Fluid & Electrolyte Imbalances

N4935

Alterations in Fluid Volume

Dehydration Fluid Volume Deficit (Hypovolemia) Fluid Volume Excess (Hypervolemia)

Who is at Risk for Fluid Volume Alterations?

Age
Disease Medications

Types of Fluid Loss

Insensible Loss
Skin ~ 400 mL/day Lungs ~ 500 mL/day

Sensible Loss

Excess perspiration

Dehydration
How does it happen?
Loss of water only

Fluid Volume Deficit/Deficient

Loss of fluids and solutes Caused by:

Excessive fluid loss Fluid loss with reduced intake Third spacing (where it cannot be readily regulated) Excessive diuretic therapy

Fluid Volume Deficit Manifestations

Dry mucous membranes Thirst Decreased skin turgor Tachycardia Orthostatic hypotension - hypotension Urine output decreased increased concentration (color & specific gravity) Restless/ anxious/drowsy/confusion Weight loss Increased urine specific gravity Shock/seizure/coma

Management
Oral fluids are generally not enough. Isotonic IV solutions Treat cause: albumin, blood, surgery Vasopressors O2 Monitor for over correction &/or progression of condition Safety

Fluid Volume Excess (Hypervolemia)

Excess water and sodium in the extracellular space. This can occur in the intravascular space or in the interstitial space Who is at risk?
The elderly and anyone with cardiac or renal problems, IV replacement (overcorrection)

Fluid Excess Manifestations

Bounding pulse, increased BP Neck vein distention Dyspnea Crackles, Cough, Frothy sputum Edema (dependent) Headache, confusion, lethargy Weight gain (1 liter=2.2 lbs) Seizure, coma

Management
Treat the cause Restrict Na and fluid intake. Diuretics Morphine O2 Bedrest, HOB up Monitor

Acid-Base Balance
Acid production, buffering, and excretion interplay to create balance. Acids release hydrogen (H+) ions; bases (alkaline substances) take up H+ ions. Degree of acidity is reported as pH. pH scale: 1.0 (very acid) to 14.0 (very base) pH of 7.0 is neutral; normal arterial blood is 7.35 to 7.45. Maintaining pH within this normal range is very important for optimal cell function.

Quick Quiz
When a nurse evaluates a patients 24 hour I & O, the fluid intake should be: a. Slightly more that the output b. Lower than the urine output c. Higher than the fluid output d. Equal to the urine output

Acid-Base Balance (contd)

Acid production CO2 +H2O H2CO3 H+ + HCO3 Carbon dioxide + water Carbonic acid Hydrogen ion + Bicarbonate Acid buffering: Buffers are pairs of chemicals that work together to maintain normal pH of body fluids HCO3 + H+ H2CO3 Bicarbonate + Hydrogen ion Carbonic acid H2CO3 H+ + HCO3 Carbonic acid Hydrogen ion + Bicarbonate

Acid-Base Balance (contd)

Acid excretion systems: lungs and kidneys Lungs excrete carbonic acid. Kidneys excrete metabolic acids. Excretion of carbonic acid When you exhale, you excrete carbonic acid in the form of CO2 and water. Excretion of metabolic acids The kidneys excrete all acids except carbonic acid.

Quick Quiz!
The bodys fluid and electrolyte balance is maintained partially by hormonal regulation. You will express an understanding of this mechanism in which of the following statements? A. The pituitary secretes aldosterone. B. The kidneys secrete antidiuretic hormone. C. The adrenal cortex secretes antidiuretic hormone. D. The pituitary gland secretes antidiuretic hormone.

Quick Quiz
Which assessment indicates deficient fluid volume? a. Negative balance of intake & output b. Decreased body temperature c. Increased blood pressure d. Shortness of breath

Calcium (Ca++)
Normal serum level = Lewis 8.6-10.2 mg/dL; P & P 8.4 10.5 mg/dL Ionized Ca++ = 4.5 5.3 mg/dL 99% stored in bones and teeth 50% of Ca in blood is bound to albumin Has an inverse relationship with PO4
(When Ca++ increase, PO4 levels decrease and visa versa)

Calcium
Influenced by dietary intake (Dairy products, legumes, green leafy vegetables, sardines, salmon, clams, oysters, rhubarb) Regulated by
Parathyroid hormone Calcitonin Vitamin D

Calcium
Functions in

Development of bones and teeth

Also requires Vitamin D and Phosphorous

Muscle contractility (skeletal, smooth, & cardiac) Transmission of nerve impulses Blood clotting Cell structure & membrane permeability

Hypocalcemia Causes <8.6 mg/dl

Insufficient intake

Dietary Deficiency of Vit D or Magnesium

Impaired absorption Excessive Ca++ loss

Acute Pancreatitis Hypoparathyroidism (functional or surgical) Diuretics

Low serum albumin levels Alkalosis Transfusions

Hypocalcemia Findings Reflect excitability of cells

Anxiety, irritability Muscle twitching Numbness & tingling in toes, fingers, or around mouth Positive Trousseaus and Chvosteks sign Tetany Arrhyhythmias/ EKG changes

Hypocalcemia Management
Give Ca++--oral or IV (slowly)

If PO, give 30 min. ac (to increase absorption)

