Student Preparation for Fluids and Electrolytes Lesson

1. Read all Nursing Alert boxes in chapter 14 of Brunner textbook

2. What is the relationship between fluid and body weight?

3. What is the best measure of fluid gains/losses?

4. Consider children, adults, and elderly adults:

Who has more and who has less water? How does this impact fluid problems?

5. Consider adult males and adult females: who has more water?

6. Consider obesity versus normal weight: who has more water?

7. What is recommended amount of water for an adult? (clue: answer is not just 8 glasses per day)

8. What is acceptable hourly urine output?

9. What does osmolarity/osmolality mean?

10. What is the difference between osmosis and diffusion?

11. What is hydrostatic pressure?

13. What is colloidal oncotic/osmotic pressure?

14. What is the difference in first, second, and third spacing of fluids?

15. What does ADH do? What stimulates its release? What happens after it is released?

16. What does renin do? What stimulates its release? What happens after it is released?

17. What does the lymphatic system have to do with fluid homeostasis?

18. What are the fluid compartments, and where is most of the body fluid?

19. See chart on IV Fluids: How are IV fluids described? What is used to determine that description? What are crystalloids? What are colloids? How do different IV fluids affect the body?

20. See chart on Electrolyte Imbalances21. Be prepared to discuss this information on Monday, January 14, 2008.

FVD RT (can be intravascular, interstitial and/or intracellular) Decreased intake (elderly < thirst, fear incontinence, dementia) Increased fluid loss (<ADH, V/D, >diaphoresis, meds, blood loss, > glucose, hypertonic IV fluid/tube

feeding) Fluid shifts (decreased albumin)

FVD AMB or AEB : List what your physical assessment would show

List what labs would show: BUN Creatinine BUN: Creatinine ratio Serum osmolality Urine osmolality Hematocrit

FVD Plan—NOC : Fluid & electrolyte balance, AB balance, hydration, adequate nutrition (food/fluid), causes corrected (must look for and treat problem)

FVD NIC: Fluid volume management

Goals for FVDClient will:

Interventions and Rationales

Eval

1. Have moist mucous membranes2. Have absence of orthostatic

hypotension <15 mm drop with changes, < 15 increase in HR

3. Have balanced 24 hour I&O, at least 30 mL/hour urine output

4. Have no further vomiting/diarrhea (if this is RT)

5. Have BUN 10 – 206. Have BUN: Creatinine Ratio 10 –

20:17. Have serum osmolality 275 – 3008. Have Na 135 – 1459. Have Hct 40 - 5010. Have no evidence of second or

third spaced fluids11. Have no changes in mental status,

no seizure activity12. Verbalize/demonstrate measures to

maintain balance

FVE RT Increased intake (oral or IV) Increased Na Increased fluid retention (CHF, renal failure) Fluid shifts (colloids, hypertonic IV)

AMB or AEB—List what your physical assessment would show

List what labs would show: BUN Srum osmolality Hematocrit Na

FVE Plan—NOC : Fluid & electrolyte balance, AB balance, hydration, adequate nutrition (food/fluid), causes corrected (must look for and treat problem)

NIC: Fluid monitoring and management

Goals for FVEClient will:

Interventions and Rationales Eval

1. Have urine output at least 30 mL/hour

2. Achieve weight appropriate for client

3. Have no edema, JVD4. Have clear breath sounds5. Have regular easy

respirations (no orthopnea, dyspnea)

6. Have vital signs WNL for client

7. Have BUN 10 – 208. Have BUN: Creatinine

Ratio 10 – 20:19. Have serum osmolality 275

– 30010. Have Na 135 – 14511. Have Hct 40 - 5012. No mental status changes,

no seizure activity13. Verbalize/demonstrate

knowledge regarding fluid and Na restrictions

14. Have no skin breakdown

HOW IV OSMOLALITY AFFECTS THE BODY

Hypotonic Solution Isotonic Solution Hypertonic Solution

Osmolarity < 240 240 - 340 > 340

Physiologic Effect

Fluid shifts out of vascularcompartment into the cells and interstitial compartments; Cells swell

