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Fluid & Electrolyte Disorders

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1 Fluid & Electrolyte Disorders
Disclaimer - Pocket Prof Apps has used reasonable efforts to ensure that the information provided is both accurate and current. However, your education is ultimately your responsibility, and Pocket Prof Apps makes no guarantee to the accuracy or applicability of any information provided, and assumes no liability for your reliance on any information we provide. Further, the information provided in resources published by Pocket Prof Apps represents the understanding and opinions of the presenters and authors, and may or may not be consistent with the opinions or preferences of your own professors. We therefore recommend that you use information provided by Pocket Prof Apps to supplement your other education resources, and not replace your own study, group discussions, and class lectures. This is a review of Fluid & Electrolyte Disorders. Another video is available for basics of Fluid & Electrolytes. Please note our standard disclaimer in the small print to the left. It basically states that we do everything we can to provide accurate, up-to-date information. However, this video is not designed to replace your professor’s information, but instead to supplement. F&E imbalances can occur even in healthy people, but it’s usually mild and self-corrected. However, F&E imbalances can be life-threatening esp. for patients at risk including the elderly, those with chronic renal and endocrine disorders, and those patients that take medications that affect F&E balance. ©2013 by Pocket Prof Apps

2 Fluid Volume Deficit (No Water, No Salt, Or Both)
No Water (hypertonic) Profuse sweating, hyperventilation, DKA, fevers, diarrhea, renal failure, DI No Salt (hypotonic) Water intoxication, chronic illness, malnutrition, renal failure Both (isotonic) NPO, poor intake, hemorrhage Fluid volume imbalances are typically accompanied by electrolyte imbalances - sudden body weight change is an excellent indicator of overall fluid volume loss or gain (1 liter = 2.2 lbs or 1 kg) Infants, clients with neurologic or pyschologic problems, and some older adults who are unable to perceive or respond to the thirst mechanism are at risk for dehydration No Water, No Salt, Or Both is what makes fluid volume deficit confusing – symptoms can vary based on the cause of fluid volume deficit, it’s not just water loss that exceeds water intake (although that is the most common) No water (hypertonic) – primarily losing water No salt (hypotonic) – primarily losing electrolytes, least common cause, problem is they are hyponatremic (b/c of dilution) so their cells begin to swell causing significant neuro problems Both (isotonic) – losing both water and electrolytes, typical dehydration Without any loss of water it’s called relative dehydration (fluid shift)

3 Fluid Volume Deficit What are the symptoms? What can you do?
Low BP, high HR Dry mouth, thirst Rapid weight loss Low urine output Confusion, lethargy SG>1.030, high Hct, high BUN, low Na, high osmo What can you do? Fluids (oral if alert) NS or LR (no potassium until urine output is increased) Daily weight, strict I/Os May need antidiarrheals, antiemetics, abx, antipyretics Signs/symptoms – low BP, high pulse, dry mouth, thirst, rapid weight loss, confusion, lethargy, low urine output, can have low grade fever (from blood vessel constriction due to hypovolemia) Lab values – urine SG >1.030, increased Hct (except in hemorrhage), increased BUN, decreased sodium, high osmo (may have hemoconcentration – increased Hgb, Hct, osmo, glucose, protein, BUN – if only water is lost, won’t happen with hemorrhage) Tx - replace fluid loss with isotonic fluids, oral fluids if alert, monitor daily weights and strict I/Os, give balanced solutions (ie. LR, NS if rapid volume is needed – fluid type is based on cause of fluid loss; may also need antidiarrheals, abx, antiemetis, antipyretics How do we know tx is working? Urine output increased, heart rate decreased

4 Fluid Volume Excess Happens when there is increased sodium and water
Causes: Hypervolemia (isotonic) Too much IV fluid, kidney failure, corticosteroids Water intoxication (hypotonic) CHF, SIADH, IV fluids, psych problems, wound irrigation Too much sodium intake (hypertonic) Too much salt, 3% saline IV, too much NaHCO3 Fluid volume excess – overhydration, hypervolemia Causes – CHF, renal failure, excessive sodium intake, excess water intake, SIADH (syndrome of inappropriate antidiuretic hormone), interstitial to plasma fluid shift Isotonic – hypervolemia, too much fluid in ECF causing circulatory overload c/b – too much IV fluid, kidney failure, corticosteroids Hypotonic – water intoxication, causes electrolyte imbalances from dilution, cell swelling c/b – CHF, SIADH, IV fluids, psych problems, wound irrigation Hypertonic – rare, excessive sodium intake c/b – too much salt, 3% saline IV, too much NaHCO3

