Fluid Volume Electrolytes

ECF Volume deficit Hypovolemia Causes Abnormal fluid loss Diarrhea Fistula drainage Hemorrhage Polyuria Fever (↑ perspiration) Inadequate intake Osmotic diuresis

ECF Volume excess Hypervolemia Causes Excessive intake of fluids Abnormal retention of fluids Heart failure Renal failure Long-term corticosteroid therapy

Functions of Sodium Regulates osmolality ICF: 14 mmol/L & ECF: 135-145 mmol/L Helps maintain blood pressure by balancing the volume of water in the body Works with other electrolytes to promote nerves, muscles and other body tissues to work properly.

Hypernatremia Na Excess Water Deficiency H20 ↑ Osmolality Normal ECF/↑ ECF H20 ↑ Osmolality ↓ ECF (Looks like excessive Na)

Hypernatremia Water loss: Causes Water loss: Signs and Symptoms Inadequate water intake (dehydration) Unconscious or cognitively impaired individuals NPO status Excessive water loss ↑ insensible water loss High fever Diuretic therapy Watery diarrhea Disease states Kidney Uncontrolled diabetes mellitus Diabetes insipidus Restlessness, agitation, twitching, confusion Seizures*, Coma Intense thirst Dry, swollen tongue Sticky mucous membranes Weight loss Weakness, lethargy Postural hypotension

Hypernatremia Na gain: Causes Na gain: Signs and Symptoms Na intake IV fluids: hypertonic NaCl, excessive isotonic NaCl Hypertonic tube feeding with out water supplement Use of Na containing drugs Corticosteroids Diseases Renal failure Restlessness, agitation, twitching Seizures, Coma Intense thirst Flushed skin Weight gain Peripheral and pulmonary edema ↑ BP

Nursing Diagnosis for Hypernatremia Risk for injury related to altered sensorium and seizures secondary to abnormal CNS function Risk for injury related to altered sensorium and seizures secondary to abnormal CNS function Potential complications: seizures and coma leading to irreversible brain damage

Group learning Discuss with your neighbor Why in Hypernatremia (water deficit) and hypernatremia (gain of more salt) there is a difference in the BP (blood pressure). List a Nursing Diagnosis for a patient with hypernatremia.

Hyponatremia H20 Water Excess (↑ ECF Volume) H20 ↓ Osmolality ↑ ECF Na deficiency (Loss of Na containing fluids) Water Excess (↑ ECF Volume) H20 ↓ Osmolality ↓ ECF Volume Excess Na Loss H20 ↓ Osmolality ↑ ECF Dilutional

Hyponatremia Dilutional (↑ ECF Volume) Causes Use of hypotonic irrigation solution Tap water enemas Excessive water gain Excessive hypotonic IV fluid Dilutional (↑ ECF Volume) Signs and Symptoms Headache, apathy, confusion Nausea, vomiting, anorexia Lethargy Weakness Muscle spasms, seizures, coma Diarrhea, Abdominal cramps Weight gain ↑ BP

Hyponatremia Na Loss: Causes Na Loss: Signs and Symptoms GI Kidney Vomiting Diarrhea NG suctioning NPO Status Kidney Diuretic Skin Burns Wounds Excessive diaphoresis Na Loss: Signs and Symptoms Irritability, apprehension, confusion Dizziness Personality changes Tremors, seizures, coma Dry mucous membranes Postural hypotension Tachycardia, thread pulse Cold & clammy skin

Functions of Potassium Maintains fluid balance in the cells Contributes to intracellular osmotic pressure Direct effect on excitability of nerves and muscles Skeletal, cardiac, and smooth muscle contraction Regulates glucose use and storage

Hyperkalemia Causes Most cases of hyperkalemia occur in hospitalized patients and in those undergoing medical treatment. Those at greatest risk for hyperkalemia are Chronically ill patients Debilitated patients Older adult

Hyperkalemia Causes Actual hyperkalemia Relative hyperkalemia Excess potassium Intake Excessive or rapid parenteral administration Shift of potassium Out of Cells Acidosis Crushing injury Tissue catabolism (fever, sepsis, burns)

Hyperkalemia Causes Failure to Eliminate Potassium Renal disease Potassium-sparing diuretics ACE inhibitors

Hyperkalemia Signs and Symptoms Clinical Manifestations Electrocardiogram Changes Irritability Abdominal cramping, diarrhea Weakness of lower extremities Irregular pulse Cardiac arrest if hyperkalemia sudden or severe Ventricular fibrillation Ventricular standstill

Nursing Diagnosis: Hyperkalemia Risk for injury related to lower extremity muscle weakness and seizures Risk for decreased cardiac output related to dysrhythmias Decreased cardiac output r/t dysrhythmias Activity intolerance r/t weakness Ineffective breathing patterns r/t muscle weakness and paralysis Diarrhea r/t neuromuscular changes and irritability Risk for injury r/t muscle weakness and seizures

Hypokalemia Causes Potassium Loss Shift of Potassium into Cells GI losses: diarrhea, vomiting, fistulas, NG suction, NPO status Renal losses: diuretics, Skin losses: diaphoresis Dialysis Shift of Potassium into Cells Alkalosis

