Fluid and Electrolytes: Balance and Disturbances

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Fluid and Electrolytes Balance and Disturbances

• Jimmy Durbin, MSN, RN

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Body Fluids

• Factors that influence body fluid
• 60 of our body is fluid (water and electrolytes.
• Perform numerous functions (what electrolytes do)
• Promote neuromuscular irritability
• Maintain body fluid osmolality
• Regulates acid/base balance
• Regulate distribution of body fluids among body
  fluid compartments

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Nursing Implications with Electrolytes

• Must assess fluid and electrolyte balance by
  doing daily IO
• Assess LOC
• Evaluate sensory and motor function and
  neuromuscular irritability
• Monitor VS and electrolytes
• Look at EKG to detect changes
• Assess the nutritional status (b/c electrolytes
  are obtained thru food intake)
• Evaluate the health history for medical
  conditions that might alter these fluid and
  electrolytes
• Evaluate medication history for prescriptions or
  OTC meds that can affect lytes

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Body Fluid Shit

• Younger ppl have a higher percentage of body
  fluid than old ppl
• Men more body fluid than women
• Obese people have less fluid than those who are
  thin (b/c fat cells contain very little water)
• Bone has a lower water content
• The highest amt of water is found in muscle,
  skin, and blood

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ICF vs. ECF

• Intracellular space (fluid in the cells) and
  Extracellular space (fluid outside a cell)
• 2/3rd located in ICF and is usually in skeletal
  mass.
• 1/3rd located in ECF.

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ICF vs. ECF

• ECF further divided
• Intravascular-contains plasma
• Plasma is 3 L of the 6 L of blood in your body.
  Plasma is half of the blood in your body
• Interstitial-fluid that surrounds the cell
• Lymph and lymph system. About 11-12 L of this in
  the body
• Transcellular
• 1 L in the body. This consists of cerebrospinal
  fluid, pericardial fluid, synovial fluid (in your
  joints), interoccular fluid, and pleural fluids.
• Shifting of fluid
• Normal (keeps normal balance)
• Third spacing
• Anything inside the cells is referred to as this.
  When its in the cell its not useable.

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Third Spacing

• Manifestations
• ?Urine output (even tho theyre drinking
  adequately, b/c the fluid is unuseable)
• Other s/s
• ?Heart rate
• ?BP, ?CVP (central venous pressure), edema
• ?Body weight
• Imbalances in I/O

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Electrolytes

• Active chemicals in body fluids
• Cations ( charge)
• Na, K, Ca, Mg, H
• Sodium, potassium, calcium, magnesium, and
  hydrogen
• Sodium concentration effects the overall
  concentration of the extracellular fluid. Its
  the most important in regulating the volume of
  body fluid
• Anions (- charge)
• Cl-, HCO3, Phos.
• Chloride, bicarbonate, and phosphorus

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Regulation of Fluid

• Osmosis and Osmolality
• Osmosis the movement of a pure solvent, such as
  water, thru a permeable membrane from a solution
  with lower solute (or concentration) to a higher
  solute (or concentration) Its trying to even out
• Diffusion
• Particles in a fluid move from an area of higher
  concentration to an area of lower concentration
  resulting in even distribution. The body always
  wants to be in homeostasis
• Filtration
• Separate out an unwanted material
• Sodium-Potassium Pump
• Protein that transports sodium and potassium ions
  across membranes against their concentration
  gradient. In other words, it doesnt naturally
  move that way, but the protein assists in moving
  it against the grain.

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Routes of Gains Losses

• Kidneys
• Lose in the form of urine
• Skin
• Sweat, visible loss.
• Lungs
• Moisture you breathe out in a vapor. Usually
  lose 400 mL of water Fever can greatly increase
  this.
• Gastrointestinal Tract
• Poop and whatnot

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Sodium

• Major electrolyte in ECF
• Normal 135-145 mEq/L
• ECF levels effect ICF levels
• ? serum Na dilute ECF
• H2O drawn into cells
• ? serum Na concentrated ECF
• H2O pulled out of cells
• Na into cell ? K moves out of cell
• Low sodium is hyponatremia
• High sodium is hypernatremia

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Function of Sodium

• Controls H2O distribution
• Determine ECF concentration
• Determine ECF volume (remember, where Na goes,
  water follows)
• Electrochemical state for proper muscle nerve
  function
• Sodium is responsible for establishing the
  electro chemical state necessary for muscle
  contraction and the transmission of nerve
  impulses

