Fluid, Electrolyte, and Acid-Base Imbalances

HOMEOSTASIS ? Maintenance of the composition and volume of body fluids within narrow limits of normal is necessary to maintain homeostasis. Homeostasis is the state of equilibrium in the internal environment of the body, naturally maintained by adaptive responses that promote healthy ? survival. Many diseases and their treatments have the ability to affect fluid and electrolyte balance.

WATER CONTENT OF BODY ? Water is the primary component of the body, accounting for approximately 60% of the body weight in the adult. ? The two major fluid compartments in the body are intracellular fluid (ICF), or inside the cells, and extracellular fluid (ECF), or outside the cells. ECF is composed of interstitial fluid, plasma, and transcellular fluids. ELECTROLYTES ? The measurement of electrolytes is important to the nurse in evaluating electrolyte balance, as well as in determining the composition of electrolyte preparations. ? Electrolyte composition varies between the ECF and ICF. MECHANISMS CONTROLLING FLUID AND ELECTROLYTE MOVEMENT ? Many different processes are involved in the movement of electrolytes and water between the ICF and ECF. Some of the processes include simple diffusion, facilitated diffusion, and active transport. Water moves as driven by two forces: hydrostatic pressure and osmotic pressure. ? Osmotic pressure is the amount of pressure required to stop the osmotic flow of water. In the metabolically active cell, there is a constant exchange of substances between the cell and the interstitium, but no net gain or loss of water occurs. ? Measuring osmolality is important because it indicates the water balance of the body. ? Hydrostatic pressure is the force within a fluid compartment and is the major force that pushes water out of the vascular system at the capillary level. ? Oncotic pressure (colloidal osmotic pressure) is osmotic pressure exerted by colloids in solution. The major colloid in the vascular system contributing to the total osmotic pressure is protein. FLUID MOVEMENT IN CAPILLARIES ? The amount and direction of movement between the interstitium and the capillary are determined by the interaction of (1) capillary hydrostatic pressure, (2) plasma oncotic pressure, (3) interstitial hydrostatic pressure, and (4) interstitial oncotic pressure.

Key Points Printable ? ? If capillary or interstitial pressures are altered, fluid may abnormally shift from one compartment to another, resulting in edema or dehydration. Fluid is drawn into the plasma space whenever there is an increase in the plasma osmotic or oncotic pressure. This could happen with administration of colloids, dextran, mannitol, or hypertonic solutions. FLUID MOVEMENT BETWEEN EXTRACELLULAR AND INTRACELLULAR FLUID ? Changes in the osmolality of the ECF alter the volume of the cells. ? Water deficit occurs when an increased ECF osmolality pulls water out of cells until the two compartments have similar osmolality. ? Decreased ECF osmolality is associated with water excess as the cells gain excess water. FLUID SPACING ? Fluid spacing describes the distribution of body water. ? First spacing describes the normal distribution of fluid in the ICF and ECF compartments. ? Second spacing refers to an abnormal accumulation of interstitial fluid (i.e., edema). ? Third spacing occurs when fluid accumulates in a portion of the body from which it is not easily exchanged with the rest of the ECF (e.g., burns, blisters). REGULATION OF WATER BALANCE ? Water balance is maintained via the finely tuned balance of water intake and excretion. ? An intact thirst mechanism is important for fluid balance. The patient who cannot recognize or act on the sensation of thirst is at risk for fluid deficit and hyperosmolality. ? An increase in plasma osmolality or a decrease in circulating blood volume will stimulate antidiuretic hormone (ADH) secretion. Reduction in the release or action of ADH produces diabetes insipidus. ? Glucocorticoids and mineralocorticoids secreted by the adrenal cortex help regulate both water and electrolytes. Aldosterone, a mineralocorticoid, has potent sodium-retaining and potassium-excreting capability. ? The primary organs for regulating fluid and electrolyte balance are the kidneys. o Kidneys regulate water balance through adjustments in urine volume. o With severely impaired renal function, the kidneys cannot maintain fluid and electrolyte balance, resulting in edema and electrolyte imbalances. o In the older adult, structural changes to the kidney and a decrease in the renal blood flow lead to a decrease in the glomerular filtration rate, decreased creatinine clearance, the loss of the ability to concentrate urine and conserve water, and narrowed limits for the excretion of water, sodium, potassium, and hydrogen ions.

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Insensible water loss, which is invisible vaporization from the lungs and skin, assists in regulating body temperature.

