Fluid & Electrolytes

Homeostasis: Electrolyte Composition • Small amounts of water are eliminated by

• State of equilibrium in body • ICF: Prevalent cation is K+ & Prevalent GI tract in feces
• Naturally maintained by adaptive responses anion is PO43- • Diarrhea & vomiting can lead to significant
• Body fluids & electrolytes are maintained • ECF: Prevalent cation is Na+ & Prevalent fluid & electrolyte loss
within narrow limits anion is Cl- • Insensible Water Loss
Water Content of the Body Mechanisms Controlling F&E Movement • Invisible vaporization from lungs & skin to
• 60% of body weight in adult • Diffusion regulate body temperature
• 45% to 55% in older adults • Facilitated diffusion • Approximately 600 to 900 mL/day is lost
• 70% to 80% in infants • Active transport • No electrolytes are lost
• Varies with gender, body mass, & age • Osmosis Gerontological Considerations
• Changes in Water Content with Age • Hydrostatic pressure • Structural changes in kidneys decrease
Compartments • Oncotic pressure ability to conserve water
• Intracellular fluid (ICF) Regulation of Water Balance • Hormonal changes lead to decrease in ADH
• Extracellular fluid (ECF) • Hypothalamic regulation & ANP
• Intravascular (plasma) • Pituitary regulation • Loss of subcutaneous tissue leads to
• Interstitial • Adrenal cortical regulation increased loss of moisture
• Transcellular • Renal regulation • Reduced thirst mechanism results in
Fluid Compartments of the Body Factors Affecting decreased fluid intake
• Electrolytes • Aldosterone Secretion • Nurse must assess for these changes &
• Substances whose molecules dissociate into implement treatment accordingly
• Gastrointestinal Regulation
ions (charged particles) when placed in • Oral intake accounts for most water
water

Fluid & Electrolyte Imbalances

• Common in most patients with illness
• Directly caused by illness or disease (burns Fluid volume excess (hypervolemia)
& HF) • Excessive intake of fluids, abnormal Nursing Implementation
• Result of therapeutic measures (IV fluid retention of fluids (HF), or interstitial-to- • I&O
replacement or diuretics) plasma fluid shift • Monitor cardiovascular changes
ECF volume deficit (hypovolemia) • Treatment: remove fluid without changing • Assess respiratory status & monitor changes
• Abnormal loss of normal body fluids electrolyte composition or osmolality of • Daily weights
(diarrhea, fistula drainage, hemorrhage), ECF • Skin assessment
inadequate intake, or plasma-to-interstitial • Nursing Management
fluid shift Nursing Implementation continued
• Treatment: replace water & electrolytes • Neurologic function
with balanced IV solutions • LOC
• Extracellular Fluid Volume Imbalances • PERLA
continued • Voluntary movement or extremities
• Muscle strength
• Reflexes
Potassium
• Most abundant cation, intracellular (97%)
• Normal range 3.5 – 5.0 mEq/L
• 80 – 90% is excreted by the kidneys
Functions
• Required for nerve impulse transmission and
conduction
• Nerve conduction and contraction of the
myocardium
• Deposits glycogen in liver cells & regulates
osmolality of ICF
Hypokalemia S/SX:
• Flat or inverted T waves, dysrhythmias
• Vertigo
• Muscular weakness
• Decreased peristalsis
Sodium
• Cation mainly found in the ECF
• Responsible for water retention
• Normal range: 135 – 145 mEq/L
Functions:
• NM: transmission and conduction of nerve
impulses (Na-K pump)
• Responsible for the osmolality of vascular
fluids
• Cellular: Na pump action. Na shifts into