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Serum sodium level decreases (water excess)
Serum sodium level increases (water deficit)
Serum osmolality falls to less than 280 mOsm/kg
Serum osmolality rises to more than 300 mOsm/kg
Thirst diminishes, leading to decreased water
intake
Thirst increases , leading to Increased water
intake
Antidiuretic hormone (ADH) release is suppressed
ADH release increases
Renal water excretion diminishes
Renal water excretion increases
Serum osmolality normalizes
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Hyponatremia

• Sodium lt 135 mEq/L
• Causes
• Excessive Na loss
• Excessive H2O gain (dilutes the Na we already
  have, which lowers levels)
• Both water and Na levels increase in ECF, but
  water is more impressive (cause it can dilute the
  Na levels). This can happen from HF, liver
  failure, or admin of hypotonic IV fluids

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Sodium Loss

• Loss of GI fluids or secretions
• Excessive sweating
• Medications
• Addisons Disease
• ? adrenocorticoid ? aldosterone secretion
• Addisons is a life threatening condition caused
  by partial or complete failure of the adrenal
  corticoid function resulting from autoimmune
  processes and also result from infection (either
  tubercular or fungal), a neoplasm, or hemorrhage

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Water Gain

• Excess IVF (hypotonic)
• SIADH (Syndrome of Inappropriate Anti-diuretic
  Hormone)
• Theres excessive or inappropriate production of
  the ADH (anti diuretic hormone) which results in
  a dilutional hyponatremia due to abnormal
  retention of water. Youre holding on to water
  which dilutes the Na you already have, which
  lowers the Na levels
• Continuous bladder irrigation
• Fresh H2O near drowning
• Psychogenic polydipsia excessive water drinking

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S/S Hyponatremia

• S/S depend on the cause, magnitude and speed at
  which the deficit occurs. (if slowly, probably
  not a lot of initial S/S, but rapid you get these
  quickly)
• Poor skin turgor
• Dry mucosa
• Headache
• Decreased saliva production
• Orthostatic fall in BP (you move them and their
  BP falls)
• Nausea
• Abdominal cramping

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S/S Hyponatremia

• Neurological changes
• Altered mental status
• Status epilepticus
• Obtundation deadening to pain or a reduced
  irritation and it blocks the sensibility at some
  level of the central nervous system. They are
  just there, they dont feel pain. You pinch them
  and they dont move.
• The more rapid the loss, the more severe and
  dangerous the signs.

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S/S Hyponatremia

• Usually due to sodium loss
• Anorexia
• Muscle Cramps
• Lethargy
• Severity of the symptoms also depend on the
  degree and speed in which it develops.
• Normally you wont see S/S until the Na is below
  120. At levels of 115, signs of increasing
  intracranial pressure are lethargy, confusion,
  muscle twitching, weakness, and they may even go
  into a coma.

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Hyponatremia Lab Data

• Serum Na lt 135 mEq/L
• Serum osmolality lt 280 mOsm/kg
• Normal serum osmolality is greater than 280
• Urinary Na lt 20 mEq/L
• Urine specific gravity lt 1.010

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Medical Treatment for Hyponatremia

• Na replacement by mouth, IV, or NG Tube
• Replacement depends on the rate lost
• Can use LR, NS
• When replacing Na, watch for signs of fluid
  overload or pulmonary edema!
• Fluid overload S/S are Tachypnea, tachycardia,
  SOB, may hear crackles or rhonchi with
  ascultation, and an increase in BP
• Rule of thumb serum Na must not be increased gt
  12 mEq/L in a 24 hour period.
• If you overcorrect this too quickly you can cause
  neurological damage.

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Medical Treatment for Hyponatremia

• Water gain
• Restrict H20 safer than giving Na (800ml/24hr)
• Hypertonic solution 3-5 NaCl
• Edema only-restrict Na
• Edema and Na- restrict both
• Loop Diuretics (lasix)
• With severe hyponatremia, goal is to elevate Na
  level until the neurological signs are gone

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Nursing Interventions

• Identify pt. at risk
• Monitor labs, IO, daily weight
• Review medications
• GI manifestations
• Monitor for S/S of hyponatremia
• Monitor for neurological changes (big sign with
  hyponatremia)
• Oral hygiene (esp when theyre on fluid
  restrictions or NG tubes)

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SIADH

• Syndrome of Inappropriate Anti-Diuretic Hormone
• Body secretes too much antidiuretic hormone (ADH)
• Disturbs fluid and electrolyte balance
• Because youre retaining fluid and dilutes your
  levels of stuff
• Major cause of low sodium levels

