Fluid and Electrolytes

CSON Spring 2009 PREPARED BY CARLA HILTON, MSN, RN PRESENTED AND REVISED BY REBECCA POWERS, MSN, RN 15 questions from all of powers stuff

Water Balance = Homeostasis

Water in the body is used to or for: Transporting nutrients & oxygen to cells Removing waste from cells Provides medium in which electrolyte chemical reactions can occur Regulation of body temperature Lubricates joints and membranes Provides medium for food digestion liter of water weighs 2.2 lbs The most accurate way to measure fluid status in a person is daily weights, not I&O!!!

Water Distribution
ICF: Intracellular fluid ECF: Extracellular fluid (lymph system, interstitial fluid, intravascular fluid or plasma) TCF: Transcellular fluid (cerebral spinal fluid, fluid in joints, GI tract, and peritoneal fluid) Third spacing: (a condition where fluid accumulates in a pocket that isnt really serving a purpose. Acieties (sp?)where fluid hangs out in your abd. The fluid is coming from somewhere else.) More fluid in intracellular than anywhere else in the body!

Osmolarity / Osmolality
Osmole:
the

amount of substance that dissociates in solution to form one mole of osmotically active particles
Concentration

of solution measured in osmoles

Osmolarity / Osmolality
Osmolality is measured in milliOsmols/Kg (mOsm/Kg) Osmolarity is measured in milliOsmols/L (mOsm/L) Evaluates serum and urine in clinical practice Normal: serum osmolality 275 295 mOsm/K Lality= total volume will equal 1 L plus the amount of volume taken up by the solids! The koolaid and water equal a L Larity= volume is going to be less than 1 L. The koolaid minus the water.

Concentrations of Solutions
Isotonic: Same osmolarity as blood plasmano osmotic pull Hypotonic: Less concentration than blood plasmalower osmotic pressure Hypertonic: More concentration than blood plasma.higher osmotic pressure

Movement of Water
Intracellular & extracellular approximately same osmolality Solvent (water) and solutes (electrolytes) move across selectively permeable membranes (compartments) in the body (the bigger the particle, the slower they move, and they may need a little boost)

Review of Terms
Osmosis Diffusion Active transport Passive transport Filtration Hydrostatic pressure

Osmosis Review
Movement of water only Speed of movement affected by: temperature of fluid concentration of fluid electrical charge of particles in solution The higher the solute concentration, the greater the osmotic pressure is.

Other Mechanisms of Movement

Diffusion: Solute (or gas) moves from area of higher concentration to area of lower concentration Facilitated diffusion: Solute moves against concentration gradient (passive transport) Active transport: Solute moved against concentration gradient using ENERGY

Active Transport
Na+/K+ pump: Maintains the higher concentrations of extracellular Na+ and intracellular K+ In the cell, K is King. i.e. K is the major cation of the cell, Na is outside the cell.

Continued
Filtration: solutes & solvent move together in response to fluid pressure; moves from area of high pressure (hydrostatic pressure) to area of low pressure Hydrostatic pressure: The force within a fluid compartment (as in the vascular system) The pressure that forces the fluid out of your capillaries. Colloidal Osmotic Pressure pulls it back into the capillaries.

Regulation of Body Fluids

Intake: osmoreceptors sense osmolality of serum, signals the hypothalamus, stimulates thirst Impact on intake: Age (decreases desire to drink), conciousness, ability to take in fluids Output: kidneys, lungs, GI tract, skin Sensible: measurable.urine output, excessive perspiration, diarrhea, vomiting Insensible: immeasurablenormal perspiration, normal breathing Output for adults should be one mL/kg (of body weight) an hour

Role of the Kidneys

Filter approx 180 Liters of blood per day; GFR (glomerular filtration rate) Produces urine between 1-2 Liters/day If loss of 1% to 2% of body water, will conserve water by reabsorbing more water from filtrate; urine will be more concentrated If gain of excess body water, will excrete more water from filtrate; urine will be more diluted

Hormonal Control
Antidiuretic hormone (ADH): Prevents diuresis; water saving Question: Osmoreceptors sensing a/an increase in osmolality will cause the release of ADH

ADH acts on kidneys via the renal tubules. Makes them more permeable to water. The water will move from the tubes back into your body.

