Fluid and Electrolyte Balance

Fluid Imbalances
Bodys two major fluid compartments
Intracellular (ICF) Extracellular (ECF)
Intravascular Interstitial transcellular

Fluid Imbalances
Fluid Pressures
Hydrostatic pressure Oncotic (Colloid osmotic) pressure

Fluid Pressures

Extracellular fluid volume Deficit

Extracellular fluid volume deficit (ECFVD)
A decrease in intravascular and interstitial fluids. Hypotonic fluid volume deficit Iso-osmolar fluid deficit Hyperosmolar fluid deficit (dehydration)

Extracellular fluid volume Deficit

Extracellular fluid volume Deficit

Clinical Manifestation
Thirst, decreased skin turgor, dry mucous, dry membranes, dry skin, sunken eyeballs, apprehension and restlessness, coma in severe cases, elevated temp, tachycardia, decreased blood pressure, oliguria.

Extracellular fluid volume deficit

Diagnostic Findings
Increased serum osmolality Increased or normal serum sodium level Elevated hematocrit Increased blood urea nitrogen (BUN) Increased urine specific gravity

Extracellular fluid volume deficit

Relative High Potassium
K= 6.0 BUN= 30 Hematocrit 58%

Actual High Potassium

K = 6.0 BUN = 20 Hematocrit 48%

Extracellular fluid volume deficit

Management
If extracellular fluid volume deficit is mild increase oral fluids If extracellular fluid volume deficit is severe give IV fluids
Isotonic ECFVD give isotonic solution Hypertonic ECFVD give hypotonic solution Hypotonic ECFVD give hypertonic solution

Overhydration
Isotonic Overhydration (hypervolemia)
Only the ECF expands and fluid does not shift between spaces Vascular space expands; Interstitial space expands Causing circulatory overload and edema

Overhydration
Hypotonic Overhydration (water intoxication) Fluids moves into the intracellular space. All the fluid spaces expands

Overhydration
Hypertonic overhydration
Rare, caused by excessive sodium intake Draws fluid from the intracellular fluid (ICF) compartment. ECF expands and ICF volume contracts

Extracellular Fluid Volume Excess

Extracellular Fluid Volume Excess

Causes
heart failure, renal disease, cirrhosis of the liver.

Diagnostic
Decreased hematocrit and BUN levels; decreased serum osmolality; decreased serum protein and albumin, H+H

Extracellular Fluid Volume Excess

Actual Low Potassium K+ = 3.0 BUN = 15

Hematocrit = 45%

Relative Low Potassium K+ = 3.0 BUN =8

Hematocrit = 35%

Extracellular Fluid Volume Excess

Clinical Manifestations
weight gain, edema, rapid and bounding pulse, elevated blood pressure, engorged veins; If fluids shifts into the lungs - crackles, dyspnea, shortness of breath, frothy or pink-tinged sputum (pulmonary edema)

Management
diuretics Digoxin diet - low sodium; salt substitute contain potassium

Intracellular Fluid Volume Excess

Intracellular Fluid Volume Excess
Hypo-osmolar fluid in the intravascular system shift into the cells (Water Intoxication).

Causes
Excessive water intake Solute deficit (decreased electrolytes) Increased secretion of antidiuretic hormone (ADH) Impaired excretion of the kidneys

Intracellular Fluid Volume Excess

Clinical Manifestations
CNS disturbances

Diagnosis
Serum osmolality less than 285 mOsm/kg

Management
Water restriction, diuretics, hypertonic (D5 1/2 NS) solutions.

