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Fluid and Electrolytes

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Title: Fluid and Electrolytes


1
Fluid and Electrolytes
  • By Diana Blum MSN
  • Metropolitan Community College
  • NURS 2140

2
Why are Fluids and Electrolytes Important for the
nurse to understand?
  • - - essential to identify and define the problem
  • - - what is the relationship to the disease
    process
  • - - what intervention is appropriate
  • - - how will the intervention affect the pt
  • - - safety management of infusion therapy
  • - - what is the IV infusion order, why was
  • it ordered
  • - - continual assessment evaluation of
  • pt progress, status of labs
  • - - response to treatment

3
Fluids and Homeostasis
  • Homeostasis a dynamic process
  • - continuous series of self-regulating
  • adjustments to maintain a balance of the
  • internal environment.
  • - needed for normal body functioning
  • Homeostasis is preserved through the intake and
    output of water.

4
Water
  • - the primary chemical component within
  • the body and a person can perceive a need for
  • - those with lean tissue mass have
  • HIGHER of body water than body
  • with more fat
  • - average adult female 52 water by weight
  • - average adult male 63 water

5
  • 60 of average adult is water and electrolytes
  • 80 of infants
  • Influences on amount
  • Age
  • Gender
  • Body fat
  • Water is in 2 spaces intracellular and
    extracellular spaces
  • 2/3 intracellular
  • 1/3 extracellular

6
Body fluid compartments60 of adult total body
weight is fluid
  • Intra-cellular
  • 75 of all body fluid.
  • Extra-cellular
  • 25 of all body fluid Three extra-cellular
    compartments.
  • 1. Intra-vascular
  • 2. Interstitial
  • 3. Third space (eyes, joints,plural
    space,etc.)

7
Osmolality
  • - refers to concentration of a solution
  • - expressed in milliosmols of solute per liter
    of
  • solution (mOsm/L) (could also be mEq/L
    or
  • mg/dL which is mg per 100 ml
  • The effect an IV solution has on fluid
    compartments depends on the solutions osmolarity
    compared to the serums osmolarity.

8
  • Water balance is detected by osmolality of the
    blood.
  • Osmolality the total solute concentration

9
Movement of body fluids (a.)Natural movement no
energy required.
  • Osmosis
  • Movement of solvent, H2O across a semi-permeable
    membrane, from an area of lesser solute
    (particle) concentration to an area of higher
    solute concentration.
  • Diffusion
  • Movement of solute (particles) from an area of
    higher concentration to an area of lower
    concentration.

10
Osmosis
  • - the passage of water through semi-permeable
    membrane in cells and capillaries
  • - water molecules are very small
  • - a membrane that is semi-permeable is more
    permeable to water since the openings on the
    membrane are so small
  • OSMOTIC PRINCIPLE water flows from a dilute
  • solution to a more concentrated solution
  • Once the concentration of solutes are equal on
    each side of the membrane the flow of water
    stops and the solutions are isosmotic to each
    other.

11
Osmotic Pressure
  • Osmotic Pressure is the amount of hydrostatic
    pressure (the physical force of water as it
    pushes against vessel walls or cellular
    membranes) needed to draw water across the
    membrane.
  • This pressure developed as a result of high conc.
    of particles colliding with one another and as
    the of solutes increase, this results in
    increased osmotic pressure.

12
Diffusion
  • May be simple or facilitated
  • Facilitated diffusion
  • a Biochemical process in which a substance is
    selectively transported across a cell membrane
    using a carrier molecule and energy.
  • Insulin/glucose
  • See page 419

13
Movement of body fluids (b.)Movement requiring
energy (Biochemical Processes)
  • Active transport
  • Movement of a substance across a cell membrane,
    through special portals in the cell wall, from an
    area of less concentration to an area of high
    concentration.
  • Calcium channels
  • Sodium-Potassium Pump
  • The most important pump in the
    whole system and one of the greatest users of
    energy in the body at rest.
  • A carrier that transports
    sodium out of the cell and pumps potassium into
    the cell
  • This is what maintains a higher
    level
  • of K intracellularly

14
Hydrostatic Pressure
  • Normal fluid exchange by the capillary wall
    depends on this
  • Definition the pressure exerted by the fluid on
    the walls of blood vessels at both the arterial
    and the venous ends of the vessel
  • The direction of the fluid depends on the
    difference in force between the 2 agents
  • Pg. 419

15
Purpose of water in body
  • - serves as a vehicle for the delivery of
  • electrolytes nutrients to body cells
  • - vehicle for excretion of waste products
  • - medium for biochemical reactions
  • - contributes to temp regulation, cushions
    organs/joints

16
Water Intake
  • Water need is signaled through the mechanism of
    thirst.
  • Mechanism of thirst derives from osmotic
    pressure from extracellular fluids and a thirst
    center in the hypothalamus.
  • - about 60 daily water from drinking
  • -about 30 from moist foods
  • -about 10 from water of metabolism (GI
    secretions)

17
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18
Water Output
  • 4 avenues for daily water loss
  • 1. lungs 3. urine
  • 2. skin 4. GI tract
  • The route of water loss depends on temp.,
    humidity, physical exercise. The higher the
  • temperature outside, water loss via skin
  • lungs increases.

