FLUID AND ELECTROLYTES IMBALANCE

INTRODUCTION FLUIDS:- Water is the primary component of the body, approximately 60% of our body weight consists of water. Water is the solvent in which body salts, nutrients are dissolved and transported. The water content varies with gender, body mass and age. The percentage of body weight that is composed of water is generally greater in men than women because men have lean body mass than women. BODY FLUID COMPARTMENTS

INTRACELLULAR FLUID (ICF)

EXTRACELLULAR FLUID (ECF)

INTRACELLULAR FLUID :- Two third of the body water is located within the cells and it constitutes approximately 40% of the body weight. EXTRACELLULAR FLUID :-it consists of interstitial fluid, composed of the fluid present in the interstitium, lymph, plasma and in body cavities. The fluid in the specialized cavities is called transcellular fluid. It consists of one third of the body weight, approximately 20% ELECTROLYTES These are the substances whose molecules dissociate or split into the ions when placed in water. Ions are the electrically charged particles. IONS

CATIONS

ANIONS

CATIONS:- These are positively charged ions. Example sodium (Na+ ), potassium (K+), calcium (Ca+) and magnesium (Mg+) ANIONS:- These are negatively charged ions. Example chloride (Cl-), phosphate (PO43-) MECHANISM CONTROLLING FLUID AND ELECTROLYTE MOVEMENT Many different processes are involved in the movement of water and electrolytes between ICF and ECF. Electrolytes move according to their concentration gradients toward the area of lower concentration and toward the area of opposite charge. Some of the processes include: Simple Diffusion Facilitated Diffusion Active Transport Osmosis

1. DIFFUSION: It is the movement of molecules from an area of high concentration to one of low concentration. It occurs in liquids, gases and solids. The membranes separating the two areas must be permeable to the diffusing substance for the process to occur. 2. FACILITATED DIFFUSION: Because of the composition of cellular membranes, some molecules diffuse slowly into the cell. When they are combined with a specific carrier molecule, the rate of diffusion accelerates. Facilitated diffusion is passive and requires no energy. 3. ACTIVE TRANSPORT: It is a process in which molecules move against the concentration gradient. External energy is required for this process. 4. OSMOSIS: It is the movement of fluidss from an area of lower solute concentration to the area of high solute concentration. It does not requires an outside energy. FLUID AND ELECTROLYTES IMBALANCES It occurs to some degree in most patients with a major illness and injury because illness disrupts the normal homeostatic mechanism. Some are directly caused by the illness and injury and some are due to the therapeutic measures. These imbalances are classified as deficits or excess.

FLUID IMBALANCES CHARACTERISTICS Definition HYPOVOLEMIA HYPERVOLEMIA

it is defined as loss of body fluid it is defined as excessive intake due to inadequate intake of fluids or of fluids, abnormal retention of shifting of the fluids. fluids. Excessive administration of isotonic and hypotonic IV fluids Heart failure Renal failure Cushing syndrome Long term use of corticosteroids Primary polydipsia Confusion lethargy Weight gain, seizures, coma Peripheral edema Distended neck veins Bounding pulse, increased BP Dysponea, crackles sounds Pulmonary edema Muscle spasm Polyurea

Causes

Increased perspiration High fever, heat stroke Diabetes insipidus Osmotic dieresis Hemorrhage Overuse of diuretics Inadequate fluid intake Shifting of fluids in case of burns, intestinal obstruction

Clinical manifestations

Restlessness, lethargy

drowsiness,

Confusion, thirst, dry mouth Decreased skin turgor Decreased capillary refill Postural hypotension Decreased urine output

Increased respiratory rate and pulse Weakness, dizziness Weight loss, seizures, coma

NURSING MANAGEMENT: Increased requirements of fluids :

 Fever Vomiting Renal failure Burn Cystic fibrosis

Shock Tachypnea Gastroenteritis Diabetes (Insipidus, mellitus - DKA)

Intake and output: The use of 24-hour intake and output records gives valuable information regarding fluid and electrolyte problems. Sources of excessive intake or fluid losses can be identified on an accurately recorded intake-output flow sheet. I. II. Irrigants. Output includes urine, excess perspiration, wound or tube drainage, vomitus, and diarrhea. III. IV. Fluid loss from wounds and perspiration should be estimated. Urine specific gravity measurements should be done.

