Fluids and Electrolytes

Sodium

-Accounts for 90% of ECF cations -Most abundant solute in ECF -Maintains ECF osmolality -Transmits impulses in nerve and muscle fibers -Regulates acid-base balance -Normal range: 136-145 mEq/L -Kidneys balance sodium -Sodium attracts and holds water -Excreted through GI, skin

How the body regulates calcium

-Daily intake and existing stores -Absorbed in the small intestine and excreted in urine and feces -Parathyroid hormone (PTH) -Draws calcium from bones when low -Promotes kidney and intestinal reabsorption -Calcitonin -Thyroid releases when calcium is high -Inhibits bone resorption -Vitamin D Active form promotes calcium absorption through intestines, calcium resorption from bone, and kidney reabsorption of calcium -Phosphorus -Inhibits calcium absorption -Serum pH -When pH rises, more calcium binds with protein

Hypercalcemia (Ca >10.5 mg/dL)

-Dangerous condition - cardiac arrest Causes: -Increase in resorption of calcium from bone -Malignancy or hyperparathyroidism 1. Primary hyperparathyroidism -Most common cause -Body excretes more PTH→calcium resorption pf bone 2. Malignancy -Bone destruction and releases hormone similar to PTH -Squamous cell carcinoma of the lung, myeloma, Hodgkin's lymphoma, renal cell carcinoma, breast cancer -Others: multiple fractures, no weight-bearing, immobilization

What to look for (hypercalcemia)

-Decrease in cell membrane excitability -Skeletal muscle, heart muscle, nervous system -Fatigue -Confusion -Memory loss -Altered mental status -Depression -Personality changes -Lethargy -Muscle tone: weakness, hyporeflexia, ataxia, decreased muscle tone, bradycardia, cardiac arrest -Intestine: thirst, anorexia, N/V, decreased bowel sounds, constipation, ileus, polyuria, kidney stones, bone pain, fractures

How the body regulates phosphorus

-Dietary intake -Absorbed through the GI tract -Hormonal regulation -Parathyroid gland controls PTH (calcium levels) -Inverse relationship with calcium -Kidney excretion -PTH affects the kidney to excrete or reabsorb -Transcellular shifts -Insulin moves phosphorus into the cell

What to look for (Hypophosphatemia)

-Low energy stores -Musculoskeletal -Muscle weakness -Diplopia -Malaise -Anorexia -Weakened hand grasp, slurred speech, dysphagia -Respiratory failure -Rhabdomyolysis -Osteomalacia -Central nervous system -Paresthesia, irritability, confusion, memory loss, -Cardiac -Hypotension, low cardiac output -Hematologic -Hemolytic anemia, infection, bruising and bleeding

Potassium

-Major cation in intracellular fluid -Maintains cells' electrical neutrality and osmolality -Aids neuromuscular transmission of nerve impulses -Assists skeletal and cardiac muscle contraction and electrical conductivity -Affects acid-base balance in relationship to hydrogen ion -Normal value: 3.5-5 mEq/L

Phosphorus

-Negatively charged ion found in intracellular fluid -Most exists in bone and teeth with calcium -Cell membrane integrity -Muscle function -Neurologic function -Metabolism of carbs, fats, proteins -Found in RBC -Buffer acid-base -Promotes energy transfer -WBC and platelet formation -Normal value: 3.0-4.5 mg/dL

Calcium

-Positively charged ion in both ECF and ICF -Most is found in bones and teeth; 1% in serum -Responsible for formation of bones and teeth -Maintains cell structure and function -Cell membrane permeability and impulse transmission -Affects contraction of cardiac muscle, smooth muscle, skeletal muscle -Blood clotting and release of hormones -Normal range 9-10.5 mg/dL

Magnesium

-Second-most abundant cation in ICF after potassium -60% contained in bones -Carbohydrate metabolism -Produce and use ATP -DNA and protein synthesis -Vasodilation and cardiac muscle contractility -Neurotransmission -Aids in production of PTH -Sodium-potassium pump -Muscle contraction -Normal value: 1.5-2.5 mEq/L

What tests show (hypercalcemia)