Hypokalemia Causes Lack of Potassium Intake Starvation Diet low in K Failure to include K in parenteral fluids if NPO TPN

Hypokalemia Signs and Symptoms Clinical Manifestations Electrocardiogram Changes Fatigue Muscle weakness, leg cramps Nausea, vomiting, paralytic ileus Soft, flabby muscles Paresthesia, decreased reflexes Weak, irregular pulse Ventricular dysrhythmias (e.g., PVCs) Bradycardia

Hypokalemia Medical Management Administration of KCl supplements K may be given orally (K chloride, K gluconate, K citrate) or IV KCl should be administered IV at a rate of 10 to 20 mEq/L over an hour. Rapid infusion could cause cardiac arrest IV K solutions irritate veins and cause phlebitis. Check IV site q 2 hrs. Discontinue IV if infiltrate to prevent necrotic and slough of tissue

Nursing Diagnosis: HypoKalemia Risk for injury related to muscle weakness and hyporeflexia Risk for decreased cardiac output related to dysrhythmias Fatigue Constipation Bathing/hygiene self-care deficit

Functions of Calcium Helps maintain muscle tone Contributes to regulation of blood pressure by maintaining cardiac contractility Necessary for nerve transmission and contraction of skeletal and cardiac muscle

Hypercalcemia Causes Increased Total Calcium Prolonged immobilization Thiazide diuretics Dehydration Renal failure

Hypercalcemia Signs and Symptoms Clinical Manifestations Electrocardiogram Changes Lethargy, weakness Depressed reflexes (DTR) Decreased memory Confusion, personality changes, psychosis Anorexia, nausea, vomiting, constipation Bone pain, fractures Ventricular dysrhythmias Hypertension

Hypercalcemia: Medical Treatment Administration of IV (.9NS) fluids followed by a loop diuretic (Excretion of Ca is followed by excretion of Na) Calcitonin via IV to promote renal excretion of Ca Nausea treated with antiemetics Stool softeners given for constipation Cardiac monitoring Dialysis: for severe hypercalcemia

Nursing Diagnosis: Hypercalcemia Risk for injury related to neuromuscular and sensorium changes Risk for decreased cardiac output related to dysrhythmias

Hypocalcemia Causes Decreased Total Calcium Decreased Ionized Calcium Chronic renal failure Loop diuretics (e.g., furosemide [Lasix]) Chronic alcoholism Diarrhea Decreased Ionized Calcium Excess administration of citrated blood

Hypocalcemia Signs and Symptoms Clinical Manifestations Electrocardiogram Changes Easy fatigability Depression, anxiety, confusion Numbness and tingling in extremities and region around mouth Hyperreflexia, muscle cramps Chvostek’s sign & Trousseau’s sign Laryngeal spasm Tetany, seizures Ventricular tachycardia

Nursing Diagnosis: Hypercalcemia Risk for injury related to tetany and seizures Potential complications: fracture, respiratory arrest Pain Diarrhea Risk for injury

Functions of Magnesium Cofactor in clotting cascade Acts directly on myoneural junction, affecting muscular irritability and contractions Maintains strong and healthy bones

Hypermagnesemia Causes Renal failure Diabetes Mellitus Clients who ingest large amounts of Mg-containing antacids such as Tums, Maalox, Mylanta, or laxatives such as MOM are also in ↑ risk for developing hypermagnesemia

Hypermagnesemia Signs and Symptoms Bradycardia and hypotension Severe hypermagnesemia: cardiac arrest Drowsy or lethargic Coma Deep tendon reflexes are reduced or absent Skeletal muscle contractions become progressively weaker and finally stop

Hypomagnesaemia Causes Malabsorption disorders Inflammatory bowel disease (IBD) Bowel resection Bariatric population who undergoes gastric bypass surgery Alcoholism Prolonged diarrhea Draining GI fistulas Diuretics

Hypomagnesaemia Signs and Symptoms Confusion Hyperactive deep tendon reflexes Tremors Seizures Neuromuscular changes Hyperactive deep tendon reflexes Numbness and tingling Painful muscle contractions Monitor for positive Chvostek’s and Trousseau’s signs (hypocalemia may

Group learning Discuss with your neighbor The questions the nurse asks to elicit risk factors for fluid and electrolyte imbalances How recent surgery causes changes in F & E imbalances How increased GI output can cause changes in F & E imbalances

Physical Assessment Daily weights Fluid intake and output (I&O) Indicator of fluid status Use same conditions. Fluid intake and output (I&O) 24-hour I&O: compare intake versus output Intake includes all liquids eaten, drunk, or received through IV. Output = Urine, diarrhea, vomitus, gastric suction, wound drainage Laboratory studies

Fluid and Electrolyte Assessment Nutritional-Metabolic Pattern What is your typical daily food intake? Describe a day’s meals, snacks, and vitamins. How much salt do you typically add to your food? Do you use salt substitutes? How is your appetite? Do you have any difficulty chewing or swallowing? What is your typical daily fluid intake? What types of fluids (water, juices, soft drinks, coffee, tea)? How much?