Fluid and Electrolytes

What are sources and losses of calcium?

-Absorbed from foods in the presence of normal gastric acidity and Vitamin D. -Lost via feces and urine -Sources include milk, milk products, cheese, dried beans; fortified orange juice; green leafy vegetables, small fish with bones, dried peas and beans

What types of questions would you ask a patient during your assessment for fluid and electrolyte balance?

-Acute and chronic illnesses -Burns -Trauma -Therapies that may disrupt fluid and electrolyte balance -Surgery

What are the sources of Potassium?

-Adequate quantities usually in a well balanced diet -Leading food sources: fruits and vegetables, dried peas and beans, whole grains, milk, meats -Lost via kidney's, stool, sweat -Gastrointestinal secretions contain potassium in large quantities, so can be lost through vomitus

What comprises fluid intake?

-Cardiovascular system -The lungs -Thyroxine -Parathyroid gland -Gastrointestinal Tract -Nervous System -The thirst center

Self Care for F/E imbalance

-Consume about 1.5 quarts water daily -Maintain normal body weight -Avoid excess amounts of products high in salt, sugar, caffeine -**Limit alcohol intake because of its diuretic effect -Obtain medical evaluation for any ongoing indications of fluid imbalance

What is the function of sodium?

-Controls and regulates extracellular fluid volume -Affects serum osmolality -Participates in muscle contraction and transmission of nerve impulses -Important in regulation of acid base balance as sodium bicarbonate -Loss or gain of sodium usually accompanied by loss or gain of water.

Caring interventions to help restrict fluid intake?

-Explain to patient the rationale for decreased fluids and the goal. -Develop short term goals for accomplishing task -Discuss time intervals that fluids will be served -Provide fluids in small glasses or cups -Use ice chips -Avoid offering dry, salty, or sweet foods -Provide oral hygiene -Set shift totals

Caring interventions to help increase fluid intake?

-Explaining to the patient the rationale for increased fluids and the goal. -Develop short term goals for accomplishing the increased fluid intake -Ensure that a larger amount of fluid is ofered during the early hours of pt's day -Offering a variety of fluids at the appropriate temperature -Always have fluids readily available -Have the patient keep a record of his/her intake when possible -Offer support, understanding, and encouragement

What is the function of Potassium?

-Helps control intracellular osmolality -Is the chief regulator of cellular enzyme activity -Plays a vital role in such processes as the transmission of electric impulses, particularly in nerve, heart, skeletal, intestinal, and lung tissue; protein and carbohydrate metabolism; and cellular building -Assists in regulation of acid base balance by cellular exchange with H+

What are aspects of delegation that need to be considered when a patient has needs related to monitoring I&O.

-Identify appropriate fluid modification -Determine whether the patient understands the rationale -Develop and implement a plan of care for patient

List the parameters that need to be considered when assessment of a patient for fluid and electrolyte balance

-Identifying patients at high risk for fluid, electrolyte, and acid base imbalances. -Determining that a specific imbalance is present and identifying the nature of the imbalance along with its severity, etiology, and defining characteristics or assessment findings. -Determining the plan of care, including the appropriate nursing diagnoses or collaborative problems, followed by the identification of specific outcomes, associated interventions, and the evaluation of the effectiveness of the plan of care.

Serum Electrolytes, BUN, Creatinine Levels

-Increased BUN-found with impaired renal function, diabetic ketoacidosis, burns -Increased Creatinine-Found with impaired renal function, heart failure, shock, dehydration

What are the two major areas of the ECF Compartment?

-Intravascular-Liquid component of blood (plasma) -Interstitial compartments- Fluid that surrounds tissue cells and includes lymph

What is the function of calcium?

-Major role in transmitting nerve impulses -Helps regulate muscle contraction and relaxation -Role in blood coagulation -Activates enzymes that stimulate essential chemical reactions in the body

What are sources and losses of sodium?