-Serum calcium level above 10.5 mg/dL -Ionized calcium level above 5.3 mg/dL -X-rays revealing pathologic fractures -Characteristic ECG changes

What tests show (Hyperphosphatemia)

-Serum phosphorus level above 4.5 mg/dL -Serum calcium level below 9.0 mg/dL -X-ray studies that reveal skeletal changes -Increased BUN and creatinine -ECG changes

What tests show (Hypophosphatemia)

-Serum phosphorus level of less than 3.0 mg/dL -Elevated creatine kinase level if rhabdomyolysis is present -X-ray studies that reveal the skeletal changes -Abnormal electrolytes (decreased Mg; increased Ca)

What tests show (hyperkalemia)

-Serum potassium level greater than 5 mEq/L -Decreased arterial pH, indicating acidosis -ECG abnormalities

What tests show (hypokalemia)

-Serum potassium level less than 3.5 mEq/L -Increased 24-hour urine level -Elevated pH and bicarbonate levels -Slightly elevated serum glucose level -Decreased serum magnesium level -Characteristic ECG changes

What tests show (hypocalcemia)

-Total serum calcium level less than 9.0 mg/dL -Low albumin level -Characteristic ECG changes

A senior student nurse delegates the task of intake and output to a new nursing assistant. The student will verify that the nursing assistant understands the task of I&O when the nursing assistant states, A. "I will record the amount of all voided urine." B. "I will not count liquid stools as output." C. "I will not record a café mocha as intake." D. "I will notate perspiration and record it as a small or large amount."

A

Third spacing

A type of dehydration: AKA interstitial fluid shift Movement of ECF, primarily IVF (intravascular fluid) into a space that does not contribute to equilibrium of fluid. Fluid is trapped - not available for normal physiological functioning. It is unavailable to help support cardiac function. S/S: decreased urine output with adequate fluid intake, increased HR, body weight, decreased BP, CVP, edema, unbalanced I/O Examples: ascites (manifestation of liver failure), burns, peritonitis, bowel obstructions, heart failure

Oncotic pressure

AKA: Colloid osmotic pressure (COP) Pressure caused by albumin (protein molecules) Helps move water from interstitial space to intravascular compartment

Collaborative interventions (hypervolemia)

Administer diuretics: -Thiazide diuretics (HCTZ), loop diuretics (furosemide) -Potassium supplements to avoid hypokalemia Labs: serum electrolytes and serum osmolality, Hct,Hgb Fluid restriction Sodium-restricted diet -May be down to 250 mg NaCl -Use salt substitutes cautiously (consider K) -Water softener solutions - source of Na Dialysis: hemodialysis or peritoneal dialysis

Intake

Adult needs: 2300 mL/day Liquid - 1000 mL/day Food - 1300 mL/day Byproduct of metabolism - 200 mL/day

Risk factors for FVD

Age Decreased thirst response Decreased intracellular reserves Pregnancy - vomiting, miscarriage - blood loss Infant or small child - higher body surface area and more fluid loss through faster respiratory rate Excessive loss of GI fluids Diuretic usage Extreme heat/extreme sweating Hemorrhage Third spacing

A patient has been having frequent liquid diarrhea for the last 24 hours. A stool sample was sent to the laboratory to confirm possible Clostridium difficile infection. The nurse should monitor the patient for which electrolyte imbalance? A. Dehydration B. Hypokalemia C. Hyponatremia D. Hypocalcemia

B. Hypokalemia. Potassium re-absorption primarily occurs through the renal system. However, approximately 10% of potassium regulation occurs in the gut. Hypokalemia can result when clients experience significant diarrhea.

