Fluid and Electrolytes

• - medium for transportation
• - transportation of RBC, WBC, glucose
• - Role in cellular metabolism
• - Acts as a solvent
• - Assist in maintaining body temperature
• - Role in digestion and elimination
• - Tissue lubricant

* 50%-60% of the body weight is total fluid in an adult

• - Influencing factors
•   * Age (infants 70-75% ECF which u lose easily so they are always at risk for fluid loss and elders have less fluid)
•   * Gender- males more fluid because of their muscle mass
•   * Fat distribution

- Intracellular (ICF)

- Extracellular (ECF)

* fluid within the cell

* 70% (2/3) of the body fluid is in ICF

* Fluid found outside the cell

• * 30% of total body fluid in ECF
•   - intravascular- liquid portion of the blood (plasma)
•   - interstitial fluid- liquid that surrounds the tissues

Intake and output should balance out in 2-3 days

usually 1500-3500 ml/day

Not all output is measurable

• Fluid Gains
•   Ingested liquid 1300 ml
•   Ingested food 1000ml
•   metabolic oxidation 300ml

• Fluid Losses
•   Urine 1500ml
•   GI 200ml
•   skin 600ml
•   lung 300ml

- Maintaining homeostasis of fluid balance and electrolytes is essential to life

- body produces balance by shifting fluid between the ECF and ICF

• - There are 4 mechanism used for shifting and transporting fluid are:
•   diffusion, active transport, filtration, osmosis

• Solute:
•   Substance dissolved in a solution ie salt

• Solvent:
•   liquid that holds the substance in a solution ie water

Cell membrane are semi-permeable, allowing some but not all solutes to pass through

Movement of molecules thru the solvent from a higher concentration to lower concentration

downhill

goal: equilibrium

It is the process that requires energy for the movement of substance thru a cell membrane from area of lower concentration to an area of higher concentration

pumping uphill

energy dependent

Goal: equilibrium

It is the passage of fluid thru a permeable membrane from an area of higher pressure to an area of lower pressure

goal: equilibrium

Major method used for transportation

it is the movement of water from lesser concentration to higher concentration across a semi permeable membrane.

Goal: Equilibrium

The concentrated particles in a solution, pulling power

Isotonic- solution has the same osmol as plasma, so fluid remains in the plasma, no shift

Hypotonic- solution has less osmol than plasma so fluid moves out of the plasma and into the cell (swell)

Hypertonic- solution has greater osmol than plasma, fluid moves out of the cell into the plasma, causing it to shrink

• Works seamless unless there is a problem
• 1. Kidneys- nephrons- form urine 1-2L per day, selectively retains electrolytes, regioangiotenson- conserving urine

2. Heart- pumps out blood

3. Lungs- act of breathing (acid based, O2, CO2)

4. Adrenal gland- aldetral releasing Na

5. Thyroid gland- metabolism secretes hormone

6. Parathyroid- calcium bones and kidneys

7. GI a lot of fluid absorbed by colon

8. Thirst Center- ADH anti diructic - retains fluid

9. Blood Vessel where fluid travels

Substance capable of breaking into particles called ions.

Ion- substance capable of developing an electrical charge when dissolved in water

Cation- positive charge (Na, K, Ca, Mg)

Anions- negative charge (Cl, P, HCO3)

measured in mEq

Function- aids in fluid balance, assist in nerve transmission, maintains neuromuscular activity

Levels 135-145 mEq

most abundant electrolyte in ECF

Primary regulator of ECF volume. gain/loss of Na leads to gain/loss of water

Causes: inadequate intake of Na. losses of GI fluid ie vomiting/diarrhea/suction, use of diuretics, excessive burns, excessive diaphoresis (jogging), excessive administration of IV fluid or drinking too much water.

