CH 17 Fluid and Electrolytes

Focus on Fluid and Electrolytes
(Relates to Chapter 17, Fluid, Electrolytes, and Acid-Base Imbalances, in the textbook)
Copyright 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Homeostasis
State of equilibrium in body Naturally maintained by adaptive responses Body fluids and electrolytes are maintained within narrow limits
Water Content of the Body

60% of body weight in adult 45% to 55% in older adults 70% to 80% in infants
Varies with gender, body mass, and age
Changes in Water Content with Age
Fig. 17-1
Compartments
Intracellular fluid (ICF) Extracellular fluid (ECF)
Intravascular (plasma) Interstitial Transcellular
Fluid Compartments of the Body
Fig. 17-2
Intracellular Fluid (ICF)

Located within cells 42% of body weight
Extracellular Fluid (ECF)

One third of body weight Between cells (interstitial fluid), lymph, plasma, and transcellular fluid
Transcellular Fluid
Part of ECF Small but important Approximately 1 L
Transcellular Fluid (Contd)

Includes fluid in
Cerebrospinal fluid Gastrointestinal tract Pleural spaces Synovial spaces Peritoneal fluid spaces
Electrolytes
Substances whose molecules dissociate into ions (charged particles) when placed into water
Cations: positively charged Anions: negatively charged
Measurement of Electrolytes
International standard is millimoles per liter (mmol/L) U.S. uses milliequivalent (mEq)
Ions combine mEq for mEq
Electrolyte Composition
ICF
Prevalent cation is K+ Prevalent anion is PO43-
ECF
Prevalent cation is Na+ Prevalent anion is Cl-
Mechanisms Controlling Fluid and Electrolyte Movement

Diffusion Facilitated diffusion Active transport Osmosis Hydrostatic pressure Oncotic pressure
Diffusion
Movement of molecules from high to low concentration
Occurs in liquids, solids, and gases Membrane separating two areas must be permeable to diffusing substance Requires no energy
Diffusion (Contd)
Fig. 17-4
Facilitated Diffusion
Movement of molecules from high to low concentration without energy Uses specific carrier molecules to accelerate diffusion
Active Transport
Process in which molecules move against concentration gradient
Example: sodiumpotassium pump
External energy required
Sodium-Potassium Pump
Fig. 17-5
Osmosis
Movement of water between two compartments by a membrane permeable to water but not to solute Moves from low solute to high solute concentration Requires no energy
Osmosis (Contd)
Fig. 17-6
Osmotic Pressure
Amount of pressure required to stop osmotic flow of water
Determined by concentration of solutes in solution
Hydrostatic Pressure
Force within a fluid compartment Major force that pushes water out of vascular system at capillary level
Oncotic Pressure
Osmotic pressure exerted by colloids in solution (colloidal osmotic pressure)
Protein is major colloid
Fluid Movement in Capillaries

Amount and direction of movement determined by
Capillary hydrostatic pressure Plasma oncotic pressure Interstitial hydrostatic pressure Interstitial oncotic pressure
Fluid Exchange Between Capillary and Tissue
Fig. 17-8
Fluid Shifts
Plasma to interstitial fluid shift results in edema
Elevation of hydrostatic pressure Decrease in plasma oncotic pressure Elevation of interstitial oncotic pressure
Fluid Shifts (Contd)

Interstitial fluid to plasma
Fluid drawn into plasma space with increase in plasma osmotic or oncotic pressure Compression stockings decrease peripheral edema
Fluid Movement between ECF and ICF

Water deficit (increased ECF)
Associated with symptoms that result from cell shrinkage as water is pulled into vascular system
Fluid Movement between ECF and ICF (Contd)

Water excess (decreased ECF)
Develops from gain or retention of excess water
Fluid Spacing
First spacing
Normal distribution of fluid in ICF and ECF
Second spacing
Abnormal accumulation of interstitial fluid (edema)
Fluid Spacing (Contd)

