Fluid & Electrolyte Imbalance

1. Fluid & Electrolyte Imbalance How to keep things flowing along! Lisa B. Flatt, RN, MSN, CHPN

2. Body Fluids • Body mostly composed of: • fluid –water • solutes - electrolytes • Osmolality- the balance between fluid and solutes – This is a delicate balance! Every organ and system reacts differently to an imbalance.

3. Swollen feet and ankles – water is attracted to sodium! • Semi-permeable membrane – selected particles move by passive diffusion – that’s how sodium follows water. • Osmotic pressure is the strength of the solution to draw the water across the SPM. • Passive diffusion – solutions of greater concentrations moves solutes to solutions of less concentration • Filtration – fluid and solutes move across a membrane from area higher pressure to lower pressure • Active transport – substances are moved from low to high concentration areas (metabolic energy & enzymes are used, ie. Sodium potassium pump)

4. Let’s see… what are the differences…. • Osmosis – • Diffusion – • Filtration – • Active transport -

5. Where you can find Body Fluid Intracellular Fluid Extracellular Fluid • Is 2/3 to ¾ of total body fluid • Found inside the cells • Outside the cells • Divided into compartments • Intravascular fluid • Plasma- vascular system • Interstitial fluid • Surrounds cells – lymph • Transcellular fluid • Epithelial cells (synovial fluid)

6. Potassium • Potassium (3.5 – 5.0 meQ/l) • Found and for: intracellular- cardiac, skeletal and smooth muscle activity • Hyperkalemia- high K • Causes-renal failure & (drug induced) • S/S – tetany, irritability, parasthesia, GI hyperactivity, cardiac arrhythmias • Nursing interventions: Kayexelate (po and pr), D50 and Insulin, dietary intake • Hypokalemia- low K • Causes-drug induced, N&V&D, gastric suctioning, exercise (shin splints) • S/S – weak, fatigued, cardiac arrhythmias • Nursing Interventions: IV and PO K, po and iv fluids, dietary intake

7. Magnesium • Magnesium (1.5 – 2.5 mEq/l) • Found and For: intracellular metabolism, protein and DNA synthesis • Hypermagnesia – high Mg • Causes-drug induced, • S/S – lethargy, coma, impaired respirations • Nursing Interventions- medication, diet • Hypomagnesia- low Mg • Causes – alcoholism • S/S – confusion, disoriented, tremors, irritability • Nursing Interventions – medications, diet

8. Sodium -- Salt sucks • Sodium (135 - 145meQ/l) • Found and For: intra&extracellular – Na and K balance needed in body – key electrolyte • Hypernatremia – high sodium • Causes – increased dietary intake, body system imbalances (kidney) – dehydration of the cells, water gets sucked from the cells and into the tissue • S/S – edema, thirst, confusion, dry mucus membranes, mental status changes • Nursing Interventions- fluid restrictions, diet restrictions • Hyponatremia – low sodium • Causes- exercise and too much water “water toxicity” – water gets sucked from the cells into the tissue (how most people die in the Grand Canyon – they need to take salt pills **Thank you Wes for the fun fact**) • S/S – muscle cramping, N&V, postural hypotension, mental status changes, hallucinations of oasis! • Nursing Interventions – medications, iv fluids, electrolytes

9. Calcium • Calcium (8.5 – 10.5 meQ/l) • For: blood coagulation, neuromuscular activity and bone growth • Found: Located in Bones • Hypercalcemia – high Ca • Causes – cancer with met’s to bone, drugs, parathyroid glandular issue • S/S – kidney stones, lethargy, weakness, decreased muscle tone • Nursing interventions: safety, iv fluid • Hypocalcemia – low Ca • Causes-alcoholism, low serum Mg, parathyroid gland removal • S/S – numbness, tremors, cardiac arrhythmia, osteoporosis • Nursing Interventions: iv fluids, medications, diet **Calcium and Phosphate work together – form bone and teeth --- if one is high the other is lower

10. Phosphates • Essential for function of: muscles, nerves and RBC • Involved in PRO, Fat and CHO metabolism • Hypophosphatemia - TPN, glucose & insulin can cause phosphates to shift into cells • Alcohol withdrawal • Antacid use (acid base imbalance) • S/S – weakness, pain, mental changes, seizures Hyperphosphatemia – Phosphates shift out of cell (trauma, chemo, malignant tumor), at risk – infants fed cow milk ((Fleets phosophosoda)) S/S – numbness, tingling **Around mouth and fingers** muscle spasm, tetany Nursing interventions: Diet, Medications, IV Fluids, Education