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SIADH

• What happens
• ADH increases the permeability of the renal
  tubules
• Increased permeability of renal tubules increases
  water retention and extracellular fluid volume
• Leads to
• Reduced plasma osmolality (less stuff in your
  plasma)
• Dilutional hyponatremia
• Dimished aldosterone secretion
• Elevated GFR (glomerular filtration rate)
• Increased sodium excretion and shifting of fluids
  into cells

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SIADH

• Can result from
• Sustained secretion of ADH from Hypothalamus
• Production of ADH-like substance from a tumor
  (remember, benign tumors like to pop out stuff
  like hormones)
• Oat cell lung tumor
• Head injury, pulmonary disorders, physical or
  psychological stress, or certain meds

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S/S of SIADH

• Same as Hyponatremia
• Fingerprinting
• When the finger is pressed over a bony prominence
  it leaves an indention. Leave an indention
  similar to pitting edema, but just not as dramatic

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Lab Values of SIADH

• Low BUN and Creatinine
• Due to over hydration
• elevated urine sodium gt 20 mEq/L
• elevated urine specific gravity gt 1.012

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Treatment of SIADH

• Treat the underlying cause
• Replace sodium
• Hypertonic solution (NS)
• NS cannot be used alone to treat hyponatrimia
  caused by SIADH because excessive Na would be
  excreted rapidly and your urine would be highly
  concentrated with Na.
• Diuretic Lasix
• If water restriction is difficult
• Use lithium or demeclocycline

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Nursing Management of SIADH

• Monitor I/O
• Daily weight
• Monitor for Neurological symptoms
• Monitor for lithium toxicity (if theyre on
  lithium, of course)
• Ensure adequate sodium intake
• Avoid excess water supplements
• Monitor urine specific gravity
• Monitor serum sodium

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Hypernatremia

• Na gt 145 mEq/L
• Causes
• ? H2O intake
• Hypertonic tube feeding with ? H2O supplement(Na
  gain)
• IVF with ? Na
• H2O loss (thru GI, burns, heat)
• CAPD (Continuous Alternating Peritoneal Dialasis.
  Tube in their abd and they run a bag of fluid in.
  Works like a filtration or something b/c their
  kidneys dont work).
• Diabetes Insipidus
• Partial salt water drowning

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S/S Hypernatremia

• Primarily neurological
• Moderate hypernatremia
• Restlessness, weakness, fatigue
• Severe hypernatremia
• Disoriented, delusional, hallucinations, may see
  some seizure activity
• Dehydration
• Thirsty (all the time)
• One of the most important signs of hypernatrimia
  is neurological b/c of the effect that fluid
  shifts have on brain cells. Make sure you dont
  give an IV thats going to push fluid into the
  cells of the brain and make them expand.
• If hyper is sever enough you can have brain
  damage.
• A healthy person that can drink usually wont get
  into trouble with this. But if their crazy or
  wandering the desert w/o water this can happen.

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S/S of Hypernatremia

• Dry, swollen tongue, sticky mucous membranes
• Flushed skin
• Mild increase in temperature
• Peripheral and pulmonary edema
• Postural hypotension
• Increased deep tendon reflexes and nuchal
  rigidity (your neck gets stiff)

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Memory Jogger

• SALT. Remember, hypernatrimia is caused by too
  much salt. S/S are as follows
• S Skin Flushed
• A Agitation
• L Low grade fever
• T Thirst (complain of intense thirst from
  stimulation of hypothalumus b/c of the increased
  serum osmolality)

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Hypernatremia Lab Data

• Serum Na gt 145 mEq/L
• Serum osmolality gt 300 mOsm/L
• Urine specific gravity gt 1.015

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Hypernatremia Medical Treatment

• ? serum Na level gradually
• We already talked about how it can cause brain
  damage if you do it too fast
• ? approx. 0.5-1mEq/L/hr over 48 hrs
• Monitor for neuro changes cerebral edema
• Hypotonic solution D5W or 0.45 NS
• Desmopressin (DDAVP)
• As Na levels rise in the blood, fluid shifts out
  of the cells to dilute the blood and equalize the
  concentration. If too much water is introduced
  too quickly the water will move into the brain
  cells causing cerebral edema

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Hypernatremia Nsg Interventions

• Identify pt at risk
• Monitor fluid loss / gain
• Neuro precautions and behavior changes
• Monitor labs
• Monitor oral Na intake
• Offer fluids
• Note medication with ? Na content
• Pts that are at risk for hyper are infants,
  confused ppl that wont take in any liquids,
  immoble people, elderly, unconscious people, and
  people post surgery procedures