Third spacing
Fluid accumulation in part of body where it is not easily exchanged with ECF
Regulation of Water Balance

Hypothalamic regulation Pituitary regulation Adrenal cortical regulation Renal regulation
Regulation of Water Balance (Contd) Cardiac regulation Gastrointestinal regulation Insensible water loss
Hypothalamic Regulation
Osmoreceptors in hypothalamus sense fluid deficit or increase
Stimulates thirst and antidiuretic hormone (ADH) release Result in increased free water and decreased plasma osmolarity
Pituitary Regulation
Under control of hypothalamus, posterior pituitary releases ADH Stress, nausea, nicotine, and morphine also stimulate ADH release
Adrenal Cortical Regulation

Releases hormones to regulate water and electrolytes
Glucocorticoids
Cortisol
Mineralocorticoids
Aldosterone
Factors Affecting Aldosterone Secretion
Fig. 17-9
Renal Regulation
Primary organs for regulating fluid and electrolyte balance
Adjusting urine volume
Selective reabsorption of water and electrolytes Renal tubules are sites of action of ADH and aldosterone
Effects of Stress on F&E Balance
Fig. 17-10
Cardiac Regulation
Natriuretic peptides are antagonists to the RAAS
Produced by cardiomyocytes in response to increased atrial pressure Suppress secretion of aldosterone, renin, and ADH to decrease blood volume and pressure
Gastrointestinal Regulation
Oral intake accounts for most water Small amounts of water are eliminated by gastrointestinal tract in feces Diarrhea and vomiting can lead to significant fluid and electrolyte loss
Insensible Water Loss

Invisible vaporization from lungs and skin to regulate body temperature
Approximately 600 to 900 ml/day is lost No electrolytes are lost
Gerontologic Considerations
Structural changes in kidneys decrease ability to conserve water Hormonal changes lead to decrease in ADH and ANP Loss of subcutaneous tissue leads to increased loss of moisture
Gerontologic Considerations (Contd) Reduced thirst mechanism results in decreased fluid intake Nurse must assess for these changes and implement treatment accordingly
Fluid and Electrolyte Imbalances

Common in most patients with illness
Directly caused by illness or disease (burns or heart failure) Result of therapeutic measures (IV fluid replacement or diuretics)
Extracellular Fluid Volume Imbalances

ECF volume deficit (hypovolemia)
Abnormal loss of normal body fluids (diarrhea, fistula drainage, hemorrhage), inadequate intake, or plasma-to-interstitial fluid shift Treatment: replace water and electrolytes with balanced IV solutions
Extracellular Fluid Volume Imbalances (Contd)

Fluid volume excess (hypervolemia)
Excessive intake of fluids, abnormal retention of fluids (CHF), or interstitialto-plasma fluid shift Treatment: remove fluid without changing electrolyte composition or osmolality of ECF
Nursing Management Nursing Diagnoses

Hypovolemia
Deficient fluid volume Decreased cardiac output Potential complication: hypovolemic shock
Nursing Management Nursing Diagnoses (Contd)

Hypervolemia
Excess fluid volume Ineffective airway clearance Risk for impaired skin integrity Disturbed body image Potential complications: pulmonary edema, ascites
Nursing Management Nursing Implementation

I&O Monitor cardiovascular changes Assess respiratory status and monitor changes Daily weights Skin assessment
Nursing Management Nursing Implementation (Contd)

Neurologic function
LOC PERLA Voluntary movement of extremities Muscle strength Reflexes
Electrolyte Disorders Signs and Symptoms

Electrolyte Sodium (Na) Excess Hypernatremia Thirst CNS deterioration Increased interstitial fluid Deficit Hyponatremia CNS deterioration
Potassium (K)
Hyperkalemia Ventricular fibrillation ECG changes CNS changes
Hypokalemia Bradycardia ECG changes CNS changes
Electrolyte Disorders Signs and Symptoms (Contd)