Edema

Can be localized or systemic 2.2 pound weight gain = 1 L of fluid Edema -At least 2.5 L of fluid in interstitial space Pitting edema -Minimum of 4.5 L additional Ascites -Edema in which fluid accumulates in peritoneal cavity; causes SOB

ANP (hormone influencing output)

Cardiac hormone Released when atrial pressure increases (aka too much fluid) Decreases blood pressure Counteracts RAAS

Ions (charged particles)

Cations: positively charged Prevalent ICF is K+; Prevalent ECF is Na+ Anions: negatively charged Prevalent ICF is PO43-; Prevalent ECF is Cl- Outside the cell: Sodium, chloride Calcium, bicarbonate Inside the cell: Potassium, phosphorus, magnesium

Hypokalemia

Causes (inadequate intake or excessive output) -Diuretics, diarrhea, vomiting, gastric suction, ileostomy, NPO, anorexia, alcoholism, fasting, corticosteroids, some penicillins, insulin Symptoms -Affects cell function -Weak in the knees: weakness, paresthesia, leg cramps, decreased or absent deep tendon reflexes, rhabdomyolysis -Affects smooth muscle: anorexia, nausea, vomiting -GI trouble: decreased bowel sounds, constipation, ileus -Telltale heart: weak and irregular pulse, palpitations, flattened T waves on ECG, ventricular dysrhythmias, cardiac arrest

Hyperkalemia (K >5.0 mEq/L)

Causes (too much intake, too little output, cell injury) -Impaired kidney function, burns, chemotherapy, rhabdomyolysis, trauma, excessive use of salt substitutes Pseudohyperkalemia -Too tight tourniquet during blood draw; hemolysis of sample; WBC >200,000 Symptoms (neuromuscular and cardiac) -Early Signal: paresthesia, irritability -Muscle messages: skeletal muscle weakness, decreased deep tendon reflexes, paralysis -Heart signs: Decreased HR, irregular pulse, decreased cardiac output, hypotension, cardiac arrest

Hypocalcemia (Ca <9.0 mg/dL)

Causes: -Intake issues Alcoholism, low magnesium, breast-fed infant, lack of sunlight exposure -Malabsorption maladies Diarrhea, laxative abuse, chronic malabsorption syndrome -Too much in the loss column Pancreatic insufficiency, thyroid surgery, medications, diuretics

Hyperphosphatemia (P >4.5 mg/dL)

Causes: -Kidney filter failure -PTH problem -Less PTH, less phosphorus is excreted -Shift work -Acid-base imbalances (DKA); cellular destruction (cehmotherapy) -Increased intake -Overadministration of phosphorus; laxatives or enemas (Fleets)

Electrolytes (mineral salts)

Compounds that separate into ions (charged particles) when they dissolve in water

A patient is diaphoretic and has an oral temperature of 104° F. These are classic signs of: A. ADH deficit. B. Extracellular fluid loss. C. Insensible water loss. D. Sensible water loss.

D

The body's fluid and electrolyte balance is maintained partially by hormonal regulation. Which of the following statements shows an understanding of this mechanism? A. "The pituitary secretes aldosterone." B. "The kidneys secrete antidiuretic hormone." C. "The adrenal cortex secretes antidiuretic hormone." D. "The pituitary gland secretes antidiuretic hormone."

D

A 25-year-old student has been taken to an urgent care clinic because of dehydration. She says she has had "the flu," with vomiting and diarrhea "all night" and has had very little to eat or drink. She says the GI symptoms have subsided, but she feels weak. The nurse expects which type of rehydration to occur? A. IV fluid replacement B. Oral rehydration therapy with tea C. Oral rehydration therapy with water D. Oral rehydration therapy with a solution containing glucose and electrolytes

D. Oral rehydration therapy with a solution containing glucose and electrolytes. Whenever possible, fluids are replaced by the oral route. When dehydration is severe or life threatening, or the patient is not able to tolerate oral fluids, IV fluid replacement is needed. Oral rehydration therapy is a cost-effective way to replace fluids for the patient with dehydration. Specifically formulated solutions containing glucose and electrolytes are absorbed even when the patient is vomiting or has diarrhea.

While monitoring a patient who has fluid overload, the nurse would be most concerned about which assessment finding? A. Bounding pulse B. Neck vein distention C. Pitting edema in the feet D. Presence of crackles in the lungs

D. Presence of crackles in the lungs. Fluid overload may lead to pulmonary edema and heart failure. Any patient with fluid overload, regardless of age, is at risk for these complications. Older adults or those with cardiac problems, kidney problems, pulmonary problems, or liver problems are at greater risk. The presence of crackles in the lungs may be indicative of pulmonary edema, which can occur very quickly and lead to death in patients with fluid overload.

