Fluids and electrolytes

Examples of hypotonic solution

-0.45% NS -0.33% NS -2.5% Dextrose

Causes/pathophys of Intracellular fluid volume deficit (ICFVD)

-Acute water loss

Interventions for Extracellular fluid volume shift: third spacing

-Assess I/O -Prevent skin breakdown -Monitor for signs of fluid overload -Promote vascular repletion

Examples of Hypertonic solution

-D5 in .45NS (D5.45) -D5 in .9NS (D5.9) -D5 in lactated Ringer's (D5LR) -D5 = 5% dextrose

Pathology of Hyponatremia (<135)

-Decreased NM excitability excitability -Delayed membrane potential -decreased serum osmolality leads to fluid shift into Intracellular Fluid -May be asymptomatic if gradual onset

Etiology of Hypokalemia (<3.5)

-Decreased intake -Increased loss from: vomiting, NG suction, intestinal fistula, ileostomy, DKA, diuresis, diuretics (LOOP=K wasting), cortisol use

Labs associated with Extracellular fluid volume shift: third spacing

-Increased BUN -Increased hematocrit -increased specific gravity may have increased weight

Pathophysiology of Hypokalemia (<3.5)

-Increased NM excitability -MAY NOT SHOW S/S

Pathology of Hypernatremia (>145)

-Increased NM excitability -Increased serum osmolality causes Fluid shift to ECF -ICF dehydration -Decreased myocardial contractility -Decrease in total body water (TBW) creats a Hyperosmolar condition.

Pathophysiology of Hyperkalemia (5<)

-Initial nerve and muscle irritability followed by decreased NM excitability

Examples of Isotonic solution

-Lactated Ringers -Ringer's injection -Normal Saline (0.9%)

labs associated with Intracellular fluid volume excess (ICFVE)

-Na <125 -Decreased hematocrit

Etiology of Hyperkalemia (5<)

-Retention of K (renal failure) -Excess K released from injured cells -Excess replacement -Medications, especially K sparing diuretics (spiral) -Adrenal insufficiency

Interventions associated with Extracellular fluid volume excess (ECFVE)

-TREAT CAUSE -Assess labs -Assess Neuro -Assess skin -Elevate legs -Support extremities -Mobilize fluids

Management of Hyperkalemia

-TREAT CAUSE -Decrease K intake -Cation exchange resin (Kayexalate) oral or enema to excrete K in stool -May give calcium -Dialysis -Low K diet -Insulin/glucose forces K into ICF -Ca to reverse membrane excitability

Interventions for Intracellular fluid volume excess (ICFVE)

-TREAT CAUSE -Fluid restriction -Hypertonic IV -Steroids + diuretics -Na administration -Interventions to decrease intracranial pressure

Interventions for Extracellular fluid volume deficit (ECFVD)

-TREAT CAUSE -I/O -Daily weights -BUN/creatinine -Specific gravity -Fluids

Management of Hyponatremia (<135)

-TREAT CAUSE -Monitor: CNS, GI, CV, resp, renal -Monitor: electrolytes, I/O, daily wt, vital signs every 2-4hrs -if FVD: 3% saline infusions for severe -if FVE: diuretics and fluid restrictions -if SIADH: declomysin *if true sodium deficiency- treat with sodium*

Management of Hypernatremia (>145)

-TREAT CAUSE -Monitor: CNS, GI, CV, resp, renal -Monitor:electrolytes, I/O, daily wt, vital signs 2-4h -Seizure precautions -Slow Hypotonic IV infusion -Diuretics + D5W (turns hypotonic) for true NA excess. NA restricted diet. meticulous skin and mouth care

Interventions for Intracellular fluid volume deficit (ICFVD)

-TREAT CAUSE -Restore fluids

Clinical Manifestations of Intracellular fluid volume deficit (ICFVD)

-Thirst -Oliguria -Confusion -Coma

CV Signs/Symptoms of Hypokalemia (<3.5)

-Thready, weak, irregular pulse, U wave on EKG, dysrhythmia; ventricular fibrillation

Management of Hypokalemia (<3.5)

TREAT CAUSE -Monitor: Organ fx, labs, I/O, PO supplements, IV diluted - 10meq/hr MAX -Monitor pt closely& cardiac monitor decreased activity until K normalizes -instruct high K foods

Signs/Symptoms of Hypernatremia (>145) with Hypervolemia

Hypervolemia: HTN, bounding pulse, Dyspnea

S/S of Hyponatremia (<135) with Hypervolemia

Hypervolemia: HTN, bounding pulse, wt gain, edema. -Increased central venous pressure

S/S Hyponatremia (<135) with Hypovolemia:

Hypovolemia: poor skin turgor, dry mucous membranes, thready pulse, tachycardia, wt loss

Labs associated with Intracellular fluid volume deficit (ICFVD)

?