5 Fluid Volume Excess What are the symptoms? What can you do?
Rapid weight gain Edema High BP, bounding pulses May have  urine output JVD, crackles, dyspnea Decreased LOC Low Hct, low BUN, high Na, low osmo What can you do? Signs/symptoms – rapid weight gain, edema (oftentimes pitting), high BP, increased urine output (if kidneys are working normally), neck vein distention, bounding pulses, crackles in the lungs, shortness of breath, decreased LOC Lab values – decreased Hct, Hgb, proteins (from dilution), decreased BUN, increased sodium, decreased osmo Tx – use of diuretics (osmotic first – ie. Mannitol – to prevent severe electrolyte imbalances), fluid restriction, sodium restriction, monitor daily weights and strict I/Os, no IV fluids Diuretics Fluid restriction (no IV fluids) Sodium restriction Daily weights, strict I/Os

6 FYI – Hematocrit normal is 3 times the hemoglobin (10-14 is normal)
Lab Normals Electrolyte Range Magic 4 Potassium 3.5 – 5.5 4 Chloride 98 – 106 104 Sodium 140 pH 7.35 – 7.45 7.4 pCO2 35 – 45 40 HCO3 22 – 26 24 FYI – Hematocrit normal is 3 times the hemoglobin (10-14 is normal) This is just a quick way to try to keep some of these normal ranges straight in your head – don’t memorize ranges As we start to talk about the disorders, know that all symptoms worsen when an electrolyte value changes rapidly, if there is a chronic, slow change the body tends to adapt and symptoms are not that severe

7 Sodium (135 – 145 mEq/L) Major cation of ECF
Sodium level reflects the ratio of sodium to water Regulated by kidneys, ADH, aldosterone GI tract absorbs sodium from food Imbalances are typically associated with fluid volume problems Foods high in sodium – processed meats, condiments, dairy Regulates body fluids, determines whether water is retained, excreted, or moved from one space to another; primary cause of osmolality Sodium is stored in the kidney and regulated by ADH, aldosterone (when low) and natriuretic peptides (when high) Average intake is 6-14 g/day, mostly thru food; most output is through urine and sweat Change in sodium will affect plasma volume, BP, ICF and ECF; combines with Cl or HCO3 to promote acid-base balance Sodium has an inverse relationship with potassium (if one is high, then the other is low) When you think of symptoms associated with sodium problems, think “brain”

8 Hypernatremia ( Na) “You Are Fried” Water loss or excess sodium
F Fever (low grade, flushed skin) R Restless (irritable) I Increased fluid retention and  BP E Edema (peripheral and pitting) D Decreased urine output, dry mouth Water loss or excess sodium  Na excretion – renal failure, corticosteroids  Na intake – eating too much salt, too much sodium in IV fluids  water loss – fever, infection, hyperventilation, sweating, diarrhea, dehydration Patho – excitable tissues leads to irritability and enhanced response to stimuli, as the sodium level gets higher there will be less response to stimuli; causes hyperosmolality which causes a shift of water out of the cells leading to cellular dehydration Causes – can be relative from increased water loss or actual with sodium gain (too little sodium excretion or too much sodium intake) Signs/Symptoms – altered mental status, lethargy, seizures, muscle twitching, hyperreflexia (as it gets higher can get muscle paralysis), increased HR, decreased BP (unless hypervolemic)

9 Hypernatremia ( Na) What can you do? Treat the underlying cause
Reduce sodium slowly! What can you do? Treat the underlying cause Diuretics Sodium restriction Seizure precautions Treatment – treat the underlying cause (ie. decreased water – water replacement, D5W; increased sodium – salt free IV fluids, diuretics, decreased sodium intake), diuretics, sodium restriction, avoid high sodium foods (ie. canned foods, lunchmeat, chinese food, soda, dairy products), seizure precautions, if severe can do dialysis Have to reduce sodium slowly to avoid swelling in the brain