1) Cardiovascular Changes: Monitoring the patient for cardiovascular changes is necessary to prevent or detect complications from fluid and electrolyte imbalances. a) In fluid volume excess : The pulse is full and bounding. The pulse is not easily obliterated. Increased volume causes distended neck veins and increased blood pressure. b) In mild to moderate fluid volume deficit, compensatory mechanism includes sympathetic nervous system stimulation of heart and peripheral vasoconstriction. Stimulation of the heart increases the heart rate and combined with vasoconstriction, maintains blood pressure within normal limits. A change in position from lying to sitting or standing may elicit a further increase in heart rate or decrease in blood pressure. Severe fluid volume deficit can cause a weak, thread pulse that is easily obliterated and flattened neck veins.

2) Respiratory Changes: Both fluid volume excess or deficit affect respiratory status. ECF excess results in pulmonary congestion and pulmonary edema as increased hydrostatic pressure in the pulmonary vessels forces fluid into the alveoli. The patient will experience shortness of breath, irritative cough, and moist crackles on auscultation. The patient with ECF deficit will demonstrate an increased respiratory rate due to decreased tissue perfusion and resultant hypoxia. 3) Neurologic Changes: ECF excess may result in cerebral edema as a result of increased hydrostatic pressure cerebral vessels. Alternatively, profound volume depletion may cause an alteration in sensorium secondary to reduced cerebral tissue perfusion. Assessment of neurologic functions includes an evaluation of: The level of consciousness, which includes responses to verbal and painful stimuli. Papillary responses to light and equality of pupil size. Voluntary movement of the extremities, degree of muscle strength and reflexes. 4) Daily Weight: Accurate daily weights provide the easiest measurement of volume status. An increase of 1 kg is equal to 1000ml of fluid retention. An accurate weight requires the patient to be at the same time every day, wearing the same garments, and on the same carefully calibrated scale. Excess beddings should be removed and all drainage bags should be emptied before the weighing. 5) Skin Assessment and Care: Skin should be examined for turgor and mobility. Skin areas over sternum, abdomen and forearm are the usual sites for evaluation of skin turgor. In ECF volume deficit: Skin turgor is diminished. There is a lag in the pinched skinfolds return to its original shape. The skin is cool and moist. Skin appears dry and wrinkled. Oral mucus membranes will be dry and tongue may be furrowed. In ECF volume excess: Skin that is edematous may feel cool because of fluid accumulation. The fluid can also stretch the skin, causing it to feel taut and hard. Edema is assessed by pressing the skin with thumb or forefinger over the edematous area. Skin areas over the sacrum, tibia, and fibula are the preferred sites to assess ECF volume excess. SKIN CARE: Edematous tissue must be protected from extremes of heat and cold, prolonged pressure, and trauma. Frequent skin care and changes in position will protect tae patient from skin breakdown.

 Elevation of edematous extremities helps promote venous return and fluid reabsorption. Dehydrated skin needs frequent care without the use of soap. 6) Other Nursing Measures: The rates of infusion of IV fluids should be carefully monitored. Patients receiving tube feedings need supplementary water added to their enteral formula. The patient with nasogastric suction should not allowed to drink water because it will increase the loss of electrolytes. A nasogastric tube should always be irrigated with isotonic saline not with water. Nurses should encourage the old and debilitated clients to maintain adequate oral intake. Assistance should be provided to older adults with physical limitations such as arthritis, to open or close the containers. Fluid losses and intake must be carefully documented in cognitively impaired patients