 RAA (Renin-angiotensin-aldosterone): cascade initiated

by decrease in renal perfusion or low Na+

Hormonal Control

If extracellular volume is decreased renal perfusion decreases renin secreted by kidneys renin acts to produce angiotensin I which then converts to angiotensin II results in massive vasoconstriction increases renal arterial perfusion and causes increased thirst, a release of aldosterone (causes the retention of Na and Water)

Hormonal Control
Aldosterone: Angiotensin II causes the adrenal gland to release aldosterone Aldosterone causes the kidneys to retain Na+ and water Volume regulator.released if Na+ is low and K+ is high; increases reabsorption of Na+ (where salt goes, water follows) and the excretion of K+

ANP
Atrial Natriuretic Peptide: (ANP): secreted from atrial cells of heart (in response to too much volume in the blood) acts as diuretic inhibits thirst mechanism suppresses the RAA cascade

Thirst Mechanism
Regulated by the hypothalamus Stimulates thirst: increased osmolality of ECF decreased ECF dry mucous membranes Causes: eating salty foods, inadequate intake, excessive water loss

Pressure Sensors
Baroreceptors: Nerve receptors that sense pressure in blood vessels (think barometer measures pressure in the atmosphere, this measures pressure in the blood vessels) Low pressure: sensors in the cardiac atria; stimulate SNS (sympathetic nervous system) & inhibits PSNS (parasympathetic nervous system) (sns will increase heart rate and BP) High pressure: sensors in the aortic arch, carotid sinus, and the juxtaglomerular apparatus in the kidney; stimulates PSNS and inhibits the SNS (psns will decrease your heart rate and lower BP)

Pressure Sensors
Osmorecptors: Sense Na+ concentration
Positioned on surface of hypothalamus Increase in Na+ concentration: stimulates release of ADH Decrease in Na+ concentration: inhibits release of ADH

ELECTROLYTES and OTHER LABS RELATED TO FLUID VOLUME STATUS

Electrolytes
Minerals and salts: electrolytes Cations: Positively charged; sodium, potassium, calcium, magnesium Major cation in ECF is sodium Anions: Negatively charged; chloride, bicarbonate, sulfate Major cation in ICF is potassium

Hyponatremia
Usually loss of Na w/o loss of fluid

Causes
Salt wasting fr. Kidney Adrenal insufficiency GI losses Profuse sweating Diuretics SIADH
Syndrome of inappropriate Anti-Diruetic Hormone

Physical Exam
Apprehension Personality change Postural hypotension Tachycardia Convulsions/coma NV&D Anorexia

Inadequate Na intake

Hyponatremia contd
Labs
Serum Na+ below 135 mEq/L Serum Osmolality below 280 mOsm/kg Urine specific gravity below 1.010

Treatment
Restrict water Sodium replacement

Hypernatremia
Causes
ingestion of salt Iatrogenic (we caused it) aldosterone Water deprivation

Signs & Sxms

Thirst, sticky tongue Dry, flushed skin Fever Convulsions, irritability

Hypernatremia contd
Labs
Serum Na+ above 145 mEq/L Serum Osmolality above 295 mOsm/kg Urine specific gravity above 1.030

Treatment Hypotonic IV solution or D5W

Urine Na+ Studies

Urine Na+
Assesses volume status Aids in diagnosing hyponatremia & acute renal failure

Random normal range = 50 -130 mEq/L 24 hour = 75-200 mEq/L

Hypokalemia
Causes
Diuretics that waste potassium D, V, & gastric suction aldosterone Polyuria, sweating Iatrogenic K+ poor solutions

Signs & Sxms

Weakness, fatigue muscle tone Hypoactive bowel sounds and distention Weak, irregular pulse Paresthesias SOMETHING ABOUT CARDIAC FUNCTION

Hypokalemia contd
Labs
K+ below 3.5 mEq/L ECG abnormalities

Treatment Oral K+ or IV solution w/K+ Increased dietary K+

Hyperkalemia
Causes
Renal failure Fluid vol. deficit Massive cellular injury (trauma/burns) Iatrogenic Potassium sparing diuretics Addisons disease

