Fluid and Electrolyte Imbalances

Body Fluid Compartments

2/3 (65%) of TBW is intracellular (ICF) 1/3 extracellular water
25 % interstitial fluid (ISF) 5- 8 % in plasma (IVF intravascular fluid) 1- 2 % in transcellular fluids CSF, intraocular fluids, serous membranes, and in GI, respiratory and urinary tracts (third space)
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Fluid Compartments in the body: 1. Intracellular space -fluid in the cells -approximately 2/3 of the total body water -primarily located in the skeletal muscle mass
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2. Extracellular Space -body fluid outside the cells -divided into: a. intravascular >contains plasma >approximately 3L out of 6L blood volume b. interstitial >fluid that surrounds the cells >approximately 11-12L in an average adult c. transcellular >smallest division of the ECF >approximately 1L of fluid >CSF, synovial, pericardial, pleural, intraocular

 Fluid compartments are separated by membranes that are freely permeable to water. Movement of fluids due to: hydrostatic pressure osmotic pressure Capillary filtration (hydrostatic) pressure Capillary colloid osmotic pressure Interstitial hydrostatic pressure Tissue colloid osmotic pressure
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Diffusion: This is passive movement of molecules across a membrane from an area of higher concentration to an area of lower concentration. Osmosis: Water moves through a selectively permeable membrane from an area of lower concentration of ions to an area of higher concentration of ions. Active transport: This is movement of molecules against a concentration as they move from an area of lower concentration to an area of higher concentration. The movement requires energy.
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Balance
Fluid and electrolyte homeostasis is maintained in the body Neutral balance: input = output Positive balance: input > output Negative balance: input < output

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Solutes dissolved particles

Electrolytes charged particles
Cations positively charged ions Na+, K+ , Ca++, H+ Anions negatively charged ions Cl-, HCO3- , PO43-

Non-electrolytes - Uncharged
Proteins, urea, glucose, O2, CO2
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Body fluids are: Electrically neutral Osmotically maintained Specific number of particles per volume of fluid

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Homeostasis maintained by:

Ion transport Water movement Kidney function

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MW (Molecular Weight) = sum of the weights of atoms in a molecule mEq (milliequivalents) = MW (in mg)/ valence

mOsm (milliosmoles) = number of particles in a solution

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Tonicity Isotonic Hypertonic

Hypotonic

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HYPOTONIC
1) If the fluid is hypotonic
Increase in extracellular volume A dilutional effect Subsequent cellular dehydration

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Hypotonic Solutions

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Cell in a hypotonic solution

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ISOTONIC
2) If the fluid retained is isotonic plasma
Expansion of the extracellular compartment No effect on cells

to

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ISOTONIC

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HYPERTONIC
3) If the excess fluid is hypertonic
Increased extracellular volume Cellular dehydration

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HYPERTONIC

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Cell in a hypertonic solution

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ICF to ECF osmolality changes in ICF not rapid IVF ISF IVF happens constantly due to changes in fluid pressures and osmotic forces at the arterial and venous ends of capillaries

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Regulation of body water

ADH antidiuretic hormone + thirst
Decreased amount of water in body Increased amount of Na+ in the body Increased blood osmolality Decreased circulating blood volume

Stimulate osmoreceptors in hypothalamus ADH released from posterior pituitary Increased thirst
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Result: increased water consumption increased water conservation

Increased water in body, increased volume and decreased Na+ concentration

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Dysfunction or trauma can cause: Decreased amount of water in body Increased amount of Na+ in the body Increased blood osmolality Decreased circulating blood volume

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Edema is the accumulation of fluid within the interstitial spaces. Causes: increased hydrostatic pressure lowered plasma osmotic pressure increased capillary membrane permeability

lymphatic channel obstruction

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Hydrostatic pressure increases due to: Venous obstruction: thrombophlebitis (inflammation of veins) hepatic obstruction tight clothing on extremities

prolonged standing
Salt or water retention congestive heart failure

renal failure
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Decreased plasma osmotic pressure: plasma albumin (liver disease or protein malnutrition) plasma proteins lost in : glomerular diseases of kidney hemorrhage, burns, open wounds and cirrhosis of liver

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Increased capillary permeability: Inflammation

immune responses

Lymphatic channels blocked: surgical removal infection involving lymphatics lymphedema

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Fluid accumulation: increases distance for diffusion may impair blood flow

= slower healing
increased risk of infection pressure sores over bony prominences Psychological effects
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Edema of specific organs can be life threatening (larynx, brain, lung)

Water is trapped, unavailable for metabolic processes. Can result in dehydration and shock. (severe burns)