Electrolyte Calcium (Ca) Excess Hypercalcemia Thirst CNS deterioration Increased interstitial fluid Deficit Hypocalcemia Tetany Chvosteks, Trousseaus signs Muscle twitching CNS changes ECG changes Hypomagnesemia Hyperactive DTRs CNS changes
Magnesium (Mg)
Hypermagnesemia Loss of deep tendon reflexes (DTRs) Depression of CNS Depression of neuromuscular function
Sodium
Imbalances typically associated with parallel changes in osmolality Plays a major role in
ECF volume and concentration Generation and transmission of nerve impulses Acidbase balance
Hypernatremia
Elevated serum sodium occurring with water loss or sodium gain Causes hyperosmolality leading to cellular dehydration Primary protection is thirst from hypothalamus
Differential Assessment of ECF Volume

Fig. 17-12
Imbalances in ECF Volume
Fig. 17-13
Hypernatremia
Manifestations
Thirst, lethargy, agitation, seizures, and coma
Impaired LOC Produced by clinical states

Central or nephrogenic diabetes insipidus
Hypernatremia (Contd)
Serum sodium levels must be reduced gradually to avoid cerebral edema

Risk for injury Potential complication: seizures and coma leading to irreversible brain damage

Treat underlying cause If oral fluids cannot be ingested, IV solution of 5% dextrose in water or hypotonic saline Diuretics
Hyponatremia
Results from loss of sodiumcontaining fluids or from water excess Manifestations
Confusion, nausea, vomiting, seizures, and coma

Risk for injury Potential complication: severe neurologic changes

Caused by water excess
Fluid restriction is needed
Severe symptoms (seizures)

Give small amount of IV hypertonic saline solution (3% NaCl)

Abnormal fluid loss
Fluid replacement with sodiumcontaining solution
Potassium
Major ICF cation Necessary for
Transmission and conduction of nerve and muscle impulses Maintenance of cardiac rhythms Acidbase balance
Potassium (Contd)
Sources
Fruits and vegetables (bananas and oranges) Salt substitutes Potassium medications (PO, IV) Stored blood
Hyperkalemia
High serum potassium caused by
Massive intake Impaired renal excretion Shift from ICF to ECF
Common in massive cell destruction

Burn, crush injury, or tumor lysis
Hyperkalemia (Contd)
Manifestations
Weak or paralyzed skeletal muscles Ventricular fibrillation or cardiac standstill Abdominal cramping or diarrhea

Risk for injury Potential complication: dysrhythmias

Eliminate oral and parenteral K intake Increase elimination of K (diuretics, dialysis, Kayexalate)

Force K from ECF to ICF by IV insulin or sodium bicarbonate Reverse membrane effects of elevated ECF potassium by administering calcium gluconate IV
Hypokalemia
Low serum potassium caused by
Abnormal losses of K+ via the kidneys or gastrointestinal tract Magnesium deficiency Metabolic alkalosis
Hypokalemia (Contd)
Manifestations
Most serious are cardiac Skeletal muscle weakness Weakness of respiratory muscles Decreased gastrointestinal motility


KCl supplements orally or IV Should not exceed 10 to 20 mEq/hr
To prevent hyperkalemia and cardiac arrest
Calcium
Obtained from ingested foods More than 99% combined with phosphorus and concentrated in skeletal system Inverse relationship with phosphorus
Calcium (Contd)
Bones are readily available store Blocks sodium transport and stabilizes cell membrane Ionized form is biologically active
Calcium (Contd)
Functions
Transmission of nerve impulses Myocardial contractions Blood clotting Formation of teeth and bone Muscle contractions
Calcium (Contd)
Balance controlled by
Parathyroid hormone Calcitonin Vitamin D
Hypercalcemia
High serum calcium levels caused by
Hyperparathyroidism (two thirds of cases) Malignancy Vitamin D overdose Prolonged immobilization
Hypercalcemia (Contd)
Manifestations
Decreased memory Confusion Disorientation Fatigue Constipation