Physical assessment

Daily weights: Indicator of fluid status 1 kg = 1 L fluid Use same conditions Fluid intake and output (I&O) -24-hour I&O: compare intake versus output -Intake includes all liquids eaten, drunk, or IV -Output includes diarrhea, vomitus, drainage Laboratory studies -Electrolytes

Nursing diagnosis

Decreased cardiac output, acute confusion, impaired gas exchange, excess fluid volume, risk for electrolyte imbalance, deficient fluid volume, deficient knowledge regarding disease management, risk for injury

Hypovolemia

Definition: Decrease in the intravascular, interstitial &/or intracellular fluid in the body either in combination with other electrolyte or acid-base balance Dehydration: fluid intake or retention is less than what is needed Hypovolemia: loss of extracellular fluid volume (circulating blood volume) Fluid and electrolyte loss is in same proportion as occurs in body Don't see big change in lab values for electrolytes

Fluid volume excess (hypervolemia)

Definition: Fluid and electrolytes retained by body Hypervolemia: fluid volume overload -Retention of fluid and Na in same proportion as found in normal ECF Edema: abnormal increase in volume of interstitial fluid

Hyponatremia

Deplete and dilute: Sodium loss, water gain (dilutional), or inadequate sodium intake (depletional) Hypovolemic hyponatremia ECF volume is abnormally decreased Na and water decrease in ECF, but Na is greater loss Causes: vomiting, diarrhea, fistulas, gastric suctioning, excessive sweating, burns, wound drainage, diuretics Hypervolemic hyponatremia ECF volume is abnormally increased Water and Na increase in ECF, but water is greater gain Causes: heart failure, liver failure, nephrotic syndrome, hypotonic IV fluids

What to look for (hyponatremia)

Drop in level quicker, more symptomatic N/V and anorexia (acute initial signs) occur between 115-120 mEq/L Primarily neurologic -Headache, irritability, disorientation -Muscle twitching, tremors, weakness -Change in LOC → lethargy → confusion Low show (hypovolemia) -Poor skin turgor, dry, cracked mucous membranes -Rapid, weak pulse -Low BP High signs (hypervolemia) -Edema, hypertension, weight gain, rapid pulse

Fluid imbalances

ECF imbalances: -Volume -Osmolality Osmolality imbalances: -Hypernatremia, "water deficit"; hypertonic -Hyponatremia, "water excess"; hypotonic Clinical dehydration: -ECV deficit and hypernatremia combined

Hypernatremia (Na >145 mEq/L)

Elevated sodium level in the plasma (blood) High serum osmolality stimulates hypothalamus and initiates sensation of thirst -Infants, confused, elderly, immobile and unconscious patients at risk Serum osmolality increases, fluid moves from inside the cell to outside -Cells become dehydrated and shrink -Neurologic symptoms -Fluid overload

Nursing Process: assessment (hypovolemia)

Fluid and nutritional intake S/S of deficit Health history (consider medications - diuretics, SEs of meds) Physical assessment Pulse - weak, rapid BP - postural hypotension Skin turgor - tongue furrow Extremities - cold

Fluid balance

Fluid balance consists of: Fluid intake Fluid distribution Fluid output -Antidiuretic hormone -Renin-angiotensin-aldosterone system -Atrial natriuretic peptide

Fluid balance cont.

Fluid output Insensible: can't be measured or seen, ex. skin, lungs Sensible: can be measured, ex. kidneys, stool, wounds Influenced by: Antidiuretic hormone (ADH)- Influences how much water is excreted in urine Renin-angiotensin-aldosterone system (RAAS)- Influences how much sodium and water is excreted in urine Atrial natriuretic peptides (ANPs)- Influences how much sodium and water is excreted in urine

Extracellular fluid

Fluid outside of cells ~1/3 of total body water 3 divisions: interstitial (in between cells), intravascular (in blood), transcellular (fluid house in specific locations, ex. CSF)

Nursing Process: diagnosis (hypovolemia)

Fluid volume deficit Confusion Risk for injury Activity intolerance Ineffective tissue perfusion