Signs & Sxms

Anxiety Dysrrhythmias Paresthesia (numbness, pins & needles feeling) Weakness Diarrhea

Hyperkalemia contd
Labs
Serum K+ above 5.0 mEq/L. ECG abnormalities can lead to arrest (if too high or too low)

Treatment
Kayexalate IV Na+ bicarb IV Ca+ gluconate Regular insulin and hypertonic dextrose IV Limit via diet Possible dialysis

Hypocalcemia
Causes
Rapid admin of blood w citrate Hypoalbuminemia Hypoparathyroidism Vit. D deficiency Pancreatitis Stuff that relates back to preexisting conditions

Signs & Sxms

Numbness, tingling of fingers & mouth Hyperactive reflexes Tetany- a muscle contraction that stays contracted Muscle cramps Pathological fractures

Hypocalcemia contd
Labs
Serum Ca++ below 4.5 mEq/L ECG abnormalities

Treatment
Increase dietary intake IV calcium gluconate Ca+ & vit D supplements

Hypercalcemia
Causes
Hyperparathyroidism Osteometastasis Pagets disease Osteoporosis Prolonged immobilization

Signs & Sxms

Anorexia, N & V Weakness, lethargy Low back pain (stones) Decreased LOC Personality changes Cardiac arrest

Hypercalcemia contd
Labs
Serum Ca++ above 5.5 mEq/L X-rays showing osteoporosis Stones & BUN / creatinine fr. FVD or renal damage

Treatment
Lasix (diuretic) Increased fluids

Hypomagnesemia
Causes
Inadequate intake
Alcohol, Malnutrition

Signs & Sxms

Tremors Hyperactive deep tendon reflexes Confusion Dysrhythmias

Inadequate absorption
V&D, Gastric aspirate Fistulas, Sm. Bowel

Loss fr. Diuretics Polyuria

Hypomagnesemia contd
Labs
Serum Mg++ below 1.5 mEq/L

Treatment
Mag sulfate IV Oral replacement Increase dietary intake

Hypermagnesemia
Causes
Renal failure Excess intake of magnesium
Signs & Sxms
Most frequently seen in acute Hypoactive deep tendon reflexes & drowsiness Decreased depth and rate of resp. Hypotension flushing

Hypermagnesemia contd
Labs
Serum Mg++ levels above 2.5 mEq/L

Treatment
IV calcium gluconate Loop diuretics NS or LR IV solutions Dialysis

Additional Lab Data

Hematocrit
Measures the volume % of RBCs in whole blood

Normal: M = 40-50%; F = 37-47%

Increases with dehydration (hemoconcentration) Decreases with overhydration (hemodilution)

Hematocrit & Fluid Volume Status From Fluids & Electrolytes Made Incredibly Easy 4th ed.

Fluids & Electrolytes Made Incredibly Easy

Lab Data (contd)

Blood urea nitrogen (BUN)
Measures kidney function Normal range: 7-20mg/dL Varies with protein intake, fever, dehydration, GI bleeding, liver failure, etc.

Lab Data (contd)

Creatinine
End product of muscle metabolism Better indicator of renal function than BUN
Doesnt vary w protein intake or metabolic state

Normal range: 0.7-1.5mg/dL in 24 hr urine collection Serum: adult female: 0.5 to 1.1mg/dL adult male: 0.6 to 1.2mg/dL

Lab Data (contd)

Urine Specific Gravity
Measures ability of kidney to excrete or conserve water

Normal range = 1.010 - 1.025

Increased S.G.= concentrated urine Decreased S.G.= dilute urine

Lab Data (contd)

Serum Osmolarity
Most accurate for kidney function

Remember norm?
280-295 mOsm/L Measured directly through blood Indirectly using Serum Osmolarity Formula
serum glucose BUN Serum Osmolarity = 2 Na + 18 3
+

Maintaining Fluid Balance

Fluid Imbalances
Isotonic
Deficit water, electrolytes and solutes lost in equal proportions to body solutions Excess water, electrolytes and solutes gained in equal proportions to body solution
FVD - fluid volume deficit-HYPOVOLEMIA