Electrolyte Imbalances
Potassium Imbalance Normal serum potassium is 3.5 - 5.0 mEq/L

Hypokalemia
Potassium less than 3.5 mEq/L Caused by movement of K+ into the cells, GI suction, diarrhea, drainage from fistula, potassium wasting diuretics,vomiting, NPO. Clinical Manifestations
Cardiovascular system - decrease strength of myocardial contraction, weak thready pulse; ECG changes shallow, weak respirations; GI decreased peristalsis; hypoactive bowel sounds Increased sensitivity of digitalis

Hypokalemia
Management
Potassium supplements Diet high in potassium Monitor pulse, blood pressure, and ECG Monitor acid-base balance Be cautious if administering drugs that are not potassium sparing Assess for Digitalis toxicity

Hyperkalemia
Potassium greater than 5.0 mEq/L Occurs with kidney failure, metabolic acidosis, Addisons disease Clinical Manifestations
Cardiovascular system - bradycardia, hypotension, EKG changes (cardiac arrest) Neurological - muscle twitching, cramps, paresthesias, paralysis GI - hyperactive bowel sounds, nausea, diarrhea

Hyperkalemia
Management
Potassium intake restricted (low K+ diet) Kayexalate (sodium polystyrene) Glucose with insulin Sodium bicarbonate Calcium gluconate Beta 2 agonist albuterol (Proventil, ventolin) Dialysis

Hyponatremia
Normal sodium is 136-145 mEq/L

Hyponatremia
Causes
Decreased sodium intake, diaphoresis, GI suctioning, vomiting, diarrhea, fistulas, increase of ADH

Clinical Manifestations
headache; seizures, confusion Increased GI motility - nausea, watery diarrhea Rapid, weak, thready pulse, decreased B/P (if due to hypovolemia Normal or increased B/P, full rapid pulse if due to hypervolemia

Hyponatremia
Management
Provide foods high in sodium Administer NaCl (3% or 2%) Assess blood pressure

Hypernatremia
Sodium over 145 mEq/L Causes
Excessive/rapid IV administration of NS kidney disease inadequate water intake (diarrhea, diaphoresis, hyperventilation, fever) Too much Na+ foods or IVs

Assessment Findings
Dry, sticky mucous membranes; flushed skin; firm skin turgor; thirst; edema; oliguria Altered cerebral function most common

Hypernatremia
Management
Sodium-restricted diet Loop diuretics (Lasix, Bumex, Edecrin) Hypotonic solutions (D5W, .225% or .3% NaCl, .45% NaCl

Calcium Imbalance
Normal serum calcium level = 8.6 -10.2 mg/dL Vitamin D promotes Calcium absorption Phosphorus inhibits calcium absorption

Hypocalcemia
Causes
Acute pancreatitis; diarrhea; hypoparathyroidism; lack of vitamin D

Assessment Findings
Positive Trousseaus and Chvosteks signs painful tonic muscle spams, muscle twitching laryngeal spasms numbness and tingling of hands, toes, lips, tetany, seizures Increased peristalsis, cramping and diarrhea Abnormal blood clotting

Hypocalcemia
Management
Calcium gluconate or calcium chloride (IV) Oral Calcium lactate High calcium diet Aluminum hydroxide Provide safety by padding side rails Provide quiet environment Monitor for bleeding Seizure precautions

Hypercalcemia
Causes
Hyperparathyroidism; Cancer; immobility; increased vitamin D;

Assessment Findings
Nausea and vomiting; anorexia; constipation; headache; confusion; lethargy; stupor; decreased muscle tone; deep bone or flank pain; blood clots

Hypercalcemia
Management
Encourage mobilization Limit vitamin D and calcium intake Administer diuretics Protect from injury Dialysis Cardiac monitoring IV NS Calcium chelators (calcium binders) plicamycin (Mithracin)

Magnesium Imbalance
Normal values = 1.2 - 2.1 mEq/L or 1.8 3.0 mg/dL 1/3 of magnesium is bound to protein

Hypomagnesemia
Causes
Diarrhea; Crohns disease; low intake of magnesium; GI suctioning; Alcoholism; intestinal fistulas

