Fluids And Electrolytes

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Hypovolemia

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 Definition: This is the loss of extra cellular fluid volume that exceeds the intake of fluid. The loss of water and electrolyte is in equal proportion. It can be called in various terms- vascular, cellular or intracellular dehydration. But the preferred term is hypovolemia.

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Hypovolemia Etiologic conditions include

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a. Vomiting
b. Diarrhea
c. Prolonged GI suctioning
d. Increased sweating
e. Inability to gain access to fluids
f. Inadequate fluid intake
g. Massive third spacing

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Hypovolemia Risk factors

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a. Diabetes Insipidus
b. Adrenal insufficiency
c. Osmotic diuresis
d. Hemorrhage
e. Coma
f. Third-spacing conditions like ascites, pancreatitis and burns

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Hypovolemia PATHOPHYSIOLOGY

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inadequate fluids in the body
decreased blood volume
decreased cellular hydration
cellular shrinkage
weight loss, decreased turgor, oliguria, hypotension, weak pulse, etc.

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Hypovolemia subjective cues

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1. Thirst
2. Nausea, anorexia
3. Muscle weakness and cramps
4. Change in mental state

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Hypovolemia Laboratory findings

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1. Elevated BUN due to depletion of fluids or decreased renal perfusion
2. Hemoconcentration
3. Possible Electrolyte imbalances: Hypokalemia, Hyperkalemia, Hyponatremia, hypernatremia
4. Urine specific gravity is increased (concentrated urine) above 1.020

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hypovolemia IMPLEMENTATION

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• Provide intravenous fluid as ordered
• Provide fluid challenge test as ordered

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hypovolemia NURSING MANAGEMENT

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1. Assess the ongoing status of the patient by doing an accurate input and output monitoring
2. Monitor daily weights. Approximate weight loss 1 kilogram = 1liter!
3. Monitor Vital signs, skin and tongue turgor, urinary concentration, mental function and peripheral circulation
4. Prevent Fluid Volume Deficit from occurring by identifying risk patients and implement fluid replacement therapy as needed promptly
5. Correct fluid Volume Deficit by offering fluids orally if tolerated, anti-emetics if with vomiting, and foods with adequate electrolytes
6. Maintain skin integrity
7. Provide frequent oral care

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Hypervolemia

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Refers to the isotonic expansion of the ECF caused by the abnormal retention of water and sodium
There is excessive retention of water and electrolytes in equal proportion. Serum sodium concentration remains NORMAL

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Pathophysiology of Fluid Volume Excess Risks factors

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Congestive heart failure
Renal failure
Excessive fluid intake
Impaired ability to excrete fluid as in renal disease
Cirrhosis of the liver
Consumption of excessive table salts
Administration of excessive IVF
Abnormal fluid retention

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Hypervolemia PATHOPHYSIOLOGY

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1. Excessive fluid
2. expansion of blood volume
3. edema, increased neck vein distention, tachycardia, hypertension.

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The Nursing Process in Fluid Volume Excess
ASSESSMENT
Physical Examination

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1. Increased weight gain
2. Increased urine output
3. Moist crackles in the lungs
4. Increased CVP
5. Distended neck veins
6. Wheezing
7. Dependent edema

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Hypervolemia subjective cues

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1. Shortness of breath
2. Change in mental state

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Hypervolemia lab values

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1. BUN is LOW because of dilution
2. Urine sodium and osmolality decreased (urine becomes diluted)
3. CXR may show pulmonary congestion

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HYPONATREMIA

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Sodium serum level of less than 135 mEq/L

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HYPONATREMIA Etiologic Factors

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1. Fluid loss such as from Vomiting and nasogastric suctioning
2. Diarrhea
3. Sweating
4. Use of diuretics
5. Fistula
6 Dilutional hyponatremia
* Water intoxication, compulsive water drinking where sodium level is diluted with increased water intake
7 SIADH

o Excessive secretion of ADH causing water retention and dilutional hyponatremia

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HYPONATREMIA Other factors

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1. ilutional hyponatremia
* Water intoxication, compulsive water drinking where sodium level is diluted with increased water intake
2. SIADH

o Excessive secretion of ADH causing water retention and dilutional hyponatremia

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HYPERNATREMIA Clinical Manifestations

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1. Restlessness, elevated body temperature
2. Disorientation
3. Dry, swollen tongue and sticky mucous membrane, tented skin turgor
4. Flushed skin, postural hypotension
5. Increased muscle tone and deep reflexes
6. Peripheral and pulmonary edema

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HYPERNATREMIA Subjective Cues

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1. Delusions and hallucinations
2. Extreme thirst
3. Behavioral changes

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HYPERNATREMIA Laboratory findings