S/s change in mental status, fluid shift into cells leading to cerebral edema, confusion, coma, fatigue, lethargy, muscle weakness, cramps, decrease BP, edema and dry skin

• Severe- less than 120
• acute confusion, seizures, CNS changes
• fluid moves from the ECF to ICF

• Intake and output daily
• monitor CNS, LOC, seizure precautions
• food increase food with Na, IV solution
• water restriction diuretics
• monitor edema, bp, P
• monitor lab values Na serum

causes- deprived of water, excessive fluid loss ie diarrhea, IV with sodium, intake of too much sodium

s/s- change in mental status, dry skin, edema, muscle weakness, tachycardia, weight gain, poor skin turgor, oliguria, orthostatic hypotension,

• S- skin flushed
• A- agitation
• L- low grade temp
• T- thirst

* fluids shift out of cell and brain cells shrink- agitation, restlessness, disoriented, hallucinations

• intake and output
• check LOC, behavior changes, safety precaution
• Na restriction, increase fluids gradually, Po/IV
• assess thirst
• monitor VS
• monitor intake of food with salts, alka seltzer
• diuretic for Na excretion
• monitor labs

Assist in regulating electrical impulses, neuromuscular transmission of nerve impulses, skeletal/cardiac muscle contraction and acid base balance. 

Levels: 3.5-5 mEq/L

No mechanism to maintain K+ so defencies happen quickly, eliminated primarily thru the kidneys

Major cation ion in ICF

Casues: excessive vomiting, suction of GI tract, prolonged diarrhea, prolonged use of K+ depleted diuretic, poor intake of K+, Excessive sweating, lasix, laxitive abuse, eating disorder, liver disease, digoxin

• S/S Muscle weakness and leg cramps 1st sign
• fatigue lethargy, confusion, depressed DTR, cardiac arrythmias, weak pulse, constipation

Cardiac condition makes pt more sensitive to hypokalemia. cardiac arrest

• Check K level
• Administer K supplements
• encourage K rich foods- OJ, bananas, cantalope
• closely monitor pt on digoxin
• monitor cardiac status

Causes: renal failure, excessive intake of K (IV/PO), Cell destruction, burns, crush injuries, trauma, K+ conserving diuretics'

S/S cardiac arrythmias, bradycardia, EKG changes, paresthesia (tingling), flaccid muscle, paralysis, vague muscle weakness

most dangerous not putting K out....

• Monitor cardiac function, slow irregular pulse- contact MD
• avoid food high in K
• Avoid administration of K supplements
• avoid K sparing diurectics, use loop diurectics
• monitor to digoxin level
• diuretics

Severe cases admin kayexelate enemas (to pull K out), IV sodiam bicarbonate, IV calcium, IV insulin, hypertonic dextrose soln as ordered.

Cell permability, bone and teeth formation, nerve impulse transmission, muscle contraction, B12 absorption, activation of enzymes, blood coagulation

Levels 8.5-10.5 mg/dl

Causes: inadequate intake of vit D, excessive loss of intestinal secretions, alcohol abuse, malabsorption, renal inefficiency, medications

S/S muscle tremors, cramps, tetany, weakened bone structure, positive trousseau's sign and chvostek sign, numbness and tingling, MS changes- confusion, memory impairment, cardiac arrythmias

Mild cases- high ca intake, ca supplements along with vit d. monitor labs

severe- safety precaution, seizure precautions, monitor airways, admins IV Ca gluconate or Ca chloride

causes: prolonged immobilization and non weight bearing, malignancy of the bone, meds- large doses of Vit d and Ca

S/s Bones, groans, stones, moans (pain, anorexia, N/V, constipation, muscle weakness, confusion, arrythemias, kidney stones

• Increase mobility to keep Ca in bones
• increase PO hydration, IV hydration
• monitor labs/ekg
• strain urine for calculi 
• check cardiac status, digoxin leve
• decrease ca intake
• medication- diuretics, neutrohos
• safe enviroment
• dietary restriction

Function- metabolism of CHO, proteins, muscle and nerve transmission, aids in movement of Na, K, Ca. RNA/DNA synthesis

Levels 1.5- 2.5 mEq/L

causes: excessive lose from the gi tract, meds, renal disease, alcohol abuse, malaborption

S/S neuromusclar irritability, changes in mental status, increase DTR, cardiac arrythemia, postive trousseau (inflate bp cuff to see if hand bends adn), positive chvostek sign touch face to see if it twitches

• monitor labs
• increase intake of food with it (seafood)
• teach healthy use of diuretics and laxatives
• assess for changes in mental status and nerve muscle irritability
• seizure precaution
• assess breathing 
• assess cardiac status, VS
• neducation- IV/PO

causes: advance renal diseas, excessive aborption of Mg (antacid) not putting out alot of urine

s/sn warm, flushed skin, bradycardia, hypotension, nausea, vomiting, generalized weakness, change in mental status, decrease DTR, decrease respirations