Assessment Findings
Paresthesias; confusion; hallucinations; convulsions; hyperactive deep reflexes; muscle spasms; muscle weakness and tremors; tetany; seizures; decrease gastric motility; anorexia; nausea; constipation; dysrythmias, sudden death

Management
diet high in magnesium; supplementary magnesium; mag sulfate IV

Hypermagnesia
Causes
Renal insufficiency; antacids or laxatives containing magnesium; dehydration

Assessment Findings
Vasodilation (flushing and sweating); hypotension; Bradycardia somnolence; coma; drowsiness, lethargy muscle weakness; depressed reflexes; decreased pulse and respirations

Hypermagnesia
Management
Increase fluids; withhold magnesium containing food/drugs; administer calcium Give lasix Sodium chloride or lactated Ringers IV

Hypophosphatemia
3.0 -4.5 mg/dL - Normal phosphorus Clinical manifestations
slow and weak pulses, weak muscles, muscle breakdown, bone density is decreased; respiratory failure due to weak muscles

Management
oral phosphorus replacement decrease foods high in calcium

Hyperphosphatemia
phosphorus >4.5 Causes renal failure, large intake of Vit.D, phosphate containing laxatives, hypoparathyroidism, chemotherapy Doesnt cause any problems except for the problems caused by hypocalcemia Management
increase calcium Treat the underlying disorder

Review Questions
1.The nurse who is conducting an assessment of fluid and electrolyte balance in an older female client should be certain to question the client about a.laxative use. b.skin turgor. c. intake of ice cream and gelatin. d.dry mouth.

Review Questions
2. Which observation by the nurse is a reliable indicator that therapy for fluid volume excess is achieving the desired outcome? A. Full, bounding peripheral pulses B. Flat neck veins with head of bed elevated. C. Hand vein emptying longer than 20 seconds D. S3 heart sound clearly audible on auscultations

Review Questions
3. A client with cancer who is receiving chemotherapy is hospitalized with a potassium level of 8.5 mEq/L. Which of the following interventions does the nurse expect to be ordered for this client? a. a potassium-restricted diet and treatment with sodium polystyrene sulfonate (Kayexalate) b. a potassium-rich diet and treatment with intravenous potassium c. cardiac monitoring and dialysis d. a health teaching plan emphasizing diet education and medication changes, particularly potassium-sparing diuretics

Review Questions
4. The nurse concludes that which of the following is a reliable sign that ascites fluid is being effectively mobilized in response to therapy? A. Weight gain of 1 pound in 24 hours B. Increase in urine output C. Drop in blood pressure D. Hand vein fills slowly

Review Questions
5. Which of the following orders should the nurse question regarding a client with severe hypokalemia? A. Infuse 1,000 mL normal saline with 20 mEq potassium chloride IV over 8 hours. B. Give KCl 20 mEq PO daily after meals. C. Infuse 1,000 mL normal saline with 40 mEq at 200 mL/hour D. Give 20 mEq KCl IV over 10 minutes

Review Questions
6. Which of the following treatment options does the nurse anticipate will be appropriate for a client with a potassium level of 3.5 mEq/L? A. Administration of Kayexalate per rectum B. Use of salt substitute in the diet C. Administration of oral KCl D. Continue to monitor and offer foods high in potassium

Review Questions
7. Which one of the following assessments should be included in a plan of care for a client who is at risk for developing hypocalcemia? A. Monitor BUN and creatinine levels to determine renal dysfunction B. Monitor client for constipation C. Monitor serum albumin and magnesium levels D. Monitor for fluid volume excess related to intravenous saline therapy

Review Questions
8. A client has been receiving 2500 mL of IV Fluid and 300 to 400 mL of oral intake daily for 2 days. The clients urine output has been decreasing and now has been less than 40 mL per hour for the past 3 hours. The nurse should initially A. Catheterize the client to empty the bladder B. Assess breath sounds and obtain the clients vital signs C. Check for dependent edema and continue to monitor I&O D. Decrease the IV flow rate and increase oral fluids to compensate