Fluid stays in vascular compartment; no movement into or out of cells; Cells aren’t affected

Fluid shifts out of cells and interstitial compartments into vascular compartment;Cells shrink

Indications Cellular dehydration(Many times the vascular bed gets into FVD first, then the cells get dehydrated as they send water out to try to restore homeostasis in serum osmolarity. Therefore, usually if there is FVD in vascular compartment, the cells will soon be in FVD also. For this reason, you may see orders to alternate IV fluids between isotonic and hypotonic--to restore fluid volume in both places)

Intravascular dehydration (FVD)

Intravascular dehydration (FVD) with intracellular and interstitial overload (FVE in those areas); Useful in restoring volume in vascular bed and drawing water out of the cells and interstitial spaces

Examples of these types of IV fluids

.45%NS NSRLD5W (initially, but then becomes hypotonic after dextrose is used for cellular energy)

D5NSD5.45%NSD5RLD10W (10% dextrose in water)3%NaCl

Imbalances of Major ElectrolytesELECTROLYTE DEFICIT EXCESS

Sodium (135 - 145 mEq/L)

Fluid balance, osmolality, transmission of nerve impulses

Foods high: canned, cheese, instant cereals, chips, etc.

Foods low: fresh or frozen fruits and vegetables

Hyponatremia (<135)

Weakness

Cellular swelling, cerebral edema, headache, seizure, stupor, coma, peripheral edema, polyuria, absence of thirst, hypothermia, tachycardia, hypotension, N/V

Hypernatremia (>145)

Irritability

Cellular shrinking may cause CNS irritability, seizure, dry and flushed skin, hypertension, thirst, hyperthermia, tachycardia, weight gain, oliguria, anuria

Potassium (3.5 - 5.5 mEq/L)

Transmission of nerve impulses to muscles, acid-base balance

Foods high: OJ, bananas, cantaloupe, raisins

Foods low: corn, sweet potatoes, apples

Hypokalemia (<3.5)

Weakness

Cramps, decreased peristalsis, paralytic ileus, metabolic alkalosis

Heart muscle so weak it becomes irritable and has irregular rhythm; Beware of “dig toxicity” if on digoxin.

Hyperkalemia (>5.5)

Irritability

Muscle cramps, paresthesias, nausea, explosive diarrhea, metabolic acidosis

Depressed conductivity of heart because of excessive stimulation

Phosphate (2.8 - 4.5 mg/dl)

Bone integrity, acid-base balance

Foods high: dairy products

Hypophosphatemia (<2.8)

Weakness

Similar S&S/ efffects as elevatedcalcium (Inverse relationship)

Hyperphosphatemia (>4.5)

Irritability

Similar S&S/effects as decreased calcium (Inverse relationship)

Calcium ( Total 9 - 11 mg/dl)

Transmission of nerve impulses to muscles; clotting, bone strengthHas a sedative effect on neuromuscular system.

Foods high: dairy, cheese, canned fish w/bones

Foods low: bananas, pasta, beef

Hypocalcemia (< 9)

Excitability/Irritability

Increased neuromuscular excitability, pathological fractures, skeletal muscle cramps, paresthesias, tetany, laryngospasm, death!

Similar S&S/effects as elevated phophate (Inverse relationship)

Hypercalcemia (>11)

Weakness

Neuromuscular sedation, stupor to coma, increased risk of bone fracture, vomiting, constipation, kidney stones

Similar S&S/effects as decreased phosphate (Inverse relationship)

Magnesium (1.5 - 2.5 mEq/L)

Transmission of nerve impulses; promotes vasodilation in peripheral arteries and arterioles.

