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 Deficit 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 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 What can you do? What are the symptoms?
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 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 Diuretics Fluid restriction (no IV fluids) Sodium restriction Daily weights, strict I/Os What can you do? What are the symptoms?
Lab Normals ElectrolyteRangeMagic 4 Potassium3.5 – 5.54 Chloride98 – Sodium pH7.35 – pCO235 – 4540 HCO322 – 2624 FYI – Hematocrit normal is 3 times the hemoglobin (10-14 is normal)
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
Hypernatremia ( Na) 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 “You Are Fried” 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
Hypernatremia ( Na) What can you do? Treat the underlying cause Diuretics Sodium restriction Seizure precautions Reduce sodium slowly!
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
Hyponatremia ( Na) What can you do? 3% normal saline If caused by fluid excess, will need fluid restri ction Usu. can’t be fixed by adding sodium to the diet Replace sodium slowly!
Potassium ( 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
Hyperkalemia ( K) 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 “MURDER” M Muscle weakness U Urine, oliguria, anuria R Respiratory distress D Decreased cardiac contractility E ECG changes R Reflexes, hyperreflexia, or areflexxia
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
Hypokalemia ( K) Causes – 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
Hypokalemia ( K) 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 Watch for Digoxin toxicity! 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 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
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
Hypercalcemia ( Ca) What can you do? What causes it? What are the symptoms?
Hypocalcemia ( Ca) “CATS C Convulsions A Arrhythmias T Tetany S Spasms and stridor
Phosphate Imbalances Hyperphosphatemia – 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
Magnesium Imbalances Hypermagnesemia – 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)
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 Don’t forget rules for giving potassium!
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Image Attribution Slide 1 – Flickr by Randy Le'Moine Photography; no attribution required Slide 6 – Flickr by IvanWalsh.com Slide no attribution required Much information on these slides (not images) was utilized from Mosby’s Fluid & Electrolyte Memory Notecards