Adult Health Nursing I: Joseph Mariano, RN, MD

Adult Health Nursing I
Joseph Mariano, RN, MD
1
Fluid and Electrolytes
2
Fluid and Electrolyte Balance
 Dynamic and essential to life
 Potential and actual disorders occur
in every setting, with every disorder
 Changes with conditions that affect
well and ill people
3
Fluids: Amount and Composition
 Water and electrolytes
 60% of body weight
 Influenced by age, gender, body fat
4
Fluids: Amount and Composition
 Intracellular Fluid Compartment
(2/3)
 Extracellular Fluid Compartment
(1/3)
 Intravascular (3L)
 Interstitial (11-12L)
 Transcellular (1L)
5
Electrolytes
 Cations and anions that are active
chemically
 Cations – Na+, K+, Ca++, Mg++, H+
 Anions – Cl-, HCO3-, HPO4--, SO4--,
proteinate
 Expressed in mEq/L – equivalent to
the electrochemical activity of 1mg
H+
6
Major Electrolytes
 ECF Cations  ECF Anions
 Na 142  Cl 103
 K 5  HCO3 26
 Ca 5  HP04 2
 Mg 2  SO4 1
 Org Acids 5
 Proteinates 17
7
Major Electrolytes
 ICF Cations  ICF Anions
 K 150  PO4, SO4 150
 Mg 40  HCO3 10
 Na 10  Proteinate 40
8
Fluid Volume Disturbances
Hypovolemia (Fluid Volume Deficit)

 ECF loss > intake
 Ratio of electrolytes to water is

unchanged
 Not synonymous with dehydration
which is loss of water alone
9
Hypovolemia, Causes
 Prolonged inadequate intake
 Vomiting, diarrhea, sweating
 Hemorrhage, diabetes insipidus
 Fluid shifts (burns, ascites)
10
Hypovolemia, Manifestations
 Acute weight loss
 Decreased skin turgor
 Oliguria*
 Postural hypotension*
 Weak, rapid HR
 Cool, clammy skin, increased T
 Thirst
11
Hypovolemia, Assessment
 Elevated BUN Creatinine ratio, Hct
 Urine specific gravity is increased
12
Hypovolemia, Medical Management

 If not severe, oral route is preferred
 IV therapy , rate based on severity

of loss and hemodynamic response
 Fluid challenge test
13
Hypovolemia, Nursing Management
 I&O monitoring
 Daily weights
 VS monitoring
 Skin and tongue turgor
 Mental functioning
 Inc OFI, considering patient
preferences
14
Hypervolemia (Fluid Volume Excess)

 Isotonic expansion of ECF
 Always due to increased Na
15
Hypervolemia, Causes
 Fluid overload
 Diminished fluid balance regulation
 Heart, kidney, liver problems
 Excessive Na intake
16
Hypervolemia, Manifestations
 Edema
 Distended neck veins
 Crackles
 Increased weight, urine output, BP
17
Hypervolemia, Assessment
 BUN and Hct decreased
 Chest xray may show congestion
18
Hypervolemia, Medical Management

 Diuretics (HCTZ, loop diuretics)
 Fluid and sodium restriction
 Hemodialysis/Peritoneal Dialysis
 Always treat the underlying cause
19
Hypervolemia, Nursing Management

 I&O, daily weights, VS monitoring
 Breath sounds
 Assess and measure edema
 Bed rest
 Positioning and turning
20
Electrolyte Imbalances: Na
Sodium (Na)
 Most abundant in electrolyte in the
ECF (135-145 mEq/L)
 Primary regulator of ECF volume
21
Hyponatremia
 < 135 mEq/L
 Related to water content
22
Hyponatremia, Causes
 Vomiting, diarrhea, diuretic use
 Dilutional (SIADH, hyperglycemia,

tap-water in enemas and GI tubes)
23
Hyponatremia, Manifestations
 Nausea and vomiting
 Muscle twitching and cramps
 Hypotension
 Neurologic changes
24
Hyponatremia, Medical Management