FLUID AND ELECTROLYTE IMBALANCES ? Fluid and electrolyte imbalances are commonly classified as deficits or excesses. ? Fluid volume deficit can occur with abnormal loss of body fluids (e.g., diarrhea, fistula drainage, hemorrhage, polyuria), inadequate intake, or a plasma-to interstitial fluid shift. ? Fluid volume excess may result from excessive intake of fluids, abnormal retention of fluids (e.g., heart failure, renal failure), or interstitial-toplasma fluid shift. ? The goals of treatment in fluid imbalances are to correct the underlying cause and to restore fluid and electrolyte balance. SODIUM IMBALANCES ? Sodium is the major ECF cation and plays a major role in maintaining the concentration and volume of the ECF. ? Hypernatremia is an elevated serum sodium that may occur with water loss or sodium gain. o Symptoms include those of dehydration and any accompanying ECF volume deficit, such as postural hypotension, weakness, and decreased skin turgor. o Hypernatremia is treated by cause. In water deficits, volume is replaced. In sodium excess, dilution is accomplished with sodium-free IV fluids. ? Hyponatremia is a low serum sodium level. Common causes include water excess from inappropriate use of sodium-free or hypotonic IV fluids. o Symptoms of hyponatremia are related to cellular swelling and are first manifested in the central nervous system (CNS). o In hyponatremia from water excess, fluid restriction is often the only treatment. If fluid loss is the cause, replacement with sodium-containing solutions is indicated. POTASSIUM IMBALANCES ? Potassium is the major ICF cation and is the major factor in the resting membrane potential of nerve and muscle cells. Potassium is critical for many cellular and metabolic functions, and disruptions cause a number of clinical problems. ? Factors that cause potassium to move from the ICF to the ECF include acidosis, trauma to cells (as in massive soft tissue damage or in tumor lysis), and exercise. ? Hyperkalemia is an elevated serum potassium level. o The most common cause is renal failure. Hyperkalemia is also common with massive cell destruction (e.g., burn or crush injury, tumor lysis); rapid transfusion of stored, hemolyzed blood; and catabolic states (e.g., severe infections). o Manifestations include cramping leg pain, followed by weakness or

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paralysis of skeletal muscles. o All patients with hyperkalemia should be monitored electrocardiographically to detect potentially fatal dysrhythmias and to monitor the effects of therapy. o The patient experiencing dangerous cardiac dysrhythmias should receive IV calcium gluconate. Hypokalemia is a low serum potassium level. The most common causes are from abnormal losses via either the kidneys or the gastrointestinal tract. o The incidence of potentially lethal ventricular dysrhythmias is increased in hypokalemia. Skeletal muscle weakness and paralysis, including the respiratory muscles, leading to shallow respirations and respiratory arrest, can occur. o Patients taking digoxin experience increased digoxin toxicity if their serum potassium level is low. o Hypokalemia is treated by giving potassium chloride supplements and increasing dietary intake of potassium.

CALCIUM IMBALANCES ? The functions of calcium include transmission of nerve impulses, myocardial contractions, blood clotting, formation of teeth and bone, and muscle contractions. ? Calcium is present in the serum in three forms: free or ionized; bound to protein (primarily albumin); and complexed with phosphate, citrate, or carbonate. The ionized form is the biologically active form. ? Hypercalcemia is an elevated serum calcium level. o Most cases are caused by hyperparathyroidism and one third are caused by malignancy, especially from breast or lung cancer, and multiple myeloma. o Manifestations include decreased memory, confusion, disorientation, fatigue, muscle weakness, constipation, cardiac dysrhythmias, and renal calculi. o Treatment is promotion of excretion of calcium in urine by administration of a loop diuretic and hydration of the patient with isotonic saline infusions. ? Hypocalcemia is a low serum calcium level, usually caused by a decrease in the production of parathyroid hormone. o It is characterized by increased muscle excitability resulting in tetany. o A patient who has had neck surgery including thyroidectomy is observed carefully for signs of hypocalcemia. o Hypocalcemia is treated with oral or IV calcium supplements. PHOSPHATE IMBALANCES ? Phosphorus is a primary anion in the ICF and is essential to the function of muscle, red blood cells, and the nervous system. ? Hyperphosphatemia is an elevated serum phosphorus level. It is usually associated with acute or chronic renal failure.

