Ch 52 Fluid/ Electrolites

• }Fluids,
• electrolytes, & acids & bases need to be balanced within the body to maintain health.

• }These
• balances are maintained by the intake & output of water & electrolytes
• & by the regulation of the kidneys & lungs

}Homeostatsis is the term we use when this balance exists

• 60% of body weight is water
• Higher % in infants & children
• Less % >60 years
• Less in women

• Intracellular (ICF)
• Extracellular (ECF)
• ◦Intravascular (Plasma)
• ◦Interstitial (Between cells)
• ◦Transcellular
• CSF, Synovial, Pericardial, Pleural, Digestive

• }Oxygen
• }Nutrients
• }Products of metabolism
• }Charged particles (ions): electrolytes

• ◦Cations- positive charge (Ca+)
• ◦Anions- negative charge (Cl-)
• ◦Measured as:
• milliequivalents (mEq/L)
• mg/100 ml)
• ◦Although concentration of lytes differ in ICF vs. ECF the balance of cations & anions always exist

F & E constantly shift from compartment to compartment

• Osmosis
• Diffusion
• Filtration
• Active Transport

Osmosis- Movement of water across semi-permeable membrane from less concentration to greater concentration

Solutes- substances dissolved in a liquid

• ◦Cystalloids- dissolve into solution
• ◦Colloids- do not dissolve easily in solution

• Concentration of solutes in the body= osmolality
• Osmolality of a solution (IV)= tonicity

• ◦Solutions such as IVs:
• Isotonic- same osmolality as body fluids (0.9%NS)
• Hypertonic- higher osmolality than body fluids
• (3% NaCl)
• Hypotonic-less osmolality than body fluids
• (0.45% NaCl)

• Primarily through drinking fluids
• Oral fluids- 1500 mL
• Water in foods- 1000 mL
• Food metabolism – 200 mL
• Fluid intake regulated by thirst
• •Change in plasma osmolality
• •Hypothalamus

• Urine: 1500 mL/day
• Skin as sweat: 100 ml/day
• Feces: 100-200 ml/day
• Insensible water loss: not measurable
• ◦Skin: 350-450 mL/day (perspiration)
• ◦Lungs: 350-400 mL/day (exhalation)

• Kidneys- primary regulator
• ◦Regulates water by reabsorption
• ◦Regulates lytes by selective retentions & excretion
• Antidiuretic hormone(ADH)
• Renin-angiotensin system
• Aldosterone
• Atrial natriuretic factor

• Hormone made in pituitary
• Diuresis- secretion & passage of large amts of urine
• ADH- hormone against diuresis: fluids retained
• ADH acts on the kidneys
• ◦Serum osmolality rises- ADH produced
• ◦Serum osmolality falls- ADH suppressed

• Sequence:
• Blood flow to kidneys is decreased
• Renin is released
• Renin converts angiotensin I to angiotensin ll
• Angiotensin ll release aldosterone from the adrenal gland

• Result:
• Kidneys retain sodium & water to restore blood volume

• Atrial natriuretic factor
• Sequence:
• Excessive blood volume stretches atrial walls & ANF is released
• Causes sodium wasting & diuresis
• Result: Reduces vascular volume
• Thirst inhibited

}Regulation needed for normal body fuction

}Concentration differs between fluid compartments but a balance always exists

• }Electrolytes mostly obtained through dietary intake
• }Some lytes not stored in body- Na & Cl
• }Some stored- K & Ca

• }Age
• ◦Young & old have different % of fluid in body
• ◦Older people – Ca+ lose & osteoporosis

• }Gender- men have more water
• }Body size
• }Environmental temperature
• ◦Lost through sweating esp. Na & Cl

• }Life style
• ◦Diet
• ◦Exercise
• ◦Alcohol consumption

• }2 basic types:
• }Isotonic imbalances:
• ◦loss or gain of fluid & lytes are in equal proportion

• }Osmolar Imbalances:
• ◦loss or gain of water only

• isotonic loss: water & lytes lost in same amount
• }Risk factors
• ◦Vomiting
• ◦Diarrhea
• ◦Sweating
• ◦Fever
• ◦Drainage- wound or NGT
• ◦Bleeding
• ◦Insufficient intake
• ◦Third spacing

• }Symptoms:
• }Weight loss
• }Decreased BP & T
• }Orthostatic hypotension
• }Flat veins
• }Hypovolemia
• }Dry skin & mucous membranes
• }Nonelastic skin turgor
• }Decreased urine output
• Sunken eyeballs