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 Fluid Volume Deficit Dehydration >causes: a. inadequate intake b. abnormal fluid losses c. other causes -diabetes insipidus -osmotic diuresis -hemorrhage -coma >signs and symptoms: weight loss, poor skin turgor, oliguria, concentrated urine, postural hypotension

rapid heart rate, decreased CVP, cool clammy skin, inc temperature >assessment: BUN and Crea Hematocrit Serum elecrolytes Urine specific gravity Fluid Challenge Test >management: a. oral route of fluid replacement -preferred method b. IV route -isotonic then hypotonic

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c. monitoring -weight, intake and output, V/S, CVP level of consciousness, breath sounds and skin color >nursing management: a. prevent fluid volume deficit b. correct fluid volume deficit Fluid Volume Excess -isotonic expansion of body water >cause: a. abnormal retention of water and sodium >s/sx: a. edema b. distended neck veins

c. crackles g. increased CVP d. tachycardia h. increased weight e. increased BP i. increased urine output f. increased PP j. shortness of breath >assessment: BUN CXR Hematocrit Serum Osmolality Serum Electrolytes >management: a. withholding excessive administration of IVF b. diuretics c. restriction of oral fluids (sodium)

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1. Pharmacologic Therapy 2. Hemodialysis 3. Nutritional Therapy >nursing management: a. preventing fluid volume excess b. detecting and controlling fluid volume excess c. teaching patients about edema

Electrolyte balance
Na + (Sodium)
90 % of total ECF cations 136 -145 mEq / L Pairs with Cl- , HCO3- to neutralize charge Low in ICF Most important ion in regulating water balance Important in nerve and muscle function

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Regulation of Sodium
Renal tubule reabsorption affected by hormones: Aldosterone Renin/angiotensin Atrial Natriuretic Peptide (ANP)

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Electrolyte imbalances: Sodium

Hypernatremia (high levels of sodium)
Plasma Na+ > 145 mEq / L Due to Na + or water Water moves from ICF ECF Cells dehydrate
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 Hypernatremia Due to: Hypertonic IV soln. Oversecretion of aldosterone Loss of pure water Long term sweating with chronic fever Respiratory infection water vapor loss Diabetes polyuria Insufficient intake of water (hypodipsia)
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Clinical manifestations of Hypernatremia

Thirst Lethargy Neurological dysfunction due to dehydration of brain cells Decreased vascular volume
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Management: >serum sodium should be reduced at a rate of 0.51mEq/L 1. IVF Therapy -hypotonic solution or isotonic non saline solution 2. Diuretics 3. Desmopressin Acetate Nursing Management: 1. Look for the hidden sources of sodium 2. Monitor for: body temperature, thirst and level of consciousness 3. Prevent hypernatremia 4. Correct hypernatremia

Hyponatremia
Overall decrease in Na+ in ECF Two types: depletional and dilutional Depletional Hyponatremia
Na+ loss: diuretics, chronic vomiting Chronic diarrhea Decreased aldosterone Decreased Na+ intake

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Dilutional Hyponatremia:
Renal dysfunction with intake of hypotonic fluids Excessive sweating increased thirst intake of excessive amounts of pure water Syndrome of Inappropriate ADH (SIADH) or oliguric renal failure, severe congestive heart failure, cirrhosis all lead to: Impaired renal excretion of water

Hyperglycemia attracts water

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Clinical manifestations of Hyponatremia

Neurological symptoms
Lethargy, headache, confusion, apprehension, depressed reflexes, seizures and coma

Muscle symptoms
Cramps, weakness, fatigue

Gastrointestinal symptoms
Nausea, vomiting, abdominal cramps, and diarrhea

Tx limit water intake or discontinue meds

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Management: A. sodium replacement -by mouth, NGT or through parenteral route -parenterally, must not exceed 12mEq/L in 24 hours > osmotic demyelination B. SIADH -give Demeclocycline or Lithium C. water restriction -safer than sodium replacement

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Potassium
Major intracellular cation ICF conc. = 150- 160 mEq/ L Resting membrane potential Regulates fluid, ion balance inside cell pH balance

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Regulation of Potassium
Through kidney Aldosterone Insulin

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Potassium Deficit -potassium serum level <3.5mEq/L causes: >alkalosis, GI losses, hyperaldosteronism, potassium losing diuretics, other drugs (corticosteroids, amphotericin B, carbenicillin and sodium penicillin), insulin hypersecretion, inability or unwillingness to eat a normal diet, magnesium depletion, Cushings syndrome signs and symptoms: >fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias, dysrhythmias and increased sensitivity to digitalis, glucose intolerance

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Confirmatory tests: 1. Decreased serum potassium 2. ECG changes -flat or inverted T waves and depression of the ST segments -elevation of the U waves 3. Metabolic Alkalosis 4. Urine potassium concentration of >20mEq/24 hours Medical Management: 1. Potassium replacement therapy
-if without abnormal potassium loss, 40-80mEqs/day -oral (Kalium Durule) or IV (K chloride, K phosphate or K acetate)