19
Water Balance
  • When a person drinks an excessive amount of
    water, urine output increases.
  • If a person did not drink any fluids OR if the
    body
  • loses excessive water, the urine volume
    decreases.
  • Water balance occurs when water intake
  • water output

20
Nursing Interventions for monitoring fluid status
  • Body Weight Changes (acute)
  • - - l Liter of body water is to 2.2 lb
    of

  • body wt
  • Accurate intake output
  • - - 1,500 to 2,000 mL daily requirement

21
Water Balance
  • -. regulated through neurosecretions of the
    hypothalamus (antidiuretic hormone - -
  • ADH or vasopressin)
  • - regulated through the mineralocorticoid
  • secreted from the adrenal cortex - -
  • (Aldosterone)

22
Water Distribution
  • The total volume of water in the body is
    distributed among 2 large compartments
  • 1. Intracellular
  • 2. Extracellular
  • (a cell membrane which is selectively permeable
    separates these 2 compartments)
  • Pg 418

23
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24
Thirst
25
Hypervolemia
26
ADH (Regulates Extracellular Fluid Osmolality)
Regulates water output
  • - - acts directly on the collecting ducts and
    tubules of the nephrons to bring about water
    reabsorption
  • ADH (produced in hypothalamus)
  • ?
  • secreted by posterior lobe of
  • pituitary gland
  • ?
  • regulates water retention and
    excretion
  • (not solutes)

27
ADH release (continued)
  • Leads to Renal water retention
  • a decrease in tonicity of ECFV

28
ADH (continued)
  • ADH release is also influenced by drugs
  • Nicotine, morphine, barbituates increase
    ADH
  • Alcohol inhibits ADH release

29
Diabetes Insipidus
  • Causes
  • Neoplasms, neurosurgical procedures in area
    of pituitary gland, vascular changes - stroke,
  • aneurysm, cerebral edema
  • Onset abrupt

30
Diabetes Insipidus
  • Uncommon 1 in 25,000
  • Decreased secretion of ADH
  • Results in polyuria (from 3 to 18 liters/day)
  • Polydipsia
  • Common form follows trauma or surgery to the
  • region of the pituitary hypothalamus
  • Hallmark Signs
  • urine specific gravity 1.005 or less (norm
    1.016-1.022)
  • Urine osmolality lt200 mOm/kg
  • Treatment Desmopressin (DDAVP)
  • - - synthetic vasopressin Dose
    intranasal or PO form

31
Diab. Insipidus (continued)
  • Fluid replacement slow correction to prevent
    rapid shift of fluids (cerebral edema)
  • IV .45 saline
  • Infants and elderly exhibit more symptoms since
    unable to adjust to fluids changes.

32
Diab. Insipidus (continued)
  • Physical exam
  • dehydration
  • - ?d tear formation, dry lips/mouth
  • - c/o excessive thirst
  • - skin tenting
  • - dizziness
  • - urine clear to pale yellow
  • - copious amounts urine
  • - tachycardia
  • -orthostatic changes

33
Diab. Insipidus Nursing Interventions
  • Focus adequate balance of fluid I O
  • - daily weights
  • - urine specific gravity (norm gt1.010)
  • - serum sodium 136 145 mEq/L (water loss
  • leads to hemoconcentration)
  • Document
  • skin turgor, UO, color of urine
  • 24 hour I O
  • Body wts

34
Syndrome of Inappropriate Antidiuretic Hormone
Secretion (SIAHS)
  • ADH is secreted without any hemodynamic disturb.
  • Excessive release of ADH
  • Diagnotics
  • hyponatremia (serum lt135 mEq/L)
  • Hypotonicity (plasma osmolality lt280
    mOsm/kg
  • - water retention, ? ECF
  • Concentrated urine gt100 mOsm/kg water
  • Increased urine sodium conc. (gt20 mEq/L)
  • Associated with underlying disorder

35
SIADH Excess ADH Secretion
  • - ? s renal tubular permeability reabsorption
    of water in circulation
  • -results in ECF excess
  • - results in decreased sodium levels
  • With No treatment
  • Water intoxication accomp. with sodium
    deficit leads to water movement in cerebral
    cells, which leads to cerebral edema coma- death

36
SIADH (continued)
  • Low serum Na may lead to seizures
  • May need airway management
  • Position pt flat or 10 degrees and this enhances
    venous return left atrial pressure and
    reduces the release of ADH
  • Fluid restriction
  • Consider piggyback fluids in Intake

37
Syndrome of Inappropriate ADH
  • Fluid restrictions
  • IV 3 saline
  • - use caution , use IV pump to infuse
  • - monitor pt carefully(Na and water
    retention may result leads to pulmonary
  • congestion, shortness of breath)

38
SIADH
  • Closely monitor this pt
  • signs of hyponatremia
  • wt change
  • fluid imbalance
  • restlessness
  • CHF
  • convulsions

39
SIADH (continued)
  • Causes
  • Idiopathic (most common)
    malignancy to lung, brain
  • head trauma
    antibiotics
  • stroke
    asthma, COPD
  • neonatal hypoxia
    pneumonia, Tb
  • brain tumor
    oral hypoglycemics
  • hydrocephalus
    thiazide diuretics
  • subarachnoid hemorrhage
  • encephalitis
  • meningitis
  • cerebral abscess

40
Aldosterone regulates Extracellular Volume
  • - - maintains water balance by Na reabsorption
    in the distal tubule and collecting ducts
    (nephrons)
  • - - When there is decreased renal blood flow,
    aldosterone causes Na retention which causes
    water retention

41
Aldosterone
  • ? Na levels or extracellular vol decreases
  • ?
  • aldosterone secreted
  • ?
  • reabsorption of water and Na by kidneys
  • ?
  • ECF increases

42
Hypotensive
  • Hypotension, ? renal blood flow
  • ?
  • stimulates renin release (secreted by
    juxtaglomerular cells in kidneys)
  • ?
  • Splits angiotensinogen (produced by liver)
    circulates in the blood, to angiotension
  • ?
  • Lungs convert angiotensin I into angiotensin II
    (potent vasoconstrictor)
  • ?
  • Stimulates secretion of aldosterone (from adrenal
    cortex)
  • ?
  • Regulates Na reabsorp in distal tubules
    collecting ducts
  • ?
  • Chloride water passively accompany Na reabsorp
    RESULTING IN
  • SALINE, 0.9NS which is ECF !!!