10 Hyponatremia ( Na) Water excess or loss of sodium
Dilution – polydipsia, freshwater drowning, SIADH, CHF  excretion – sweating, diuretics, GI wound drainage, renal disease  intake – NPO, low salt diet, severe vomiting/diarrhea Symptoms: Confusion, headaches Seizures (can progress to coma) Abd cramps, n/v Patho – cells swell, decreased membrane depolarization as the sodium drops lower the cells become excitable; when there is too little sodium in the tissue fluids water moves into the cells, usually not a problem because tissues will expand but in the brain there is no room for expansion, most symptoms of hyponatremia are related to the brain’s inability to expand in the cranium Hyponatremia (low sodium) – water excess or loss of sodium, most common electrolyte disorder in the US, occurs frequently in the seriously ill Signs/Symptoms - Most symptoms are r/t the brain’s inability to expand in the cranium; first symptoms are in the CNS as brain cells swell, confusion, headaches, seizures, can progress to coma, muscle weakness, abdominal cramps, nausea, vomiting; may have signs of hypovolemia or hypervolemia

11 Hyponatremia ( Na) What can you do? 3% normal saline
Replace sodium slowly! 3% normal saline If caused by fluid excess, will need fluid restriction Usu. can’t be fixed by adding sodium to the diet Treatment – usually can not be fixed by adding sodium to the diet, can give NS (3% normal saline – watch for fluid overload – crackles, edema, bounding pulses) to increase sodium content in the vascular fluid, if caused by fluid excess will need fluid restriction, may need osmotic diuretics (ie. Mannitol) b/c it causes excretion of water but not sodium; if caused by SIADH treat with Lithium or Declomycin

12 Potassium (3.5 - 5.0 mEq/L) Major cation of ICF
Sodium-potassium pump is a major controller Moves into cells during formation of new tissues and leaves the cell during tissue breakdown Source of potassium – diet Primary route of loss - kidneys Foods – avacado, fish, banana, OJ, raisins, dried fruits, meat, milk, fruits, veggies, salt substitutes Major cation in ICF, but low values in the ECF Sodium-potassium pump moves potassium into the cell and pumps sodium out, there are no hormonal controls for potassium, the kidneys reabsorb potassium; however since aldosterone increases sodium, it will decrease K by having the kidneys excrete it If kidney function is impaired then potassium levels will be too high Normal intake is 2-20 g/day, poorly stored in the body, have to ingest it daily K will increase when pH is low (as hydrogen ions shift in & out of cells, K will shift in the opposite direction b/c K will move from cells to ECF) When you think of symptoms associated with cardiac problems, think “heart” – it disrupts electrical conduction (high or low levels)

13 Hyperkalemia ( K) “MURDER” M Muscle weakness
U Urine, oliguria, anuria R Respiratory distress D Decreased cardiac contractility E ECG changes R Reflexes, hyperreflexia, or areflexxia Causes – kidney failure (most common), use of salt or potassium supplements, receiving old blood, cell destruction, acidosis, hypoxia, exercise, catabolic state, use of potassium-sparing diuretics Can get false high results if specimen not handled properly Patho – increased cell excitability, takes less stimuli to excite, may discharge spontaneously The body is more sensitive to small changes in potassium levels than any other serum electrolyte, very important for cardiac function; can get false high results if lab specimen is not drawn or handled properly but otherwise rarely happens with normal kidney function Causes – kidney failure is most common cause, use of salt substitutes or potassium supplements, receiving old or improperly administered blood, cell destruction (ie. crush injuries, heart attack, burns, hemolysis), DKA, acidosis, hypoxia, exercise, catabolic state (ie. severe infection), use of potassium-sparing diuretics (all of these move K from the cells into the blood) Signs/symptoms – Change in ECG (wide QRS, prolonged PR, no P waves), muscle weakness and cramping leg pain progressing to areflexia, slow pulse, low BP, diarrhea, abdominal cramping, nausea, oliguria

14 Hyperkalemia ( K) What can you do? Cardiac monitor
Kayexalate, calcium gluconate, or glucose & insulin IV Lasix if kidneys are functioning Stop potassium in IV fluids Have pt avoid foods high in potassium Dialysis if severe Treatment – cardiac monitor, give Kayexalate (either orally or as an enema), calcium gluconate, glucose & insulin IV (helps move potassium into cells by exchanging Na ions for K ions), teach pt to avoid foods high in potassium (ie. meats, dairy, bananas, OJ, avacados, broccoli, potatoes, spinach), stop potassium in IV fluids, diuretics (ie. Lasix) if kidneys are functioning, may need dialysis if critically high