 Na replacement (diet or IV)
 Water restriction (800 ml in 24 hr)
 Only up to the point of relieving

neurologic signs and symptoms
(125 mEq/L)
25
Hyponatremia, Nursing Management

 GI and Neuro manifestations
 Dietary intake, fluid restriction
26
Hypernatremia
 >145 mEq/L
 Related to water content
27
Hypernatremia, Causes
 Fluid deprivation in those who
cannot perceive, respond or
communicate their thirst
 Watery diarrhea
 Insensible water loss
 Diabetes insipidus
28
Hypernatremia, Manifestations
 Neurologic
 Subarachnoid hemorrhage
 Dry, swollen tongue, sticky mucus

membranes
 Increased muscle tone and DTRs
29
Hypernatremia, Medical Management

 Hypotonic or isotonic fluid infusion
 Diuretics
 Desmopressin if insipidus is the

cause
30
Hypernatremia, Nursing Management

 Monitor thirst
 Neuro symptoms
 Ensure fluid intake
31
Electrolyte Imbalances: K
Potassium
 Major intracellular electrolyte
 The extracellular portion (2%) is

important in neuromuscular function
 3.5-5.0 mEq/L
 Balance primarily regulated by the

kidneys
32
Hypokalemia, Causes
 <3.5 mEq/L
 Actual total deficit
 In alkalosis, K shifts into cells
 GI loss most common (vomiting,
diarrhea)
 Diuretics
 Insulin therapy
33
Hypokalemia, Manifestations
 Cardiac/respiratory arrest
 Muscle weaknesss, leg cramps,

decreased bowel motility,
paresthesia
 Increased sensitivity to digitalis
 Decreased BP, reflexes
34
Hypokalemia, Assessment
 ECG changes
 ST segment depression
 Flat or inverted T-waves
 U wave is specific
35
Hypokalemia, Medical Management

 Oral or IV replacement
36
Hypokalemia, Nursing Management

 Give fruits, vegetables, legumes,
whole grains, milk and meat
 Closely monitor patients receiving
digoxin
37
Hypokalemia, Nursing Management

 Do not give if UO < 20ml/hr in 2
hours
 Do not give by bolus
 No faster than 20-40 mEqs per hour
38
Hyperkalemia
 >5.0-5.5 mEq/L
 Seldom occurs with normal renal

function
 More dangerous than hypo
 Major cause is decreased renal

excretion
39
Hyperkalemia
 Hypoaldosteronism, Addison’s dx
 Potassium sparing medications
 acidosis
40
Hyperkalemia, Manifestations
 Cardiac effects start at >6, almost
always present by 8 mEq/L
 Skeletal muscle weakness up to
flaccid paralysis
41
Hyperkalemia, Assessment
 ECG changes
 Peaked, narrow T-waves
 ST-segment depression
 Shortened QT interval
 Eventually PR interval prolongs and P
waves disappear, QRS prolongs
42
Hyperkalemia, Medical Management
 Potassium restriction
 Kayexalate (cation exchange resin)
orally or by enema
 Calcium gluconate, NaHCO3
 Insulin and hypertonic dextrose
 B2 agonist
 Dialysis
43
Hyperkalemia, Nursing Management

 Monitor BP and cardiac response
 Avoid coffee, cocoa, tea, dried

fruits, milk and eggs
 Never added to hanging bottle, mix
by inverting bottle several times
44
Electrolyte Imbalances: Ca
Calcium
 Total: 8.5-10.5 mg/dL (2.1-2.6
mmol/L, 4.5-5.5 mEq/L)
 Ionized (50%), bound, complexed
 Ionized: 4.5-5.1 mg/dL (1.1-1.3

mmol/L)
 Primarily excreted in feces
45
Hypocalcemia
 Common in renal failure with inc
phosphate levels
 Hypoparathyroidism, pancreatitis,
glucagon secretion, vitamin D deficit
 diuretics
46
Hypocalcemia, Manifestations
 Tetany
 Chvostek’s and Trousseau’s sign
 Seizures, alterations in mental

status
 ECG: prolonged QT, torsades de
pointes
47
Hypocalcemia, Medical Management

 IV administration of Ca
 Vit D
 Aluminum hydroxide antacids
48
Hypocalcemia, Nursing Management

 IV administration of Ca – slow,
diluted
 Seizure precautions
 Watch out for hypotension
 Give milk products, green leafy

vegetables, sardines
49
Hypercalcemia
 >5.5 mg/dL
 Malignancies, hyperthyroidism
 Vit A and D intoxication
 Cardiac standstill at 18 mg/dL (4.5

mmol/L)
50
Hypercalcemia, Manifesations
 Decreased neuromuscular
excitability
 Polyuria and thirst
 Altered mental status
 Hypercalcemic crisis (>17 mg/dL or