11. Chloride • Imbalances occur with Na imbalances • Hypochloremia – low Chloride • Causes: sweating, kidney loss, GI tract losses • S/S – twitching, tremors, tetany • Hyperchloremia – high Chloride • Causes: Na retention or high potassium • S/S – tremors, acidosis, weakness, lethargy, arrhythmias, coma • NURSING INTERVENTIONS: Medication, IV Fluids

12. Electrolyte Imbalances Universality • Nursing Interventions: diet, med’s, iv fluids, education, assessment, labs • Causes: Diet, Medication issues, metabolism (cancers, diseases) • S/S – muscle tremors, twitches, LOC, Mental status, cardiac affects

13. Look at your patient- be a spy • Previous history? Alcoholic = mg or K • Malnourished? • Objective and Subjective findings? • Labs – the blood • EKG

14. Homeostatic Mechanisms • Control the levels of fluids and electrolytes • Found throughout the body • _kidneys________ • __endocrine_______ • __cardiovascular_______ • ___GI______ • _____Lungs____

15. Kidneys (not kidney beans!) • Regulate what? • __water____ • __electrolytes____ • __acid/base content of blood____ • __all body fluids____ • Adjust what? Reabsorption of water • Excrete what? Water and waste == pee pee

16. Antidiuretic Hormone ADH • ADH regulates water excretion • Increases in response to increased serum (blood) osmolality • Ducts become more permeable to water and it is reasborbed easier into the blood and urine output will decrease

17. Renin-angiotensin-aldosterone system • Renin (enzyme) splits Angiotensinogen into angiotensin I and this transforms to angiotensin II (with the help of an ACE inhibitor). • Angiotensin II – stimulates vasoconstriction and secretes aldosterone • Aldosterone – increases Na reabsorption to regulate BP and electrolyte levels

18. Put it together • Increased osmolality – need more water in blood so: ADH secretion increases and water travels to the blood • R-A-A system – renin excreted to make angiotensin II and secrete aldosterone • Aldosterone causes vasoconstriction increase bp Give ACE inhibitor – stops angiotensin I to II and aldosterone (thereby lowers BP). This may also affect the ability of the body to maintain extracellular fluid (without edema).

19. Atrial Natriuretic Factor ANF • Secreted from atrial heart tissue • Increases sodium and water elimination (urine) • Lowers the blood volume and decreases cardiac output • Decreases the workload of the heart • OPPOSITE EFFECT OF ADH

20. pH acids and bases • Acid = substance that releases Hydrogen ion in a solution • Base = low hydrogen ion concentration • Buffers prevent excessive ph changes by: adjusting the ions • **Major buffer is H2CO3*** • Kidneys and Lungs play a key

21. Factors that affect fluid and electrolyte balance • Sex • Body size • Age • Diet • NPO • General adaption syndrome (GAS) hehe • Altered LOC

22. More factors……. • Body temperature • Renal, cardiac, pulmonary system • Medications • Steroids • NSAIDs • Diuretics • Laxatives • Electrolyte supplements

23. More factors…… just when you thought you were done! • Dehydration • Surgical procedures • Vomiting • Diarrhea • Exercise • Culture and traditional foods MSG • Religious practices • Socioeconomic • Emotional

24. Definitions and conditions • Fluid volume deficit is__hypovolemia_______ • Fluid volume excess is__hypervolemia____ • Ascites__fluid in the abdominal cavity______ • Edema _fluid in the interstitial space_______

25. Hypovolemia • Define: low fluid volume • Causes: increased sodium chloride intake (po, iv), dehydration, CHF, Renal failure, Cushing’s, trauma • Nursing ramifications: identify cause and educate, medications, iv’s, etc… • S/S: weak, nausea, low pulse, SOB, low BP

26. Hypervolemia • Define: increased volume in vascular system • Causes: water toxicity, iv fluids, disease states • Nursing ramifications: medication, educate • S/S: elevated BP, moist crackles in lungs, bounding pulse, SOB