43
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44
Extracellular Fluid (ECF)
  • Intravascular
  • 3 of the 6 liters of blood is plasma
  • Other 3 liters is erythrocytes, leukocytes,
    thrombocytes
  • Interstitial
  • Contains fluid that surrounds the cell
  • Totals 11-12 liters
  • Lymph is example
  • Transcellular
  • CSF, pericardial, synovial, intraocular, pleural
    fluids, sweat, digestive secretions

45
Two Main Functions of Extracellular Fluid
  • 1. To maintain cell membrane permeability
    membrane potential for appropriate membrane
    function
  • 2. To serve as the vehicle for the movement of
    life-sustaining substances to from various
    areas of the body

46
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47
Shifting
  • Fluid shifts b/w spaces to maintain equillibrium
  • Third spacing
  • Fluid goes into a space that is not ICF or ECF
  • s/s decreased urine output, increased heart
    beat, hypotension, edema, wt gain
  • Happens in ascites, burns, peritonitis, bowel
    obstruction, massive bleeding

48
Hypertonic ECF
  • When excess Na OR ? blood vol.
  • ?
  • Release of ADH
  • ?
  • Results in sensation of thirst while
  • conserving body water through
  • reabsorption

49
Hypotonic ECF
  • When ECF becomes hypotonic or if
  • there is increased blood volume
  • ?
  • Pituitary is signaled to inhibit
  • release of ADH
  • ?
  • Stimulates the excretion of urine (to
    concentrate the ECF )

50
3 major purposes of IV therapy
  • 1. to meet daily maintenance needs
  • 2. to replace ongoing losses
  • 3. to supply electrolytes to correct any
  • exisiting disturbances

51
TonicityThe concentration and size of particles
in solution.
52
Intravenous Fluids
  • Colloids
  • Contain large protein molecules. Stay in vascular
    space.
  • Not used pre-hospital.
  • Plasmanate
  • Dextran
  • Hetastarch
  • Crystalloids
  • Contain non-protein particles.
  • Commonly used Pre-hospital.
  • Normal saline
  • Lactated Ringers
  • D5W

53
Pre-hospital Intravenous Fluids
54
In terms of Osmolality
  • Isotonic solution has the SAME
  • osmolality as normal plasma
  • - NO osmotic pressure difference is
  • created, so fluids stay in ECF
  • - usually corrects fluid status in 48 hr
  • Uses of
  • - replace ECF losses to expand
  • vascular vol. quickly,
  • hemorrhage
  • Potential problems Circulatory Overload

55
Isotonic IV fluids
  • 1. 0.9 NaCl or called NS
  • sodium and chloride in water has
    similar
  • osmolality of plasma ( a
    little higher,
  • 308 mOsm/L)
  • provides NO calories
  • Problems since Na Cl more
    than pt
  • needs, watch for circulator overload,
    hypernatremia
  • esp in elderly in pt in stress ,
    chronic glomerulonephritis
  • (need more water to excrete salt than
    normal renal funx)

56
  • 2. Ringers solution
  • contains Na, K, Ca,
  • NO dextrose, Mg, bicarbonate
  • NO calories or free water
  • similar to NS and preferred for
  • treating pts with dehydration after water loss
    or reduced intake (vomiting, diarrhea, fistula
    drainage)

57
Lactated Ringers very close to a
near-physiological solution
  • 3. Lactated Ringers
  • contains Na, Cl, K, Ca, lactate in
  • concentrations most similar to
    normal
  • plasma
  • - - provides some dextrose
  • - - prevents catabolism
  • -- useful for burns/bile loss/diarrhea
  • - - do not give with liver disease
    (lactate ion metabolized in liver to bicarbonate
    which
  • helps combat acidosis Would have to infuse
    Ringers solution instead

58
HYPOTONIC
  • - has lower osmolality than normal plasma
  • water is pulled out of vessels into the cells,
    resulting in ? vascular volume ? cell water.
  • USES - - to prevent treat cellular
    dehydration by providing free water to cells
  • - - NEVER used in acute brain injuries
    because cerebral cells are very sensitive to free
  • water, absorbing it quickly leading to CELLULAR
    EDEMA!!!!!!!!

59
Hypotonic IV Solutions
1.
  • 1. D5W (5 Dextrose in Water)
  • - - remember this about D5W as it is
  • isotonic in the bag, it has a
  • hypotonic effect on the body since
  • the dextrose is rapidly metabolized
  • once infused leaving FREE WATER
  • that shifts by osmosis from vessels
  • into cells
  • For each liter of D5W
  • 2/3 of it enters cells, 1/3 remains in
  • extracellular space

60
Half-Strength Saline
  • 2. 0.45 saline (1/2 NS)
  • 0.224 saline (1/4 NS)
  • These IV fluids provide free
  • water to cells small amts of NA
  • and Cl
  • Treats fluid needs with a pt with
  • hypovolemic pts with
    hypernatremia
  • ½ of each liter moves INTO cells
  • the other ½ remains in ECS
  • EXCESSIVE use causes dilutional hyponatremia

61
  • 3. D5 ½ NS (5 dextrose in 0.45 saline)
  • D5 ¼ NS (5 dextrose in 0.225 saline
  • Both are hypertonic
  • Both are composed of hypotonic saline
    solutions
  • Dextrose doesnt meet daily nutritional
    requirements
  • but enough to help prevent
    ketosis in starvation
  • hydrates
  • use cautiously in edematous pts

62
Hypertonic
  • - - has a higher osmolality than normal
  • plasma
  • - - water will be pulled from the cells into
  • the vessels
  • - - results in increased vascular volume
  • and decreased cell water

