King Saud University College of Nursing Adult Nursing (NUR 316)

1. King Saud University College of Nursing Adult Nursing (NUR 316) Fluid and Electrolyte ImbalanceAcid and Base Imbalance

2. Introduction • Approx. 60% of the body weight is fluid (water and electrolytes). • Body fluid is located in 3 compartment: • Intracellular fluids contained within the cells (ICF): 2/3 of TBF • Extracellular fluid (ECF): 1/3 of TBF compose of IVF + 3rd space (interstitial space which is the fluid between the cells ) • Fluid compartment are separated by semi permeable membrane

3. DISTRIBUTION AND COMPOSITION OF BODY FLUID COMPARTMENTS 3rd space IVF ICF

4. Average daily intake and output in an adult: IntakeOutput Oral Liquids 1300ml. Urine 1500ml Water in foods 1000ml. Stool 200ml Water produced Insensible lungs 300ml by metabolism 300ml Skin 600ml 2600ml 2600ml

5. Normal Lab Results: - Na→ 135−145mEq/L. - K+ → 3.5−5.5mEq/L. - Ca++→ 8.5−10.5mEq/L. - Cl → 96−106mEq/L. - Mg→ 1.5−2.5mEq/L.

6. Fluid Volume Disturbance: I-Hypovolemia (fluids volume deficit): − Contributing Factors: * Loss of water and electrolyte. e.g.( vomiting,diarrhea,burns). * Decrease intake. e.g. (anorexia, nausea, inability to gain access to fluids). * Some disease.e.g (D.M, Diabetic Insipidus). − Sings and symptoms: Weight loss, general weakness, dizziness, increase pulse.

7. Assessment & Diagnostic evaluation • Health History & Physical examination • Serum BUN & Creatinin • Hematocrit level “great than normal” • Urine specific gravity • Serum electrolytes level • Hypokalemia in case of GI & renal loss • Hyperkalemia in case of adrenal insufficiency • Hypernatremia in case of ↑insensible losses & diabetic insepedus

9. ♣ Management treatment of the causes of FVD should be go with treatment of FVD itself factors influence the pt fluid needs should be taken in consideration In case of sever or acute FVD IV replacement should be started Isotonic solutions used to treat hypotension resulted from FVD Renal function & hemodynamic status should be evaluated ♣Nursing Management Monitor I&O as needed “urine” Monitor V/S, skin turgor , mental status & daily weight Extensive Hemodynamic CVP, arterial pressure Mouth care & ↓ irritating fluids

10. Fluid Volume Disturbance: II- Hypervolemia (fluid volume excess): − Contributing Factors: * Compromised regulatory mechanism such as renal failure, congestive heart failure, and cirrhosis. * Administration of Na+ containing fluids. * Prolong corticosteroid therapy. * Increase fluid intake. − Sings and Symptoms: Weight gain, increase blood pressure, edema, and shortness of breathing.

11. Assessment & Diagnostic Evaluation - Decreased BUN , Creatinin , Serum osmolality & hematocrete because of plasma dilution, &↓protein intake - Urine sodium is increased if kidneys excrete excess fluid - CXR may disclosed pulmonary congestion

12. Management • Direct cause should be treated • Symptomatic treatment consist of : • Diuretics • Restrict fluid & Na intake. • Maintained electrolytes balance • Hemodialysis in case of renal impairment • K+ supplement & specific nutrition • Nursing Management: • - Assess breathing , weight ,degree of edema regularly • - I & O measurement regularly • - Semifowlers position in case of shortness of breath • - Patient education

13. Electrolyte imbalance: I- SodiumDeficit (Hyponatremia): −Contributing Factors: * Use of a diuretic. * Loss of GI fluids. * Gain of water. − Sings and Symptoms: Anorexia, nausea and vomiting, headache, lethargy, confusion, seizures.

14. Hyponatremia, continued • Treatment: correct underlying disorder • Fluid restrict, + diuretics • Hypertonic saline to increase level 2-3 mEq/L/hr and max rate 100cc of 5% saline/hr

15. Electrolyte imbalance: II- Sodium Excess (Hypernatremia): − Contributing Factors: * Water deprivation in patient. * Hypertonic tube feeding. * Diabetes Insipidus. − Sings and Symptoms: Thirst, hallucination, lethargy, restless, pulmonary edema.

17. Hypernatremia, continued • Treatment: correct underlying disorder • Free water replacement: (0.6 * kg BW) * ((Na/140) – 1). Slow infusion of D5W give ½ over first 8 hrs then rest over next 16-24 hrs to avoid cerebral edema.

18. Electrolyte imbalance: III- Potassium Deficit (Hypokalemia): − Contributing factors: * Dirrhea, vomiting, gastric suctions. * Corticosteroid administration. * Diuretics. − Sings and symptoms: Fatigue, anorexia, nausea, vomiting, muscle weakness, change in ECG. • EKG: low, flat T-waves, ST depression, and U waves

19. Hypokalemia, continued • ECG changes in hypokalemia

20. Hypokalemia, continued • ECG changes in hypokalemia

21. Hypokalemia, continued • Treatment: • Check renal function • Treat alkalosis, decrease sodium intake • PO with 20-40 mEq doses • IV: peripheral 7.5 mEq/hr, central 20 mEq/hr and increase K+ in maintenance fluids.

