Advanced Medical Surgical Nursing, Theory Academic Year (AY) 1435—1436 H

F L U I D S AND ELECTROLYTES

Water Overview  Water comprises about 60% -70% of the total body weight Varies with: age weight gender

Normal Composition in Average Man When a person loses more than 10% of his total body fluids,he can DIE!!!

Functions of Water in the Body 1.Transporting nutrients to cells and wastes from cells 2. Transporting hormones, enzymes, blood platelets, and red and white blood cells 3. Facilitating cellular metabolism and proper cellular chemical functioning 4. Facilitating digestion and promoting elimination 5. Acting as a solvent for electrolytes and non-electrolytes 6. Acting as a tissue lubricant and cushion 7. Helping maintain normal body temperature

 Intracellular fluid (ICF) (70%) fluid within cells large amounts of K+, PO4--, Mg++ Extracellular fluid (ECF) (30% fluid outside cells large amounts of Na+, Ca+, Cl-, HCO3-- Includes intravascular(15%) and interstitial fluids(5%) Two Compartments of Fluid in the Body

Daily total intake – 2400 to 3200 ml Liquids – 1400 to 1800 ml Solid foods – 700 to 1000 ml Water of oxidation (combined H 2 O & O 2 in respiratory system) – 300 to 400 ml Daily total output – 2400 to 3200 ml Lungs (respiration) – 600 to 800 ml Skin (perspiration) – 300 to 500ml Kidneys (urine) – 1400 to 1800 ml Intestines (feces) – 100 ml

Fluid Losses: Insensible Losses – immeasurable; evaporation through skin (affected by humidity & body surface area) & lungs (affected by respiratory rate & depth); fever causes loss through the skin and lungs Sensible Losses – measurable; from urination, defecation.

Water Loss ROUTES OF WATER LOSS -SENSIBLE-INSENSIBLE Urine Lungs Feces Sweat

Causes of Increased Water Loss Fever Diarrhea Diaphoresis Vomiting Gastric suctioning Tachypnea Causes of Increased Water Gain Increased sodium intake Increased sodium retention Excessive intake of water Excess secretion of ADH

Fluid Volume Deficit Involves either volume or distribution of water or electrolytes Hypovolemia — deficiency in amount of water and electrolytes in ECF with near normal water/electrolyte proportions Dehydration — decreased volume of water and electrolyte change Third-space fluid shift — distributional shift of body fluids into potential body spaces

Fluid Volume Excess Hypervolemia — excessive retention of water and sodium in ECF Overhydration — above normal amounts of water in extracellular spaces Edema — excessive ECF accumulates in tissue spaces Interstitial-to-plasma shift — movement of fluid from space surrounding cells to blood

Hypotonic solutions have a lower concentration of solutes and is more dilute than extracellular fluid.Net movement extracellular to intracellular Examples :1/2 Normal Saline; 1/3 Normal Saline

Types of IV Solutions ISOTONIC -solution has the same osmolality as the extracellular fluid. Examples: D5W ; Normal Saline, Ringer’s 5% Albumin,Hetastarch Normosol Hypertonic solutions have a higher concentration of solute and are more concentrated than extracellular fluids. Net movement intracellular to extracellular Examples : 3% saline; 5% saline, Dextrose 5% in Lactated Ringer’s, 3% sodium chloride, 25% albumin,7.5% sodium chloride

defined as "the excessive loss of water and electrolytes from the body“ Dehydration can be caused by losing too much fluid, not drinking enough water or fluids, or both.

Infants and children are more susceptible to dehydration than adults because of their smaller body weights and higher turnover of water and electrolytes. So are the elderly and those with illnesses

dehydration occurs when losses are not replaced adequately and a deficit of water and electrolytes develop. These may occur in Vomiting or diarrhea Presence of an acute illness where there is loss of appetite and vomiting:  Pneumonia  DHF  Other Acute Ilnesses Excessive urine output, such as with uncontrolled diabetes or diuretic use Excessive sweating (sports) Burns

Dehydration is classified as no dehydration, some dehydration, or severe dehydration based on how much of the body's fluid is lost or not replenished. When severe, dehydration is a life-threatening emergency

There are usually no signs or symptoms in the early stages As dehydration increases, signs and symptoms develop. Initially, thirst, restlessness, irritability, decreased skin turgor, sunken eyes and sunken fontanelles. As more losses occur, these effects become more pronounced. Assesment of Dehydration

Signs of hypovolemic shock (SEQUELAE): 1.diminished sensorium (lethargy) 2.Lack of urine output 3.Cool moist extremities 4.A rapid and feeble pulse 5.Decreased BP 6.Peripheral cyanosis 7.DEATH.