-Normally enters the body through the gastrointestinal tract -Derived easily from dietary sources, such as salt added to processed foods, sodium preservatives added to processed foods. -Lost from gastrointestinal tract, kidneys, and skin

What are the main functions of water in the body?

-Provides a medium for transporting nutrients to cells and wastes from cells. -Provides medium for transporting substances such as hormones, enzymes, blood platelets, RBC & WBC throughout the body. -Facilitate cellular metabolism and proper cellular chemical functioning -Act as a solvent for electrolytes and nonelectrolytes -Help maintain normal body temperature -Facilitate digestion and promote elimination -Act as a tissue lubricant

Key Points Cont

-Pulse increase with FVD -Irregular pulses occur with potassium imbalances -Pulse volume is decreased with FVD. -Respirations- Moist crackles indicate FVO -Blood Pressure-A fall in systolic pressure greater than 15mmHg from lying to sitting position indicates FVD] -30-50 ml/hr output -Body weight most accurate indicator of fluid gain/loss -Rapid gain of 1kg of body weight is equal to gain of 1 L of fluid

Key Points

-Skin turgor over sternum; resilient -Dry mouth may be result of FVD or mouth breathing -Tearing and salivation decrease with age and FVD -Face appears sunken in with FVD -Periorbital (around the eyes) edema with FVO -Edema not usually apparent until retention of 5-10lbs -Elevation of body temperature in hypoernatremia

What comprises fluid output?

-The kidneys -The adrenal gland -Thyroxine -Parathyroid Gland -Nervous system -Neurons, osmoreceptors

What is the normal sodium level?

135-145 mEq/L

What is the desirable amount of fluid intake and loss in adults?

1500-3500 ml each 24 hours with most people averaging 2500-2600 ml per day.

What is the normal Potassium Level?

3.5-5.0 mEq/L

Gastrointestinal tract

Absorbs water and nutrients that enter the body through this route

Nervous System

Acting as a switchboard to inhibit and stimulate mechanisms that influence fluid balance, functions chiefly as the regulator of sodium and water intake and excretion

Why are infants more prone to fluid volume deficits?

Because ECF is more easily lost from the body than ICF, infants are more prone to fluid volume deficits.

Hypocalcemia

Calcium Deficit in ECF (<8.9 serum calcium, <4.5 mEq/L ionized calcium) -Impaired calcium absorption, excessive calcium loss

Hypercalcemia

Calcium Excess in ECF (>10.1 serum calcium, >5.1 mEq/L ionized calcium) -Cancer and hyperparathyroidism

Define cations and anions

Cations-positively charged Anions-Negatively charged

Alkalosis

Condition characterized by Ph being higher than 7.45

Acidosis

Condition characterized by Ph being lower than 7.35

Deficient Fluid Volume: Risk for Deficient Fluid Volume Related Factors

Decreased fluid intake: imposed fluid restrictions, inability to obtain or swallow fluids Abnormal fluid loss: vomiting, diarrhea, abnormal drainage, enemas, diuretics, blood loss, burns, diaphoresis Increased needs for fluids: Strenuous exercise, extreme heat or dryness, fever

Why is there an increased risk for fluid imbalance in older adults?

Decreasing % of body fluid in older people is related to an increase in fat cells . They also lose muscle mass. The combined affect is decreased total body water.

Fluid Volume Excess Assessments

Decresed: Urine specific gravity, BUN, Hematocrit, Serum Sodium Interventions: Assess for presence or FVO, Encourage adherence to sodium/fluid restricted diets, Avoid OTC drugs with high sodium, monitor patients response to diuretics, teach self monitoring of weight and I&O, skin care, respiratory status.

Define colloid osmotic pressure

Drawing power for water or the attraction for water exerted by solute particles

What are the primary solutes in the body?