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1. Serum sodium level exceeds 145 mEq/L
2. Serum osmolality exceeds 295 mOsm/kg
3. Urine specific gravity and osmolality INCREASED or elevated

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HYPERNATREMIA implementations

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1. Administer hypotonic electrolyte solution slowly as ordered
2. Administer diuretics as ordered
3. Desmopressin is prescribed for diabetes insipidus

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HYPOKALEMIA

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Condition when the serum concentration of potassium is less than 3.5 mEq/L

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HYPOKALEMIA Etiology

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1. Gastro-intestinal loss of potassium such as diarrhea and fistula
2. Vomiting and gastric suctioning
3. Metabolic alkalosis
4. Diaphoresis and renal disorders
5. Ileostomy

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HYPOKALEMIA Other factor/s

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1. Hyperaldosteronism
2. Heart failure
3. Nephrotic syndrome
4. Use of potassium-losing diuretics
5. Insulin therapy
6. Starvation
7. Alcoholics and elderly

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Hypokalemia clinical manifestations

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1. Muscle weakness
2. Decreased bowel motility and abdominal distention
3. Paresthesias
4. Dysrhythmias
5. Increased sensitivity to digitalis
1. Nausea , anorexia and vomiting
2. Fatigue, muscles cramps
3. Excessive thirst, if severe

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Hypokalemia Laboratory findings

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1. Serum potassium is less than 3.5 mEq/L
2. ECG: FLAT “T” waves, or inverted T waves, depressed ST segment and presence of the “U” wave and prolonged PR interval.
3. Metabolic alkalosis

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HYPOKALEMIA IMPLEMENTATION

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1. Provide oral or IV replacement of potassium
2. Infuse parenteral potassium supplement. Always dilute the K in the IVF solution and administer with a pump. IVF with potassium should be given no faster than 10-20-mEq/ hour!
3. NEVER administer K by IV bolus or IM

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HYPERKALEMIA

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Serum potassium greater than 5.0
mEq/L

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HYPERKALEMIA Etiologic factors

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1. Iatrogenic, excessive intake of potassium
2. Renal failure- decreased renal excretion of potassium
3. Hypoaldosteronism and Addison’s disease
4. Improper use of potassium supplements

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HYPERKALEMIA other factors

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1. Pseudohyperkalemia- tight tourniquet and hemolysis of blood sample, marked leukocytosis
2. Transfusion of “old” banked blood
3. Acidosis
4. Severe tissue trauma

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Hyperkalemia Clinical Manifestations

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1. Diarrhea
2. Skeletal muscle weakness
3. Abnormal cardiac rate
4. Nausea
5. Intestinal pain/colic
6. Palpitations

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Hyperkalemia Laboratory Findings

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1. Peaked and narrow T waves
2. ST segment depression and shortened QT interval
3. Prolonged PR interval
4. Prolonged QRS complex
5. Disappearance of P wave
6. Serum potassium is higher than 5.0 mEq/L
7. Acidosis

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Hyperkalemia IMPLEMENTATIONS

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1. Monitor the patient’s cardiac status with cardiac machine
2. Institute emergency therapy to lower potassium level by:
1. Administering IV calcium gluconate- antagonizes action of K on cardiac conduction
2. Administering Insulin with dextrose-causes temporary shift of K into cells
3. Administering sodium bicarbonate-alkalinizes plasma to cause temporary shift
4. Administering Beta-agonists
5. Administering Kayexalate (cation-exchange resin)-draws K+ into the bowel

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Hypocalcemia

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<9 mg/dL;

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Hypocalcemia Clinical Manifestations

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1. Extensive spasm of skeletal muscle causing cramps and tetany

2. Laryngospasm with stridor
3. Convulsions with paresthesias of the lips and extremities
4. Abdominal pain
5. Chvostek’s sign
6. Trousseau’s sign
7. Laboratory Findings:
8. Low serum calcium
9. Elevated serum phosphorus
10. Low serum magnesium
11. Prolonged QT interval on the ECG

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Hypocalcemia Implementation

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1. Treat the cause
2. Oral (ca carbonate)or Iv (ca gluconate)
3. High diet in Ca and Vit D
4. Treat pain and anxiety to prevent hyperventilation

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Hypercalcemia

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>11mg/dl

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Hypercalcemia causes

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# Hyperparathyroidism (2/3 of cases)
# Malignancy
# Vit D overdose
# Prolonged immobilization

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Hypercalcemia clinical manifestations

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* Decrease in reflexes
* Decreased memory, confused, personality changes
* Lethary, stupor, coma, anorexia
* Nausea and Vomiting
* Bone pain, fracture
* Polyuria
* Dehydration
* Renal calculi

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Hypercalcemia Implementation