Excretion of Ca with loop diuretic Hydration with isotonic saline infusion Synthetic calcitonin Mobilization
Hypocalcemia
Low serum Ca levels caused by
Decreased production of PTH Acute pancreatitis Multiple blood transfusions Alkalosis Decreased intake
Hypocalcemia (Contd)
Manifestations
Positive Trousseaus or Chvosteks sign Laryngeal stridor Dysphagia Tingling around the mouth or in the extremities
Tests for Hypocalcemia
Fig. 17-15

Risk for injury Potential complication: fracture or respiratory arrest

Treat cause Oral or IV calcium supplements
Not IM to avoid local reactions
Treat pain and anxiety to prevent hyperventilation-induced respiratory alkalosis
Phosphate
Primary anion in ICF Essential to function of muscle, red blood cells, and nervous system Deposited with calcium for bone and tooth structure
Phosphate (Contd)
Involved in acidbase buffering system, ATP production, and cellular uptake of glucose Maintenance requires adequate renal functioning Essential to muscle, RBCs, and nervous system function
Hyperphosphatemia
High serum PO43- caused by
Acute or chronic renal failure Chemotherapy Excessive ingestion of phosphate or vitamin D
Hyperphosphatemia (Contd)
Manifestations
Calcified deposition in soft tissue such as joints, arteries, skin, kidneys, and corneas Neuromuscular irritability and tetany
Hyperphosphatemia (Contd)
Management
Identify and treat underlying cause Restrict foods and fluids containing PO43 Adequate hydration and correction of hypocalcemic conditions
Hypophosphatemia (Contd)
Low serum PO43- caused by
Malnourishment/malabsorption Alcohol withdrawal Use of phosphate-binding antacids During parenteral nutrition with inadequate replacement
Manifestations
CNS depression Confusion Muscle weakness and pain Dysrhythmias Cardiomyopathy
Management
Oral supplementation Ingestion of foods high in PO43 IV administration of sodium or potassium phosphate
Magnesium
50% to 60% contained in bone Coenzyme in metabolism of protein and carbohydrates Factors that regulate calcium balance appear to influence magnesium balance
Magnesium (Contd)
Acts directly on myoneural junction Important for normal cardiac function
Hypermagnesemia
High serum Mg caused by
Increased intake or ingestion of products containing magnesium when renal insufficiency or failure is present
Hypermagnesemia (Contd)
Manifestations
Lethargy or drowsiness Nausea/vomiting Impaired reflexes Respiratory and cardiac arrest
Hypermagnesemia (Contd)
Management
Prevention Emergency treatment
IV CaCl or calcium gluconate
Fluids to promote urinary excretion
Hypomagnesemia (Contd)
Low serum Mg caused by
Prolonged fasting or starvation Chronic alcoholism Fluid loss from gastrointestinal tract Prolonged parenteral nutrition without supplementation Diuretics
Manifestations
Confusion Hyperactive deep tendon reflexes Tremors Seizures Cardiac dysrhythmias
Management
Oral supplements Increase dietary intake Parenteral IV or IM magnesium when severe
IV Fluids
Purposes
1. Maintenance
When oral intake is not adequate When losses have occurred
2. Replacement
IV Fluids (Contd)
Hypotonic
More water than electrolytes
Pure water lyses RBCs
Water moves from ECF to ICF by osmosis Usually maintenance fluids
IV Fluids (Contd)
Isotonic
Expands only ECF No net loss or gain from ICF
IV Fluids (Contd)
Hypertonic
Initially expands and raises the osmolality of ECF Require frequent monitoring of
Blood pressure Lung sounds Serum sodium levels
D5W
Isotonic Provides 170 cal/L Free water
Moves into ICF Increases renal solute excretion
D5W (Contd)
Used to replace water losses and treat hyponatremia Does not provide electrolytes
Normal Saline (NS)