15 Hypokalemia ( K) Causes Signs/symptoms
Vomiting, NG suction, diarrhea, medications (diuretics, laxatives, insulin), metabolic alkalosis, rapid cell building (ie. B12 or erythropoietin to increase RBCs) Signs/symptoms Dysrhythmias, weakness, n/v, paralytic ileus, constipation, low BP, weak pulse, increased digoxin toxicity, muscle weakness and paralysis, diuresis Patho – decreased excitability of cells, esp in nerves and muscles making them less responsive to stimul Hypokalemia (low potassium) – the body is more sensitive to small changes in potassium levels than any other serum electrolyte, very important for cardiac function Causes – excessive vomiting, suctioning, dehydration, vomiting, diarrhea, medications (diuretics, laxatives, insulin all cause increased potassium loss), alkalosis (causes exchange of H+ for K+), beta adrenergic stimulation, rapid cell building (ie. B12 or erythropoietin to increase RBCs), aldosterone Signs/symptoms – weakness, nausea, vomiting, dysrhythmias (ST depression, change in T waves, increase in U waves), constipation, low BP, increased pulse, increased digoxin toxicity, muscle weakness and paralysis, muscle cramping, rhabdomyolosis, hyperglycemia, diuresis, decreased peristalsis can even lead to paralytic ileus

16 Hypokalemia ( K) What can you do? Cardiac monitor
Watch for Digoxin toxicity! What can you do? Cardiac monitor Foods high in potassium Watch for dig toxiciity Potassium IV (only if good urine output) Spirinolactone Treat constipation Keep pt safe from falls Potassium Administration Must have urine output Never give IV push Must be on cardiac monitor Assess IV site often (prefer CVC) Always dilute and give no more than 20 mEq, no faster than 1 hr Max concentration in IV fluids is 40 mEq/L Treatment – for slightly low levels encourage foods high in potassium (fruit juice, citrus fruits, dried fruits, bananas, nuts, veggies), cardiac monitor, watch for digitalis toxicity, stop giving HCTZ, Lasix, cortisone, be very careful if they have renal disease (urine output must be at least 600 mL/day) must have good urine output (>600 ml/day) before giving any potassium supplements, never give potassium IV push, always must be diluted and given as a drip at 20 mEq/hr max, max concentration in IV fluids is 40 mEq/L, put on ECG monitoring, assess IV site often, give in CVC if possible

17 Calcium (9.0 – 10.5 mg/dL) Primary source is bones
Regulated by parathyroid hormone, calcitonin, and vitamin D Affects transmission of nerve impulses, heart and muscle contractions, blood clotting, and forming of teeth and bone Free (ionized) calcium versus bound (attached to proteins), free or ionized calcium is the one we measure; calcium is important for blood clotting Calcium is stored in our bones, but to absorb it, we must have vitamin D Get calcium from dietary intake and absorption in the intestines PTH (parathyroid hormone) causes calcium to increase by releasing it from the bones (resorption thru osteoclasts), increasing Vit D activation, and decreasing kidney excretion of calcium Calcitonin is secreted by the thyroid to decrease calcium levels by inhibiting bone resorption thru osteoblasts and Vit D activation and increasing kidney excretion of calcium If low causes excitability and tetany If high inhibits neurons and muscle cells, can cause heart arrythmias Calcium and phosphorus have an inverse relationship

18 Hypercalcemia ( Ca) What are the symptoms? What causes it?
What can you do? Causes – hyperparathyroidism or hyperthyroidism, malignancy (esp. breast cancer, lung cancer, multiple myeloma), vitamin D or calcium overdose, prolonged immobilization, renal failure, use of glucocorticoids Signs/symptoms – lethargy, confusion, depressed reflexes, severe muscle weakness, fractures, kidney stones, constipation, faster clotting times (risk of DVT) Treatment – promotion of excretion of calcium in urine with a loop diuretic (ie. Lasix), hydration with isotonic saline (promotes excretion of calcium), drink mL daily, synthetic calcitonin (inhibits calcium resorption from bone), weight-bearing activity, Mithracin (cytotoxic antibioitic that is a calcium chelator/binder) will inhibit bone resorption; with malignancies give pamidronate (Aredia) instead, no antacids (most have calcium), if severe may need dialysis and cardiac monitoring

