NC - Fluids/Electrolytes

1. Hypervolemia

2. Too much fluid in the VASCULAR SPACE

• Heart failure
• Renal Failure
• *things with too much sodium

• The heart is WEAK
• So cardiac output goes DOWN
• which means kidney perfusion goes DOWN
• Therefore, urinary output goes DOWN

The volume stays in the vascular space.

• Kidney's aren't working. 
• So urinary output is decreased, resulting in the fluid staying in the vascular space.

• Effervescent soluble medications - meds that have high amounts of sodium
• Canned/processed foods
• IV fluid with sodium

• Aldosterone
• ANP (Atrial Natriuretic Peptide)
• Anti-diuretic Hormone

• Aldosterone is a steroid released by the adrenal glands on the kidneys
• Helps control BP by holding onto salt and losing potassium from the blood.

• When blood volume gets low (such as from vomiting, hemorrhage, etc.), aldosterone secretion is increased. 
• Aldosterone makes you retain sodium and water 

• and lose potassium
• therefore, blood volume goes up

• Cushings disease
• Conns Syndrome

You retain TOO MUCH SODIUM AND WATER, causing blood volume to go up = fluid volume excess.

• this disease causes you to make to many hormones, one of which is aldosterone
• so you have too much aldosterone (among other hormones)

• another name for Hyperaldosteronism
• a disease in which the adrenal gland(s) make too much aldosterone which leads to hypertension (high blood pressure) and low blood potassium levels.

• Addisons
• you lose too much sodium and water

• Atrial Natriuretic Peptide
• Found in the atria of the heart
• Works the opposite of aldosterone and causes the excretion of sodium and water.
• When there is fluid volume excess, it stretches the right atrium which causes the release of ANP
• Works on kidneys to excrete sodium and water

• Anti-diuretic Hormone
• Makes you retain water

Found in the pituitary gland

• SIADH (Syndrome of Inappropriate ADH)
• *think too many letters, too much water
• Makes you retain water, so you go into fluid volume excess! 

• Urine becomes concentrated
• Blood becomes diluted

• You diurese = losing lots of water
• Will have LARGE amounts of diluted urine

• Diabetes Insipidus! (DI = Diureses) = SHOCK is possible!!
• Urine will be diluted
• Blood will be concentrated

• Any condition that can lead to an increased ICP (Intracranial pressure)
• Ex: Craniotomy, head injury, sinus surgery, etc.

• Vasopressin
• or Desmopressin Acetate
• Can be utilized as ADH replacement in DI

• Urine specific gravity
• Sodium
• Hematocrit

• Distended neck veins/peripheral veins (Vessels are full!)
• Peripheral edema/third spacing (Vessels can't hold anymore, so they start leaking)
• Increased CVP
• Lung sounds are wet & crackly
• Bounding pulse, increased HR
• Increased BP (MORE VOLUME, MORE PRESSURE)
• Fast weight gain

• Central Venous Pressure
• measured in the right atrium
• "More volume, more pressure"
• 2-6 mmHg or 5-10cmH2O (depending on what device is used)

Think HEART PROBLEMS first

• Low sodium diet/restrict fluids
• I&O's and daily weights
• Diuretics
• Bed Rest
• Physical assessment - focus on pertinent s/s

• Loop
• Hydrochlorothiazide
• Potassium sparing

• Furosemide (Lasix)
• Bumetanide 

Will lose potassium

• Thiazide (brand name) or HCTZ
• Another type of diuretic
• Will cause you to lose potassium

Spironolactone

• More blood volume to truck =more blood to heart
• This stretches the atrium, thereby releasing ANP
• The release of ANP reduces the production of ADH

• Hypovolemia
• Big Time Deficit = SHOCK!!

*not enough O2 getting to tissues for metabolism.