Assess Vit D intake Encourage dietary intake Avoid laxatives Seizure precautions Injury prevention Monitor Ca, albumin, and clotting levels

Hypocalcemia Nursing Considerations

Assess for symptoms Tracheotomy tray, seizure precautions Heart monitor IV site monitoring Monitor lab values Watch for overcorrection

Hypercalcemia Causes >10.2 mg/dl

Hyperparathyroidism
Malignancies (lung, breast, multiple myeloma) Prolonged immobility Loss of Ca++ from bone into plasma

Hypercalcemia Manifestations
relate to decreased excitability

Muscle weakness, Decreased DTRs Fracturescan occur spontaneously (aka: pathologic fx) Confusion, personality changes, depression Lethargy, drowsiness, apathy, coma Anorexia, vomiting, constipation Polyuria Renal calculi (kidney stones cause flank pain in low back)

Hypercalcemia Management
Increase fluids to help with excretion

IV NSto replace Na+ which follows Ca++ w/diuresis

Loop diuretics Weight-bearing physical activitywatch increased fall risk because of confusion Meds to promote reabsorption

Hypercalcemia Nursing Management

Monitor cardiac rhythms, VS, & lab values Strain urine for calculi Activity with caution (pathological fx) Teaching Safety

Quick Quiz
Which of the following influences serum Ca levels?
A. Vitamin K B. Sodium C. Potassium D. Parathyroid hormone

Quick Quiz
What is the normal calcium serum level? A. 7.5-9.0 mg/dL B. 8.0-9.5 mg/dL C. 8.6-10.2 mg/dL D. 9.5-11.0 mg/dL

Quick Quiz
Which of these is a function of calcium?
A. Contraction ability of muscles B. Renal balance C. Regulation of water D. Transports potassium into the cell

Quick Quiz
Your patient has low serum calcium. You observe for?
A. Increase urine output B. Hypertension C. Muscle twitching D. Coma

Quick Quiz
What manifestation of low serum Ca would you check for in this patient?
A. Rough, dry skin B. Bradycardia and dysrhythmias C. Decreased urine output D. Constipation

Quick Quiz
Your patient has an elevated serum Ca++ level. What do you suspect as the cause?
A. Metabolic acidosis B. Bone tumors C. Hypoparathyroidism D. Hyperphosphatemia

Quick Quiz
One aspect of the treatment of hypercalcemia is?
A. Decrease fluid intake B. Give Ca++ supplements C. Antacids D. Weight bearing, walking

Magnesium Mg ++
Normal serum level 1.5 2.5 mEq/L Absorbed from food

Tied to Ca++ function

Primarily excreted by kidneys

Magnesium Functions
Helps with CHO & protein metabolism Affects cardiac and skeletal muscle contractility Vasodilation Regulation similar to Ca++ in GI & renal system

Assess Ca++, K+, albumin

Hypomagnesemia <1.5mEq/L
Malabsorption, starvation
Chronic alcoholism Uncontrolled diabetes mellitus Vomiting, diarrhea, NG suction

Hypomagnesemia Manifestations (CNS irritation)

Confusion Hyperactive DTRs Tremors, twitching, tetany Positive Trousseau and Chvosteks signs Seizures Dysrhythmias HTN

Hypomagnesemia Management
Slow infusion of MgSO4 (Again, can cause tissue damage!)

Or PO supplement

Dietary intake (Nuts, leafy greens,

bananas, oranges, peanut butter, chocolate, grains)

Nursing Management of Hypomagnesemia

Reduce environmental stimuli Seizure precautions Monitor cardiac and neuro status Assess DTR every 1 4 hrs Dysphagia

Hypermagnesemia >2.5mEq/L
Chronic renal failure
Excessive intake antacids & laxatives Treatment of pre-eclampsia/eclampsia (to be expected)

Hypermagnesemia
Flushed & sensation of warmth Lethargy, drowsiness Hypoactive DTRs Facial numbness EKG changes Respiratory depression or paralysis Cardiac arrest Nausea & vomiting

Hypermagnesemia Management
Dialysis if renal failure is the cause IV fluidsif renal function is normal Avoid laxatives and antacids with Mg++ IV calcium gluconate Diet therapy-reduce intake of Mg++ Prevent future episodes

Nursing Management of Hypermagnesemia

Encourage po fluid intake
Monitor cardiac and respiratory status Monitor I&O, VS, DTR, labs Safety

Quick Quiz
Magnesium functions to:
A. Prevent Ca+ absorption B. Aid in cell metabolism C. Regulate ECF of Ca++ and K+ D. Inhibit parathyroid function

Quick Quiz
Which of the following in the history, physical and review of data would lead to a diagnosis of hypomagnesemia?
A. Increased serum Ca++ B. Intake of antacids with Mg++ C. Excessive diarrhea and vomiting D. Hypoaldosteronism

Quick Quiz
Where will you see the primary effects of Mg++ deficit?
A. Cardiac dysrhythmias and muscle tetany B. Hypoactive reflexes C. Hypertension D. Depression

Quick Quiz
Which of the following patients should be observed for Mg++ excess?
A. Over hydration B. Hypoparathyroidism C. Hyperparathyroidism D. Chronic renal failure