22. Electrolyte imbalance: IV- Potassium Excess (Hyperkalemia): − Contributing Factors: * Renal Failure. * Crush injury, burns. * Blood transfusion. * Administration of IV K+. − Sings and Symptoms: Bradycardia, dysarrythmia, anxiety, irritable. - ECG: peaked T waves then flat P waves, depressed ST segment, widened QRS progressing to sine wave and V fib.

23. Hyperkalemia – ECG Changes

24. Hyperkalemia – ECG Changes

25. Hyperkalemia, continued • Treatment: • Remove iatrogenic causes • Acute: if > 7.5 mEq/L or EKG changes • Ca-gluconate – 1 gm over 2 min IV • Sodium bicarbonate – 1 amp, may repeat in 15min • D50W (1 ampule = 50 gm) and 10U regular insulin • Emergent dialysis • Hydration and diuresis, kayexalate 20-50 g, in 100-200cc of 20% sorbitol q 4hrs or enema

26. Calcium • Hypocalcemia: • Seen in hypoalbuminemia. Check ionized Ca • Often symptomatic below 8 mEq/dL • Check PTH: • low may be Mg deficiency • High think pancreatitis, hyperPO4, low Vitamin D, pseudohypoparathyroidism, massive blood transfusion, drugs (e.g. gentamicin) renal insufficiency • S/Sx: numbness, tingling, circumoral paresthesia, cramps tetany, increased DTR’s, Chvostek’s sign, Trousseau’s sign • EKG has prolonged QT interval

27. Calcium, continued • Hypocalcemia cont. • Treatment: • Acute: (IV) CaCl 10 cc of 10% solution = 6.5 mmole Ca or CaGluconate 10cc of 10% solution = 2.2 mmole Ca • Chronic: (PO) 0.5-1.25 gm CaCO3 = 200-500 mg Ca. • Phosphate binding antacids improve GI absorption of Ca • Vit D (calciferol) must have normal serum PO4. Start 50,000 – 200,000 units/day

28. Calcium, continued

29. Calcium, continued • Hypercalcemia • Usually secondary to hyperparathyroidism or malignancy. Other causes are thiazides, milk-alkali syndrome, granulomatous disease, acute adrenal insufficiency • Acute crisis is serum Ca> 12mg/dL. Critical at 16-20mg/dL • S/Sx: N/V, anorexia, abdominal pain, confusion, lethargy MS changes= “Bones, stone, abdominal groans and psychic overtones.”

30. Calcium, continued • Treatment: Hydration with NS then loop diuretic. Steroids for lymphoma, multiple myeloma, adrenal insufficiency, bone mets, Vit D intoxication. May need Hemodialysis. • Mithramycin for malignancy induced hyperCa refractory to other treatment. Give 15-25 mcg/kg IVP • Calcitonin in malignant PTH syndromes

31. Types of IV solutions: * Serum plasma osmalarity (280-300 m osmol). I- Isotonic Solutions: A solution with the same osmalality as serum and other body Fluids. e.g. N/S 0.9%, Ringer Lactate, D5W. II- Hypotonic Solutions: A solution with an osmolality lower than that of serum plasma. e.g. half strength saline (0.45% sodium chloride). III- Hypertonic Solution: A solution with an osmalality higher than that of serum. e.g. 1.4 % NS

32. Hypertonic fluids • IVF have a higher osmolarity than the ICF &3rd space. • Pulls fluid and electrolytes from the ICF &3rd into IVF . H2O+ Elect 3rd space H2O+ Elect

33. Hypertonic fluids • Can help stabilize blood pressure, increase urine output, and reduce edema.  • Dangerous in the setting of cell dehydration. • Examples: 1.4 % NS, Colloids & blood products

34. Hypotonic fluids • IVF have a lower osmolarity than the ICF &3rd space. • Pulls fluid and electrolytes from the IVF into the ICF &3rd . 3rd space H2O+ Elect

35. Hypotonic fluids • Can be helpful when cells are dehydrated, hyperglycemic, diabetic ketoacidosis. • Can cause cardiovascular collapse and increased Intracranial pressure (ICP) in some patients. • Example: O.45% Nacl, D5NS.45 (5% dextrose in 1/2 normal saline).

36. Isotonic fluids • IVF have same osmolarity as the ICF &3rd space. • Fluid stay inside the IVF. H20+Elect 3rd space

37. Isotonic fluids • After a few hours 80 % goes into 3 rd space while 20% stay in IV ( we need 3 liters of isotonic fluid to replace 1 liter of blood loss). • Can be helpful in hypotensive or hypovolemic patients. • Examples: Lactated Ringer's (LR), 0.9% NS.

38. Question?