Isotonic No calories More NaCl than ECF 30% stays in IV (most)
70% moves out of IV
Normal Saline (NS) (Contd)

Expands IV volume
Preferred fluid for immediate response Risk for fluid overload higher
Does not change ICF volume Blood products Compatible with most medications
Lactated Ringers
Isotonic More similar to plasma than NS
Has less NaCl Has K, Ca, PO43-, lactate (metabolized to HCO3)
Expands ECF
D5 NS
Hypertonic Common maintenance fluid KCl added for maintenance or replacement
D10W
Hypertonic Provides 340 kcal/L Free water Limit of dextrose concentration may be infused peripherally
Plasma Expanders
Stay in vascular space and increase osmotic pressure Colloids (protein solutions)
Packed RBCs Albumin Plasma
Case Study
Case Study
76-year-old male is brought to emergency department with confusion and lethargy He has a history of chronic heart failure, type 2 diabetes, and hypertension
Case Study (Contd)

Lab values reveal low potassium levels and Hct 56% Poor skin turgor
BP 110/58 mm Hg
Case Study (Contd)

Heart rate 135 beats/min
Respiratory rate 26 breaths/min

Temperature 99 F Recent flu
Case Study (Contd)

Patient forgot he took furosemide (Lasix) and doubled dose twice in 1 week Started on 0.45 NaCl and IV potassium chloride
Discussion Questions
1. What important teaching should be done with him? 2. What resources are available to help him manage his medications?

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Focus on Fluid and Electrolytes

Water Content of the Body

Changes in Water Content with Age

Fluid Compartments of the Body

Intracellular Fluid (ICF)

Extracellular Fluid (ECF)

Transcellular Fluid (Contd)

Mechanisms Controlling Fluid and Electrolyte Movement

External energy required

Fluid Movement in Capillaries

Fluid Exchange Between Capillary and Tissue

Fluid Shifts (Contd)

Fluid Movement between ECF and ICF

Fluid Movement between ECF and ICF (Contd)

Fluid Spacing (Contd)

Regulation of Water Balance

Adrenal Cortical Regulation

Factors Affecting Aldosterone Secretion

Effects of Stress on F&E Balance

Insensible Water Loss

Fluid and Electrolyte Imbalances

Extracellular Fluid Volume Imbalances

Extracellular Fluid Volume Imbalances (Contd)

Nursing Management Nursing Diagnoses

Nursing Management Nursing Diagnoses (Contd)

Nursing Management Nursing Implementation

Nursing Management Nursing Implementation (Contd)

Electrolyte Disorders Signs and Symptoms

Hyperkalemia Ventricular fibrillation ECG changes CNS changes

Hypokalemia Bradycardia ECG changes CNS changes

Electrolyte Disorders Signs and Symptoms (Contd)

Differential Assessment of ECF Volume

Imbalances in ECF Volume

Impaired LOC Produced by clinical states

Nursing Management Nursing Diagnoses

Nursing Management Nursing Implementation

Nursing Management Nursing Diagnoses

Nursing Management Nursing Implementation

Severe symptoms (seizures)

Nursing Management Nursing Implementation (Contd)

Common in massive cell destruction

Nursing Management Nursing Diagnoses

Nursing Management Nursing Implementation

Nursing Management Nursing Implementation (Contd)

Nursing Management Nursing Diagnoses

Nursing Management Nursing Implementation

Nursing Management Nursing Diagnoses

Nursing Management Nursing Implementation

Tests for Hypocalcemia

Nursing Management Nursing Diagnoses

Nursing Management Nursing Implementation

Treat pain and anxiety to prevent hyperventilation-induced respiratory alkalosis

Fluids to promote urinary excretion

Water moves from ECF to ICF by osmosis Usually maintenance fluids

Normal Saline (NS)

Normal Saline (NS) (Contd)

Case Study (Contd)

Case Study (Contd)

Respiratory rate 26 breaths/min