Labs associated with Extracellular fluid volume deficit (ECFVD)

ALL LABS ELEVATED -Na >145 * -BUN >25 mg/dl -hematocrit >55% -Osmolality >295 * *If water loss greater than solute loss Urine specific gravity above 1.030

Labs associated with Extracellular fluid volume excess (ECFVE)

ALL LABS LOW -Osmolality <275* -Na <135* -Hematocrit <45% -BUN <8 Specific gravity less than 1.010 *If water retention greater than solute retention

Causes/pathophys of Extracellular fluid volume deficit (ECFVD)

Abnormal loss of body fluids, inadequate intake, fluid from plasma to interstitial, DI, third-space fluid burns, fever ADH and aldosterone secreted Thirst mechanism is signaled Vasoconstriction and tachycardia Different "sub-types"

Effects of Hypertonic Solution

Draws fluid and electrolytes into the intravascular compartment, dehydrating the intracellular and interstitial compartments

What kind of patient received a Isotonic solution?

During surgery, trauma, Hypotension, fluid replacement, draining copious amounts of body fluid, burn patients

NM Signs/Symptoms of Hyperkalemia (5<)

Early: muscle twitches, cramps, tingling Late: skeletal muscle weakness, paralysis, flaccidity

Causes/pathophys of Extracellular fluid volume excess (ECFVE)

failure to excrete,increased total body sodium, Heart failure, renal failure, SIADH, excessive isotonic or hypotonic IV fluids, fluid overload, pulmonary/peripheral overload Increased hydrostatic pressure, pulmonary and peripheral overload Decreased oncotic pressure, ascites

Hyponatremia

(<135)

Hypokalemia

(<3.5)

What intracellular changes occur with Albumin (5% or 25%), Hetastarch (Hespan), Dextran,and Mannitol?

Albumin (5% or 25%) : Decrease Hetastarch (Hespan): Decrease Dextran: Decrease Mannitol: Decrease

What interstitial changes occur with Albumin (5% or 25%), Hetastarch (Hespan), Dextran,and Mannitol?

Albumin (5% or 25%): Decrease Hetastarch (Hespan): Decrease Dextran: Decrease Mannitol: Decrease

What Vascular changes occur with Albumin (5% or 25%), Hetastarch (Hespan), Dextran,and Mannitol?

Albumin (5% or 25%): Increase Hetastarch (Hespan): Increase Dextran: Increase Mannitol: Increase

Management of Hyperkalemia (5<)

Assess and monitor/ treat cause give fluids, diuretics. cation exchange resin -kayexalate- po or per enema maybe calcium IVP or Insulin with D50; NaBicarb. IVP-- all will decrease serum K Cardiac monitoring

Respiratory S/S of Hypernatremia (>145)

Crackles and pulmonary edema if FVE;

Effects of Isotonic Solution

Expands intravascular compartment only; no net fluid movement

Define Hypertonic Solution

Fluid in cells moves into blood these solutions raise serum osmolarity and pull fluid from interstitial compartments into intravascular compartments ** DO NOT GIVE TO A PATIENT WITH DIABETIC KETOACIDOSIS**

Clinical Manifestations of Extracellular fluid volume excess (ECFVE)

Headache, confusion, lethargy, peripheral edema, bounding pulse, increase BP, weight gain, JVD, polyuria, crackles

CNS S/S with Hyponatremia (<135)

Headache, fatigue, irritability, confusion, weakness, personality changes, decrease Deep tendon reflexes ** COMA is severe and prolonged**

Causes/pathophys of Extracellular fluid volume shift: third spacing

Increased capillary permeability, decreased serum protein/albumin, obstructed lymphatic drainage, tissue injury, protein malnutrition, Increased capillary hydrostatic pressure Tissue injury or protein malnutrition leading to fluid shift

Clinical Manifestations of Intracellular fluid volume excess (ICFVE)

Increased intracranial pressure, altered LOC Plasma sodium less than 125 meq/l Decreased hematocrit

GI S/S of Hyponatremia (<135)

Increased motility, nausea, cramping,

What Vascular changes occur with Isotonic, hypotonic, hypertonic fluids?