63
Hypertonic (continued)
  • - these IV solutions are carefully controlled
  • to avoid vascular vol. overload cell
  • dehydration
  • - ALSO used to pull excess fluid from
  • cells and to promote osmotic diuresis
  • - - replaces massive Na loss or removes
    intracellular fluid
  • MUST KNOW REASON FOR INFUSION, CONDITION OF PT,
    PROPER RATE OF INFUSION, S/S OF HYPERTONIC
    EXPANSION

64
Hypertonic IV Solutions
  • 3 Saline
  • 5 Saline
  • 10 Dextrose
  • 50 Dextrose
  • these are all used cautiously
  • always use IV pump infuse slowly
  • ONLY USED RARELY FOR SEVERE SYMPTOMATIC
    HYPERNATREMIA
  • CAN CAUSE SEVERE VOL OVERLOAD,
  • PULMONARY EDEMA

65
The Composition of Body Fluids
  • - water is the main constituent of all body
    fluids
  • - acts as a solvent ---able to hold substances
    and act to dissolve them
  • Solutes---the substances dissolved in the water
    (solvent).
  • THE COMBINATION OF THE SOLVENT AND SOLUTE FORMS A
    SOLUTION.

66
2 Major categories of solutes
  • 1. Electrolytes
  • - cations (positive ions)
  • - anions (negative ions)
  • 2. Nonelectrolytes
  • - dextrose
  • - creatinine
  • - urea

67
Electrolytes
  • - - make up 95 of the bodys solute molecules
  • - - are chemicals that carry an electric charge
    (ions)
  • - - ions converts a solution into a product
    capable
  • of conducting electricity
  • Ions with a negative charge anions
  • Ions with a postive charge cations

68
Electrolytes (continued)
  • - - expressed in milliequivalents per liter
    (mEq/L)
  • - -the number of electrical charges per liter of
    fluid
  • - - crucial for distribution movement of water
  • - - needed for maintenance of acid/base balance
  • - - the chemical needed to carry out cellular
    reactions
  • - - necessary for transmission of electrochemical
    impulses in muscles nerve fibers

69
Electrolyte Imbalances
  • can occur suddenly
  • - must be able to assess these changes
  • - intervene appropriately timely manner
  • - frequent review of lab values, diagnostic
  • tests, meds, IV fluids orders

70
Fluids ElectrolytesIons Charged particles
  • Cation Positively Charged particles.
  • Sodium ( Na )
  • Potassium ( K)
  • Calcium (Ca)
  • Magnesium (Mg)
  • Major players in ECF sodium
  • Low concentration of potassium and can only
    tolerate small changes in it
  • Anion Negatively charged particles.
  • Chloride (Cl-)
  • Bicarbonate (HCO3-)
  • Phosphate (HPO4 -)
  • Major players in ICF potassium and phosphate

71
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72
HyponatremiaSerum level lt135 mEq/L
  • Greater concentration of water than that of Na
  • (hypervolemic state)
  • Etiology
  • Conditions that cause loss of body
    fluids
  • abnormal loss of GI secretions
  • vomiting, diarrhea, drainage from
  • suction, fistulas, excessive tap water
  • enemas
  • excessive sweating
  • excessive water consumption
  • Burns

73
Hyponatremia
  • Hypovolemic hyponatremic pts treat with isotonic
    saline.
  • If severe infuse 3 to 5 NS slowly in small
    volumes. Monitor for s/s of circ. overload
    (dyspnea, crackles, engorged veins)
  • Monitor IV site closely (irritating to veins)
  • Use IV pump
  • Wts, I O

74
Hyponatremia
  • Risk Factors
  • very young, elderly
  • female
  • Meds thiazide diuretic use
  • IV of hypotonic solutions (D5W)
  • irrigations
  • tap water enemas
  • Surgery that requires irrigations (TURP)

75
HyponatremiaClinical Manifestations
  • Signs are related to shift of water into the
    cells
  • Cardiovascular
  • bounding pulse, tachycardia, hypotension
  • (with decreased ECV), hypertension (with
  • increased ECV)
  • Integumentary
  • pale, dry skin, dry MM (with decreased
  • ECV, edema, wt gain ( with increased
    ECV)
  • Renal
  • thirst, renal failure
  • Neuromuscular
  • weakness, headache, confusion, seizures
  • GI
  • Vomiting, diarrhea

76
Hyponatremia etiology (continued)
  • Conditions that increase extracellular fluid
  • disease states that add to increased vol
    (CHF)
  • Syndrome of inappropriate anti-
  • diuretic hormone secretion (SIADH)
  • Hyperglycemia
  • Prolonged use Hypotonic IV

77
Hypernatremia
  • Elevated Sodium
  • ?
  • Hypertonicity occurs which stimulates thirst and
    ADH release
  • ?
  • Body takes in water (thirst is such a powerful
    stimulus that it is uncommon for a person with a
    normal thirst mechanism and access to water to
    develop hypernatremia!!!)
  • ADH release leads to water retention to
  • lower sodium concentration

78
Hypernatremia symptoms (continued)
  • Cardiovascular tachycardia, hypertension
  • decreased cardiac contractility
  • Integumentary dry sticky mucous
  • membranes, rough, dry tongue,
  • flushed skin
  • Renal thirst, increased urine output
  • Neuromuscular twitching, tremor, hyperreflexia
  • agitation, central nervous
    system
  • irrability, seizures, coma
  • GI Watery diarrhea, nausea

79
Hypernatremia (continued)
  • Since sensitivity to thirst declines with age
    will see in elderly pts
  • Water shift out of cells to establish osmotic
  • equilibrium, brain cells shrink.
  • Symptoms
  • progressively lethargic
  • comatose
  • intracranial bleed may occur (with brain
    tissue shrinking, puts pressure on meninges/vein
    in skull) Autopsies who died from hypernatremia
    have
  • Been found to have widespread cerebral bleeds.