cells as K shifts out, repeatedly, to maintain
water balance and NM activity. When Na
shifts into the cell, it stimulates
depolarization (cell activity); and when Na
shifts out of the cell, K shifts back into the
cell, and repolarization occurs
• Na combines readily with Cl or bicarbonate
to regulate the acid-base imbalance
Hyperkalemia S/SX:
• Nausea, diarrhea, abdominal cramps
• Tachycardia, (later bradycardia) and then
cardiac arrest
• Peaked, narrow T waves, prolonged PR
interval and disappearance of P wave,
prolonged QRS
• Weakness, numbness, tingling sensation,
muscle cramps
• Oliguria
Hypokalemia: Mgmt:
• PO supplements & IV replacement
Hyperkalemia: Mgmt:
• Dietary restriction, IV restriction
• IV sodium bicarbonate, calcium salt
• Insulin and glucose
• Kayexalate
Hyponatremia: S/SX:
• N/V, diarrhea
• Tachycardia, hypotension
• Headaches, lethargy, confusion, seizures
• Muscular weakness
• Dry skin, pale, dry mm
Hypernatremia: S/SX:
• N/V, anorexia
• Tachycardia, possible hypertension
• Restlessness, agitation, stupor
• Muscular twitching, tremor, hyperreflexia
• Flushed, dry skin, dry, sticky membranes
Drugs that influence levels:
• Hyponatremia: diuretics-sodium excretion
• Hypernatremia: corticosteroids-promote Na
retention & K excretion
Drugs that influence levels:
• Diuretics – potassium-sparing, potassium
wasting
• Digitalis – K deficit enhances the action of
digitalis, digitalis toxicity (slow, irregular
pulse, N/V, anorexia)
• Laxatives – cause K depletion
• Captopril – renal excretion of potassium
• Corticosteroids – promote K loss
• Licorice
Clinical considerations:
• Oral potassium should be taken with food
and/or fluid
• IV potassium should be well diluted in IV
solution. NEVER administer as a bolus (IV
push)
• Normal dose is 20 – 40 mEq in 1 liter of
IVF over 8 hours
• Monitor IV site, irritating to veins
Clinical Management:
• Hyponatremia: NS (0.9%) or 3% salt
solution
• Hypernatremia: diuretics
Clinical considerations
• Sodium causes water retention
• Vomiting causes sodium, chloride losses,
and diarrhea causes sodium, chloride, and
bicarbonate losses
• A 3% saline should be given for severe
serum sodium deficit, check for pulmonary
edema
• Na and K have opposite effects on cellular
activity.
• Steroids promote Na retention and thus
water retention
Calcium
• Electrolyte found in the ICF Hypocalcemia: causes • Impaired blood clotting • Calcitonin
and ECF • Lack of intake Hypercalcemia: S/SX • IV phosphates
• Normal range: 9 – 11 • Chronic diarrhea • Muscles flabby Clinical Considerations
mg/dL • Renal failure • Cardiac arrest • Administer oral supplements
Functions: • Hypoparathyroidism • Pathologic fractures with vitamin D, give 30 in
• Causes transmission of nerve • Increased phosphorus level • Calcium stones before meals
impulses and contraction of Hypercalcemia: causes • Flank pain • Dilute IV calcium salts in
skeletal muscles, • Thiazide diuretics Hypocalcemia: Mgmt 5% dextrose
myocardium • Malignant bone tumors • Dietary • Infiltration can cause
• Maintenance of cellular • Hyperparathyroidism • Oral supplements sloughing
permeability • Decreased phosphorus level • Vitamin D • Elevated levels can enhance
• Coagulation of blood. teeth, • Prolonged immobilization • IV calcium salts the action of digoxin
bone formation Hypocalcemia: S/SX: Hypercalcemia: Mgmt. • Diuretics (loop) and steroids
• Tetany • IV normal saline can decrease levels
• +Chvostek’s & Trouseau’s • Diuretics • Thiazide increase levels
sign • Loop (furosemide- Lasix)