4.3 mmol/L)
 ECG: shortened QT
51
Hypercalcemia, Medical Management

 Isotonic IV to dilute
 Furosemide and calcitonin
 IV phosphate with caution
52
Hypercalcemia, Nursing Management

 Ambulate
 Encourage oral fluid intake
 Monitor patients on digoxin closely
53
Electrolyte Imbalances: Mg
Magnesium
 Important in neuromuscular
function
 Inhibits release of Ach at NMJ
 Direct vasodilation
 1.5-2.5 mEq/L (1.8-3.0 mg/dL)
 2/3 is ionized form
54
Hypomagnesemia
 < 1.5 meq/L
 Alcohol withdrawal
 Diarrhea, citrate administration
 insulin
55
Hypomagnesemia
 Neuromuscular irritability
 Torsades de pointes
 Arrhythmias
 Chvostek’s and Trousseau’s
56
Hypomagnesemia
• ECG:
• prolonged PR and QT
• Widened QRS
• Depressed ST
• Flattened T
• Prominent U
57
Hypomagnesemia, Medical
Management
 Magnesium replacement
 IV, do not exceed 150 mg/min
 Keep calcium gluconate around
58
Hypomagnesemia, Nursing
Management
 Green leafy vegetables, nuts,
legumes, seafoods
 Monitor for dysphagia and DTR
changes
59
Hypermagnesemia
 >3.5 mEq/L
 Commonly due to renal failure
 DKA, Addison’s, antacid use
60
Hypermagnesemia, Manifestations
 CNS depression
 Sensations of warmth
 Loss of DTRs
 >10 mEq/L depresses the

respiratory center
61
Hypermagnesemia, Manifestations
 ECG:
 Prolonged PR
 Tall T waves
 Widened QRS
 Prolonged QT, AV Blocks
62
Hypermagnesemia, Medical
Management
 Ventilatory support
 IV calcium
 Loop diuretics
 Dialysis
63
Hypermagnesemia, Nursing
Management
 Monitor for hypotension and shallow
breaths
 Check DTRs
64
Electrolyte Imbalances: HPO4
Phosphorus
 Essential to muscle and RBC
 Essential in ATP and nutrient

metabolism
 2.5-4.5 mg/dL (0.8-1.5 mmol/L)
 Primary anion of the ICF
65
Hypophosphatemia
 With severe protein-calorie
malnutrition, alcohol withdrawal,
poor intake, vit D deficiency
66
Hypophosphatemia, Manifestations
 Irritability, numbness, seizures to
coma
 Respiratory alkalosis
 Ms weakness, pain
 Rickets, osteomalacia
67
Hypophosphatemia, Medical
Management
 Oral phosphate replacement
 IV not more than 10 mEq/hr
68
Hypophosphatemia, Nursing
Management
 Gradual replenishment of nutrition
 Prevent infection
 IV site checked for sloughing and

necrosis
69
Hyperphosphatemia
 Commonly due to renal failure
 Hypoparathyroidism
70
Hyperphosphatemia, Manifestations
 Tetany
 Muscle weakness, hyperreflexia
 Skeletal changes on xray
71
Hyperphosphatemia, Medical
Management
 Restrict intake
 Dialysis
72
Hyperphosphatemia, Nursing
Management
 Avoid hard cheese, cream, nuts,
whole-grain cereals, milk products
 Avoid laxatives
73
Electrolyte Imbalances: Cl
Chloride
 Major ECF anion
 Changes along with Na and

bicarbonate
 96 mEq/L-106 mEq/L
74
Hypochloremia
 Metabolic alkalosis
 Hyperexcitable neuromuscular
system
 Dysrhythmias
75
Hypochloremia, Medical Management

 Ammonium chloride
 Isotonic solution
76
Hypochloremia, Nursing Management

 Provide tomato juice, fruits,
processed meat
 Monitor ABGs
 Assess neuro and respiratory

functions
77
Hyperchloremia
 Due to bicarbonate losses in the
kidney or GI tract
 Consequences: Hypernatremia,
bicarbonate loss, metabolic acidosis
78
Hyperchloremia, Manifestations
 Tachypnea, deep, rapid respirations
 Hypertension
 Neurologic changes
79
Hyperchloremia, Medical Management