80
Hypernatremia diagnostic lab
  • Plasma levels greater than 145 mEq/l
  • May see increase U.O.
  • Chloride may be elevated
  • Serum Osmolality gt290 mOsm/kg
  • Increased BUN,HCT

81
  • Brain cells are are very sensitive to changes in
    sodium levels!
  • Hyponatremia Hypernatremia
  • ?
    ?
  • brain swelling brain shrinking
  • Too rapid of a correction in sodium further
    compromises the pts condition.

82
Hypernatremia (continued)
  • Etiology
  • decreased fluid intake
  • increased insensible loss
  • watery diarrhea
  • osmotic diarrhea ( due to
    enteral tube feedings)
  • increased sodium intake
    (dietary or infusion of
  • sodium fluids)
  • diabetes insipidus (defect in
    ADH secretion
  • causing sodium
    retention increased
  • secretion of
    dilute urine) can occur head trauma
  • High Glucose levels (osmotic
    diuresis)
  • Admin. Of hypertonic IV
    solution
  • (usually happens with
    NaHCO3 or 3 Saline)
  • Can occur with 0.9 NS

83
Treatment of Severe Hypernatremia
  • 1. first with 0.9 NS
  • - - administered at rate to correct
  • but avoids cerebral edema
  • - - correction occurs in 36-72 hrs
  • 2. Once volume deficit restored then
  • D5W
  • (these steps will prevent cerebral edema from an
    overly rapid correction)

84
Hypernatremia Nursing Interventions
  • Monitor labs
  • Accurate I O
  • Daily Wts
  • Monitor for central nervous system changes
  • Seizure precautions (safe environment)
  • Limit Na intake

85
Potassium
  • Most abundant intracellular cation.
  • Necessary for transmission and conduction of
    nerve impulses.
  • Maintenance of normal cardiac rhythm.
  • Necessary for smooth and skeletal muscle
    contraction.

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87
Potassium major cation intracellularNormal 3.5
to 5.0 mEq
  • ECF K
  • maintains action potentials in muscle,
    neuron cells.
  • assists in controlling cardiac
    rate/rhythm,
  • conduction of nerve impulses, skeletal muscle
  • contraction, function of smooth muscles
  • endocrine tissues.

88
WHAT CAUSES K Movement intra/extracellularly??
  • 1. The sodium-potassium pump controls the
    conc. of K by removing 3 sodium ions from the
    cell for every 2 K that return to the cell
  • 2. INSULIN moves K into cells. ( deficiency of
  • insulin places pt at risk for hyperkalemia)

89
  • 3. extracellular pH changes acidosis causes K
    to move out of cells in exchange for H to move
    into cells
  • 4. stimulation of Beta2 receptors causes
  • K to shift into cells (increased activation
    of Na/K ATPase pump)
  • 5.movement of water out of cell carries K with
    it due to increase in osmolality

90
Potassium (continued)
  • Kidneys eliminate 90 of K, remaining is
    eliminated through stool perspiration.
  • Body cannot store K, need daily intake
  • Usually daily intake loss
  • Need 1 mEq/kg body/wt /day
  • 20 loss of GFR will cause hyperkalemia
  • Hyperkalemia stimulates aldosterone which
  • increases Na/K exchange(increase Na
  • reabsorp thus K excreted in urine)

91
Hypokalemia
  • Serum level lt 3.5 mEq/l
  • A common disturbance
  • If not corrected quickly - - leads to cardiac
    resp arrest
  • Alkalosis causes K to migrate into cells as H
    move out to correct the high pH.
  • Water intoxication causes dilution of serum K.
  • K wasting diuretics
  • Excessive loss in GI tract (most common cause can
    be
  • 30 mEq/L in liquid stools)
  • Hemodialysis
  • NPO without sufficient IV replacement therapy
    with K
  • Malnutrition

92
Hypokalemia other causes
  • Prolonged use of digitalis or corticosteroids
  • Laxative abuse
  • Excessive vomiting or diarrhea
  • Excessive diaphoresis
  • Excessive wound drainage (esp. from GI)
  • Prolonged NG suctioning
  • Abnormal movement of K from ECF to ICF from
    alkalosis
  • hyperalimentation

93
Hypokalemia other causes
  • Hyperinsulinism
  • Transfusion of frozen RBC (low in K)
  • Prolonged use K wasting diuretics
  • Severe burns
  • Increased secretion of aldosterone as in
  • Cushings syndrome
  • Renal disease

94
Hypokalemia Manifestations
  • Weak, thready pulse
  • Pedal pulses difficult to palpate
  • ECG changes ST segment depression
  • flattened T wave
  • appearance of U wave
  • PVCs, heart block
  • Enhanced effects of Digoxin (toxicity at
  • therapeutic levels)

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Hypokalemia Manifestations (continued)
  • Decreased breath sounds
    cardiac dysrhythmias
  • Shallow respirations
    sudden cardiac death
  • Dyspnea
  • Polyuria
  • Decreased deep tendon reflexes
  • Muscle weakness
  • Anxiety
  • Lethargy
  • Leg cramps
  • Abd. Distention
  • Hypoactive bowel sounds
  • Nausea/vomiting
  • Constipation
  • Paralytic ileus

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Hypokalemia Nursing Interventions
  • Monitor vitals - orthostatic hypotension common
  • Monitor serum K levels
  • Assess heart rate/rhythm
  • Assess ECG changes
  • Assess Resp. rate, depth, pattern
  • Protect from injury
  • Monitor I O
  • Check for signs of metabolic alkalosis
  • Give K supplements as ordered
  • Use infusion pump for parenteral K Assess IV
    site freq. for
  • infiltration, phlebitis
  • Assess mental status (confused, apathetic,
    anxious, irritable)

99
Hypokalemia Nursing interventionswith oral
replacement agents
  • If admin. Liquid K remember to dilute
  • If admin slow-release K follow with water
  • Admin. After meals
  • Observe for GI bleeding
  • Do not crush
  • Be aware of hyperkalemia
  • Do not give with pts on potassium sparing
  • diuretics
  • GI IRRITATION SYSTEMS N/V, ABD DISCOMFORT,
  • DIARRHEA - - so need to dilute, or dose ?