SODIUM Sodium is the main cation of extracellular fluid and plays a major role in maintaining the concentration and volume of ECF. FUNCTIONS OF SODIUM: - It affects the water distribution between ECF and ICF. It is also important in the generation and transmission of nerve impulses and regulation of acid base balance. Normal Range of Serum Sodium: - 135mEq/L. CHARACTE RISTICS Definition It is the condition where the level of It is the condition where serum sodium serum sodium is less than 135mEq/L. Causes Excessive sodium loss: GI losses(diarrhea, level raises above 135mEq/L. Excessive Sodium intake: vomiting, IV Fluids( hypertonic NaCl, Hyponatremia Hypernatremia

fistulas) Renal losses( diuretics, adrenal

excessive isotonic NaCl) Near drowning in salt water

insufficiency) Skin losses( burns,

Inadequate water intake

wound (unconscious or cognitively impaired individuals) Excessive water loss( high fever, heatstroke, failure, therapy) Disease states( diabetes insipidus, primary hyperaldosteronism osmotic diuretic

drainage) Inadequate sodium intake Excessive water gain Disease states( heart

hypoaldosteronism)

uncontrolled diabetes mellitus) Clinical Manifestations Hyponatremia with decreased ECF volume: Hypernatremia ECF: Restlessness, agitation, twitching, seizures, coma Intense thirst; dry, swollen tongue, sticky mucous membrane Weakness, lethargy with decreased

Inability, confusion, dizziness, tremors, coma personality changes,

Dry mucous membrane Postural hypotension, decreased CVP, tachycardia Cold and clammy skin

Hypernatremia diarrhea,

with

Hyponatremia

with Normal/Increased ECF Volume: Restlessness, agitation, twitching, seizures, coma Intense thirst, flushed skin Weight gain, peripheral and

Normal/Increased ECF Volume: Headache, apathy, confusion,

seizures, coma Nausea, vomiting,

abdominal cramps Weight Gain, increased BP

pulmonary edema, increased BP, increased CVP

POTASSIUM Potassium is the main ICF cation. Diet is the main source of potassium. The kidneys are the primary route for potassium loss.

FUNCTIONS OF POTASSIUM: Regulates intracellular osmolarity and promotes cellular growth. It plays role in neuromuscular and cardiac functions as well as in acid base balance. Normal Serum Potassium Level: 3.5 to 5.0mEq/L CHARACTE RISTICS Definition It is the condition where serum It is the condition where serum potassium 3.5mEq/L. Causes Potassium Loss: Excess Potassium Intake: excessive or rapid administration Potassium containing drugs Potassium containing salt substitute losses( diuretics, of potassium intake GI losses ( diarrhea, vomiting, fistulas) Renal level is less than potassium level rises above 5.0mEq/L. HYPOKALEMIA HYPERKALEMIA

magnesium depletion) Skin losses( diaphoresis) Dialysis Lack

Failure to eliminate potassium Renal disease Potassium sparing diuretics ACE inhibitors

includes starvation, low intake in diet

Clinical manifestations

Fatigue Muscle weakness, leg cramps Nausea, vomiting Paralytic ileus Paresthesias, decreased reflexes Polyurea, hyperglycemia Weak, irregular pulse

Irritability, anxiety Abdominal cramping, diarrhea Weakness of lower extremities Paresthesias Irregularr pulse Cardiac arrest

ECG CHANGES ST segment depression Widening of QRS Flattened T wave Presence of U wave Ventricular dysarythmias Bradycardia

ECG CHANGES Prolonged PR interval ST segment depression Widening of QRS Tall, peaked T wave Loss of P wave Ventricular fibrillation

CALCIUM Calcium is obtained from ingested food. Bones serve as a readily available store of calcium. Calcium is found in the serum in three forms: free or ionized, bound to protein, and complexed with phosphate, citrate, or carbonate .Vitamin D is essential for the absorption of calcium from the GI tract. FUNCTIONS OF CALCIUM: Transmission of nerve impulses, myocardial contractions, blood clotting, formation of teeth, and bone, and muscle contractions. Normal Serum calcium level: 4.5mEq/L 5.5mEq/L CHARACTERI STICS Definition It is a condition where serum calcium It is a condition where serum HYPOCALEMIA HYPERCALEMIA

level is less than 4.5mEq/L Causes Decreased total calcium level: Chronic renal failure Elevated phosphorus Vitamin D deficiency Magnesium deficiency Acute pancreatitis Loop diuretics Chronic alcoholism Diarrhea

calcium level rises above 5.5mEq/L. Increased total calcium level: Multiple myeloma Prolonged immobilization Hyperparathyroidism Vitamin D overdose Thiazide diuretics Milk alkali syndrome malignancies metastasis Increased ionized calcium: Acidosis with bone

