Chapter 14: Fluid and Electrolytes: Balance and Disturbances

Hypovolemia- Fluid Volume Deficit

Hypervolemia- Fluid Volume Excess

k Due to fluid overload k Caused by abnormal retention of sodium (which pulls the water in)

k Loss of fluid exceeds intake of water, and electrolytes are lost in the same proportion (losing more fluid than is taken in and Causes: electrolyte in equal amounts so electrolytes k Heart failure levels stay constant). k Renal failure Not able to filter the water or k Third spacing is an example because fluid leaves sodium. the extracellular and goes into a body cavity so it k Cirrhosis of the liver The body makes excessive cannot be used in osmosis. amounts of adolsterone, which retains sodium. k Dehydration refers to loss of water alone with Manifestations: increased serum sodium level (Do not lose k Edema (makes skin very fragile) electrolytes) k Distended neck veins (Jugular venous Causes: distention) k Fluid Loss from vomiting k Abnormal lung sounds Crackles-fluid in lungs. k Diarrhea k Tachycardia k GI Suctioning k Increased Blood pressure k Sweating k Increased Pulse pressure (difference between k Decreased Intake of Fluids systolic and diastolic) k Diabetes Insifitus Not enough ADH made, which k Increased Weight causes increased urination and they lose a lot of k Increased Urine Output fluid) k Decreased Urine specific gravity Manifestations: k Shortness of breath k Rapid Weight Loss (1 lb [1/2 kg] of loss of k Cough weight= 500 mL of fluid) Laboratory data: k Increased Specific Gravity (concentrated urine) k Decreased BUN k Rapid and Weak Pulse (because of decreased k Decreased Hematocrit blood pressure) k Decreased Hemoglobin k Decreased Skin Turgor Medical management: k Oliguria (less urine produced) k Measure Intake and Output k Postural Hypotension k Check lung sounds k Thirst k Check for edema (common in the sacrum k Confusion [bedrest], ankles, and feet) restrict fluids and sodium (may be contained in bottle waters or Laboratory data: tap water or even water softeners) k Increased Hematocrit k administration of diuretics k Increased BUN (out of proportion to 20:1 to k Pt should be in semi-fowlers to allow lungs to creatinine) because of less fluid, which causes expand better and promote oxygen increased concentration exchange.Medications can be used Diuretics Medical management: provide fluids to meet body needs k Oral fluids k Isotonic IV solutions k Monitor vital signs k Fluid volume deficit pt. can have low temperatures k Monitor Intake and Output

Hyponatremia- Sodium Deficit Serum Sodium < 135 mEq/L Causes:

k Caused by a loss of sodium or excess of fluid k Sodium is used primarily to Fluid equilibrium (regulate body fluid) k Sodium is also used for muscle contraction and nerve impulses. k Loss of sodium is going to cause intracellular swelling[cells to swell] (seizures and neurological changes) k Causes: k Adrenal insufficiency Aldosterone is not released will cause sodium not to be reabsorbed and excreted by the kidneys. k SIADH Increased amounts of ADH is made, which causes increased amounts of water retained and decreases sodium [because increased water dilutes the fluid]. k Water intoxication k Losses by vomitinga k Diarrheaa k Sweatinga k Diuretics

Hypernatremia- Sodium Excess Serum Sodium > 145 mEq/L Causes:

Excess water loss Excess sodium administration Tube feedings without water Diabetes insipidus (deficient of ADH (ADHretains water) hormone, which cause water loss) k Heat stroke k Hypertonic IV solutions Manifestations: k Thirst k Dry mucous membranes k Swollen tongue k Dry, sticky mucosa k Edema (swelling) k Neurologic symptoms; (delusion, increased confusion, and hallucinations.) k Restlessness k Increased muscle tone k Deep tendon reflexes k The cells become dehydrated which causes neuro symptoms (water moves out of the cells and causes cellular dehydration). k Unconscious, infant, immobile people are at higher risk because the cant response to their thirst. k ADH- is released so that water is retained to try to dilute the sodium which will causes swelling and edema. k k k k

Manifestations:
k k k k k k k k k k Poor skin turgor Dry mucosa Headache Decreased Salivation Decreased BP Nausea Abdominal cramping Hyperactive bowel wounds Neurologic changes (confusion) Seizures

Medical management:
k Hypotonic electrolyte solution Less particles than blood, so fluid is going to leave the extracellular into intracellular.D5W k Older patient loss the thirst response, so offer water frequently. k Inform patients that OTC medications are sometimes high in sodium (alka-seltzers).