100
Hypokalemia Nursing Interventions (continued)
  • ORAL replacement is preferred.
  • IV replacement with severe
  • Remember, always use a pump
  • observe site freq.
  • always verify K in
    solution
  • before hanging
  • Do not exceed safe
  • administration
    rate
  • Observe pts mental status during therapy

101
K IV replacement continued
  • Rate of administration NO more than 10 mEq/hr or
    concentration greater than 40 mEq/L
  • Higher concentrations admin. through Central
    line
  • The diluent should be Dextrose free to prevent
  • release of insulin
  • If more than 20 mEq/hr is given, then
  • continuous ECG monitoring and check
  • serum levels every 4 to 6 hr until normal

102
Hypokalemia nursing interventions (continued)
  • Assess skeletal muscle weakness by bilateral
    hand grasps, inability to stand,
    hyporeflexia,profound flaccid paralysis
  • Abd distention
  • Hypoactive bowel sounds

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Hyperkalemia
  • Serum levels gt 5.0 mEq/L usually assocd with
    renal impairment
  • K moves from ECF to ICF
  • Myocardium most sensitive to ? K levels
  • Etiology
  • Rapid infusion IV K
  • Addisons disease (due to ? aldosterone
    that leads to Na
  • renal failure depletion K
    retention)
  • K sparing diuretics
  • Ace inhibitors
  • massive cell damage
  • burns
  • GI bleeds
  • hemolysis of blood sample from prolonged
    tourniquet use
  • during blood draws may cause RBC hemolysis

105
Hyperkalemia Clinic Manifestations
  • CV irreg, slow heart rate
  • decreased BP
  • ECG changes narrow, peaked T
  • waves, widened QRS, prolonged
  • PR intervals, flattened P waves
  • freq. ectopy, V-fib, V-standstill
  • Resp unaffected until extreme high level
  • then resp. failure due to muscle
  • weakness
  • GI hypermobility, hyperactive, nausea, abd
    cramping
  • bowel sounds, diarrhea (due to
    hyperactivity)
  • Neuromuscular Early muscle twitching
  • Late paralysis
    arms/legs

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Hyperkalemia Lab
  • K gt 5.0 mEq/L
  • If dehydration causing hyperkalemia
  • - expect Hct, Hgb, Na,Cl- elevated
  • If assoc. with renal failure
  • - creatinine, BUN levels
  • Blood gases to monitor Metabolic Acidosis
  • - hyperkal. freq. seen with acidotic
  • state ( often self corrects with pH is
  • corrected)

109
Hyperkalemia Therapeutic Interventions
  • No K oral, in IV
  • Promote K excretion ? U.O.
  • Monitor pt
  • Kayexalate or 70 Sorbitol (given oral or rectal)
    (works to exchange Na with K in the GI tract
    K excreted in stool)
  • Calcium gluconate given IV
  • - does not promote K loss
  • - decreases myocardial irritability
  • Regular Insulin and dextrose (short term
    therapy)
  • - to shift K from ECF to ICF
  • Sodium Bicarbonate
  • - to make cells more alkaline ( ? pH) as
    this shifts K back
  • into cells
  • Diuretics (K wasting type loop diuretics
    thiazide)

110
Potassium Electrolyte Imbalances3.5 - 5.5 mEq/L
  • Hyperkalemia
  • EKG changes, paresthesia, GI motility
  • Stop K - oral or IV
  • Administer K excreting diuretics (lasix) and
    Kayexlate dialysis if severe K insulin
    administration
  • Hypokalemia
  • Hand grasp weak, hyporeflexia, muscle weakness,
    shallow respirations, pulse thready and weak,
    dysrhythmia, lethargic, confusion, coma, GI
    hypoactivity VS, EKG changes fiber and fluids
  • Administer K oral or IV, monitor lab work,

111
Calcium
  • Extracellular cation
  • Plays role in nerve impulse transmission.
  • Increases force of muscle contractions.
  • Functions as an enzyme co-factor in blood
    clotting.
  • Necessary for structure of bone and teeth.

112
Calcium
  • Major ECF cation
  • Stored in hard bones
  • Concentration is kept constant by calcium pump
  • moving calcium in out of cells
  • Normal levels 8.5 to 10.5 mg/dl
  • Changes in serum protein (esp. albumin) causes
  • changes in calcium level (since calcium is
    bound to protein)
  • Parathyroid hormone responsible for transfer
  • of calcium from bone to plasma
  • - also, aids in intestinal
    absorption
  • - enhances renal calcium
    reabsorption

113
Calcium Functions
  • Enhances bone strength durability (with phos.)
  • - an ? in calcium causes ? in phosphate
    reverse also
  • Helps maintain cell-membrane structure,
  • function, permeability
  • Affects activation, excitation, contraction of
  • cardiac skeletal muscle
  • Helps activate specific steps in blood coag.
  • Assists in regulation of acid-base bal.
  • Plays major role in nerve impulse transmission
  • as it determines the speed of ionic refluxes
  • through nerve membranes

114
Hypocalcemia
  • Level lt 8.5 mg/dl
  • Most common cause inadeq. secretion
  • of parathyroid hormone caused by
  • hypoparathyroidism
  • Other causes
  • - diarrhea
  • -wound exudate
  • - acute pancreatitis