• monitor labs, assess vs and dtr
• assess for flushed skin, diaphoresis
• assess for urine output, change in ms
• adequate intake, diuretics
• avoid products that have Mg ie antacids
• emergency- Ca gluconate, renal dialysis (temp)

Fluid Volume Deficit (FVD)- dehydration, hypovolemia

Fluid Volume Excess (FVE)-  hypervolemia

both water and electrolyte deficiencies in ECF

Cause- insufficient fluid intake, excessive fluid loss, med therapy (diuretics), disease processes- DI, renal failure, prolonged fever, or diarrhea, hypoglycemia, psychiatric disorder (thinking someone posioned your food), third space shifting

• Tachycardia
• pulse rate increase
• weight loss in short time frame
• weakness, fatigue, thirst, fever
• decrease urinary output and tearing
• hypotension (postural)
• intake less than output
• decreased bowel sounds
• slow cap refill

• check electrolytes
• BUN
• U/A, urine osmolarity 
• serum osmolarity
• H&H- concentration would go up
• urine concentration would go up

• 1. assessment- look for sunken facial features, skin turgor, cap refill
• 2. IV therapy and electrolytes
• 3. push oral fluids and mouth care (dry mucous membrane, crack if we don't check)
• 4. Monitor I/O daily weights, VS
• 5. safety needs- monitor LOC
• 6. Interventions to prevent skin breakdown
• 7. treat cause

Excessive retention of sodium and water

Causes: excessive Na or fluid intake. fluid or Na retention, medication therapy steriods, pathological disorders- CHF, RF, liver disease, water intoxication- polydypsia: not thirsty but you continuously keep drinking

• acute weight gain over a short period of time
• peripheral edema
• SOB, increase respiration, orthoapnea, cough, dyspnea, changes in lung sounds, increase bp, increase pulse and pulse bounding*, change in LOC, lethargy, confusion, cool pale skin, ascites, 

edema 5-10lbs increase, pitting edema

• Chest x-ray
• BUN
• H&H decrease? diluted
• Serum Sodium

• 1. Assessments
• 2. D/C or slow down IV fluids
• 3. fluid/sodium restriction
• 4. assess I/O, weight, edema, e-lytes, VS
• 5. assess lung sounds, respiratory status
• 6. encourage rest period with activity
• 7. diuretics if ordered
• 8. skin assessment and care

1. assess risk factors- age, people with handicaps may not be able to recognize thirst, diuretics, NPO, fluid restrictions, IV, burns, trauma, crush injuries

2. Assess VS- pulse, temp (fever-dehydration), pink forthy septum because of fluid in lungs

3. assess I/O- check this over several days, assess risk for FVE/FVD

4. Assess weight each day (more accurate than I/O)

5. Physical exam: skin turgor, mucous membrane, decrease tears, salivation, cards arrythmias, edema, pitting edema > 10lbs

6. mental status- confused, irritiable, dizzy

7. IV fluids and replacements

8. Monitor labs- BUN, electrolytes, CBC

9. Safety- seizures, confused irritatable 

10. patient teaching

• Goal/purpose
• Maintain or restore fluid balance
• electrolyte balance
• means to admins medication
• provide nutrition while resting the GI
• acid base balance
• admin blood components

Solutions: isotonic, hypotonic, hypertonic

solution has the same concentration as the body's plasma

action- no fluid shift, expand circulating volume, replace actual fluid loss (vascular expansion)*, electrolyte replacement

Tx: FVD from hemorrhage, GI loss, draining wounds, fistulas, burns, peri-op fluid replacement

• ex: 0.9% sodium chloride (saline), lactated ring
• * closely monitor pts for FVE, esp HF, HTN

Solution has a lower concentation than the body's plasma- causes the water to be pulled out of the plasma into the cell (intestitional) which can cause it to burst

Action/use: cellular dehydration from excessive diuresis, gastric fluid loss, fluid shifts out of blood vessels into the intravascular and interstitual space, hydration occurs

ex. 0.45% NS

Contraindicated: pt at risk for ICP, not for rapid rehydration, note: DO Not use on pt with stroke, head trauma, neurosurgery, or risk for 3rd space shift