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* Promote the excretion of Ca with loop diuretic
* Increase hydration with isotonic saline 3000-4000ml a day
* Synthetic calcitonin
* PREVENT by:
* Avoiding ca rich foods
* Ambulating patients as early and as much as possible
* Monitor electrolyes

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Hypermagnesemia

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>2.5mEq/l

* Caused by an increased intake accompanied by renal insufficiency or failure
* Excessive administration for eclampsia
* Adrenal insufficiency

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Hypermagnesemia clinical manifestations

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* Lethardy, drowsiness, nausea and vomiting, loss of deep tendon reflexes followed by somnolence
* Respiratory and cardiac arrest are late stages

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Hypermagnesemia implementations

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In Emergency: administer IV Ca chloride or Ca gluconate

Encourage fluids to rid excess

Monitor the vitals, cardiac rhythm, check meds and hyperalimentation for MG

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HYPOMAGNESEMIA

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<1.5 mEq/L

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HYPOMAGNESEMIA caused by

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* Prolonged starvation or fasting
* Chronic alcoholism
* Fluid loss from GI
* Prolonged parenteral nutrition w/o supplements
* Diuretics
* Unconcrolled Diabetes Mellitus

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HYPOMAGNESEMIA Clinical manifestations

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* Confusion
* Hyperactive deep tendon relfexies
* Tremors
* Seizures
* Cardiac dysrythmias
* *can resemble hypocalcemia, and hypokalemia (does not respond to K meds)

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HYPOMAGNESEMIA Management

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# Monitor increased risk patients for
# Anorexia
# Nausea and vomiting
# Diarrhea
# Digoxin therapy
# TPN w/o mg
# Seizure precautions and monitor cardiac rhythm
# Give mg IV SLOW

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Hypochloremia

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< 96 mEq/L

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Hyperchloremia

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>106mEq/L

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HYPOPHOSPHATEMIA

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<2.8 mg/dL

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Hyperphosphatemia

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>4.5 mg/dL

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HYPOPHOSPHATEMIA Causes

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* Hyperparathyroidism (serum Ca will be elevated)
* Hyperinsulinism
* Continuous administration of IV glucose
* Treatment of diabetic ketoacidosis
* Prolonged respiratory alkalosis
* Excessive use of phosphate containing antacids
* Malabsorption syndromes
* Hyperalimentation with inadequate amounts of phosphorus
* Alcoholism

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Hypophosphatemia Clinical Manifestations

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* Parashetisa
* Muscle weakness; tremors
* Ataxia, incoordination
* Disorientation, confusion, coma
* Seizures
* Long bone pain
* Shallow respirations
* Dysphagia
* Nsytagmus, unequal pupils

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Hypophosphatemia Treatment

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* Oral phosphate supplements neutral-phos
* IV phosphate-containing solutions
* Monitor serum calcium carefully

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HYPERPHOSPHATEMIA causes

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# Renal insufficiency or renal failure
# hypoparathyroidism
# chemo agents
# excessive dairy and laxatives

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HYPERPHOSPHATEMIA treatments

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* ID and treat the cause
* Dietary restrictions of phosphate foods
* Adequate hydration
* Correct hypocalcemic conditions

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Hydrostatic Pressure:

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* force within a fluid compartment
* The major force that pushes water out of vascular system at the capillary level
* Ex. The pressure generated by the heart when contracting

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Oncotic pressure:

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is exrted by the colloids in solution (called osmotic pressure)
Protein is the major colloid that causes the water to move towards it

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Functions of Electrolytes

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* Maintains fluid balance
* Regulates acid-base balance
* Needed for enzymatic secretion and activation
* Needed for proper metabolism and effective processes of muscular contraction, nerve transmission

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¨Clinical Manifestations hyponatremia

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* lethargy
* Confusion
* muscular twitching
* focal weakness
* hemiparesis
* papilledema
* convulsions

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Hyponatremia other signs

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1. Altered mental status
2. Vomiting
3. Lethargy
4. Muscle twitching and convulsions (if sodium level is below 115 mEq/L)
5. Focal weakness
1. Nausea
2. Cramps
3. Anorexia
4. Headache

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Hyponatremia IMPLEMENTATION

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* Provide sodium replacement as ordered. Isotonic saline is usually ordered.. Infuse the solution very cautiously. The serum sodium must NOT be increased by greater than 12 mEq/L because of the danger of pontine osmotic demyelination
* Administer lithium and demeclocycline in SIADH
* Provide water restriction if with excess volume

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Hyponatremia labs

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1. Serum sodium level is less than 135 mEq/L
2. Decreased serum osmolality
3. Urine specific gravity is LOW if caused by sodium loss
4. In SIADH, urine sodium is high and specific gravity is HIGH