Medical management: k Sodium replacement, k Water restriction (usually no more than 800
ml/day)

k Hypertonic saline (severe cases) if given to

quickly it can cause CHF and monitor for excess fluid (respiratory rate) k Initiate seizure precautions. (bed low position, side rails up, suction equipment, and monitoring for neuro symptoms (agitated and confusion). k Monitor for orthostatic hypotension. k Monitor for tachycardia

Hypokalemia- Potassium Deficit Serum Potassium< 3.5 mEq/L Contributing Factors:

k Most common k Potassium influences both skeletal and cardiac muscle activity. (muscle excitability) k Small fluctuations have significant impact on the body. k Less muscle excitability which will cause abnormal rhythms with the heart. k Will see flat T waves or inverted T waves, or both, prominent U wave on the ECG. k Insulin and Diuretics (thiazide and loop) will cause hypokalemia. k Low potassium puts pt. at risk for digitoxicity. (digitoxicity level: normal < 2) k Patients with digitoxicity may have nausea and irregular heart rates.

Hyperkalemia- Potassium Excess Serum Potassium > 5.0 mEq/L Contributing Factors:
k Serum potassium greater than 5.0 mEq/L k Usually related to kidneys problems k ECG will show wide QRS, wide, flat P wave, and peaked T wave. k Patients should not use a salt substitute. k Hyperkalemia will increase the excitability of the muscles. k If a tourniquet is left on too long, or if blood is drawn above a IV site with potassium infusing it can cause a false high reading of hyperkalemia.

Causes:
k Impaired renal function (primary cause) k Aldosterone deficiency k Burns -Cells are destroyed which release potassium k Medications k Potassium-sparing diuretics and ace inhibitors which end in prile

Causes:
k GI losses (GI contains large amounts of potassium) k Gastric suctioning k Vomiting k Diarrhea k Medications k Poor dietary intake

Signs and Symptoms

k Cardiac changes and dysrhythmiasLeads to cardiac arrest. k Muscle weakness Can lead to blasted paralysis. k Numbnessa k Tinglinga k Anxiety k GI manifestations Nausea and Diarrhea

Signs/Symptoms: k Fatigue k Anorexia (loss of appetite) k Nausea k Vomiting k Dysrhythmias k Muscle weakness k Cramps k Decreased muscle strength k Decreased deep tendon reflexes (DTRs) Medical Management:
k Increased dietary potassium bananas, citrus fruits, tomatoes, raisins, spinach, and salt substitutes k Potassium supplement Are not very tasty and can upset stomach, so mixed with a juice, so don t take on an empty stomach. k All IV potassium is always diluted (usually in 1000 mL bag), never IV pushed and always needs to be agitated [mixed]. k IV for severe deficit

Medical Management: k Kayexalate (given orally or with a retention

enema)Put in a tube or Folley catheter with balloon inserted into the rectum and lower GI to keep in place for about 30 minutes. The medication will bind with the potassium and the longer it stays in there the more it potassium it will bind to and is excreted with stool. Recommended to use a cleaning enema afterwards with a retention enema.Orally Kayexalate works the same way by binding to the potassium and excreted through stool. IV Sodium Bicarbonate, IV Calcium Gluconate- Is used for extremely high potassium levels.Does not help reduce potassium but helps to reduce cardiac side effects of high potassium. Regular Insulin Dextrose IV Forces potassium back into the cells. Limit dietary potassium Perform dialysis

k k

k k k k

Hypocalcemia- Calcium Deficit Serum calcium< 8.5 mg/dL Contributing Factors:

k Serum level less than 8.5 mg/dL k Calcium is used for nerve contractions, low calcium will increase muscle contractions. k 99% of calcium is found in the bones and skeletal system. k Calcium usually remains very stable. k Calcium and phosphate work in opposition to each other, which means one is elevated and the other is lowered. k Parathyroid gland releases parathyroid hormone, which the parathyroid hormone stimulates calcium release. k Pt. after thyroid surgery need to carefully monitored for hypocalcemia because the parathyroid gland is rite beside the thyroid gland and if they is inadvertly damage the parathyroid will not make enough parathyroid hormone which will lead to hypocalcemia

Hypercalcemia- Calcium Excess Serum Calcium> 10.0 mEq/L Contributing Factors:

k k k k Decreases muscle function. Can lead to cardiac arrest. Encourage a low calcium diet. Long term hypercalcemia causes less calcium in the bones.The patient will be at increased risk for fractures because the bones are weak.Turn and reposition carefully and watch for spontaneous fractures. k The most common cause is malignancy and hyperparathyroidism k Often cause by tumor of the parathyroid gland. Causes excessive parathyroid hormone to be released.Parathyroid hormone stimulates the bones to release more calcium.

