Electrolyte Imbalance

the movement of WATER btwn two compartments separated by a semipermeable membrane.

Water moves thru the membrane from an area of of low solute concentration to an area of high solute concentration.

osmosis

movement of molecules from high concentration to low.

• Stops when concentrations are equal in both areas.
• (liquids, gases, and solids)

molecules moving against the concentration gradient using ATP as it's energy.

sodium moves out of the cell and potassium moving in to the cell to maintain a concentration gradient.

osmotic pressure exerted by colloids (proteins) in a solution.

Proteins attracting water, pulling fluid from the tissue space to the vascular space.

Proteins are too large to get out of the vascular space.

Sodium

Consists of interstitial, intravascular and transcellular fluid

potassium

Consists of fluid within the cell itself

used to describe fluids inside the body...

ie-concentration of urine and plasma

used to describ fluids outside of the body.

• normal is btwn 275-295
• above 295 =high concentration or low water content "water deficit"

below 275=little solute for the amount of water or too much water "water excess"

hypotonic/hypoosmolar

hypertonic/hyperosmolar

in to the cell causing it to swell and possibly burst

out of the cell to dilute the ECF, causing the cell to shring and possible death

transfer of water and dissolved substances thru a permeable membrane from a region of high pressure to low pressure

• hypotonic
• hypertonic

Cations-Ca, K and Na

Anions-Cl (chloride) and HCO3 (bicarb)

• promote neuromuscular irritability needed for proper functioning of nerves and muscles
• regulate acid/base balance
• distribute body water btwn fluid compartments
• maintain body fluid volume and osmolality

• Water moves in same proportion as body fluids
• 0.9% NS
• D5W (w is water)
• D5 1/4 NS
• D5 & 1/4 NS
• LR (Lactated Ringer)

Causes less movement of body water than body fluids do.

• 1/2 NS (0.45% sodium chloride solution)
• 1/4 NS (0.225% sodium chloride solution)

• Causes more movement of water than body fluids do
• 3% (or greater) Sodium Chloride Sol.
• 10% (or greater) D/W
• 5% D 1/2 NS
• 5% D/0.9% NS
• 5% D in Ringers Lactate Solution

Increased particles in the solution

Decreased particles in the solution

300mL....insensible water loss

• Antidiuretic Hormone
• Causes the body to retain water by water reabsorption

decreases the amount of ADH released, allowing for water loss

causes sodium and water to be retained and the excretion of potassium

decrease in aldosterone causes sodium and water loss and potassium retention

stimulates the adrenal cortex to release Aldosterone

causes vasoconstriction of arterial smooth muscles.....increasing BP

increased PTH causes elevated serum calcium and lowered serum phosphate.

decreased PTH causes lowered serum calcium and increased serum phosphate.

Elevation of one means a decrease in the other

When plasma proteins are lowered, by colloid osmotic pressure, the fluids are shifted from the intravascular compartments in to the interstitial space.  These fluids are not available for use by the body. (ascites)

• 1500mL
• 60mL

• 30mL's for 2 hours....call Dr.
• minimal amount is 400-600mL/day

• Stool-200mL
• Respiration-300mL
• Perspiration-600mL

an equal loss of fluids and electrolytes from the ECF

NO shift of fluid from intracellular space-lose sodium and water in = amounts

• Sport/marathon runner
• Hemorrhage
• Vomiting/Diarrhea
• NG Suctioning
• Burns

losing more solutes from the ECF than water

Causing ECF to have a lower osmotic pressure than ICF so fluid shifts from ECF to ICF causing vascular swelling

• Anorexia/Severe malnutrition
• Chronic renal failure
• Over admin of hypotonic IV fluids (0.45 NS or D5)

a greater loss of EC Fluid than electrolytes

Causes a shift of fluid from ICF to ECF, resulting in cellular dehydration and shrinking

hypotonic sodium is low

hypertonic sodium is high

• decreased water intake
• excess loss of water without loss of elctrolytes
• increased solute intake without sufficient water
• excess accumulation of solutes due to disease process

NPO for a procedure....procedure may get pushed back to NPO for all day!