• Loss of fluid from anywhere
• Third spacing
• Diseases with polyuria

• When fluid is in the place that does you no good. 
• Can be caused by burns
• Can result in Ascites

• Fluid leaks out into the abdominal space
• If it continues, will push up on diaphragm and cause breathing problems

• Will need to monitor BP as it can cause it to go down
• Measure abdominal girth daily

• Weight loss
• Decreased skin turgor
• Dry mucus membranes
• Decreased urine output (Kidneys are being perfused or their trying to hold onto any fluid)
• Decreased BP (less volume, less pressure)
• Increased HR (heart trying to pump what it can)
• Increased RR (think HYPOXIA!!)
• Cool Extremities
• Increased urine specific gravity

• Prevent further fluid loss
• Replace volume: PO fluids for mild, IV fluids for severe

• They will have a higher risk for falls due to orthostatic hypotension.  Watch for changes in VS and LOC
• Make sure to monitor for fluid overload when replacing volume

• IV fluid that stays in the vascular space.
• Increases BP

• NS
• LR - best for shock, more electrolytes
• D5W
• D5 NS

Don't give to pt's with hypertension, cardiac disease or renal disease

Isotonic can cause fluid volume excess, hypertension, or hypernatremia (IF the solution contains sodium).

• Goes into the vascular space and then shifts into the cells to replace cellular fluid
• It rehydrates but DOES NOT cause hypertention
• Wont increase BP

• D2.5W
• 1/2 NS
• 0.33% NS

*less than 0.9%

A client who has hypertension, renal or cardiac disease and needs fluid replacement because of nausea, vomiting, burns, hemorrhage, etc.

Also used for dilution when a pt had hypernatremia and for cellular dehydration

• Watch for cellular edema
• Fluids are moving into the cells, which could lead to fluid volume deficit and decreased BP

• Volume expanders that will draw fluid into vascular space from the cell
• Packed with particles

• TPN (most common)
• Albumin
• D10W
• 3% or 5% NS
• D5LR
• D5 NS

*More than 0.9%

• With a client with hyponatremia or a client who has shifted large amounts of volume into a 3rd space
• Also used with severe edema, burns, or ascites

• Watch for fluid volume excess & pulmonary edema
• Monitor vitals and CVP!

they both act like sedatives

*Magnesium is excreted by the kidneys, but can be lost in other ways (such as GI tract) but if they kidneys aren't working, they can't excrete

Think muscles first!!

1.3 - 2.1 mEq/L

9.0 - 10.5 mg/dl

• Renal failure
• Antacids

• Flushing
• Warmth
• Mg makes you vasodialate

*Because Mg makes you vasodialate, can help with seizures

• May require:
• ventilator
• dialysis
• Calcium gluconate (which is antidote for mag. toxicity. works by reversing respiratory depression and arrhythmias)

They are sedatives!!!

• DECREASED DTR's (deep tendon reflexes)
• DECREASED muscle tone
• DECREASED LOC
• DECREASED Pulse
• DECREASED Respiration

INCREASED Arrhythmias

Phosphate

• *Calcium goes down, phosphate goes up
• *Calcium goes up, phosphate goes down

• Hyperparathyroidism - too much PTH
• Thiazides - you retain calcium
• Immobilization - you have to bear weight to keep Ca in the bone

• When your serum calcium gets low, parathormone (PTH) kicks in and pulls Ca from the bones and puts it in the blood
• Therefore, serum calcium goes up.

• Bones are brittle
• Kidney stones - which a majority are made of calcium

• Move!!
• Fluids to prevent kidney stones
• Add protein to diet, as protein has phosphorus. This has inverse relationship with Ca, so will help decrease serum Ca. 
• Steroids

• Remember: Pt will be SEDATED!!
• Monitor frequently for decreased HR & RR
• Keep Ca Gluconate at bedside to reverse possible RR depression
• Heart monitor for possible arrhythmia's
• Assess for decreased LOC = Fall Risk!!