• Decreased:
• }Hematocrit
• }Specific gravity in urine
• }BUN

• }Increased:
• ◦Hematocrit
• Normal: Men- 40-54%
• Women- 37-47%

• ◦◦Urine specific gravity
• Normal: 1.005-1.030

• ◦Blood Urea nitrogen (BUN)
• Normal: 5-20 mg/dL
• 8-23 if >60 years old

isotonic gain: water & lytes gained in same amount

• }Risk factors
• ◦Too much Na IV fluids
• ◦Excess ingestion of diet or meds with water & NA
• ◦Medical Dx: heart, kidney, or liver failure
• ◦Meds: steroids

• }Symptoms
• ◦Wt gain
• ◦Increased BP
• ◦Distended neck & peripheral veins
• ◦Hypervolemia
• ◦Fluid in lungs, short of breath
• ◦Mental confusion
• ◦Edema
• ◦Pitting edema

• }Hyperosmolar
• }Water lost
• }Dehydration
• }Serum osmolality & serum Na increased
• }SX: cell dehydration
• }Cause:
• ◦Elders- decreased thirst
• ◦Enteral feeding without water

• }Hypoosmolar
• }Water gain
• }Overhydration
• }Serum osmolality & serum Na decreased
• }SX: cerebral edema

• }Cause:
• ◦Fluid replacement w/o lytes
• ◦ADH imbalances

• }Assess for sx of FVD or FVE
• }Daily weights
• }Assess VS
• }Monitor I & O
• }Assess skin turgor
• }Assess veins
• }Assess lung sounds
• }Assess for edema
• }Restrict or provide fluids
• }Provide mouth care
• }Assess labs

• }Function:
• }Maintaining fluid balance
• }Acid-base balance
• }Enzyme reactions
• }Neurotransmission & muscle contraction

• }Sodium- most abundant cation in ECF
• •135-145 mEq/L

• }Potassium
• - most abundant cation in ICF
• 3.5-5 mEq/L

• }Calcium- Stored in bone mostly
• •8.5- 10.5 mg/dL

• Risk Factors:
• Loss of sodium
• GI fluids
• diuretics
• Sweating
• Gain of water:
• Hypotonic tube feedings, oral ingestion, IV-D5W

• Disease:
• SIADH: head injury, tumor

• Signs & Symptoms:
• Serum Na <135
• Serum osmolality <280
• Neuromuscular: Confusion, headache, muscle twitching, seizures, lehtargy
• GI: abdominal cramps, N/V, anorexia

• }Monitor I/O
• }Monitor labs
• }Restrict water intake
• }Increase oral sodium intake
• }Assess closely if receiving hypertonic solutions

• Risk factors
• }Potassium loss:
• ◦GI- low K intake, vomiting, gastric suction, diarrhea
• Meds- K wasting diuretics
• Steroid Administration
• ◦Disease- Hyperaldosteronism
• Anorexia or bulemia

• Signs & Symptoms
• Serum K < 3.5
• ECG changes
• Neuromuscular: Muscle weakness
• leg cramps
• Fatigue
• GI: Anorexia, Nausea/vomiting
• Decreased bowel sound
• Cardiac: dysrhythmias

• }Administer prescribed K supplements
• }Monitor HR and rhythm
• }Assess digitalized clients for symptoms of digitalis toxicity (hypokalemia increases risk of digitalis toxicity)
• }Prevention: encourage K rich foods for at risk clients

• Risk Factors
• }Decrease potassium excretion:
• ◦Renal failure
• ◦Potassium sparing diuretics
• ◦Hypoaldosteronism
• }High K intake:
• ◦ improper use of supplements
• ◦Salt subst. containing K
• }Shift of K out of cells: acidosis, burns, tissue trauma

• Signs & Symptoms
• Serum K >5
• Neuromuscular:First sign is vague muscle weakness
• Irritability, apathy, confusion, absent reflexes
• GI: Diarrhea, GI hyperactivity
• Cardiac: ECG changes, dysrhythmias

• ◦Monitor K levels
• ◦Hold K supplements
• ◦Monitor EKG
• ◦Administer diuretics, glucose and insulin as ordered
• ◦Hyperkalemia is life threatening-it must be detected early
• ◦Teach at risk clients to avoid foods high in K

• Risk factors
• }Neck surgery:
• ◦Hypoparathyroidism
• ◦Thyroid cancer
• }Acute pancreatitis
• }Vitamin D deficiency:
• ◦Malabsorption
• ◦Alcohol abuse

• Signs & Symptoms
• Total serum Ca <8.5
• Neuromuscular:
• Numbness
• Tingling of fingers and toes
• Muscle cramps
• Convulsion, seizures
• Laryngeal spasms
• ECG changes
• Positive signs
• Chvostek’s sign
• Trousseau’s sign

• ◦Monitor serum calcium
• ◦Monitor airway
• ◦Seizure precautions
• ◦Administer parenteral calcium as ordered
• ◦Educate women about calcium supplements