• Solution is greater than the plasma in the blood causing the fluid to leave the cell and go into the plasma causing the cell to shrink
• if too much, cellular dehydration can occur

tx- short term hypovolemia, correct electrolytes and acid base imbalance, suppressed inflammation, cerebral edema

special consideration- do not administer to pt with impaired cardiac and renal function, monitor for circulation overload, admin by IV pump

ex. D5NS, D5 .45%NS, DRLR

- Blood and blood products- reciepent has to match the donor

• -TPN/PPN- hypertonic, glucose solution (why in large vein), provides calories, electrolytes, fluids, 
• TPN- needs to be infused from the central line
• PPN needs to be infused thru the picc line
• - multiples electrolyte solutions

• Short term
• heplock or saline lock
• peripheral catheter- 1-1 1/2 inch length 
• site change every 72 hours

• Can be single or multiple lumen
• usually inserted thru antecubital region
• tip rest in the SVC (superior vena cava)
• Can be inserted by a trained nurse

more invasive, more infection prone can last for months

• Intended for long term therapy
• maybe used for pt with poor venous access
• suitable for pt who PPN or vesicant solutions
• PPN lumen should be only for that
• cost effective, fewer complications
• chest x-ray for placement prior to use (always wait for radiology to see it is placed right..

• what is this? 
• a venous catheter inserted in the vein to go into the vena cava or right atrium
• allows concentration solutions to be infused with complications
• permits administration of IV fluids, blood components, meds, nutrition solution
• dangerous cause could puncture lung

Escape of fluid into the subcutanous tissue (asso with perpheral IV)

cause cannula dislodges and goes into the tissue

s/s cold clampy cool, complaints of pain and burning, blanched

TR: stop the IV, change sites, warm compress, elevate

Inflammation of vein 

cause- cannula in too long, irritating solution, sepsis can lead to thrombus formation

s/s red, hot swollen, pain, may have red line inflammation

TR: stop IV, move site, identify cause, warm compress.

causes: bacterial invasion which can spread to the bloodstream, older pts are more prone. 

s/s drainage at the IV site, fever, chills, nausea, headache elevated WBC

TR: stop the IV, remove the cannula, send tip to the lab for testing, notify the MD, 

prevention- use a sterile technique for tubing changes

• loss of skin integrity- 1st line of defense
• multiple invasive procedures,
• malnutrition
• antibiotic therapy
• age- older pts poor circulation

infiltration/leakage of a irritating (vesicant) solution (ie chemo, dopamine, vancomycin, gentamycin) into the tissue which can lead to tissue damage, nerve damage, or death of a cell. trauma

s/s swelling, edema, pain, changes, tissue slough, tissue necrosis

• tr: remove IV, use syringe to attempt to aspirate the solution, notify the MD, inject 
• antidote, elevate, apply cool/warm compress depending on solution, apply corticosteriod cream, assess and document

s/s bounding pulse, tachycardia, increase bp, SOB, orthopnea, cough, changes in lung sounds, crackles, distended neck veins, edema

tr: slow or stop IV, monitor IV infusion, assess vs and s/s, notify md, raise the HOB, admin O2. admin diuretic, prevention

air in the blood stream can be life threatening since it could stop the blood from flowing to where it needs to go. seen in stroke and MI pts

s/s CP, SOB, weak rapid pulse, decrease bp, change in mental status, respiratory distress

TR: accurate assessment, notify MD, place pt in trendelenberg position (head down left side so the air doesn't go into the lung), apply O2, admin anticoagulant therapy, 

prevention- prime all IV tubing carefully

leakage of blood into surrounding tissues caused by break in blood vessels

s/s bruising, tenderness, small edema

tr: assess the site, elevate the extremity, cold compress, apply pressure, prevention

closely monitor pts on anticoagulant (heparin, coumadin) 

• verify:
• COrrect pt
• correct fluid
• correct rate
• admin using sterile technique

• assess IV site/infusion every hour
• assess for sign and symptoms of fluid overload

• fluid volume excess
• fluid volume deficient
• fluid volume, risk for imbalanced

• breathing patterns ineffective
• cardiac output decrease
• risk for injury