Key Points Printable Symptoms include neuromuscular irritability, tetany, and calcified deposits in soft tissues. o Management is aimed at the underlying cause. Hypophosphatemia is a low serum phosphorus level. It is most commonly seen in the patient who is malnourished or has a malabsorption syndrome. It is often asymptomatic and treated with oral or IV phosphorus.
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MAGNESIUM IMBALANCES ? Magnesium is important for cardiac function and is a coenzyme in the metabolism of carbohydrates and proteins. ? Hypermagnesemia is an elevated serum magnesium level. It usually occurs only with an increase in magnesium intake accompanied by renal insufficiency or failure. o Initial clinical manifestations include lethargy, drowsiness, and nausea and vomiting. With rising levels, deep tendon reflexes are lost, followed by somnolence, then respiratory and cardiac arrest. o Treatment is focused on prevention. IV calcium can be given in emergencies. ? Hypomagnesemia, a low serum magnesium level, is associated with malnutrition states, such as fasting or starvation. It produces neuromuscular and CNS hyperirritability; treatment involves replacing magnesium. ACID-BASE IMBALANCES ? Patients with a number of clinical conditions frequently develop acid-base imbalances. The nurse must always consider the possibility of acid-base imbalance in patients with serious illnesses. ? Normally the body has three mechanisms by which it regulates acid-base balance to maintain the arterial pH between 7.35 and 7.45. These mechanisms are the buffer system, the respiratory system, and the renal system. o The buffer system is the fastest acting system and the primary regulator of acid-base balance. o The lungs help maintain a normal pH by excreting CO and water, which 2 are by-products of cellular metabolism. o The three renal mechanisms of acid elimination are secretion of small + amounts of free hydrogen into the renal tubule, combination of H with + ammonia (NH ) to form ammonium (NH ), and excretion of weak acids. 3 4 Alterations in Acid-Base Balance ? Acid-base imbalances are classified as respiratory or metabolic. Respiratory imbalances affect carbonic acid concentrations; metabolic imbalances affect the base bicarbonate. ? Respiratory acidosis (carbonic acid excess) occurs whenever there is

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hypoventilation. Respiratory alkalosis (carbonic acid deficit) occurs whenever there is hyperventilation. Metabolic acidosis (base bicarbonate deficit) occurs when an acid other than carbonic acid accumulates in the body or when bicarbonate is lost from body fluids. Metabolic alkalosis (base bicarbonate excess) occurs when a loss of acid (prolonged vomiting or gastric suction) or a gain in bicarbonate occurs. Arterial blood gas (ABG) values provide valuable information about a patients acid-base status, the underlying cause of the imbalance, the bodys ability to regulate pH, and the patients overall oxygen status. In cases of acid-base imbalances, the clinical manifestations are generalized and nonspecific. The treatment is directed toward correction of the underlying cause.

ASSESSMENT OF FLUID, ELECTROLYTE, AND ACID-BASE IMBALANCES ? The nurse would assess for the specific clinical manifestations of fluid, electrolyte, and acid-base imbalances as presented throughout this chapter. ? Other health history data consist of assessment of past health history, medications, surgery or other treatments, and a review of systems using functional health patterns. ? There are no specific physical assessment findings to assess for fluid, electrolyte, and acid-base imbalances. ? Assessment of serum electrolyte values is the best starting point for identifying imbalances. Other useful tests include osmolality, glucose, BUN, creatinine, and specific gravity. ORAL FLUID AND ELECTROLYTE REPLACEMENT ? In all cases, treatment is directed toward correction of the underlying cause. ? Mild deficits can be corrected using the appropriate oral rehydration or electrolyte solution. INTRAVENOUS FLUID AND ELECTROLYTE REPLACEMENT ? Fluid replacement therapy is used to correct many fluid and electrolyte imbalances. The amount and type of solution used is determined by patient requirements and laboratory results. ? Hypotonic solutions, such as 5% dextrose in water and 0.45% NaCl, provide more water than electrolytes, diluting the ECF and producing movement of water from the ECF to the ICF. ? Administration of an isotonic solution, such as lactated Ringers and 0.9% NaCl, expands only the ECF. There is no net loss or gain from the ICF. ? A hypertonic solution initially raises the osmolality by the ECF and expands it, making them useful in the treatment of hypovolemia and hyponatremia. ? KCl, CaCl, MgSO , and HCO are common additives to the basic IV solutions. 4 3

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Plasma expanders stay in the vascular space and increase the osmotic pressure.

CENTRAL VENOUS ACCESS DEVICES ? Central venous access devices (CVADs) are often preferred over peripheral venous access for patient comfort, to decrease complications, and to provide more effective treatment options. ? Central venous access can be achieved by three different methods: centrally inserted catheters, peripherally inserted catheters, or implanted ports. ? These devices are placed in large blood vessels and permit frequent, continuous, rapid, or intermittent administration of IV fluids, complex medication treatments, vesicant agents, blood and blood products, and parenteral nutritional therapy. ? Advantages of CVADs include a reduced need for multiple venipunctures, decreased risk of extravasation injury, and immediate access to the central venous system. The major disadvantage is an increased risk of systemic infection. ? Nursing management of CVADs includes assessment, dressing change and cleansing, injection cap changes, and flushing.