FVE - fluid volume excess-HYPERVOLEMIA

Fluid Disturbances
Osmolar Imbalances
Hyperosmolar Dehydration Hypoosmolar Water excess Loss or excesses of water only Leads to alteration in concentration of serum

ISOTONIC FLUID DISTURBANCES

Fluid Volume Deficit (FVD)

Water AND solutes lost in equal proportion.
Diarrhea, vomiting, fistulas, drains Bleeding, burns Fever, excessive perspiration Inadequate fluid intake Diuretics GI suctioning

FVD: Signs & Symptoms

Mild
Dry mouth, furrowed tongue Orthostatic or postural hypotension Restlessness & anxiety Tachycardia Less than 5% weight loss

Moderate
Confusion, irritability, thirst, cool & clammy Urine output 30cc/hr or less Rapid weight loss Slowed vein filling

FVD: Signs & Symptoms (contd)

Severe
Pale Flattened neck veins, delayed capillary refill Urine output less than 10cc/hr Marked hypotension, tachycardia, weak or absent pulses (shock) Can lead to unconsciousness

FVD: Labs
Lab findings vary depending on the cause
Decreased H/H with hemorrhage Increased Hct Elevated BUN Urine specific gravity greater than 1.030

FVD: Nursing Diagnosis Statement

Example:
Fluid volume deficit r/t active fluid volume loss as evidenced by decreased blood pressure (90/50 mmHg), thirst, fever (102), rapid heart rate (110 bpm), urine output less than or equal to 25 mL/hr, & urine specific gravity of 1.040.

FVD: Goal Statement

Client will achieve fluid balance AEB
urine output equal to or greater than 30 mL/hr Elastic skin turgor and moist mucous membranes

FVD: Medical Interventions

Treat cause Replacing fluids intravenously isotonic if hypotensive (expand plasma volume) hypotonic if normotensive (provides electrolytes and water) Encourage fluids Ensure adequate O2 and perfusion Increase blood counts, BP, & albumin levels Teaching

FVD: Nursing Interventions

Ensure patent airway, adjust O2 levels as ordered Lower HOB if tolerated or not contraindicated Direct pressure to bleeding, if present Administer meds, blood, albumin, & IV fluids

FVD: Nursing Interventions (contd)

Weigh patients daily Provide skin care Maintain strict I&O Monitor vital signs Monitor lab work

FVD: Teaching
Nature of condition & causes Warning S/S Treatments & importance of compliance Change positions slowly Monitor BP & pulse rate Give prescribed medications

Fluid Volume Excess (FVE)

Water AND solutes gained in excess of normal body levels Causes:
Isotonic fluid overload Excess sodium intake CHF, renal failure, cirrhosis Increase in steroids or serum aldosterone

FVE: Signs & Symptoms

Generalized
Acute weight gain
Mild-mod 5-10% Severe > 10%

Cardiovascular
Tachycardia, bounding pulse, distended neck veins, increased BP

Edema
dependent, sacral, pulmonary

Respiratory
Dyspnea, tachypnea, crackles, frothy cough

FVE: Lab Values

Decreased hematocrit Decreased BUN Low O2 levels

FVE: Nursing Diagnosis Statement

Fluid volume excess r/t excess fluid intake aeb Hct of 23, 10# weight gain in two days, dyspnea (Pt states, I cant get enough air.), and crackles on inspiration and expiration in all lobes.

FVE: Related Nursing Diagnoses

Ineffective breathing pattern r/t increased fluids Impaired skin integrity r/t excess fluids Confusion

FVE: Client Goals & Outcomes

Aimed at cause Decrease circulating fluid volume Lower BP and pulse Improve breathing status Maintain skin integrity Teaching

FVE: Goal Statement

Client will achieve fluid balance manifest in following outcomes
Clear breath sounds Denies dyspnea and affirms the ability to breathe adequately

FVE: Nursing Interventions

Restrict Na+ & fluid intake Watch for edema - dependent & respiratory Provide measures to facilitate breathing Provide skin care for weeping & edema

FVE: Nursing Interventions (contd)

Monitor response to medications Accurate I/O, Consistent daily weight, VS, monitor labs Advise HCP if poor response to therapy
Hemodialysis may be needed

FVE: Teaching
Nature of condition and causes Signs and symptoms Treatments and importance of compliance Need to monitor BP, P, O2 Sat, & weight Rationale for Na+ and fluid restrictions Medications

Osmolar Imbalances

Hyperosmolar: Dehydration
Loss of water = increased serum osmolality increased serum Na+ Compensatory Mechanism: water shifts out of cells (ICF) into the ECF..if not corrected, water continues to move out of cells (ICF) and into ECF causing the cells to shrink.shrunken cells dont function properly!!

