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 FluidExtracellular 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 (3 rd spaced) Causes: liver – cardiac dx, sodium retention, some cancers Nursing ramifications: educate, diet, fluids, albumin (pulls fluid from 3 rd 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? DehydrationOverhydration 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 AlkalosisMetabolic 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 alkalosisRespiratory 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