CLINICAL ASSESSMENT DEHYDRATIONMILDMODERATESEVERE Skin turgorNormalTentingNone Skin touchNormalDryClammy Buccal mucosaMoistDryParched/cracked EyesNormalDeep setSunken TearsPresentReducedNone FontanellesFlatSoftSunken CNSConsolableIrritableLethargic/ obtund Pulse rateNormalSl increasedIncreased Pulse qualityNormalWeakPeeble Capillary refillNormal~ 2 secs>3 secs Urine outputNormalDecreasedanuric

Electrolyte Imbalance

Electrolytes Ions Cations — positive charge Anions — negative charge -An electrolyte is a substance, that when dissolved in water, gives a solution that can conduct electricity -Simple inorganic salts -All inorganic acids, bases, salts, are electrolytes -Also known as Ionic solutes

Importance of electrolytes -Maintain voltages across cell membranes -Carry electrical impulses to other cells -Found in blood or the human body in the form of acids, bases or salts (Sodium, calcium, potasium, chlorine, magnesium, bicarbonate) -Conduct an electric current that transports energy thoughout the body

ANIONS (-) Chloride Phosphorus Bicarbonate CATIONS (+) Sodium Potassium Calcium Magnesium

EXTRACELLULAR Sodium Chloride Calcium Bicarbonate INTRACELLULAR Potassium Phosphate Magnesium

Major Electrolytes/Chief Function Sodium — controls and regulates volume of body fluids Potassium — chief regulator of cellular enzyme activity and water content Calcium — nerve impulse, blood clotting, muscle contraction, B12 absorption Magnesium — metabolism of carbohydrates and proteins, vital actions involving enzymes Chloride — maintains osmotic pressure in blood, produces hydrochloric acid Bicarbonate — body’s primary buffer system Phosphate — involved in important chemical reactions in body, cell division and hereditary traits

Hypokalemia (<3.5mEq/L) Pathophysiology – Decrease in K+ causes decreased excitability of cells, therefore cells are less responsive to normal stimuli Contributing factors: – Diuretics – Shift into cells – Digitalis – Water intoxication – Corticosteroids – Diarrhea – Vomiting

Hypokalemia (<3.5mEq/L) Interventions – Assess and identify those at risk – Encourage potassium-rich foods – K+ replacement (IV or PO) – Monitor lab values – D/c potassium-wasting diuretics – Treat underlying cause

Hyperkalemia (>5.0mEq/L) Pathophysiology – An inc. in K+ causes increased excitability of cells. Contributing factors: – Increase in K+ intake – Renal failure – K+ sparing diuretics – Shift of K+ out of the cells

Hyperkalemia (>5.0mEq/L) Interventions – Need to restore normal K+ balance: – Eliminate K+ administration – Inc. K+ excretion Lasix Kayexalate (Polystyrene sulfonate) – Infuse glucose and insulin – Cardiac Monitoring

Hyponatremia (<135mEq/L) Contributing Factors – Excessive diaphoresis – Wound Drainage – NPO – CHF – Low salt diet – Renal Disease – Diuretics

Hyponatremia (<135mEq/L) Assessment findings: – Neuro - Generalized skeletal muscle weakness. Headache / personality changes. – Resp.- Shallow respirations – CV - Cardiac changes depend on fluid volume – GI – Increased GI motility, Nausea, Diarrhea (explosive) – GU - Increased urine output

Hyponatremia (<135mEq/L) Interventions/Treatment – Restore Na levels to normal and prevent further decreases in Na. – Drug Therapy – (FVD) - IV therapy to restore both fluid and Na. If severe may see 2-3% saline. (FVE) – Administer osmotic diuretic (Mannitol) to excrete the water rather than the sodium. – Increase oral sodium intake and restrict oral fluid intake.

Hypernatremia (>145mEq/L) Contributing Factors – Hyperaldosteronism – Renal failure – Corticosteroids – Increase in oral Na intake – Na containing IV fluids – Decreased urine output with increased urine concentration – Diarrhea – Dehydration – Fever - Hyperventilation

Hypernatremia (>145mEq/L) Assessment findings: – Neuro - Spontaneous muscle twitches. Irregular contractions. Skeletal muscle wkness. Diminished deep tendon reflexes – Resp. – Pulmonary edema – CV – Diminished CO. HR and BP depend on vascular volume. - GU – Dec. urine output. Inc. specific gravity - Skin – Dry, flaky skin. Edema r/t fluid volume changes.

