surgery
Fever, draining wounds, fistulas
Nursing History:
Treatments
Chemotherapy
IV therapy and TPN
Nasogastric suction
Enteral feedings
Mechanical ventilation
Meds: Diuretic, Anti-hypertensive therapy,
Physical Assessment
Focus on the skin
Oral cavity and mucous membranes
Eyes
Cardiovascular system
Respiratory system
Neurologic status
Muscular system
impressions on feet
Fontanels in infants: sunken, soft vs. Bulging,
firm
Compress & inspect skin over dorsal foot,
Physical Assessment:
Oral Cavity
Make a visual inspection
Mucous membranes dry, dull in
appearance
Tongue dry with cracks
Physical Assessment:
Cardiovacular System
irregular dysrhythmias
Palpate peripheral pulses weal or thready;
bounding
B/P postural hypotension, Korotkoffs sounds
Breathing rate & patterns, depth, crackles, or
moist rales
Physical Assessment:
Neurological System
stregth
Deep tendon Reflex (DTP) hyperactive or
depressed
Physical Assessment:
Neurological
System
Chvosteks
sign
tap over facial nerve
Observe twitching of facial muscles
Calcium depletion
Trousseaus sign
Carpal spasm ocurring during inflation of BP
cuff
hypoclacemia
Physical Assessment:
LAB
results
Serum electrolytes
Complete blood count hematocrit, 40%-54%
Serum osmolality: Na, glucose, BUN
Urine pH 500-800 mOsm/kg.
Physical Assessment:
ABGs
Respiratory Acidosis:
Hypercapnia
A state of excessive carbon dioxide in the
body.
pH < 7.35
PaCO2: > 45 mmHg (excess CO2 & carbonic
acid)
HCO3: normal, > 26 mEq/L with renal
compensation
Respiratory Alkalosis
A state of excessive loss of carbon dioxide in
the body.
pH > 7.45
PaCO2: < 35 mmHg (inadequate CO2 &
carbonic acid)
HCO3: normal, < 22 mEq/L with renal
compensation
Metabolic Acidosis
A condition characterized by a deficiency of
compensation
HCO3:
Metabolic Alkalosis
A condition characterized by an excess of
compensation
HCO3: > 26 mEq/L (excess bicarbonate)
Volume
Impaired Gas Exchange
Planning
Maintain or restore normal fluid balance
Maintain or restore normal electrolyte balance
oxygenation.
Prevent associated risks: tissue breakdown,
Electrolyte Replacement
Modify fluids: push
Change diet to meet electrolyte demands
Oral electrolyte supplements
Parenteral Fluid administration