 LR to increase bicarbonates
 Diuretics to eliminate chloride
80
Hyperchloremia, Nursing Management

 Monitor VS and I&O
 Diet changes (avoid tomato juice,

fruits, processed meat)
 Monitor for signs and symptoms
81
Acid-Base Imbalances
Normal Values
 pH = 7.35-7.45
 paCO2 = 35-45 mm Hg
 HCO3 = 22-26 mEq/L
 Base excess/deficit = +/- 2 mmol/L
 O2 Sat = 93-98%
82
Respiratory Acidosis
 pH <7.35, paCO2 > 42 mm Hg,
HCO3 elevated
 Hypoventilation, COPD
 Sx: Dyspnea, rapid shallow

breathing, weakness
83
Respiratory Acidosis
• Tx: ventilation, encourage coughing
and deep breathing
• Monitor VS and ABGs
84
Respiratory Alkalosis
 pH >7.45, paCO2 <35 mm Hg,
HCO3 normal
 Hyperventilation, pneumonia,
aspirin overdose
 Sx: Tachypnea, light-headedness,
numbness
 Tx: CO2 rebreathing, treat the
cause
85
Metabolic Acidosis
 pH <7.45, HCO3 <22 mEq/L,
paCO2 normal or slightly increased
 Renal failure, ketoacidosis, diarrhea
 Sx: Hyperventilation, confusion to

coma
 Tx: NaHCO3, treat the cause
86
Metabolic Alkalosis
 pH >7.45, HCO3 >26 mEq/L,
paCO2 normal or slightly increased
 Hypokalemia, vomiting,
hyperaldosteronism
 Sx: hypoventilation
87
For all of these:

 Treat the underlying cause
 The compensatory mechanism is

the reverse
 Monitor VS and ABGs
 Monitor cardiovascular and

neurologic status
88
The End
89

Adult Health Nursing I: Joseph Mariano, RN, MD

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Adult Health Nursing I

Joseph Mariano, RN, MD

Hypovolemia (Fluid Volume Deficit)

 Ratio of electrolytes to water is

 Vomiting, diarrhea, sweating

 Hemorrhage, diabetes insipidus

 Fluid shifts (burns, ascites)

 Urine specific gravity is increased

Hypovolemia, Medical Management

 IV therapy , rate based on severity

Hypervolemia (Fluid Volume Excess)

 Always due to increased Na

 Diminished fluid balance regulation

 Heart, kidney, liver problems

 Distended neck veins

 Increased weight, urine output, BP

 Chest xray may show congestion

Hypervolemia, Medical Management

 Fluid and sodium restriction

 Always treat the underlying cause

Hypervolemia, Nursing Management

 Assess and measure edema

 Positioning and turning

 Related to water content

 Dilutional (SIADH, hyperglycemia,

 Muscle twitching and cramps

Hyponatremia, Medical Management

 Water restriction (800 ml in 24 hr)

 Only up to the point of relieving

Hyponatremia, Nursing Management

 GI and Neuro manifestations

 Dietary intake, fluid restriction

 Related to water content

 Insensible water loss

 Dry, swollen tongue, sticky mucus

Hypernatremia, Medical Management

 Desmopressin if insipidus is the

Hypernatremia, Nursing Management

 Ensure fluid intake

 The extracellular portion (2%) is

 Balance primarily regulated by the

 Muscle weaknesss, leg cramps,

 Decreased BP, reflexes

Hypokalemia, Medical Management

Hypokalemia, Nursing Management

Hypokalemia, Nursing Management

 No faster than 20-40 mEqs per hour

 Seldom occurs with normal renal

 Major cause is decreased renal

 Potassium sparing medications

Hyperkalemia, Nursing Management

 Avoid coffee, cocoa, tea, dried

 Ionized: 4.5-5.1 mg/dL (1.1-1.3

 Chvostek’s and Trousseau’s sign

 Seizures, alterations in mental

Hypocalcemia, Medical Management

 Aluminum hydroxide antacids

Hypocalcemia, Nursing Management

 Watch out for hypotension

 Give milk products, green leafy

 Vit A and D intoxication

 Cardiac standstill at 18 mg/dL (4.5

 Altered mental status