Hypernatremia (>145mEq/L) Interventions/Treatment – Drug therapy (FVD).45% NSS. If caused by both Na and fluid loss, will administer NaCL. If inadequate renal excretion of sodium, will administer diuretics. – Diet therapy Mild – Ensure water intake

Hypocalcemia (<9.0mg/dL) Contributing factors: – Dec. oral intake – Lactose intolerance – Dec. Vitamin D intake – End stage renal disease – Diarrhea - Acute pancreatitis - Hyperphosphatemia - Immobility - Removal or destruction of parathyroid gland

Hypocalcemia (<9.0mg/dL) Assessment findings: – Neuro –Irritable muscle twitches. carpal Positive Chvostek’s sign. – Resp. – Resp. failure d/t muscle tetany. – CV – Dec. HR., dec. BP, diminished peripheral pulses – GI – Inc. motility. Inc. BS. Diarrhea

Positive Trousseau’s Sign

Positive Chvostek’s Sign

Hypocalcemia (<9.0mg/dL) Interventions/Treatment – Drug Therapy Calcium supplements Vitamin D – Diet Therapy High calcium diet – Prevention of Injury Seizure precautions

Hypercalcemia (>10.5mg/dL) Contributing factors: – Excessive calcium intake – Excessive vitamin D intake – Renal failure – Hyperparathyroidism – Malignancy – Hyperthyroidism

Hypercalcemia (>10.5mg/dL) Assessment findings: – Neuro – Disorientation, lethargy, coma, profound muscle weakness – Resp. – Ineffective resp. movement – CV - Inc. HR, Inc. BP., Bounding peripheral pulses, Positive Homan’s sign. Late Phase – Bradycardia, Cardiac arrest – GI – Dec. motility. Dec. BS. Constipation – GU – Inc. urine output. Formation of renal calculi

Hypercalcemia (>10.5mg/dL) Interventions/Treatment – Eliminate calcium administration – Drug Therapy – Isotonic NaCL (Inc. the excretion of Ca) – Diuretics – Calcium reabsorption inhibitors (Phosphorus) – Cardiac Monitoring

Hypophosphatemia (<2.5mg/L) Contributing Factors: – Malnutrition – Starvation – Hypercalcemia – Renal failure – Uncontrolled DM

Hypophosphatemia (<2.5mg/L) Assessment findings: (Chart 13-7) Neuro – Irritability, confusion CV – Dec. contractility Resp. – Shallow respirations Musculoskeletal - Rhabdomyolysis Hematologic – Inc. bleeding Dec. platelet aggregation

Hypophosphatemia (<2.5mg/L) Interventions – Treat underlying cause – Oral replacement with vit. D – IV phosphorus (Severe) – Diet therapy Foods high in oral phosphate

Hyperphosphatemia (>4.5mg/L) Causes few direct problems with body function. Care is directed to hypocalcemia. Rarely occurs

Hypomagnesemia (<1.4mEq/L) Contributing factors: – Malnutrition – Starvation – Diuretics – Aminoglcoside antibiotics – Hyperglycemia – Insulin administration

Hypomagnesemia (<1.4mEq/L) Assessment findings: *Neuro - Positive Trousseau’s sign. Positive Chvostek’s sign. Hyperreflexia. Seizures *CV – ECG changes. Dysrhythmias. HTN *Resp. – Shallow resp. *GI – Dec. motility. Anorexia. Nausea

Hypomagnesemia (<1.4mEq/L) Interventions: – Eliminate contributing drugs – IV MgSO4 – Assess DTR’s hourly with MgSO4 – Diet Therapy

Hypermagnesemia (>2.0mEq/L) Contributing factors: – Increased Mag intake – Decreased renal excretion Assessment findings: Neuro – Reduced or weak DTR’s. Weak voluntary muscle contractions. Drowsy to the point of lethargy CV – Bradycardia, peripheral vasodilatation, hypotension. ECG changes.

Hypermagnesemia (>2.0mg/dL) Interventions – Eliminate contributing drugs – Administer diuretic – Calcium gluconate reverses cardiac effects – Diet restrictions