Causes of Dehydration
Causes: Diabetes insipidus, prolonged fever, watery diarrhea, hyperglycemia, failed thirst drive Iatrogenic: hypertonic solutions (IV & tube feeding) Diuresis of water alone

Dehydration: Signs & Symptoms

Irritability, confusion, weakness, dizziness Decreased urine output, darkened urine Dry, sticky mucous membranes, sunken eyeballs, poor turgor, extreme thirst !!! Fever (insensible continuous) Coma Tachycardia, weak, thready pulse, hypotension

Dehydration: Labs
Elevated hematocrit Elevated serum osmolarity > 295 mOsm/kg Elevated serum sodium > 145 mEq/L Urine specific gravity > 1.030

Dehydration: Nursing Diagnoses

Fluid volume deficit r/t fluid loss Deficient fluid volume r/t excessive fluid loss from GI tract Risk for impaired skin integrity r/t altered metabolic state If youve lost 20% of you initial weight from dehydration, youre probably dead

Dehydration: Potential Nursing Diagnoses

Deficient knowledge: unfamiliarity of disease process Disturbed thought processes r/t neurologic changes / decreased cardiac output Decreased cardiac output r/t excessive fluid loss

Dehydration: Client Goals & Outcomes

Aimed at correcting cause Replace fluids hypotonic, slowly re-hydrate over 48 hrs (if you go too quickly, you die) Maintain skin integrity Teaching

Dehydration: Nursing Interventions

Replace fluids by PO route first SLOW admin. of salt-free IV solutions Monitor S/S cerebral & pulmonary edema Monitor accurate I/O, VS, daily weights Monitor labs Provide skin and mouth care

Dehydration: Teaching
Disease process of dehydration Treatments Warning signs and symptoms Medications / IV (Vasopressin D5W) Importance of compliance with therapy
Fluid intake not based on thirst alone

Hypoosmolar
Water excess Causes
SIADH or excess water intake

Signs & Sxms

Decreased LOC, convulsions, coma

Labs
Serum Na+ below 135 mEq/L and Serum osmolality below 280 mOsm/kg

Nsg Dx Goals - Interventions

Similar to FVE Make relevant to underlying cause Is very acute illness

Physical Assessment

History
Medical Acute Illness, surgery, burns Environment exercise, hot/cold/dry areas Diet proteins, lytes, fluids Lifestyle smoking/alcohol Medication history

Areas of Concern in PA
Mental status BP and pulse Skin I & Os & WEIGHT Lungs

Geriatric Focus
Body-water content (mass related) Kidney function Cardiac & respiratory function Hormonal regulatory function Thirst sensation Medication Use Skin & subcutaneous fat

Assessment of Geriatric Clients

Skin turgor
Assessment is performed where?

Cognition Physical being Continence

Laboratory Data
BMP / CMP Serum osmolarity Urine specific gravity Urine sodium Hematocrit Blood urea nitrogen (BUN) Creatinine

Clients at Risk for F&E Imbalances

Age
Very young Very old
Malnutrition Chronic obstructive pulmonary disease Renal disease, such as progressive renal failure Changes in level of consciousness

Chronic Diseases
Cancer Cardiovascular disease, such as congestive heart failure Endocrine disease, such as Cushing's disease and diabetes

Clients at Risk for F&E Imbalances

Trauma

Gastrointestinal losses
Gastroenteritis Nasogastric suctioning Fistulas

Crush injuries Head injuries Burns Major surgery

Diuretics Steroids Intravenous (IV) therapy Total parenteral nutrition (TPN)