Causes: k HyperparathyroidismCauses increased amounts

of calcium to be released from the bones. k Bone loss related to immobilityHypercalcemia occurs in bedrest patients because calcium is released from the bones, BUT the end affect in HYPOcalcemia.Keep patient mobile and moving to bring the calcium level down and prevent hypercalcemia. k Increased Vitamin D

Causes: k Hypoparathyroidism k Inadequate vitamin D intake k Renal failure (high phosphorus and low calcium) k Immobility or the elderly with osteoporosis
(bone is going to decrease the re-absorption and cause Hypocalcemia)

Signs and Symptoms:

k k k k k k k k Muscle weakness Incoordination Anorexiaa Constipationa Nauseaa Vomitinga Abdominal and bone pain Confusion

Signs/Symptoms: k Tetany Tingling in the tips of the fingers and k k k k

around the mouth and more spasms of muscles. Hyperactive DTRs Positive Trousseau s sign or chovstek s sign Caused by the increased excitability of muscle contractions. Seizures Because of increased irritability in the CNS in the peripheral nerves, so put on seizure precautions. Dyspnea Increased risk for laryngeal spasms and laryngeal obstructions

Medical Management:
k Treat underlying cause k Administer fluids 3 to 4 quarts of fluid and lots of fiber because of the constipation and to try to flush the calcium out of the system. k Diuretics Lasix (furosemide) k Phosphates k Calcitonin

Medical Management:
k IV of Calcium Gluconate- Do not administer to quickly and make sure it is diluted because it can cause cardiac arrest.Make sure pt. has patent IV because it can leak into the tissue (infiltration) it can cause tissue necrosis and death (extravasation). k Calcium and Vitamin D Supplements k Encourage a high calcium diet

Hypomagnesemia- Magnesium Deficit Serum magnesium< 1.8 mg/dL Contributing Factors

k Decreased magnesium increases the excitability of neuromuscular transmission. k Encourage foods high in magnesium (green leafy vegetables, yogurt, peanut butter, cocoa, seeds, legumes, whole grains, and seafood. k These patients are also at risk for digitoxicity. k These patients are at increased risk for seizures. k Often times if someone is hypokalemic and hypocalcemic, they are most often going to be hypomagnesemic.

Hypermagnesemia- Magnesium Excess Serum Magnesium> 2.7 mg/dL Contributing Factors:

k Primary cause is renal failure. k Excessive amounts of magnesium are found in Antacids, Maalox, Mylanta, and Milk of Magnesia. k Patients abusing laxatives (Milk of Magnesia) can end up with hypermagnesemia. k With hypermagnesemia there is a decreases in neuromuscular functions (suppress it like a sedative) . k Instruct renal patient to avoid high amounts of magnesium and to check with the physician before taking OTC medication. k Monitor Vital Signs.

Causes:
k Alcoholism k GI losses NG suctioning (high) Diarrhea Or anything from the small intestine (bowel) k Low intake of magnesium

Causes:
k Renal failure k Dehydration k Excessive administration of magnesium

Signs/Symptoms: k Neuromuscular irritability k Muscle weakness k Tetany k Tremors k ECG changes and dysrhythmias k Alterations in mood and level of consciousness k Trousseau s sign k Chovstek s sign Medical Management:
k Diet k Oral magnesium k Magnesium sulfate IV Should be administered slow and patient should be monitored. Rapid or too much can cause cardiac dysrhythmias.

Signs and Symptoms:

k k k k k k k k k Decreased Blood pressure Nausea Vomiting Hypoactive reflexes Drowsiness Muscle weakness Depressed respirations Bradycardia Dysrhythmias

Medical Management:
k IV calcium gluconate k Loop diuretics Are used if the cause in not kidney failure. Causes magnesium to be excreted in the urine. k Increase fluids Causes magnesium to be diluted in the fluid. k Hemodialysis Reduce magnesium to a safer level by filtering it out of the fluid.