Movement of fluids in the body

Fluids normally move back and forth between ICF and ECF components Fluid compartments are separated by a semi-permeable membrane (cell membranes and capillary membranes) Fluid moves easily Small solutes (O2, CO2, ions) move easily Large solutes (protein, glucose) move with more difficulty

Intracellular fluid

Fluids within the cells ~2/3 of total body water

Total fluid volume is influenced by

Gender: men > women, men have more lean body mass Age: younger > older Amount of body fat: thin > obese (fat cells hold less water)

Hypertonic solutions

Have an osmolarity greater than 300 mOsm/L Draw water out of the cells into the ECF (cells shrink) D5NS, D10 Used to replace electrolytes Nursing actions: monitor for s/s fluid overload

Isotonic solutions

Have same osmolarity as that of normal body fluids (270-300 mOsm/L) Expands only the ECF NS (0.9% NaCl), Lactated Ringers, D5W Used as fluid replacement for a patient with ECF volume deficit (e.g., blood loss) D5W acts like a hypotonic solution once it enters the bloodstream because cells quickly consume the dextrose Nursing actions: monitor for s/s fluid overload

Nursing process: assessment (hypervolemia)

Health history: Recent weight gain, cough, SOB, peripheral edema, difficulty sleeping supine Physical assessment: Daily weight, VS, peripheral pulses, LS, urine output, mental status, presence of pitting edema

Nursing implementation

Health promotion: Fluid replacement education Teach patients with chronic conditions about risk factors and signs and symptoms of imbalances Acute care- Enteral replacement of fluids Restriction of fluids Parenteral replacement of fluids and electrolytes -TPN -Crystalloids (electrolytes) -Colloids (blood and blood components)

Intravenous therapy

IV therapy: crystalloids Types of solutions: Isotonic Hypotonic Hypertonic Caution: Too rapid or excessive infusion of any IV fluid has the potential to cause serious problems Vascular access devices

Causes of fluid volume excess (FVE)

Impaired homeostatic measures in body due to CHF (fluid and Na retention) Renal failure Cirrhosis (fluid and Na retention) Increased intake of sodium Others? Excessive administration of sodium containing fluids Administration of hypertonic fluids causes fluids to shift into the intravascular space

Electrolyte Balance

Intake and absorption Distribution: Plasma concentrations of K, Ca, Mg, and phosphate (Pi) are very low compared with their concentrations in cells and bone Concentration differences are necessary for normal muscle and nerve function Output: Urine, feces, and sweat Vomiting, drainage, and fistulas

Interventions

Interventions for electrolyte imbalances: Support prescribed medical therapies Provide for patient safety

Types of fluid volume deficit (FVD)

Isotonic FVD (isotonic dehydration): Loss of fluid and electrolytes (sodium) in equal proportions from extracellular component Causes: vomiting, diarrhea Hypotonic FVD (hyponatremic dehydration): Greater proportion of Na is lost in relationship to water loss More extracellular dehydration Causes: burns, renal disease, prolonged vomiting and diarrhea Hypertonic FVD (hypernatremic dehydration): Greater proportion of water is lost than Na is lost Serum Na level is above normal By time symptoms appear, serious condition

What tests show (hypervolemia)

Low Hct due to hemodilution Normal serum sodium Low serum potassium and BUN due to hemodilution Decreased serum osmolality Low oxygen level Pulmonary congestion on CXR

Electrolytes: Major Functions

Maintain fluid balance: Na, Cl - serum osmolality Assist in acid-base regulation: Cl, bicarbonate Facilitate enzyme reactions: Mg - protein & DNA synthesis in cells Phosphorus - chemical actions in cells Facilitate nerve conduction or neuromuscular reactions: K - skeletal, cardiac, smooth muscle Ca - cardiac, neuromuscular

Serum osmolality

Measure the number (weight) of solutes in the blood - the concentration Osmolality affects movement of fluid (higher concentration to lower) Normal = 270-300 mOsm/kg in serum Increase = fluid volume deficit

Nursing process: diagnosis (hypervolemia)

Monitor: VS Respiratory patterns Distended veins Record I/O hourly Lung sounds Edema ABG results Lab tests