Foods high: green vegetables, nuts, bananas, PB, chocolateFoods low: chicken, eggs, white bread

Hypomagnesemia (<1.5)

Irritability

Hypertension, tachycardia, seizures, tetany, convulsions

Hypermagnesemia (>2.5)

Weakness

Hypotension, bradycardia, respiratory depression

For the most part, electrolytes come from eating and drinking them and absorption from small intestine.

Sodium: Major contributor to serum osmolality (normal 135 – 145)

Hyponatremia RT: Na loss (diuretics, prolonged vomiting, NG suction) Diet restrictions Water gain (dilutional hyponatremia due to >, or too much ADH-pituitary problem SIADH)

AMB : symptoms due to muscle/nerve weakness and cellular swellingList what you would see on physical assessment

Nursing Diagnoses for hyponatremia: FVE Nutrition < body requirements High risk for injury RT confusion, weakness, seizure potential secondary to low sodium Altered thought processes

Plan/Goals/Outcomes for HyponatremiaNOC: Fluid and electrolyte balance, nutritional balance, no injury, normal mental status

Interventions for hyponatremiaList what you will do

Hypernatremia

RT: Na gain (increased intake, hypertonic IV, increased aldosterone, steroids) Water loss in excess of Na loss (very watery diarrhea, burns, osmotic diuresis, too little

ADA (diabetes insipidus—very clear, watery urine), impaired thirst (cause)

AMB : symptoms due to muscle/nerve irritability and cellular shrinking List what you would see on physical assessment

\

Nursing Diagnoses for Hypernatremia: FVD Nutrition > body requirements Altered oral mucous membranes High risk for injury RT confusion, weakness, seizure potential secondary to low Na Altered thought processes

Plan/Goals/Outcomes for HypernatremiaNOC: Fluid and electrolyte balance, nutritional balance, No injury, normal mental status

Nursing Interventions for HypernatremiaWhat will you do?

Potassium Normal 3.5 – 5.596% is inside cellsGenerally, as Na increases, K decreases, and vvPlays role in AB balance

Hypokalemia RT: Decreased intake (starvation, alcoholism, NPO and no K in IV fluids) GI losses>>>alkalosis from vomiting, NG suction, intestinal malabsorption Medications (K wasting diuretics, steroids, insulin)

AMB (overall weakness and cardiac irritability) Hypoactive bowel sounds and constipation, lethargy, apathy, mental dullness Cardiac dysrhythmias, flattened or inverted T wave, Dig toxicity if on Dig and K is low Muscle irritability (cramping of legs) Nursing Diagnoses for hypokalemia Nutrition < body requirements RT decreased intake, alcohol intake, acid-base imbalance Constipation RT hypoactive peristalsis secondary to decreased serum potassium Risk for injury RT muscle weakness, cardiac dysrhythmias Pain RT muscle cramping Knowledge deficit RT potassium replacement needed with potassium wasting diuretics, etc.

Plan/Goals/Outcomes for Hypokalemia: Fluid and electrolyte balance, nutritional balance, No injury, normal mental status

Nursing Interventions for HypokalemiaWhat will you do?

HyperkalemiaRT: Renal insufficiency or failure Traumatic injuries (ruptured cells releasing K) Acidosis (shock and decreased circulation leads to decreased perfusion to tissues, and glucose is used

without adequate oxygen and leads to lactic acidosis) Excessive intake (RL has K and other lytes) Serum drawn from IV line with K infusion Tourniquet too tight, Suction during blood draw, hemolyzed sample (be sure to match results to client)

AMB (cells become more irritable and them become weaker and paralyzed) Muscle cramps, hyperactive peristalsis and explosive diarrhea Heart muscle irritated at first, then becomes weak and contraction slows, cardiac output

decreases, cardiac arrest may occur) Tall T wave

Nursing Diagnoses for hyperkalemia High risk for injury RT muscle weakness, cardiac irritability secondary to elevated K levels Pain RT muscle cramping, bowel cramping FVD RT diarrhea secondary to muscle irritability due to elevated K levels Knowledge deficit of NURSE! (when we give out K meds and don’t even note labs)