27. Ascites • Define: serous fluid in peritoneal cavity (3rd spaced) • Causes: liver – cardiac dx, sodium retention, some cancers • Nursing ramifications: educate, diet, fluids, albumin (pulls fluid from 3rd space, interstitially back into the blood stream). Albumin has high osmolality. • S/S: swelling, fluid shift – the wave~~~~~~~ • Treatment: Albumin and Pericentesis

28. Edema • Define: fluid in the tissues • Causes: increased sodium, electrolyte imbalances, poor cardiac output, kidney failure, hypervolemia, diseases • Nursing ramifications: fluid restrictions, educate & elevate body parts, sodium restrictions, medications • S/S: swelling (LOL), weeping skin, pain, numbness, cool skin, bruised/discolored

29. Edema Pitting – leaves a small depression or pit Areas of edema: body parts, periorbital edema, axillary, groin, generalized Note how many seconds it takes for pit to disappear (normally 10-30seconds)

30. What’s the Difference? Dehydration Overhydration • Define: loss body fluid, normal electrolytes • Causes: decreased fluid intake • Nursing ramifications: IVF, educate, diet, assessment • S/S: jugular vein distention, tachycardia, mental status changes, confusion, weight loss, dry skin, poor skin turgor, dry mucus membranes, increased thirst • Define: water intake is greater than electrolyte intake • Causes: increased fluid intake • Nursing ramifications: education, diet, medications, assessment • S/S: altered mental status, edema, SIADH (water toxicity), possible decreased urine output

31. Acid-Base Balance • Normal pH of blood:_7.35-7.45____ • Acidic pH of blood: __<7.35_____ • Alkaline pH of blood (basic):_>7.45___ • Blood is acidotic if the pH is __low__ • Blood is alkalitic if the pH is __high__

32. Metabolic condition Metabolic Alkalosis Metabolic Acidosis • HCO3 – high • Causes: excess intake of baking soda (antacid) or alkalitic substances; lots of puking • The body compensates: • CO2 is retained and carbonic acid levels increase to help balance the excess HCO3 • HCO3 – low • Causes: starvation, renal impaired, DM • The body compensates: • Stimulates respiratory system and eliminates CO2

33. Respiratory condition Respiratory alkalosis Respiratory acidosis • HCO3 – high • Causes: hyperventilation, fever, anxiety, pulmonary infections • The body compensates: kidneys excrete HCO3 (or stop hyperventilation ASAP) • HCO3 – low • Causes: hypoventilation, lung dx, asthma, COPD • The body compensates: • Kidneys retain NAHCO3 **may take hours or days to restore pH

34. Intrepretation practice!

35. Nursing Interventions Include: • Dietary education • Menus • Special diets • Oral fluid/food intake • Restrictions • Administering medications as ordered • IVF • Diuretics • Electrolyte supplements • Education on medication uses/side effects and complications

36. Educating on Diuretics • Loop diuretic – Lasix/Furosemide • Thiazide sparing – HCTZ • Potassium sparing - Aldactone

37. Educating on Electrolyte supplements • Potassium • Magnesium • Sodium Bicarbonate • Others? Gatorade, Power waters, Coconut water • What do we recommend if you are exercising in the heat? Water and Power/Gatorade, etc… • Babies who have diarrhea need? Pedialyte • We use __kayexelate, D50 and Insulin_to reduce Potassium

38. Intravenous Fluids - Types • Hypotonic solutions: .45%NS, .33%NS, 2.5%Dextrose – lower osmotic pressure than plasma –DO not give if at risk for IICP • Hypertonic solutions:D5NS, D51/2NS, D5LR D5W – higher osmotic pressure than plasma – kidney, cardiac and dehydration • Isotonic solutions:0.9 NS, LR – expand vascular volume – LR has extra ingredients, treats metabolic acidosis • Electrolyte replacement: Potassium, KCL, MG, Banana bags!

39. Ethical consideration with IVF • Life sustaining? • Religious and/or cultural issues? • Comfort measure? • Emotional?

40. Calculations (oh no….not math!)

41. Assessing the patient • Urine • Skin • Mental state • MS • Bowel status

42. Further Assessment • Labs • BUN 7-18 mg/dl • Increased indicates- renal failure • Decreased indicates - malnutrition, over hydration, liver damage • Creatinine 0.6 – 1.5 mg/dl • Increased indicates – renal failure, CHF, shock • Decreased indicates – fluid status, dehydration

43. Let’s do a care plan! CHF Patient See pg 98-100