• watery diarrhea
• fevery
• cough
• pneumonia
• increased respiratory rate

• TPN
• Tube Feedings
• Ensure

diabetes mellitus

Subjective-c/o dry mouth, dysphagia, weakness, hx of vomiting, diarrhea, polyuria

• Objective-output greater than intake
• dry skin-tenting turgor
• Increased HR, RR and depth, temp, but decreased BP
• Decreased urine output
• Elevated specific gravity-above 1.0125

it will increase but you dont have more blood cells

decreased urine output

Subjective-SOB, weight gain, fatigue, HTN, Hx of cardiac or renal disease, steroid therapy, history of use of excessive tap water enemas

• pedal or sacral edema (+1-+4)
• Shiny taut skin
• Increased BP, bounding pulse
• Decreased urinary output
• Change in behavior-confused and lack of coordination

accumulation of fluid in all body tissues-can hear as fluid in lungs

• vomiting
• diarrhea
• polyuria
• fever

• causes ECF excess and edema
• fluid overload
• CHF
• Renal failure
• Increased secretion of Aldosterone
• Steroid therapy
• inflammatory rxns
• 3rd spacing

• causes Cellular edema....
• excess intake of electrolyte free fluids-athelete drinking pure water
• SIADH
• Renal failure
• Sodium deficit

• Control vomiting/diarrhea/reduce fever
• daily weights
• replace fluid loss as order by MD(IV or parentally)
• monitor vs

• Orthostatic
• BP taken laying, sitting and standing with 2 min. btwn each. 

+ sign is 15mmhg drop in systolic or 5 mmhg drop or +10 in diastolic

replace with isotonic iV solution

replace with isotonic or hypotonic solutions (solutions that contain less electrolytes or solutes than the bloodstream)

replace with isotonic or hypertonic solutions (solutions that contain more electrolytes or solutes than the bloodstream

• Encourage pt. to decrease salt intake
• keep edematous extremity elevated above heart
• TEDs
• Fluid restriction as ordered
• Diuretics
• Monitor I&O

135-145 mEq/L

3.5-5 mEq/L

• 4.5-5.5mEq/L or
• 8-10mg/dl

• headache
• apprehension/apathy
• delussions and hallucinations
• muscle weakness
• abdominal cramps/anorexia/NV
• Postural Hypotension
• Convulsions/coma....death

it causes brain cells to swell....cerebral edema and ICP

• Dry, sticky mucous membranes
• low urinary output
• rubbery tissue turgor
• Manic excitement
• tachycardia

• weakness/fatigue
• anorexia/NV
• apathy, confusion, coma
• muscle weakness
• abdominal distention/cramping
• CONSTIPATION
• shallow breathing
• CARDIAC ARRHYTHMIAS

No clinical symptoms in mild cases

• Initially-skeletal muscle spasms
• Nausea
• Colic
• Diarrhea

• Later-muscles become weak
• cardiac arrhythmias

• muscle spasms and rigidity
• Tingly lips, nose and fingertips
• Tetany
• Anxiety, irritability, seizures

• hands and feet
• Chvostek sign-cheek spasm
• Trousseau's sign-blood pressure cuff tightened and muscle contraction occurs at hand and wrist

• Severe thirst
• Polyuria
• GI upset-anorexia, NV and constipation
• Respiratory weakness
• Lethargy, confusion, coma
• Bone and flank pain (kidney stones)

• Potent diuretics
• Diarrhea
• GI Suctioning
• Decreased aldosterone

• NS only
• Using water will deplete Na

flushing tubes, before, between and after medication administration

• Renal disease
• SIADH
• Cirrhosis fo the liver
• CHF
• Hyperglycemia

• Syndrome of Inappropriate Antidiuretic Hormone
• Excess secretion of ADH causing hyponatremia

hyponatremia

• Hyperaldosteronism
• Renal failure/Cushings
• Use of corticosteroids
• Diabetes Insipidus
• Fever, infection, excessive diaphoresis, dehydration