Plan/Goals/Outcomes for Hyperkalemia: Fluid and electrolyte balance, nutritional balance, No injury, normal mental status, no discomfort, no diarrhea

Nursing Interventions for HyperkalemiaWhat will you do? Look at Kayexalate, renal dialysis, and insulin & glucose as therapies

Calcium (Normal Total serum Ca is 9 – 11, ionized is 4.5—5.5 )

99% of body calcium is found in bones and teethAbout 1/2 of Ca is bound to proteinNerve impulses and muscle contractions like all the others & plays role in blood clottingHas an inverse relationship with phosphorous

HypocalcemiaRT: Decreased dietary intake Decreased absorption in small intestine Vitamin D deficiency Increased phosphorous levels (inverse relationship) Excessive losses secondary to loop diuretics Binding to necrotic areas in autodigestion of pancreas Hypofunction of parathyroid glands Decreased ionization of calcium secondary to alkalotic conditions Hypokalemic conditions that result in alkalosis

AMB (due to neuromuscular hyperexcitability)What will you see on physical assessment? (paresthesias, Chvostek’s, Trousseau’s)

Nursing Diagnoses for hypocalcemia Nutrition < body requirements for calcium RT decreased intake, impaired absorption Nutrition > body requirements for phosphorous causing decreased calcium levels Risk for injury RT increased neuromuscular irritability Pain RT muscle spasms Risk for injury RT bone fractures due to increased losses from bones secondary to

decreased oral intake or due to hyperfunction of parathyroid glands, Knowledge deficit RT balanced nutrition, intake of Calcium supplements

Plan/Outcomes for hypocalcemia: Calcium levels WNL, Balanced nutrition, No neuromuscular irritability, no discomfort, no respiratory distress, adequate clotting, no fractures

Nursing Interventions for HypocalcemiaWhat will you do?

How are oral calcium supplements best given?How should IV calcium be given?

HypercalcemiaRT: Increased intake of calcium and vitamin D Hyperfunction of parathyroid gland Prolonged immobility Altered cell growth (cancer): bone resorption and paraneoplastic syndrome Decreased phosphorous levels Acidotic conditions where ionization of calcium is increased

AMB (most symptoms due to sedation to nerves and muscles)What will you see on physical assessment?

Nursing Diagnoses with Hypercalcemia Risk for injury RT pathological fractures,

RT cardiac dysrhymias,

RT treatment with thiazide diuretics, RT mental confusion Knowledge deficit or altered health maintenance RT excessive ingestion of calcium products Nutrition < BR RT decreased intake secondary to nausea, vomiting, constipation due to elevated calcium FVD RT decreased intake secondary to nausea, vomiting, and increased urine output due to elevated

Calcium levels

Plan/Outcomes: Fluid and electrolyte balance, no fractures, no cardiac dysrhythmias, no changes in mental status, no pain, no renal damage

Nursing Interventions for Hypercalcemia:What will you do?

Magnesium Normal is 1.5 – 2.5Promotes vasodilation of peripheral arteries and arterioles

HYPOMAGNESEMIA RT: Malnutrition (starvation, anorexia, alcoholism) Malabsorption Prolonged loss from GI or GU Prolonged NPO with IV/TPN without magnesium

AMB: What will physical assessment reveal?

Nursing Diagnoses with Hypomagnesemia (Same as others)

Plan/Outcomes with Hypomagnesemia: No evidence of NM irritability, BP WNL, HR regular rhythm and rate

Nursing Interventions for Hypomagnesemia:What will you do?

HypermagnesemiaRT: Impaired renal secretion (Renal insufficiency or failure)

Excessive intake of Mg antacids or laxatives (Maalox, MOM) Excessive intake of IV magnesium (pregnancy)

AMB: What will physical assessment reveal?

Nursing Interventions for HypermagnesemiaWhat will you do?