Therapies

Fluid & Electrolytes Nursing DXs

Risk for imbalanced Body temperature Ineffective Breathing pattern Decreased Cardiac output Deficient Fluid volume Risk for deficient Fluid volume Excess Fluid volume Impaired Gas exchange Knowledge deficient regarding disease management Impaired Mobility Impaired Oral mucous membrane Impaired Skin integrity Risk for impaired Skin integrity Ineffective Therapeutic regimen management Impaired Tissue integrity Ineffective Tissue perfusion

Intravenous Fluid Therapy in Fluid Balance Disorders

ISOtonic solutions
Same osmolarity as body fluids
280 - 300 mOsm/kg

Expands the IVC without pulling fluids from other compartments Examples
Normal saline (NS) Lactated Ringers (LR)

IVs: Normal Saline (NS)

Isotonic 0.9% Sodium Chloride Different amounts Sample order
NS @ 75cc/hr

IVs: Lactated Ringers (LR)

Isotonic Solution Contents
Na+, Cl-, K+, Ca++, Lactate in sterile water

One strength, two common amounts Sample orders

LR @ 100cc/hr RL @ 75cc/hr

HypOtonic solutions
Osmolarity less than serum Pulls fluid from the IVC into the ICC causing cells to expand
Over hydration Rehydration

RISK

Example
NS D5W - after absorbed into body

IVs: Dextrose Solutions

Concentrations
5% in water (hypotonic after enters body) 10% in water (hypertonic) 50% in water (rescue solution small volume) As additive to NS or LR
D5NS or D5LR

HypERtonic solutions
Osmolarity of solution is higher than serum osmolarity
>300 mOsm/kg

Pulls fluid from ICC into IVC causing cells to shrink

dehydrate

Examples
D51/2 NS - D5NS - D5LR 3% NS (CRITICAL Strength)

IVs: Common Additives

Potassium (never add to a bag!) Multivitamins Additives makes the solution hypertonic to some extent depends on amount

IV Additives: Potassium
Available as KCl (potassium chloride) NEVER add K+ to a bag of fluid
Added by pharmacy or premixed

Different strengths Sample orders

NS c 20 mEq KCl @ 75 cc/hr LR c 40 mEq KCl @ 75 cc/hr

Medications Used in Fluid & Electrolyte Imbalance Disorders

Meds: Antidiarrheals
Assess I /O & electrolytes Provide oral care Monitor for constipation Teaching
Take as directed Avoid overdose

Examples: Lomotil & Immodium

Meds: Antiemetics
Assess VS & emesis status before and after Monitor for extrapyriamidal side effects
involuntary movement of eyes, face or limbs, flat affect, shuffled gait, drooling

Provide fluid replacements

Oral electrolyte solutions Water

Sample Meds: Zofran, Phenergan & Vistaril

Meds: Diuretics
Assess
Weight, edema, skin turgor, & mucus membranes, lung sounds Monitor
weight, I /O, electrolytes

Examples:
Thiazides (HCTZ) HTN Potassium sparing (spironolactone) Osmotic (mannitol) decrease ICP Loop (lasix) pull fluids

Teaching
diet, weigh daily, & dosing times

Meds: Potassium
Forms: tablets (SR), effervescent, EC, IV Administration considerations
PO: Give on a full stomach at mealtime am/pm IV: NEVER give as bolus, follow protocol, dilute for IV administration, can burn & lead to infiltration

Monitor: K+ levels monitor EKG if elevated

Meds: Kayexelate
Removes K+ from system Available as enema or by PO route
Retain enema for to 1 hr Follow resin w 100 mL water After expulsion, rinse colon w 1 liter of water and drain out immediately

Other Meds r/t F/E status

Glucocorticosteroids Digoxin Electrolyte supplements

Stuff To Add for the Test

A L of fluid weighs 2.2 lbs
1 lb of fluid is 454 mL If a L of fluid weighs 2.2 lbs you need to be able to figure out how many mL a lb is

10% fluid loss is serious, but 20% loss is mostly death If you have someone who begins to have a transfusion reaction (hemolytic) watch for
Fever, low back pain, itching, hypotension, N/V, drop in urine output, chest pain, dyspnea If you are doing VS for these people and they have these symptoms, GO FIND THE NURSE IMMEDIATELY! They dont need any more blood whatsoever!