Filtration

Movement across a membrane, under pressure, from higher to lower pressure Hydrostatic pressure: pressure a fluid in a closed system (circulatory system) exerts on walls of container (blood vessel walls) Higher hydrostatic pressure and lower osmotic pressure = fluid filters out of blood vessel

Active transport

Movement of ions against osmotic pressure to an area of higher pressure; requires energy Energy is expended during movement of solute across the cell membrane The solute combines with a carrier substance (usually an enzyme) and together the combined substance crosses the membrane

Osmosis

Movement of water (or other solute) from an area of lesser to one of greater concentration Tonicity = ability of solutes to cause an osmotic driving force

How the Body Regulates Potassium

Must be ingested daily 80% is excreted in urine, rest is excreted in feces and sweat Sodium-potassium pump Moves sodium out of the cell and pumps potassium into the cell Change in pH Hydrogen ions and potassium ions freely exchange across plasma cell membranes (acidosis)

What to look for (hypocalcemia)

Neurologic -Anxiety, confusion, irritability -Seizures, dementia Neuromuscular -Paresthesia, twitching, muscle cramps, tremors -Spasms, tetany Other -Fractures, diarrhea, hyperactive deep tendon reflexes, ECG changes

What to look for (hypernatremia)

Neurologic symptoms (brain cells shrink) -Restlessness, anxiety -Anorexia -N/V -Weakness, lethargy, confusion, stupor, seizures coma Neuromuscular -Twitching, hyperreflexia, ataxia, tremors Low-grade fever, flushed skin, intense thirst Hypervolemic (increased BP, bounding pulse, dyspnea) Hypovolemia (dry mucous membranes, oliguria, orthostatic hypotension)

Hypovolemia (what tests show)

No single test can confirm hypovolemia Normal or high serum sodium level (>145 mEq/L) Decreased hemoglobin and Hct with hemorrhage Elevated BUN and creatinine ratio Increased urine specific gravity (1.002-1.028 g/ml) Increased serum osmolality

Nursing process: assessment

Nursing history: Age: very young and old at risk Environment: Excessively hot? Exercise? Physical work? Dietary intake: fluids, salt, rich in potassium, calcium, and magnesium? Diets? Ability to chew and swallow? Lifestyle: alcohol intake history Medications: include over-the-counter (OTC) and herbal, in addition to prescription medications (i.e., antacids, laxatives) Medical history: Recent surgery (physiological stress) Increased aldosterone, glucocorticoids, ADH Gastrointestinal output Acute illness or trauma Respiratory disorders Burns Trauma (i.e., hemorrhage) Chronic illness Cancer Heart failure Oliguric renal disease

Hypotonic solutions

Osmolarity below 270 mOsm/L Move water into the cell (cells swell) D2.5W, ½ NS (0.45% sodium chloride), D50.45 NS Replaces ICF; used as maintenance fluid because normal daily losses are hypotonic Potential to cause sudden fluid shifts from ECF to ICF Nursing actions: monitor for s/s of phlebitis and infiltration, stop hypotonic fluids when patient can drink enough to meet fluid needs

Diffusion

Passive movement of electrolytes or other particles down the concentration gradient (from higher to lower) "Go with the flow" Random movement of molecules Move from area of high concentration to lower concentration Rate of diffusion depends on: Size of molecules - larger slower than smaller Concentration - high to low Temperature of solution - hotter faster

Nursing Process: interventions (hypovolemia)

Patent airway Oxygen therapy Lower head of bed Apply pressure to bleeding IV access Administer IV fluids, vasopressor Consider transfusion Monitor mental status Monitor peripheral pulses and skin temp Encourage fluids Foley catheter -I/O every hour Lung sounds -Fluid overload Daily weights Skin care

Aldosterone (hormone influencing output)

RAAS Renin is released in response to low blood pressure/low blood flow Converts angiotensinogen to angiotensin I in liver Travels to lungs and angiotensin converting enzyme (ACE) converts to angiotensin II -Angiotensin II is a vasoconstrictor, increases BP Stimulates release of aldosterone from adrenal glands -Aldosterone reabsorbs sodium, which leads to retained water, increasing blood volume