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Nursing Management: 1. Monitoring for s/sx or progression of hypokalemia 2. Preventing hypokalemia 3. Correcting hypokalemia 4. Administering IV potassium -after adequate urine flow -20mEqs/hour or less -30-40mEqs/L and below unless severe

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 Potassium Excess -less common but more severe than hypokalemia -causes: >renal failure, excessive intake of potassium, infection, hyporaldosteronism and Addisons disease, medications (KCl, heparin, ACE inhibitors, NSAIDS and K sparing diuretics) and acidosis -clinical manifestations: >dysrhythmias, skeletal muscle weakness and paralysis >CNS and PNS involvement >Flaccid quadriplegia, respiratory and speech muscle paralysis

Hyperkalemia
Serum K+ > 5.5 mEq / L Check for renal disease Massive cellular trauma Insulin deficiency Addisons disease Potassium sparing diuretics Decreased blood pH Exercise causes K+ to move out of cells 72

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Clinical manifestations of Hyperkalemia

Early hyperactive muscles , paresthesia Late - Muscle weakness, flaccid paralysis Change in ECG pattern Dysrhythmias Bradycardia , heart block, cardiac arrest
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Confirmatory tests: 1. ECG -peaked, narrow T waves, ST segment depression and a shortened QT interval -prolonged PR interval then absence of P wave 2. ABG 3. Serum potassium level increase Medical Management: 1. Monitoring of serum potassium with ECG findings 2. Emergency pharmacologic therapy >calcium gluconate or calcium chloride >sodium bicarbonate >insulin and glucose >beta 2 agonist 3. Dialysis

Nursing Management: 1. Monitoring 2. Preventing hyperkalemia 3. Correcting hyperkalemia Pseudohyperkalemia >use of tourniquet in an exercising muscle >marked leukocytosis and thrombocytosis >familial pseudohyperkalemia

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Calcium Deficit -less than 8.5mg/dl of calcium in the serum -causes: >hypoparathyroidism >those who received citrated blood >pancreatitis, renal failure >vitamin D deficiency, magnesium deficiency >medullary thyroid carcinoma >low albumin levels, alkalosis and alcohol abuse -signs and symptoms: >tetany, seizures and mental changes -confirmatory test: >ECG- prolonged QT interval

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Hypocalcemia
Diagnosis:
Chvosteks sign Trousseaus sign

Treatment
IV calcium for acute Oral calcium and vitamin D for chronic

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Management: 1. Administer calcium salts -calcium carbonate, calcium chloride, calcium gluceptate Risks: a. Sloughing of tissues b. Bradycardia then cardiac arrest c. Digitalis toxicity 2. IVF but not normal saline or solutions containing phosphates and bicarbonate 3. Vitamin D therapy 4. Aluminum hydroxide, calcium acetate, calcium carbonate 5. Nutritional therapy 6. Screen for and treat hypomagnesemia

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Nursing Management: 1. Monitor hypocalcemia for patients at risk 2. Airway management 3. Seizure precaution 4. Patient education -caffeine and alcohol decreases absorption -nicotine increases excretion -medications to decrease bone loss (alendronate, raloxifene and calcitonin)

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Calcium Excess -with high mortality rate -causes: >malignancies and hyperparathyroidism >immobilization >use of Thiazide diuretics >milk-alkali syndrome >Vitamin A and D intoxication -signs and symptoms: *proportional to the elevation of serum calcium >muscle weakness, incoordination, anorexia and constipation >cardiac arrest

>dehydration >abdominal and/or bone pain >abdominal distention and paralytic ileus >excessive urination then polyuria >s/sx of PUD >changes in the LOC and mental status *hypercalcemic crisis Laboratory tests: 1. Serum calcium determination 2. ECG - shortening of the QT interval and ST segment - prolongation of the PR interval - dysrhythmias 3. Double antibody PTH test

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4. X-Ray - osteoporosis 5. Sulkowitch test Management: 1. Pharmacologic therapy -dilute the serum calcium and promote its exc. (normal saline, administer phosphates, diuretics, calcitonin) -Cancer treatment -Corticosteroid therapy > to decrease bone turnover and tubular reabsorption -Biphosphonates (pamidronate) >causes myalgia, pyrexia and decreased WBC -Mithramycin >causes thrombocytopenia and nephrotoxicity and hepatotoxicity

-IV phosphates should be used with caution >Phospho-Soda, Neutra-Phos Nursing Management: 1. Monitor the s/sx 2. Increase mobility 3. Increase oral fluid intake

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