Interventions for Clients with Fluid and Electrolyte imbalances

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3 Body Fluid Compartments 2/3 (65%) of TBW is intracellular (ICF) 1/3 extracellular water –25 % interstitial fluid (ISF) – 5- 8 % in plasma (IVF intravascular fluid) –1- 2 % in transcellular fluids – CSF, intraocular fluids, serous membranes, and in GI, respiratory and urinary tracts (third space)

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6 Fluid compartments are separated by membranes that are freely permeable to water. Movement of fluids due to: – hydrostatic pressure – osmotic pressure\ Capillary filtration (hydrostatic) pressure Capillary colloid osmotic pressure Interstitial hydrostatic pressure Tissue colloid osmotic pressure

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8 Balance Fluid and electrolyte homeostasis is maintained in the body Neutral balance: input = output Positive balance: input > output Negative balance: input < output

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11 Solutes – dissolved particles Electrolytes – charged particles –Cations – positively charged ions Na +, K +, Ca ++, H + –Anions – negatively charged ions Cl -, HCO 3 -, PO 4 3- Non-electrolytes - Uncharged Proteins, urea, glucose, O 2, CO 2

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13 Regulation of body water ADH – antidiuretic hormone + thirst –Decreased amount of water in body –Increased amount of Na+ in the body –Increased blood osmolality –Decreased circulating blood volume Stimulate osmoreceptors in hypothalamus ADH released from posterior pituitary Increased thirst

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15 Result: increased water consumption increased water conservation Increased water in body, increased volume and decreased Na+ concentration

Fluid Volume Excess Occurs when the body retains both water and sodium in similar proportions to normal ECF. It is also called hypervolemia. Common causes include:- - Excessive intake of sodium chloride - Administering sodium-containing infusions too rapidly Disease processes that alter regulatory mechanisms such as heart failure, renal failure.

Edema  Excess interstitial fluid. Edema typically is most apparent in areas where the tissue pressure is low, such as around the eyes, and in dependent tissues (known as dependent edema), where hydrostatic capillary pressure is high. Pitting edema: edema that leaves a small depression or pit after finger pressure is applied to the swollen area.

Electrolyte Imbalances

RISK FACTOR Loss of sodium, as in: Loss of GI.fluids Use of diuretics Gains of water, as in: Excessive administration of D5W Water intoxication Disease states associated with SIADH (a form of hyponatremia) Pharmacologic agents that may impair water excretion Assessments Anorexia Nausea and vomiting Lethargy Confusion Muscle cramps Fingerprinting over sternum Muscular twitching Seizures Coma Serum Na below 135 mEq/L Urine specific gravity <1.010 Nursing interventions -Monitor fluid losses and gains. -Monitor for presence of GI and CNS symptoms. - Monitor serum Na levels. - Check urine specific gravity. -If able to eat, encourage foods and fluids with high sodium content. -Be aware of sodium content of common -IV fluids. -Avoid giving large water supplements to -Patients receiving isotonic tube feedings. -Take seizure precautions when hyponatremia is severe Hyponatremia

RISK FACTOR Water deprivation Increased sensible and insensible water loss Ingestion of large amount of salt Excessive parenteral administration of sodium- containing solutions Profuse sweating Diabetes insipidus Assessments Thirst Elevated body temperature Tongue dry and swollen, sticky mucous Membranes Severe hypernatremia Disorientation Hallucinations Irritable and hyperactive Focal or grand mal seizures Coma Serum Na above 145 mEq/L Urine specific gravity >1.015 Nursing interventions - Monitor fluid losses and gains. - Observe for excessive intake of high sodium foods. - Monitor for changes in behavior such as restlessness, lethargy, and disorientation. - Look for excessive thirst and elevated body temperature. - Monitor serum Na levels. - Check urine specific gravity. - Give sufficient water with tube feedings to Keep serum Na and BUN at normal limits. Hypernatremia

RISK FACTOR Diarrhea Vomiting or gastric suction Potassium-wasting diuretics Poor intake as in anorexia nervosa, alcoholism, potassium- free parenteral.fluids Polyuria Assessments Fatigue Anorexia, nausea, and vomiting Muscle weakness Decreased bowel motility Cardiac arrhythmias Polyuria, nocturia, dilute urine Postural hypotension Serum K below 3.5 mEq/L ECG changes T waves flattening and ST segment depression on ECG Nursing interventions - Monitor for occurrence of Hypokalemia. - Prevent Hypokalemia by: - Encouraging extra K intake if possible - Educating about abuse of laxatives and diuretics -Administer oral K supplements if ordered. - Be knowledgeable about danger of IV potassium administration. Hypokalemia

RISK FACTOR Decreased potassium excretion: Oliguric renal failure Potassium-sparing diuretics High potassium intake, especially in presence of renal insufficiency Shift of potassium out of cells into the plasma (acidosis, tissue trauma, infection, burns) Assessments Vague muscle weakness Cardiac arrhythmias Paresthesias of face, tongue, feet, and hands Flaccid muscle paralysis GI symptoms such as nausea, intermittent intestinal colic, or diarrhea may occur Serum K above 5.0 mEq/L Peaked T waves, widened QRS on ECG Nursing interventions Monitor for hyperkalemia, which is life threatening. Prevent hyperkalemia by: Following rules for safe administration of K Avoiding giving patients with renal insufficiency K-saving diuretics, K supplements, or salt substitutes Cautioning about foods high in potassium content Hyperkalemia

RISK FACTOR Surgical hypoparathyroidism Malabsorption Vitamin D deficiency Acute pancreatitis Excessive administration of citrated blood Alkalotic states Assessments Trousseau’s and Chvostek’s signs Numbness and tingling of fingers and toes Mental changes Seizures Spasm of laryngeal muscles ECG changes Cramps in muscles of extremities Total serum calcium <8.5 mg/dL Nursing interventions Take seizure precautions when hypocalemia is severe. Monitor condition of airway. Take safety precautions if confusion is present. Educate people at risk for osteoporosis about need for dietary calcium intake. Discuss calcium-losing aspects of nicotine and alcohol use. Hypocalcaemia

Hypocalcemia

A positive Trousseau's sign Muscular contraction including flexion of the wrist and metacarpophalangeal joints, hyperextension of the fingers and flexion of the thumb on the palm

A positive Chvostek's sign. Twitching or contraction of the facial muscles produced by tapping on the facial nerve at specific point

RISK FACTOR Hyperparathyroidism Malignant neoplastic disease Prolonged immobilization Large doses of vitamin D Overuse of calcium supplements Thiazide diuretics Assessments Muscular weakness Tiredness, lethargy, Constipation Anorexia, nausea, and vomiting Decreased memory and attention span Polyuria and polydipsia Renal stones Cardiac arrest Serum calcium >10.5 mg/dL Nursing interventions Increase mobilization when feasible. Encourage sufficient oral intake. Discourage excessive consumption of milk products. Encourage bulk in the diet. Take safety precautions if confusion is present Be alert for signs of digitalis toxicity in Hypercalcaemia patients. Force fluids to prevent formation of renal stones. Hypercalcaemia

Hypercalcemia

Hypomagnesemia Signs/symptoms Causes