Electrolytes and nonelectrolytes

Nursing Diagnoses

Excess Fluid Volume Deficient Fluid Volume Risk for Deficient Fluid Volume Risk for Imbalanced Fluid Volume Impaired oral mucous membrane r/t FVD Impaired skin integrity r/t FVD or FVO Disturbed thought processes r/t cerebral edema or disorientation Ineffective tissue perfusion:(type) r/t decreased cardiac output

Fluid Volume Excess

Excess of isotonic fluid, hypervolemia

Define fluid volume excess and assessment data related.

Excessive retention of water and sodium in ECF in near equal proportions results in fluid volume excess. Pitting edema (1+-4+), non pitting edema

What are the two fluid compartments?

Extracellular Fluid (ECF), Intracellular Fluid (ICF)

Dietary Changes

FVD- Increase foods with high water content (citrus fruit, melons, celery) Hypokalemia-Increase floods with high potassium (Bananas, citrus fruits, apricots, melons, broccoli, potatoes) Hypernatremia-Avoid foods high in sodium (processed cheese, lunch meats, canned soups/vegetables, salted snack foods, table salt)

What is the definition of fluid volume volume deficit?

Fluid volume deficit can be caused by a loss of both water and solutes in the same proportion from the ECF space.

Hypertonic

Has greater osmolarity than plasma. Because of the greater osmolality, water moves out of the cells and is drawn into the intravascular compartment causing the cells to shrink

Hypotonic

Has less osmolarity than plasma. Because of the lower osmolarity, the hypotonic solution in the intravascular space moves out of the intravascular space and into the intracellular fluid, causing cells to swell and possibly burst.

Diuretics

Helpful in treating patients with fluid volume excess, but increase risk for fluid volume deficit and serious electrolyte deficiencies (particularly serum K+)

10% dextrose in water (D10W)

Hypertonic Used for peripheral parenteral nutrition (PPN)

5% Dextrose in 0.45% NaCl

Hypertonic Used to treat hypovolemia -Maintains fluid intake

0.45% NaCl (1/2 strength normal saline

Hypotonic Provides Na, Cl, and free water. -Often used to treat hypernatremia

0.33% NaCl (1/3 strength normal saline)

Hypotonic Provides Na, Cl, and free water. Na and Cl allow kidneys to select and retain needed amounts. Free water desirable as air to kidneys in elimination of solutes.

Complete blood count

Increased hematocrit values: found in severe FVD and shock

Fluid Volume Deficit Assessments

Increased: Urine specific gravity, BUN, Hematocrit, Serum Sodium Interventions: Assess for presence or worsening of FVD, administer oral fluids if indicated, anticipate TPN or tube feedings if pt unable to eat/drink, monitor patients response to fluid intake, be alert for signs of fluid overload, provide skin care

Measuring I&O

Instruct pt and family that you need to keep a record of all fluids entering and leaving the body. Record intake and output totals for each 8 hr shift and total each 24 hours.

Lactated Ringers Solution

Isotonic -Contains multiple electrolytes in about the same concentrations as found in plasma. -Can treat hypovolemia, burns, fluid lost as bile or diarrhea, mild metabolic acidosis

0.9% NaCl (normal saline)

Isotonic Not desirable as routine maintenance solution because it provides only Na and Cl which are provided in excessive amounts. May be used to expand ECF temporarily if circulatory insufficiency is a problem; can treat Diabetic ketoacidosis.

5% Dextrose in water (D5W)

Isotonic Shouldn't be used in excessive amounts because it doesn't contain any sodium; thus the fluid dilutes the amount of sodium in the serum. Brain swelling can develop rapidly and cause death unless it is promptly treated

Fluid Volume Deficit

Isotonic fluid loss, hypovolemia

How would damage to the kidneys affect fluid and electrolyte balance?

Kidneys are referred to as the master chemists in the body so if they don't work right, things aren't excreted properly. They normally filter 180 L of plasma daily in the adult and excrete 1.5 L of urine. The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the bodies needs.

Thirst Center

Located in hypothalamus of the brain. ADH is manufactured in the hypothalamus and is stored in the posterior lobe of the pituitary gland.