Isotonic: Increase Hypotonic: Decrease Hypertonic: Increase

What interstitial changes occur with Isotonic, hypotonic, hypertonic fluids?

Isotonic: No change Hypotonic: Increase Hypertonic: Decrease

What intracellular changes occur with Isotonic, hypotonic, hypertonic fluids??

Isotonic: No change Hypotonic: Increase Hypertonic: Decrease

GI S/S of Hypernatremia (>145)

Nausea, vomiting, anorexia secondary to fluid retention in gastric cells.

What kind of patient received a hypotonic solution?

Need cellular hydration: Diabetic Ketoacidosis , or patients receiving diuretic therapy

Potassium supplements

O: K liquid, K-lor, K-lyte, K-Dur, 10-40 meq/dosePO IV potassium- never IVP; always diluted - may be irritating to veins Never exceeds 20 meq/hr

Respiratory Signs/Symptoms of Hyperkalemia (5<)

Respiratory failure (late)

Effects of Hypotonic Solution

Shifts fluid and electrolytes out of intravascular compartment, hydrating intracellular and interstitial compartments

What causes the Signs/Symptoms of Hypernatremia (>145)

Usually related to volume deficit, hypertonicity, and shrinkage of brain cells.

Causes/pathophys of Intracellular fluid volume excess (ICFVE)

Water excess, sodium deficit, intracellular shift of water toward sodium

Clinical Manifestations of Extracellular fluid volume shift: third spacing

Weak pulse, pallor, hypotension, oliguria, decreased LOC,

Clinical Manifestations of Extracellular fluid volume deficit (ECFVD)

Weight loss, weakness, decreased skin turgor, increased RR, thirst, dry mucous membranes,

Blood Products

Whole blood, packed RBC's, white blood cells, platelets, plasma, clotting factors, given when individual blood produts components are required

GI Signs/Symptoms of Hypokalemia (<3.5)

constipation, paralytic ileus, , decreased motility, distension, n/v

Colloids

contain undissolved large particles such as protein, sugar, and starch molecules that normally do not diffuse through membranes

Signs/Symptoms of Hypernatremia (>145) with Hypovolemia

dry mucous membranes, oliguria, ortho b/p changes,

Crystalloids

fluids (with glucose and/or electrolytes) that move freely from less concentrated compartments to more concentrated compartments by passing through semipermeable membranes (vascular and cellular )

What kind of patient received a hypertonic solution?

given post op to Reduce post-op edema, stabilize BP, maintain urine output

GI Signs/Symptoms of Hyperkalemia (5<)

hypermotility, Diarrhea (e.g. to get rid of it)

CV Signs/Symptoms of Hyperkalemia (5<)

irregular heart rate, EKG changes: peaked T wave, dysrhythmia. heart block. cardiac standstill

NG Tubes & Hyponatremia (<135)

irrigate NG tubes with normal saline (0.9% NS), avoid Tap Water Enema, treat nausea with antiemetics if appropriate; dietary consult.

NM Signs/Symptoms of Hypokalemia (<3.5)

lethargy, muscle cramps, weakness with eventual flaccidity, paralysis, decreased deep tendon reflexes.

Purpose of Hypotonic solutions

lower serum osmolarity because fluid in blood moves into cells fluid shifts out of the blood vessels and into cells and interstitial spaces Hydrates cells while depleting circulatory system. remaining water from D5W after dextrose is metabolized is hypotonic

Extracellular

outside cells; in vascular space-plasma; or interstitial space. Interstitial fluid and plasma have essentially same composition except plasma contains higher concentrations of protein.

Integumentary S/S of Hypernatremia (>145)

poor turgor, flushed dry skin, fever; dry mucous membranes; low grade fever

CNS S/S of Hypernatremia (>145)

restlessness, agitation, muscle twitches, confusion, irregular muscle contractions, weakness, abnormal speech. s/sof increasing ICP; seizures

Definition of Isotonic

same osmolarity as blood plasma. D5W is isotonic in the container.- but once the dextrose is metabolized the remaining water is hypotonic.

Respiratory Signs/Symptoms of Hypokalemia (<3.5)

shallow resp, decreased breath sounds due to muscle weakness.

Respiratory S/S of Hyponatremia (<135)

shallow, ineffective-- may be a late finding; if in setting of fluid overload, pulmonary edema

CV S/S of Hypernatremia (>145)

weight loss, ortho b/p changes; tachycardia.