Vit D

• Biphosphates
• Prostaglandin Synthesis Inhibitors
• Calcitonin - lowers calcium levels by driving Ca back into the bones. Used to treat osteoporosis

Not enough sedative!

• Diarrhea - theres lots of Mg in intestines
• Alcoholism - not eating or drinking (we get a majority of Mg from our diet)

Alcohol suppresses ADH & it's hypertonic

• Muscle tone will be tight and rigid
• Client could have seizure
• As airway is smooth muscle, could have stridor/laryngospasm
• Swallowing problems - esophagus is smooth muscle. Risk for aspiration
• Positive Chvostek's 
• Positive Trousseau's
• Arrhythmias (heart is muscle)
• Increased DTR's
• Mind changes

• tap the cheek and it twitches 
• shows hyperactivity in facial muscles

("C" is for Cheek)

Occurs when you pump up BP cuff and the hand tremors

• Give some Mg
• Check kidney function (before and during IV Mg)
• Seizure precautions
• Eat Magnesium

• spinach
• summer squash
• broccoli
• halibut
• pumpkin seeds
• peppermint

• Hypoparathyroidism
• Radical Neck
• Thyroidectomy

*All these = NOT ENOUGH PTH

• Give Vit D
• Phosphate binders
• calcium acetate

IV Ca - give SLOWLY and make sure pt is on heart monitor.

• Only electrolyte that follows water
• The sodium level in blood is totally dependent on how much water you have in the blood

*Think neuro changes

• Dehydration
• Too much sodium = not enough water

• Hyperventilation - when exhaling, losing H2O
• Heat stroke
• DI

• *Think neuro changes with either hyper/hypo
• Dry mouth
• Thirsty - your already dehydrated by the time you're thirsty
• swollen tongue

• Restrict sodium
• Dilute client with fluids which will decrease Na

• If theres a problem with Na, there is a fluid problem, so treatment will include:
• Daily weights
• I&O
• Lab work

• TPN has everything but water. 
• Important to watch for dehydration

• Dilution
• Too much water = not enough sodium

• Drinking H2O for fluid replacement (vomiting, sweating) - this only replaces water and dilutes the blood
• Psychogenic polydipsia - mental illness where pt loves to drink water
• D₅W (sugar and water)
• SIADH - makes you retain water

• Headache
• Seizure
• Coma

*Brain hates it when sodium is messed up

Client needs sodium, doesn't need water!

• If having neuro problems, need hypertonic saline: means "packed with particles" 
• ex: 3% or 5% NS

Potassium!!

• Kidney trouble 
• Spironolactone - "K-sparing" diuretic which makes you retain Potassium

• Think LIFE THREATENING ARRHYTHMIAS!!
• Begins with muscle twitching 
• Then proceeds to muscle weakness
• Then flaccid paralysis

• Bradycardia
• Tall and peaked T waves
• Prolonged PR intervals
• Flat or absent P waves
• Widened QRS
• conduction blocks
• V-Fib

• Dialysis - Kidney's aren't working
• Calcium gluconate - decreases arrhythmias
• Glucose and insulin
• Sodium polystyrene sulfonate

• Insulin carries glucose and potassium into the cell.
• You'll give insulin to avoid hypoglycemia.
• Anytime you give IV insulin, worry about hypoglycemia and hypokalemia

• Vomiting
• NG suction (there is lots of potassium in stomach)
• Diuretics
• Not eating

• ARRHYTHMIAS
• Muscle cramps
• Muscle weakness

• U waves
• PVC's
• V tach

• Give potassium
• Spironolactone - makes pt retain potassium
• Eat more potassium

3.5 - 5.0

• spinach
• kale
• dark green veggies
• cantaloupe
• tomatoes
• strawberries
• oranges
• kiwi
• halibut
• potatoes

Upset stomach so give with food

• NEVER give by IV push
• always put on pump
• Burns during infusion as it eats up peripheral veins so MONITOR IV SIGHT!!