• Risk factors
• }Lost from bone:
• }Prolonged immobility
• }Bone cancer
• }Hyperparathyroidism
• }Excessive ingestion
• } Calcium
• }Supplements
• }Antacids
• }Vitamin D-megadoses

• Signs & Symptoms
• Serum Ca >10.5
• Neuromuscular:
• Muscle weakness
• Changes in behavior
• Cardiac- slow heart
• GI:
• Constipation
• Anorexia, N&V
• Kidney stones

• ◦Keep client well hydrated
• ◦Discourage excessive dietary milk products
• ◦Fiber in diet
• ◦Safety precautions for confusion, weakened bones
• ◦Eliminate calcium supplements & avoid calcium based antacids
• ◦Prevention: Encourage mobility to the extent possible

• Magnesium
• •Found in bone & ICF
• •1.5- 2.5 mEq/L
• •Foods: grains, nuts, dried fruit, legumes, green leafy veges
• •Alcoholism leads to low levels

• Chloride
• •Bound to other ions
• ◦95-108 mEq/L
• ◦Regulates osmolality & blood volume

• Phosphate
• •Bound with calcium in teeth and bones; inverse relationship

• Bicarbonate
• •Regulated by kidneys to maintain acid-base balance

• }Nursing History
• ◦Environmental factors- temperature
• ◦Diet-intake of fluids & foods containing lytes
• ◦Lifestyle- exercise, alcohol consumption
• ◦Medications
• Diuretics, Steroids, Potassium supplements, Respiratory center depressants, Antibiotics

• }Physical Assessment – Table 52-8 pg 1446
• ◦Skin, mucus membranes, cardiovascular, respiratory & neurological systems

• }Clinical measurements
• ◦Vital signs
• ◦I/O’s
• ◦Weights

• }Lab values: Electrolytes, CBC (hematocrit), BUN,
• Creatinine, Urine specific gravity, Serum osmolality

• }Deficient fluid volume
• }Excess fluid volume
• }Risk for imbalanced fluid volume
• }Impaired oral mucous membranes
• }Impaired skin integrity
• }Acute confusion

• Preventing Fluid & Electrolyte Imbalances
• Promoting Wellness
• ◦Client teaching: Promoting Fluid & Electrolyte
• Balance, p. 1453
• Dietary Changes
• ◦Potassium- box 52-1
• Oral Electrolyte supplements- K, Ca
• Fluid Intake modifications
• ◦Facilitating Fluid Intake- pg 1454
• ◦Facilitating Fluid Restriction- pg 1454
• Enteral Replacement

• }Explain reason for required intake and amount needed
• }Establish 24 hour plan for ingesting fluids
• }Set short term goals
• }Identify fluids client likes and use those
• }Help clients select foods that become liquid at room temperature
• }Supply cups, glasses, straws
• }Serve fluids at proper temperature
• }Encourage participation in recording intake
• }Be alert to cultural implications

• }Parenteral Replacement
• ◦Isotonic- expand ECF volume

• ◦Hypertonic- osmolality > body fluids-
• pulls fluid from ICF & interstitial into vascular compartment. Check kidneys 1st

◦Hypotonic- osmolality < body fluids- IV fluid pushed into cells for rehydration

• }Type of solution
• ◦0.9% NS
• ◦D5W
• ◦D5 1/2NS

• }Vascular Access – pg 1456-7
• ◦Peripheral
• ◦PICC
• ◦Central

}Pumps

• Side Effects to be aware of
• }Infiltration
• ◦Localized swelling,
• pallor,
• ◦coldness,
• ◦pain around infusion site

• }Phlebitis
• ◦Localized redness,
• ◦warmth,
• ◦mild edema of the vein above insertion site

}Air embolism

• Avacado
• Spinach
• Raw carrot
• baked potato
• Raw tomato

• banana
• dried fruits
• apricot
• cantalopue
• orange

• been
• cod
• pork
• veal

• milk
• OJ
• apricot necter

• decrease in thirst sensations
• decrease in ability of kidneys to concentrate urine
• decrease in ICF and total body water
• decrease in response to body hormones that help regulate fluid & lyte balance

• Increase use of diuretics for hypertension & heart disdease
• Decrease intake of food & water
• Prep for tests that have client NPO for long periods of time or diarrhea from laxative preps

• Risk Factors
• Loss of water:
• profuse sweating
• diarrhea
• water deprivation

• Gain of sodium:
• high salt intake
• hypertonic tube feedings with inadequate water
• Excess administration of hypertonic saline, sodium bicarb

• ◦Monitor I/O
• ◦Assess for abnormal water loss or low water intake
• ◦Increase water intake
• ◦Restrict dietary sodium
• ◦Prevention: if using tube feedings, give enough water to keep Na and BUN levels in normal limits
• ◦Medical: hypotonic IVs