Nursing Process: interventions (hypervolemia)

Raise head of bed Administer oxygen Restrict fluids Foley catheter IV access Administer diuretics Mouth care Daily weight Skin care

hypovolemia interventions

Rehydration (volume expansion) Oral rehydration (moderate) Need 30 mL/kg body weight - replace deficit over 24 hours Beverages with sugar OK - helps with absorption of Na - no diet beverages IV: Isotonic solution (severe) LR solution, 0.9% NaCl Switch to hypotonic solution (0.45% NaCl) when BP is normal for patient

ADH (hormone influencing output)

Released from posterior pituitary gland Renal cells resorb water and put it back into blood Decreases urine volume, concentrates urine, and dilutes blood Levels increase when blood volume decreases; decrease when body fluids dilute

What test show (hyponatremia)

Serum osmolality less than 280 mOsm/kg (dilute blood) Serum sodium level less than 135 mEq/L (low sodium in blood) Urine specific gravity less than 1.010 Elevated hematocrit and plasma protein levels

What tests show (hypernatremia)

Serum sodium level greater than 145 mEq/L Urine specific gravity greater than 1.030 Serum osmolality greater than 300 mOsm/kg

Hypophosphatemia (P <3.0 mg/dL)

Shift of phosphorus from ECF to ICF -Respiratory alkalosis → hyperventilation Mechanism unknown; phosphorus moves into cells -Hyperglycemia Releases insulin; transports phosphorus into cell Malnourished patients Enteral or parenteral feeding (refeeding syndrome) Decrease in intestinal absorption -Malabsorption syndromes, starvation, prolonged exercise, excessive use of antacids, inadequate intake of vitamin D, chronic diarrhea, laxative abuse Increased loss through kidneys -Diuretic use, DKA, hyperparathyroidism, hypercalcemia, burns

What to look for (Hyperphosphatemia)

Signs and symptoms of hypocalcemia -Paresthesias -Muscle spasms, cramps, pain, weakness -Positive Chvostek's and Trousseau's signs -Decreased mental status, delirium, seizures -ECG changes -Hypotension, heart failure -Anorexia, N/V -Calcium phosphate (calcification) -Arrhythmias, irregular heart rate, decreased urine output, cataracts

Hyponatremia (Na <136 mEq/L)

Sodium concentration in the plasma (outside the cell) is lower than normal -Body fluids are diluted; cells swell -Involves both fluid and sodium shift When vessels contain more water and less sodium, fluid moves into the more concentrated ICF More fluid in cells and less in blood vessels -Cerebral edema and hypovolemia can occur

Signs and symptoms of FVD

Tachycardia Compensating for volume loss Orthostatic hypotension Restlessness/anxiety Delayed capillary refill Cool, pale skin Decreased urine output Dry mucous membranes Weight loss -Indicates rapid fluid changes -5-10% mild-moderate; ->10% severe Confused Irritable Dizziness Nausea Extreme thirst Unconscious

Osmotic pressure

The pressure needed to move water (fluid) across the semi-permeable membrane

Fluid balance cont.

Thirst An important regulator of fluid intake when plasma osmolality increases Thirst-control mechanism is located within the hypothalamus in the brain

Evaluation

Through the patient's eyes Review with patients how well their major concerns regarding fluid, electrolyte, or acid-base situations were alleviated or addressed Patient outcomes- evaluate the effectiveness of interventions using the goals and outcomes established for the patient's nursing diagnoses

Hypokalemia management

Treatment -Oral or IV K replacement (40-80 mEq/day) -High-potassium, low-sodium diet -Potassium-sparing diuretic Nursing management -Monitor VS, ECG -Assess respirations & oxygen level (weakens respiratory muscles) -Monitor serum potassium Hold potassium supplement if output <20 mL/hr for 2h -Monitor I/O -Monitor for symptoms -Administer IV potassium Use IV pump and ECG monitor DO NOT GIVE IV PUSH!!!!