What assessment data would be related to fluid volume deficit?

Loss of body fluids

Define osmosis

Major method of transporting body fluids. Lesser to greater concentration

Kidneys

Master Chemists* -Normally filter 180 L of plasma daily in the adult, and exrete 1.5 L of urine. Selectively retain electrolytes and water and exrete wastes and excesses according to the body's needs

What is the unit of measurement for electrolytes?

Milliequivalent

Neurons

Osmoreceptors Sensitive to changes in the concentration of ECF, sending appropriate impulses to the pituitary gland to release ADH or inhibit its release to maintain ECF volume concentration.

Excess Fluid Volume Nursing Diagnoses Related Factors

Pathophysiologic factors: Renal Failure, decreased cardiac output, liver disease, abnormal fluid accumulation, hormonal problems. Situational factors: excessive IV infusion Nutritional Factors: excessive sodium intake, low protein intake

List the variations that affect fluid content.

Person's age, body fat, gender Fat cells contain little water, lean tissue is rich in water

Hypokalemia

Potassium Deficit in ECF (<3.5 mEq/L) -May be lost through vomiting, gastric suction, alkalosis, diarrhea

Hyperkalemia

Potassium Excess in ECF (>5 mEq/L) -May result from renal failure, hypoadosteronism, use of certain meds (NSAIDs, heparin, ACE inhibitors)

What are the major electrolytes in the ICF compartment?

Potassium, phosphorus, magnesium

Third space fluid shift

Refers to a distributional shift of body fluids into the transcellular compartment such as the pleural, peritoneal, or pericardial areas, joints, bowels interstitial space. Fluid moves out of intravascular spaces (plasma) and into these spaces. -Can decrease albumin*, increase Fluid volume, hyponatremia -May result from a severe burn*, bowel obstruction, or hypoalbuminemia

Lungs

Regulate oxygen and carbon dioxide levels of the blood. Regulation of carbon dioxide levels is especially crucial in maintaining acid base balance

Thyroxine

Released by the thyroid gland, increases blood flow in the body, leading to increased renal circulation and resulting in increased glomerular filtration and urinary output.

5% dextrose in 0.9% NaCl (normal saline)

Replaces nutrients and electrolytes Can temporarily be used to treat hypovolemia

Cardiovascular System

Responsible for pumping and carrying nutrients and water throughout the body.

Adrenal Glands

Secrete aldosterone, which helps body conserve sodium, helps save chloride and water, and causes potassium to be excreted

Parathyroid Glands

Secrete parathyroid hormone, which regulates the level of calcium and phosphorus. Parathyroid hormone draws calcium into the blood from the bones, kidneys, and intestines. It also facilitates the movement of phosphorus from the blood to the kidneys

Hypernatremia

Sodium Excess in ECF (>145 mEq/L) -Lack of fluid consumption, fluid deprivation

Hyponatremia

Sodium deficit in ECF (<135 mEq/L) -Sodium lost through vomiting, diarrhea, sweating

What are the major electrolytes in the ECF compartment?

Sodium, chloride, calcium, bicarbonate

Urine PH and Specific Gravity

Specific Gravity is measurement of urine's concentration -Normal values range from 1.005-1.030 concentrated urine, <1.001-1.010 dilute urine -Increased urine specific gravity can occur with dehydration, vomiting, diarrhea, and heart failure.

Pituitary Gland

Stores and releases the antidiuretic hormone (ADH), which makes the body retain water -Posterior

Define Electrolytes

Substances that are capable of breaking into particles called ions.

Define Diffusion

Tendency of solutes to move freely throughout a solvent. Solute moves from an area of higher concentration to an area of lower concentration.

What is the primary solvent in the body?

Water

Primary Body fluid

Water 50-60 % of body weight in healthy person

Who is most at risk for fluid volume deficit?

Young children, elderly people, people who are ill.