115
Hypocalcemia Common Signs
  • CV ? BP, ECG changes with prolonged QT
  • interval, lengthened ST segment, cardiac
  • arrest
  • Resp laryngospasm
  • Renal renal failure
  • Neuromuscular Positive Trousseaus Sign
  • (carpopedal spasm)
  • Positive Chvosteks
    Sign
  • - tapping over
    facial nerve just
  • ant. to ear
    cause ipsilateral facial

  • contraction/twitching
  • Hyperactive deep
    tendon reflexes
  • seizures

116
Hypocalcemia common symptoms
  • Neuromuscular paresthesias/tingling in
  • hands/feet
  • muscle spasms of extremities/face
  • hyperactive reflexes
  • increased irritability
  • mental changes
  • Other intestinal cramps, dry, brittle nails
  • dry hair, bone pain, ? bruising

117
Hypocalcemia signs (continued)
  • GI possible hyperactive bowel sounds/diarrhea
  • Musculoskeletal Possible bone fractures due to
  • demineralization, osteoporosis

118
Hypocalcemialengthened QT interval
119
Hypocalcemia (continued)
  • Trousseass Sign
  • Test for tetany
  • positive test in hypocalcemia
  • hypomagnesemia
  • A carpal spasm is induced by
    inflating BP cuff on
  • upper arm to a pressure
    exceeding systolic BP
  • for 3 minutes
  • Chvostekls sign
  • - test for tetany
  • - an abnormal spasm of facial muscles
    elicited by
  • light tap on the facial nerve
  • - seen in hypocalcemia

120
Hypocalcemia treatment
  • Calcium gluconate(oral)
  • or
  • 10 Calcium gluconate IV 500mg 2 g
  • at a rate of lt0.5 ml/min (10-20 mL)
  • SLOW IV push
  • - if too rapid can cause bradycardia
  • or cardiac arrest

121
Hypocalcemia Nursing Interventions
  • Seizure precautions
  • Calcium labs
  • Monitor ECG
  • Monitor IV site if calcium given this route
  • Monitor for hypocalcemia if pt receiving
  • many units of citrated preserved blood
  • since phosphorus is in it

122
Hypercalcemia
  • Excessive release of calcium from bone due to
    malignancy, hyperparathyroidism,
  • thiazide-diuretic use, excessive calcium
  • intake.
  • Symptoms seen when level gt 12 mg/dL

123
Hypercalcemia due to
  • Hyperparathyroidism
  • Metastatic cancer
  • Use ot thiazide diuretics
  • Immobility
  • Vit. D intoxication
  • Hypophosphatemia
  • Hyperthyroidism (excessive bone resorption)

124
Hypercalcemiaclinical manifestations
  • Common signs/symptoms
  • CV hypertension, ? ST segments
  • shortened QT interval, hrt block
  • cardiac arrest
  • Neuromuscular depressed neuromuscular
  • excitability, decreased deep tendon
  • reflexes, impaired memory,
    lethargic,
  • coma
  • GI hypoactive bowel sounds, constip. N/V
  • Renal polyuria, polydipsia, renal calculi
  • Musculoskeletal bone fractures/thinning, deep
    bone
  • pain

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Hypercalcemia Treatment
  • Admin. 0.9 NS to dilute serum
  • calcium level promote renal excretion
  • Admin. Phospate orally or enema
  • Lasix to prevent fluid overload during saline
    admin.
  • Hydration 3,000-4,000mL/day

127
Hypercalcemia Nursing Interventions
  • Monitor calcium/phos. levels
  • ECG monitoring
  • Strict IO
  • Daily wt
  • Monitor neuro status
  • Drug therapy
  • Isotonic saline IV
  • Loop diuretics (enhances calcium
  • excretion, prevent fluid overload)
  • Corticosteroids (inhibit calcium absorp.
    in
  • intestine, increase urinary
    excretion of calcium
  • Phosphate (oral or rectal)

128
Calcium Electrolyte Imbalances
  • Hypocalcemia
  • Trousseaus and Chvostecks signs, vs, heart rate
    up or down, weak, thready pulse, active bowel
    sounds
  • Administer Calcium gluconate, foods high in
    calcium, assess for injury
  • Seizure precautions
  • Hypercalcemia
  • Heart rate and blood pressure severe
    hypercal-slow heart rate, dysrhythmias
  • VS, EKG T wave, QT interval
  • Homans sign
  • Lethargic, confusion, muscle weakness, coma
    deep tendon reflexes without paresthesia
  • Renal calculi IO, strain urine bowels
    sounds
  • Discontinue calcium oral or IV drugs
    (antacids)adm. Saline IV, Lasix diuretics,
    calcium binders, NSAID, dialysis

129
Magnesium
  • Intracellular cation.
  • Activates (ATP-ase) the primary energy source for
    the sodium potassium pump.
  • Plays important role in the relaxation of smooth
    muscle.
  • Stabilizes cardiac muscle cells - decreases
    fibrillation threshold.

130
Magnesium
  • Normal 1.4 to 2.1 mEq/L
  • Needed for
  • enzyme action at least 300
  • reactions
  • regulation of neuromuscular activity
  • - import. For skeletal muscle
  • relaxation following contraction
  • powers the sodium-K pump
  • normal heart rhythm
  • relaxes lung muscles that open airways

131
Hypomagnesemia
  • Due to altered absorption, increased renal loss,
  • Chronic alcoholism ( most common cause)
  • Prolonged IV therapy without Mg supplement
  • - - Mg moves into cells leading to low
    magnesium levels
  • Vomiting, diarrhea
  • Vit D intoxication

132
HypomagnesemiaClinical Manifestations
  • Able to detect symptoms when levels drop below
    1mEq/L
  • Muscle twitching, tremors
  • Hyperreactive reflexes
  • Laryngeal stridor
  • Supraventricular tachycardia
  • PVCs, V-fib
  • Increased susceptibility to dig. Toxicity
  • Mood changes
  • Nausea/vomiting, diarrhea
  • Positive Chvoskeks sign
  • SIGNS SYMPTOMS SIMILAR TO HYPOKALEMIA OR
  • HYPOCALCEMIA BECAUSE THEY ARE ALL CATIONS.