Phosphorus • CNS dysfunction: confusion, coma

• Anion, intracellular • Causes: chronic alcoholism, hypercalcemia, Excess Mgmt:
• 1.7-2.6 mEq/L malabsorption • Aluminum antacids
Functions: Excess S/X:
• Bone and teeth formation • Tetany Clinical Considerations
• Normal nerve and muscle activity • Tachycardia • Vomiting and diarrhea cause a loss of
• Needed for cellular metabolism, adenosine • Causes: hypocalcemia phosphorus
triphosphate (ATP) Deficit Mgmt: • Concentrated IV phosphates are
• Plays a role in delivering oxygen to the • PO, IV: sodium phosphate/Phospho Soda, hyperosmolar and must be diluted
tissues Neutra-Phos K • Aluminum-containing antacids decrease the
Deficit S/SX: • IV: IV infusion, rate should be no more than serum phosphorus level
• Muscle weakness (pain) 10 mEq/h to avoid phlebitis • Continuous use of laxatives or antacids can
• Bradycardia, arrhythmias, cardiomyopathy • Dietary: milk, meat, whole grain cereals, cause an elevated phosphorus level
dried beans
 Magnesium
• Intracellular cation
• Normal range – 1.5 – 2.5 mEq/L
Functions
• Mediator for neural transmission in the CNS
• Contracts the myocardium
• Activates enzymes for carbohydrate and
protein metabolism
• Transports Na and K across cell membranes
Hypo
• Chronic alcoholism
• Inadequate intake
• ARF: diuretic phase
• Hypokalemia, hypocalcemia
IV Fluids
Purpose
• Maintenance, replacement
• When oral intake is not
adequate, loss occurred
Hypotonic
• More water than electrolytes
• Pure water lyses RBCs
• Water moves from ECF to
ICF by osmosis
• Usually maintenance fluids
Isotonic
• Expand only ECF
• No net loss or gain from ICF
Hypertonic
• Initially expands & raises
the osmolality of ECF
• Requires frequent
monitoring of
• Blood pressure
• Lung sounds
• Serum sodium levels
Hyper
• Prolonged use of magnesium-containing Clinical Management
antacids or laxatives • Hypo – Oral replacement, IV supplements,
• Renal failure IV, dietary
• Severe dehydration • Hyper – IV saline or Calcium salts, dialysis
Clinical manifestations Clinical Considerations
• Hypo – tetany-like symptoms, cardiac • S/S are similar to potassium
dysrhythmias, increased DTRs • Excess laxatives or antacids containing Mg
• Hyper – lethargy, drowsiness, weakness, can cause hypermagnesemia
loss of DTR, complete heart block, • Mg deficit is often accompanied by K and
respiratory depression Ca deficit
• Administer IV Mg slowly, diluted (rapid
infusion can cause hot and flushed feelings)
• Diuretics decrease serum magnesium levels
D5W
• Isotonic 0.9% Normal Saline
• Provides 170 cal/L • Expands IV volume D5 1/2NS
• Free water: Moves into ICF • Preferred fluid for • Hypertonic
• Increases renal solute immediate response • Common maintenance fluid
excretion • Risk for fluid overload • KCl added for maintenance
• Used to replace water losses higher or replacement
& treat hypernatremia • Does not change ICF D10W
• Does not provide volume • Hypertonic
electrolytes • Blood products • Provides 340 kcal/L
Sodium Chloride • Compatible with most • Free water
• Isotonic 0.9% NS: Same medications • Limit of dextrose
tonicity as body fluid Lactated Ringer’s concentration may be
• Hypotonic 0.45% NS: Less • Isotonic infused peripherally
sodium than body fluids • More similar to plasma than Plasma Expanders
NS • Stay in vascular space &
• Hypertonic 3% or 5% NS:
More sodium than body • Has less NaCl increase osmotic pressure
fluids • Has K, Ca, PO43-, lactate • Colloids (protein solutions)
(metabolized to HCO3-) • Packed RBCs
• Expands ECF • Albumin
• Plasma
Acid-Base Balance
• Acids :Produced as end products of metabolism
 • Bases : Neutralize & promote excretion of acids
• Health Problems Buffers
• Diabetes Mellitus • Substances that either bind to or release hydrogen ions to prevent drastic
• COPD changes in pH
• Kidney disease Buffer Systems:
Normals: • Bicarbonate-carbonic acid
• pH: 7.35-7.45 • Phosphate buffer system
• PaCo2: 35-45 (carbon dioxide) • Hemoglobin-oxyhemoglobin buffer system
• HCO3: 22-26 (bicarb) • Protein buffer system
Respiratory component: release of CO2 & H2O from body
Renal component: reabsorb & manufacture bicarb to buffer acid, excrete H into urine
Metabolic Acidosis
• ↓ pH, ↓ HCO3, ↓ Anion gap
• Decrease in bicarbonate concentration or acid excess S/S
Causes: •
Increased respiratory rate & depth: Kussmaul respirations
• Lactic acidosis (anaerobic metabolism) • HA, lethargy leads to coma
• Ketoacidosis • N&V, diarrhea, abdominal pain
• Ingestion of acidic substances • Elevated serum K+ (shift of K+ out of cell, H+ into cell)
• renal disease Loss of bicarbonate or reduced H+ excretion Compensation:
• ↑ RR to blow off CO2 (↓acid)
Metabolic Alkalosis
• ↑ pH, ↑ HCO3 • Hyperaldosterone (steroids) loss of chloride retention of bicarb
• Increase in bicarbonate concentration or loss of the hydrogen ion in the ECF S/S:
Causes: • Weakness, muscle cramps, hyperactive reflexes, dysrythmia (hypokalemia)
• Vomiting, NG drainage (loss of acid) • Decreased respiratory depth and rate (leads to elevated pCo2 levels)
• Diuretics loss of chloride retention of bicarb • Confusion, seizure
• Excessive ingestion of antacids or IV bicarb Compensation:
• ↓ RR to retain CO2 (retain acid)
Respiratory Acidosis
• An increase in carbonic acid / retention of carbon dioxide (pCo2) • Pulmonary embolism, pulmonary edema
• ↓ pH, ↑ Pco2 S/S
Causes: • SOB, restlessness
• Respiratory depression, drugs, head injury • Lethargy, disorientation, seizure, coma
• Respiratory muscle paralysis • Warm flushed skin (vasodilation from increased CO2 levels)
• Disorders of the lung tissue (COPD, pneumonia) Compensation:
• Kidneys ↑ H excretion & bicarb reabsorption
Respiratory Alkalosis
• Excessive respiratory rate and depth, reduction in carbon dioxide levels S/S
• ↑ pH, ↓ Pco2 • Dizziness confusion ( cerebral vasoconstriction)
Causes: • Paresthesias, carpopedal spasm, (hypocalcemia)
• Hyperventilation (hysteria, mechanical ventilation) • Rapid deep respirations
• Hypoxemia in pulmonary disease or CHF Compensation:
• Hypermetabolic states (fever, anemia, thyroid storm) • Kidneys ↓ H excretion, ↑ bicarb reabsorption