19 Hypocalcemia ( Ca) “CATS C Convulsions A Arrhythmias T Tetany
S Spasms and stridor Causes – removal of parathyroid gland, acute pancreatitis, multiple blood transfusions, alkalosis, immobility, lactose intolerance, malabsorption syndromes, decreased Vit D intake, renal failure, drugs (ie. citrate, mitramycin, Calcibind), increased phosphorus, post-menopausal women Signs/symptoms – tetany, Trousseau’s sign (carpal spasms caused by inflating a BP cuff above systolic pressure), Chvostek’s sign (contraction of the facial muscle with a tap over the facial nerve in front of the ear), stridor, numbness/tingling around the mouth/extremities, can have cardiac symptoms (change in HR, thready pulse), leg or foot cramps, abd cramps/diarrhea; if chronic may have brittle bones Treatment – oral/IV calcium supplements (never given IM), diet high in calcium (ie. broccoli, dairy, spinach) with vitamin D supplements, very closely observe those who have had thyroid or neck surgery

20 Phosphate Imbalances Hyperphosphatemia Hypophosphatemia
Cause - renal failure, tumor lysis syndrome S/S – calcium deposits in joints, skin, kidneys, eyes; hypocalcemia, tetany, neuromuscular irritability Tx – fix hypocalcemia Hypophosphatemia Cause – malnutrition, malabsorption syndrome, alcohol abuse, too many antacids S/S – CNS depression, confusion, muscle weakness, dysrhythmias, fractures Tx – oral supplements (Neutra-Phos), decrease calcium intake, IV phosphate (but this can cause sudden hypocalcemia), stop anatacids and calcium supplements Normal 3.0 – 4.5 mg/dL Most phosphorus is in the bones and ICF, helps with nutrient metabolism and acid-base buffering and calcium homeostasis; intertwined with calcium balance – any change in one causes an opposite change in the other (reciprocal relationship) Kidneys are major route of excretion Found in fish, cheese, milk, yogurt, meats; regulated by PTH (increased PTH causes decreased phosphorus) Hyperphos – most symptoms are usu. due to the low calcium instead of the phosphorus Hypophos – usu. more problematic if chronic

21 Magnesium Imbalances Hypermagnesemia Hypomagnesemia
Cause – increased intake (ie. MOM, Maalox) with chronic kidney disease S/S – lethargy, n/v, loss of DTRs, can have respiratory and cardiac arrest Tx – avoid magnesium-containing drugs, increased fluid intake, may need dialysis Hypomagnesemia Cause – prolonged fasting or starvation, chronic alcoholism, diuretics S/S – confusion, hyperactive DTRs, tremors, seizures, cardiac dysrhythmias Tx – oral supplements, increase green veggies, nuts, bananas, oranges, peanut butter, chocolate; IV or IM magnesium (if given too rapidly can cause cardiac or respiratory arrest) Normal is 1.3 – 2.1 mg/dL Most magnesium is stored in the bone and cartilage, found in the ICF, affects skeletal muscle contraction and blood coagulation Foods – avacado, spinach, meats, dairy veggies (most of us get about 300 mg/day from food) Regulated by GI absorption and renal excretion but not really sure how These imbalances look very similar to calcium imbalances, oftentimes have potassium imbalance too Important for normal cardiac function and neuromuscular function

22 Don’t forget rules for giving potassium!
Medications Loop diuretics Thiazide diuretics Potassium sparing diuretics Electrolytes Kayexalate General Rules Don’t give at night Commonly given with an anti-hypertensive All but potassium- sparing will decrease potassium levels Need pictures Loop diuretics – Lasix, causes a loss of potassium Thiazide diuretics – potentiates Digoxin, causes a loss of potassium Potassium sparing diuretics – spirinolactone, triamterene, potentiate digoxin and lithium, too much potassium could be harmful Electrolytes – potassium is most common, safety, have to have good urine output, should not exceed 40 mEq/L in IV fluids, should never exceed a rate of mEq/hr, CVC should be used if rapid correction is needed, put on ECG monitoring, assess IV site often Kayexalate – binds with potassium to remove it from the body, liquid or powder, can be given as an enema, antacids can decrease the effectiveness of this med Don’t forget rules for giving potassium!

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25 Image Attribution Slide 1 – Flickr by Randy Le'Moine Photography; no attribution required Slide 6 – Flickr by Slide no attribution required Much information on these slides (not images) was utilized from Mosby’s Fluid & Electrolyte Memory Notecards

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