133
Hypomagnesemia
  • Mg levels lt1.4 mEq/L
  • Also decreases in calcium, potassium, phosphate
    levels
  • Treatment
  • oral replacement Mg 300 mg/day
    divided
  • doses
  • IV MgCl 48 mEq/day by continuous IV
  • infusion,
    slowly,
  • If too
    rapid could lead to
  • resp. or
    cardiac arrest.
  • Also,
    flushing, sweating if rate
  • is too
    fast.

134
HypomagnesemiaAssociated labs
  • Decreased Mg (increased renal excretion)
  • Serum Calcium up
  • Blood gases may show resp or met acidosis.

135
Hypermagnesemia
  • Mg level greater than 2.1 mEq/L
  • Most common cause renal failure
  • Other causes
  • - hyperparathyroidism
  • - hyperthyroidism
  • - ingestion of med high in Mg

136
Hypermagnesemia Sign Symptoms
  • Flushing, sense of skin warmth
  • Hypoactive deep tendon reflexes
  • Depressed respirations
  • Hypotension
  • Bradycardia, heart block, cardiac arrest
  • Increased susceptibility to dig. Toxicity
  • N/V
  • Seizures

137
Chloride
  • Balances cations
  • Plays role in fluid balance and renal function.

138
Chloride
  • Normal 95-108 mEq/L
  • Role regulation of serum osmolarity
  • fluid balance
  • Major anion in ECF
  • Reciprocal relationship with bicarbonate
  • Binds with other cations NaCl, HCL, KCL

139
Chloride
  • Important role in acid-base balance
  • chloride shift (chloride shifts is an
    ionic exchange that occurs within RBCs)
  • Maintains a 120 ratio of carbonic acid
    and HCO3 that is essential for pH balance in
    plasma

140
Hypochloremia
  • Level lt95 mEq/L
  • Results from vomiting diarrhea
  • Prolonged use of IV D5 water
  • Signs/symptoms
  • - increased muscle excitability
  • - tetany
  • - decreased respirations

141
Hyperchloremia
  • Lab greater than 106 mEq/L
  • Seen with severe dehydration
  • Head trauma
  • SignsSymptoms
  • - drowsiness, lethargy, headache
  • - weakness, tremors
  • - cardiac dysrhythmias

142
Bicarbonate
  • Principle buffer of body pH. (extracellular)
  • Neutralizes acids.
  • Plays important role in acid / base balance.
  • Acts as chemical sponge to soak up Hydrogen ions.
    (Acidic metabolic waste) For every one Hydrogen
    ion twenty bicarbonate ions are released to
    maintain balance.

143
Phosphate
  • Plays an important role in ATP storage.
  • Chief intracellular buffer acts to maintain
    intracellular pH.

144
Phosphorus
  • Essential to all cells
  • Role in metabolism of proteins, CHO, fats
  • Needed in the formation of ATP
  • Functions in formation of RBC enzyme that aids in
    oxygen delivery
  • 80 contained in bone/teeth
  • 20 in ICF
  • Remember phosphorous and calcium levels
  • that an increase in one will cause a
    decrease in the other.

145
Hypophosphatemia
  • Serum level lt2.5 mg/dL
  • Can result from TPN without phosphorus
  • malabsorption syndromes, alcohol withdrawal
  • vomiting, chronic diarrhea
  • aluminum-containing antacids (which
  • binds phosphorus)
  • diuretics, corticosteroids
  • Treatment of diabetic ketoacidosis
    dextrose
  • with insulin cause phosphorus to move
    into cells

146
Hypophosphatemia Signs Symptoms
  • Anemia from ? fragility of RBC from low
  • ATP levels
  • Bruising (platelet dysfunction)
  • Slurred speech
  • Confusion
  • Seizures, coma
  • Reports of circumoral and fingertip/extrem.
  • numbness tingling
  • Muscle weakness, paresthesias
  • Tremors, tetany
  • Chest pain
  • Dysrhythmias due to decreased oxygen

147
HypophosphatemiaSigns Symptoms (continued)
  • Increased rate/depth breathing in response to
    hypoxemia
  • Hypoactive bowel sounds, vomiting

148
Hypophosphatemia treatment
  • Oral phosphate supplements (Neutra-Phos) for mild
    deficiency
  • IV phosphorus for severe (watch for hypocalcemia,
    hyperphosphatemia)
  • - may be added to TPN
  • - hypotension may occur if too fast
  • admin.
  • watch infusion site for infiltration (unless in
    central line)

149
Hyperphosphatemia
  • Major cause renal disease
  • Phosphate shifts into the ECF
  • Signs symptoms
  • tetany, mental changes
  • Levels gt4.5 mg/dL
  • Hypocalcemia may occur in sudden
    hyperphosphatemis such as in IV admin.
  • of phosphates.

150
HyperphosphatemiaManagement
  • Promote phosphorus excretion
  • - use aluminum-containing antacids to bind
    phosphates in the GI tract

151
Use this as quick reference when studying
electrolyte imbalances
  • Na helps balance fluid levels in
  • the body facilitates neuro-
  • muscular functioning
  • K A main component of cellular
  • fluid, helps regulate neuro-
  • muscular functioning
  • osmotic pressure
  • Ca Affects neuromuscular
  • performance contributes to
  • skeletal growth blood
    coagulation
  • Mg Influences muscle contractions
  • intracellular activity
  • Cl- Regulates blood pressure
  • HPO4 Impacts metabolism regulates
    acid-base bal.
  • calcium levels
  • HCO3 Assists in regulation of blood pH
    levels
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