1. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Focus on Fluid and Electrolytes (Relates to Chapter 17, “Fluid, Electrolytes, and Acid-Base Imbalances,” in the textbook)

2. Copyright © 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

3. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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

4. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Changes in Water Content with Age Fig. 17-1

5. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Compartments  Intracellular fluid (ICF)  Extracellular fluid (ECF)  Intravascular (plasma)  Interstitial  Transcellular

6. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Compartments of the Body Fig. 17-2

7. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Intracellular Fluid (ICF)  Located within cells  42% of body weight

8. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Extracellular Fluid (ECF)  One third of body weight  Between cells (interstitial fluid), lymph, plasma, and transcellular fluid

9. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Transcellular Fluid  Part of ECF  Small but important  Approximately 1 L

10. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Transcellular Fluid  Includes fluid in  Cerebrospinal fluid  Gastrointestinal tract  Pleural spaces  Synovial spaces  Peritoneal fluid spaces

11. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Electrolytes  Substances whose molecules dissociate into ions (charged particles) when placed into water  Cations: positively charged  Anions: negatively charged

12. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Measurement of Electrolytes  International standard is millimoles per liter (mmol/L)  U.S. uses milliequivalent (mEq)  Ions combine mEq for mEq

13. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Electrolyte Composition  ICF  Prevalent cation is K +  Prevalent anion is PO 4 3   ECF  Prevalent cation is Na +  Prevalent anion is Cl 

14. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Mechanisms Controlling Fluid and Electrolyte Movement  Diffusion  Facilitated diffusion  Active transport  Osmosis  Hydrostatic pressure  Oncotic pressure

15. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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

16. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diffusion Fig. 17-4 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

17. Facilitated Diffusion  Movement of molecules from high to low concentration without energy  Uses specific carrier molecules to accelerate diffusion

18. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Active Transport  Process in which molecules move against concentration gradient  Example: sodium–potassium pump  External energy required

19. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Sodium–Potassium Pump Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig. 17-5

20. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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

21. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Osmosis Fig. 17-6

22. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Osmotic Pressure  Amount of pressure required to stop osmotic flow of water  Determined by concentration of solutes in solution

23. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hydrostatic Pressure  Force within a fluid compartment  Major force that pushes water out of vascular system at capillary level

24. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Oncotic Pressure  Osmotic pressure exerted by colloids in solution (colloidal osmotic pressure)  Protein is major colloid

25. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Movement in Capillaries  Amount and direction of movement determined by  Capillary hydrostatic pressure  Plasma oncotic pressure  Interstitial hydrostatic pressure  Interstitial oncotic pressure

26. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Exchange Between Capillary and Tissue Fig. 17-8

27. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Shifts  Plasma to interstitial fluid shift results in edema  Elevation of hydrostatic pressure  Decrease in plasma oncotic pressure  Elevation of interstitial oncotic pressure

28. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Shifts  Interstitial fluid to plasma  Fluid drawn into plasma space with increase in plasma osmotic or oncotic pressure  Compression stockings decrease peripheral edema

29. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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

30. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Movement between ECF and ICF  Water excess (decreased ECF)  Develops from gain or retention of excess water

31. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Spacing  First spacing  Normal distribution of fluid in ICF and ECF  Second spacing  Abnormal accumulation of interstitial fluid (edema)

32. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Spacing  Third spacing  Fluid accumulation in part of body where it is not easily exchanged with ECF

33. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Regulation of Water Balance  Hypothalamic regulation  Pituitary regulation  Adrenal cortical regulation  Renal regulation

34. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Regulation of Water Balance  Cardiac regulation  Gastrointestinal regulation  Insensible water loss

35. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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

36. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pituitary Regulation  Under control of hypothalamus, posterior pituitary releases ADH  Stress, nausea, nicotine, and morphine also stimulate ADH release

37. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Adrenal Cortical Regulation  Releases hormones to regulate water and electrolytes  Glucocorticoids CortisolCortisol  Mineralocorticoids AldosteroneAldosterone

38. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Factors Affecting Aldosterone Secretion Fig. 17-9

39. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Renal Regulation  Primary organs for regulating fluid and electrolyte balance  Adjusting urine volume Selective reabsorption of water and electrolytesSelective reabsorption of water and electrolytes Renal tubules are sites of action of ADH and aldosteroneRenal tubules are sites of action of ADH and aldosterone

40. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Effects of Stress on F&E Balance Fig. 17-10

41. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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

42. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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

43. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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

44. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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

45. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Gerontologic Considerations  Reduced thirst mechanism results in decreased fluid intake  Nurse must assess for these changes and implement treatment accordingly

46. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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)

47. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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

48. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Extracellular Fluid Volume Imbalances  Fluid volume excess (hypervolemia)  Excessive intake of fluids, abnormal retention of fluids (CHF), or interstitial-to-plasma fluid shift  Treatment: remove fluid without changing electrolyte composition or osmolality of ECF

49. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses  Hypovolemia  Deficient fluid volume  Decreased cardiac output  Potential complication: hypovolemic shock

50. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses  Hypervolemia  Excess fluid volume  Ineffective airway clearance  Risk for impaired skin integrity  Disturbed body image  Potential complications: pulmonary edema, ascites

51. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  I&O  Monitor cardiovascular changes  Assess respiratory status and monitor changes  Daily weights  Skin assessment

52. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  Neurologic function  LOC  PERLA  Voluntary movement of extremities  Muscle strength  Reflexes

53. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Electrolyte Disorders Signs and Symptoms ElectrolyteExcessDeficit Sodium (Na) HypernatremiaThirst CNS deterioration Increased interstitial fluid Hyponatremia CNS deterioration Potassium (K) Hyperkalemia Ventricular fibrillation ECG changes CNS changes HypokalemiaBradycardia ECG changes CNS changes

54. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Electrolyte Disorders Signs and Symptoms ElectrolyteExcessDeficit Calcium (Ca) HypercalcemiaThirst CNS deterioration Increased interstitial fluid HypocalcemiaTetany Chvostek’s, Trousseau’s signs Muscle twitching CNS changes ECG changes Magnesium (Mg) Hypermagnesemia Loss of deep tendon reflexes (DTRs) Depression of CNS Depression of neuromuscular function Hypomagnesemia Hyperactive DTRs CNS changes

55. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Sodium  Imbalances typically associated with parallel changes in osmolality  Plays a major role in  ECF volume and concentration  Generation and transmission of nerve impulses  Acid–base balance

56. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypernatremia  Elevated serum sodium occurring with water loss or sodium gain  Causes hyperosmolality leading to cellular dehydration  Primary protection is thirst from hypothalamus

57. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Differential Assessment of ECF Volume

58. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Imbalances in ECF Volume

59. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypernatremia  Manifestations  Thirst, lethargy, agitation, seizures, and coma  Impaired LOC  Produced by clinical states  Central or nephrogenic diabetes insipidus

60. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypernatremia  Serum sodium levels must be reduced gradually to avoid cerebral edema

61. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses  Risk for injury  Potential complication: seizures and coma leading to irreversible brain damage

62. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  Treat underlying cause  If oral fluids cannot be ingested, IV solution of 5% dextrose in water or hypotonic saline  Diuretics

63. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hyponatremia  Results from loss of sodium- containing fluids or from water excess  Manifestations  Confusion, nausea, vomiting, seizures, and coma

64. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses  Risk for injury  Potential complication: severe neurologic changes

65. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  Caused by water excess  Fluid restriction is needed  Severe symptoms (seizures)  Give small amount of IV hypertonic saline solution (3% NaCl)

66. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  Abnormal fluid loss  Fluid replacement with sodium- containing solution

67. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Potassium  Major ICF cation  Necessary for  Transmission and conduction of nerve and muscle impulses  Maintenance of cardiac rhythms  Acid–base balance

68. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Potassium  Sources  Fruits and vegetables (bananas and oranges)  Salt substitutes  Potassium medications (PO, IV)  Stored blood

69. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. ECG Effects of Altered Potassium

70. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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

71. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hyperkalemia  Manifestations  Weak or paralyzed skeletal muscles  Ventricular fibrillation or cardiac standstill  Abdominal cramping or diarrhea

72. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses  Risk for injury  Potential complication: dysrhythmias

73. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  Eliminate oral and parenteral K intake  Increase elimination of K (diuretics, dialysis, Kayexalate)

74. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  Force K from ECF to ICF by IV insulin or sodium bicarbonate  Reverse membrane effects of elevated ECF potassium by administering calcium gluconate IV

75. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypokalemia  Low serum potassium caused by  Abnormal losses of K + via the kidneys or gastrointestinal tract  Magnesium deficiency  Metabolic alkalosis

76. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypokalemia  Manifestations  Most serious are cardiac  Skeletal muscle weakness  Weakness of respiratory muscles  Decreased gastrointestinal motility

77. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses  Risk for injury  Potential complication: dysrhythmias

78. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  KCl supplements orally or IV  Should not exceed 10 to 20 mEq/hr  To prevent hyperkalemia and cardiac arrest

79. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Calcium  Obtained from ingested foods  More than 99% combined with phosphorus and concentrated in skeletal system  Inverse relationship with phosphorus

80. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Calcium  Bones are readily available store  Blocks sodium transport and stabilizes cell membrane  Ionized form is biologically active

81. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Calcium  Functions  Transmission of nerve impulses  Myocardial contractions  Blood clotting  Formation of teeth and bone  Muscle contractions

82. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Calcium  Balance controlled by  Parathyroid hormone  Calcitonin  Vitamin D

83. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypercalcemia  High serum calcium levels caused by  Hyperparathyroidism (two thirds of cases)  Malignancy  Vitamin D overdose  Prolonged immobilization

84. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypercalcemia  Manifestations  Decreased memory  Confusion  Disorientation  Fatigue  Constipation

85. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses  Risk for injury  Potential complication: dysrhythmias

86. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  Excretion of Ca with loop diuretic  Hydration with isotonic saline infusion  Synthetic calcitonin  Mobilization

87. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypocalcemia  Low serum Ca levels caused by  Decreased production of PTH  Acute pancreatitis  Multiple blood transfusions  Alkalosis  Decreased intake

88. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypocalcemia  Manifestations  Positive Trousseau’s or Chvostek’s sign  Laryngeal stridor  Dysphagia  Tingling around the mouth or in the extremities

89. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tests for Hypocalcemia Fig. 17-15

90. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses  Risk for injury  Potential complication: fracture or respiratory arrest

91. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation  Treat cause  Oral or IV calcium supplements  Not IM to avoid local reactions  Treat pain and anxiety to prevent hyperventilation-induced respiratory alkalosis

92. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Phosphate  Primary anion in ICF  Essential to function of muscle, red blood cells, and nervous system  Deposited with calcium for bone and tooth structure

93. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Phosphate  Involved in acid–base buffering system, ATP production, and cellular uptake of glucose  Maintenance requires adequate renal functioning  Essential to muscle, RBCs, and nervous system function

94. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hyperphosphatemia  High serum PO 4 3  caused by  Acute or chronic renal failure  Chemotherapy  Excessive ingestion of phosphate or vitamin D

95. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hyperphosphatemia  Manifestations  Calcified deposition in soft tissue such as joints, arteries, skin, kidneys, and corneas  Neuromuscular irritability and tetany

96. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hyperphosphatemia  Management  Identify and treat underlying cause  Restrict foods and fluids containing PO 4 3   Adequate hydration and correction of hypocalcemic conditions

97. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypophosphatemia  Low serum PO 4 3  caused by  Malnourishment/malabsorption  Alcohol withdrawal  Use of phosphate-binding antacids  During parenteral nutrition with inadequate replacement

98. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypophosphatemia  Manifestations  CNS depression  Confusion  Muscle weakness and pain  Dysrhythmias  Cardiomyopathy

99. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypophosphatemia  Management  Oral supplementation  Ingestion of foods high in PO 4 3   IV administration of sodium or potassium phosphate

100. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Magnesium  50% to 60% contained in bone  Coenzyme in metabolism of protein and carbohydrates  Factors that regulate calcium balance appear to influence magnesium balance

101. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Magnesium  Acts directly on myoneural junction  Important for normal cardiac function

102. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypermagnesemia  High serum Mg caused by  Increased intake or ingestion of products containing magnesium when renal insufficiency or failure is present

103. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypermagnesemia  Manifestations  Lethargy or drowsiness  Nausea/vomiting  Impaired reflexes  Respiratory and cardiac arrest

104. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypermagnesemia  Management  Prevention  Emergency treatment IV CaCl or calcium gluconateIV CaCl or calcium gluconate  Fluids to promote urinary excretion

105. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypomagnesemia  Low serum Mg caused by  Prolonged fasting or starvation  Chronic alcoholism  Fluid loss from gastrointestinal tract  Prolonged parenteral nutrition without supplementation  Diuretics

106. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypomagnesemia  Manifestations  Confusion  Hyperactive deep tendon reflexes  Tremors  Seizures  Cardiac dysrhythmias

107. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypomagnesemia  Management  Oral supplements  Increase dietary intake  Parenteral IV or IM magnesium when severe

108. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. IV Fluids  Purposes 1.Maintenance When oral intake is not adequateWhen oral intake is not adequate 2.Replacement When losses have occurredWhen losses have occurred

109. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. IV Fluids  Hypotonic  More water than electrolytes Pure water lyses RBCsPure water lyses RBCs  Water moves from ECF to ICF by osmosis  Usually maintenance fluids

110. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. IV Fluids  Isotonic  Expands only ECF  No net loss or gain from ICF

111. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. IV Fluids  Hypertonic  Initially expands and raises the osmolality of ECF  Require frequent monitoring of Blood pressureBlood pressure Lung soundsLung sounds Serum sodium levelsSerum sodium levels

112. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. D5W  Isotonic  Provides 170 cal/L  Free water  Moves into ICF  Increases renal solute excretion

113. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. D5W  Used to replace water losses and treat hyponatremia  Does not provide electrolytes

114. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Normal Saline (NS)  Isotonic  No calories  More NaCl than ECF  30% stays in IV (most)  70% moves out of IV

115. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Normal Saline (NS)  Expands IV volume  Preferred fluid for immediate response  Risk for fluid overload higher  Does not change ICF volume  Blood products  Compatible with most medications

116. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

117. Lactated Ringer’s  Isotonic  More similar to plasma than NS  Has less NaCl  Has K, Ca, PO 4 3 , lactate (metabolized to HCO 3  )  Expands ECF

118. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. D5 ½ NS  Hypertonic  Common maintenance fluid  KCl added for maintenance or replacement

119. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. D10W  Hypertonic  Provides 340 kcal/L  Free water  Limit of dextrose concentration may be infused peripherally

120. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Plasma Expanders  Stay in vascular space and increase osmotic pressure  Colloids (protein solutions)  Packed RBCs  Albumin  Plasma