Hypocalcemia management

Treatment: -IV calcium gluconate or IV calcium chloride -Magnesium replacement -Vitamin D supplements -Oral calcium supplements -Diet -Increase intake of calcium, vitamin D, and protein Nursing management: -Monitor VS, especially respirations -Cardiac monitor -Chvostek's and Trousseau's signs -IV calcium therapy -Oral calcium supplements -Monitor lab values -Take calcium with Vitamin D -Promote exercise -Seizure precautions

Hypernatremia Management

Treatment: Hypotonic electrolyte solution or isotonic D5W Sodium restriction Administer diuretics Interventions: Monitor VS, neurologic status, I/O, daily wt Assess skin and mucous membranes Monitor labs Offer fluids frequently (PO, IV, NG) Oral hygiene Enteral feedings with free H2O

Hyponatremia Management

Treatment: Low Na intake: 0.9% NaCl or LR Excess H2O with low Na: fluid restriction (800 mL/24 hours) If neuro symptoms (<120 mEq/L): 3% NaCl Nursing management: Monitor: I/O, wt., GI symptoms (anorexia, N/V, cramps), neuro symptoms (lethargy, confusion, twitching, seizures), urine sodium Restrict fluids to 800 mL/day if fluid intake high Diet: high in Na (tomato juice, beef bullion)

Hyperkalemia Management

Treatment: Mild -Loop diuretic -Potassium-restricted diet Stronger steps -Hemodialysis -Kayexalate -Orally, NG, retention enema -10% calcium gluconate or 10% calcium chloride -IV sodium bicarbonate -10 units of regular insulin IV and glucose Nursing management: -Assess VS, ECG, I/O -Administer calcium chloride or gluconate -Check for hypoglycemia -Administer Kayexalate -Monitor bowel sounds and BM -Monitor labs -Administer antidiarrheals -Diet: low potassium

Hypercalcemia management

Treatment: -Decrease dietary calcium -Treat underlying cause -IV NaCl -Diuretics (furosemide) -Hemodialysis -IV corticosteroids -Bisphophonates -Calcitonin Nursing management: -Monitor VS, arrhythmias -Neurologic and neuromuscular (LOC) -I/O -Labs -Administer IV fluids and diuretics -Encourage fluids -Strain urine; assess flank pain -Ambulate -Position gently

Hypophosphatemia Management

Treatment: -High-phosphorus diet Eggs, nuts, whole grains, organ meats, fish, poultry, milk products -Oral supplements -IV phosphorus (potassium phosphate; sodium phosphate) -D/C antacids and calcium supplements Nursing management: -Monitor VS, LOC and neurologic status -Monitor respirations and ABGs -Monitor for heart failure -Monitor temperature -Assess for decreasing muscle strength -Administer phosphorus -Bed rest, seizure precautions -Record I/O -Monitor labs

Hyperphosphatemia Management

Treatment: -Low-phosphorus diet -D/C laxatives and enemas -Phosphate-binding antacids, calcium salts, phosphate binders, aluminum, magnesium -Treat underlying cause -IV saline solution -Diuretics -Dialysis Nursing management: -Monitor VS -Watch for s/s hypocalcemia -Monitor I/O -Monitor labs -Administer medications, such as antacids

Output

Urine 1 mL/kg/hr Skin: 500 mL Perspiration Evaporation (insensible loss) Lungs: 300 mL Water vapor (insensible loss) GI/feces: 100-200 mL/day

Hypernatremia

Water deficit (more water lost than sodium) -Insensible water loss of several liters (i.e., fever, heat stroke, pulmonary infections, burns) Excess sodium intake (more sodium gained than water) -High-sodium foods, salt tablets, medications (Kayexalate) -IV solution administration -Tube feedings -Near drowning in salt water

Fluid

Water that contains dissolved or suspended subtances such as glucose, mineral salts and proteins Fluid amount = volume Fluid concentration = osmoality Fluid composition = electrolyte concentration

Signs and symptoms of FVE

Weight gain Full, bounding pulse Distended neck veins (JVD) and peripheral veins Other -Tachycardia -Elevated BP -Increased urine output -Peripheral edema, ascites -Dyspnea and wheezing, crackles -Pink, frothy sputum -Hallmark sign of pulmonary edema