Decreased ionized calcium: Alkalosis Excess administration of citrated blood Clinical Manifestation Easy fatigability Depression, anxiety, confusion Numbness extremities Hyperreflexia and muscle cramps Chvostek sign Laryngeal spasm Tetany, seizures Trousseaus sign: and tingling

in

Lethargy, weakness Depressed reflexes Decreased memory Confusion, personality changes, psychosis Bone pain, fracture Polyuria, dehydration Nephrolithiasis Stupor, coma

ELECTROCARDIOGRAM CHANGES: Elongation of ST segment Prolonged QT interval Ventricular tachycardia

ELECTROCARDIOGRAM CHANGES: Shortened ST segment Shortened QT interva Ventricular dysrhythmias Increased digitalis effect

MAGNESIUM Magnesium is the second most abundant intracellular cation. The kidneys are able to conserve magnesium in times of need and excrete excesses. FUNCTIONS OF MAGNESIUM: Magnesium functions as a coenzyme in the metabolism of cellular nucleic acids and proteins. Magnesium is regulated by GI absorption and renal excretion. Normal Serum Magnesium Level: 1.5 to 2.5mEq/L. CHARACTERISTICS HYPOMAGNESEMIA Definition HYPERMAGNESEMIA

It is defined as a condition where It is a condition where serum serum magnesium level is less magnesium than 1.5mEq/L. 2.5mEq/L. Renal Failure Excessive administration of level rises above

Causes

Diarrhea Vomiting Chronic Absorption Malnutrition Alcoholism Diseases of small intestine Hyperaldosteronism Polyuria NG suction Muscular Tremor Hyperactive deep tendon reflex Confusion disorientation Dysrhythmias Chvostek sign and

magnesium for treatment of eclampsia Adrenal insufficiency

Clinical Manifestations

Hypoactive reflexes

deep

tendon

Decreased depth and rate of respirations Hypotension Flushing

NURSING MANAGEMENT OF ELECTROLYTE IMBALANCES:

1. SODIUM IMBALANCES:- Nursing management of the patient with hyponatremia and hypernatremia include: In primary water deficit, the continued water loss must be prevented and water replacement must be provided. Serum sodium levels must be reduced gradually to prevent too rapid a shift of water back into the cells. The goal of treatment for sodium excess is to dilute the sodium concentration with sodium free IV fluids. In hyponatremia, that is caused by water excess, fluid restriction is needed to treat the problem. If severe symptoms develop, small amounts of IV hypertonic saline solutions are given to restore serum sodium levels. Treatment of hyponatremia associated with abnormal fluid loss includes fluid replacement with sodium containing solutions.

2. POTASSIUM IMBALANCES: Nursing measures for hyperkalemia and hypokalemia includes the following: In case of hyperkalemia, eliminate oral and parenteral intake. Increase elimination of potassium with diuretics, dialysis, and use of ion exchange resins such as sodium polystyrene sulfonate. Force potassium from ECF to ICF by administration of IV insulin or by administration of sodium bicarbonate. Reverse the membrane potential effects of the elevated ECF potassium by administering calcium gluconate IV. Hypokalemia is treated by giving potassium chloride supplements and increasing dietary intake of potassium. KCL supplements added to IV solutions should never exceed 60mEq/L. Central IV lines should be used when correction of hypokalemia is necessary. 3. CALCIUM IMBALANCE: Nursing management of the patient with hypercalcemia and hypocalcemia is as follows: The basic treatment of hypercalcemia is promotion of excretion of calcium in urine by administration of loop diuretics and hydration of patient with isotonic saline solutions. In hypercalcemia, the patient must drink 3000 to 4000ml of fluid daily to promote the renal excretion of calcium. A diet low in calcium may be prescribed. Mobilization with weight-bearing activity is encouraged to enhance bone mineralization. Hypocalcemia can be treated with oral or IV calcium supplements.

 Calcium is not given intramuscularly because it may cause severe local reactions, such burning and necrosis. A diet high in calcium rich foods is ordered along with vitamin D supplements. Oral calcium supplements such as calcium carbonate may be used when patient is unable to consume enough calcium in the diet.