Hypernatremia

• Hyperaldosteronism
• Chronic Steroid use
• Potent loop diuretics
• Loss of gastric/intestinal juices

over secretion of aldosterone, which causes the kidneys to hold on to water and excret K+

insulin causes K+ and glucose to move in to the cell and lowers serum K+

• decreased secretion of aldosterone (adrenal insufficiency)
• Excessive admin of parenteral K+
• Respiratory acidosis
• Renal failure
• Tissue trauma
• Medication with K+ sparing diuretics

H+ moves in to the cell and K+ moves in to the ECF

• Hypoparathyroidism
• Acute pancreatitis
• Renal failure
• Malabsorption syndromes (Crohns/Celiac)
• Diarrhea/GI wound drainage
• Lack of sunlight

• Hyperparathyroidism
• Excessive calcium intake
• V. D intoxication
• Metastatic cancer of the bone
• Prolonged immobilization

when pancrease is inflamed, it releases an enzyme that reacts on fatty tissue to release fatty acids...which combine with Ca+ and inactives it

serum phosphate levels rise in renal failure...two have an inverse relationship, if phospherous rises, calcium decreases and vice versa

it causes excessive amounts of CA+ to be released from the bone

disuse causes increased bone resorption...CA+ moves from the bones in to the ECF

• IV 0.9% NS
• Monitor VS
• Monitor for ICP/seizure precuations
• Watch for fluid overload
• Treat whatever is causing imbalance

• Water replacement orally or D5W
• Monitor for fluid overload
• Diuretics
• Reduce salt intake

• K+ replacement-orally is best:
• KLyte
• Ktabs
• KDur
• KCL

IV...but watch for hyperkalemia and cardiac arrest!!

Eat foods rich in K+

• bananas
• spinach
• avocado
• oranges
• fruits

• Hold K+ admin
• Kayexalate admin
• IV infusion of dextrose and insulin (if ordered)
• Dialysis

• treats hyperkalemia by:
• exchanging K+ for Na+ in the bowel, so K+ is excreted in the stool

Must retain enema for 45 minutes!!!

by tricking K back in to the cell and out of the vasculature

• Admin of calcium-IV calcium gluconate
• admin of v. D
• Ca supplements

EKG changes

After meals

• dairy
• yogurt
• green leafy vegetables

• decrease stimulation by:
• lights out
• speak calmly
• seizure precuations

fractures

• hydration to prevent kidney stones
• admin of meds to inhibit CA resorption
• Lasix
• assess bowel activity and treat constipation

• phospherous (soda)
• NSAIDS

people taking digoxin experience increased digoxin toxicity if their serum potassium is low

Skeletal muscle weakness and paralysis may occur

Increase elimination of potassium by diuretics

Force potassium from the ECF to the ICF by admin of IV insulin or IV sodium bicarb

Admin of IV calcium gluconate to reverse the membrance excitability (membrane potential)

• physiologic changes increase their susceptability to this:
• renal fxn changes-excretion of  problems
• hormonal changes-decreased/increased release
• Skin changes
• Decrease in thirst mechanism
• Musculoskeletal changes-cant hold cup

the person has excreted lots of K+, if it is low....then they are holding on to K+

+1 is barely perceptible...when push on skin the pit is lasting up to 5 seconds

+4 is edema when the pit lasts 20-30 seconds  and is 1 inch deep

• salt shaker
• Processed meats
• Ketchup
• Cheese

Risk for injury

it is an effervescent tab that must be DISSOLVED in water

1.5-2.5 mEq/L

NS

• 5% D 1/2NS
• 5% D 0.9%
• 5% D in Ringers Lactate Solution

pulls in

pushes out

osmolality is concerned with weight (kg)

osmolarity is concerned with fluids (litres)

• change positions every 2 hours
• watch for SKIN BREAKDOWN, especially in edematous areas