Nur 102 Spring 2015 Belinda Lowry, MSN, RN, CCRN

Body Fluid Adult body is 60% water; Older adult 45-55% water 40% is intracellular fluid 20% extracellular fluid 15% interstitial (tissue) fluid 5% intravascular fluid

Body Fluids Osmolality (aka osmolarity) The osmotic pull exerted by all particles (solutes) per unit of water Mainly controlled by sodium Tonicity The effect of fluid on cellular volume

Tonicity IV fluids have different tonicities, giving different results on body fluid maintenance Isotonic 0.9% sodium chloride (normal saline), D 5 W, LR Hypotonic 0.45% sodium chloride (1/2 NS) Hypertonic D 5 ½ NS, D 5 LR, D 10 W

Movement of Water & Electrolytes

IV Fluids: Four classifications Crystalloids: replacement and maintenance of fluids NS, ½ NS, D5’s, LR, etc. Colloids: volume expanders Hetastarch (hespan), dextran Blood and blood products Whole blood, PRBC, platelets, plasma, albumin Lipids: fat emulsion solution TPN (total parenteral nutrition) “IV food”

Fluid Balance Intake: Anything going in Oral fluids, IV fluids, irrigations Output: Anything coming out Urine, liquid stool, emesis, NGT output, drains Intake – Output = Balance 1200 ml intake – 3000 ml output = balance Is patient “overloaded” or “dry”? Insensible loss: sweat, weeping, lungs, formed stool

Fluid Imbalance Volume imbalance Disturbances in the amount of fluid in the extracellular compartment Osmolality imbalance Disturbances of the concentration of body fluids Mostly affects sodium

Fluid Overload & Deficit Causes

Fluid Overload Shortness of breath Adventitious breath sounds Swelling, edema Neck vein distention Weight gain 1 liter water = 1 kg 1 kg = 2.2 lbs Sometimes ALOC

Fluid Deficit s/sx Low BP Increased HR Decreased urine output (UO) Decreased skin turgor Dry mucous membranes Sometimes ALOC

Causes of Fluid Imbalance *** TABLE 41-3 *** (p. 888) Volume deficit Decreased salt and water intake, increased GI output, bleeding, diuretics Volume excess Increased salt and water intake, excess isotonic IV fluid, decreased renal output/function

I/O Practice: shift Oral intake: 600 ml IV fluids: 1000 ml Urine: 850 ml Emesis: 200 ml What is the total I/O for the shift? What is patient’s balance for the shift?

I/O Practice: shift Oral intake: 300 ml IV fluids: 850 ml IV medication: 50 ml Blood: 350 ml Urine: 400 ml Ileostomy: 300 ml What is the total I/O for the shift? What is the patient’s balance for the shift?

I/O Practice: shift Oral intake: 500 ml IV fluids: 750 ml Irrigation: 100 ml (down nasogastric tube) Urine: 530 ml Amount in NGT suction canister: 200 ml (canister was marked at 50 beginning of shift) Wound drain: 30 ml What is the total I/O for the shift? What is the patient’s balance for the shift?

BONUS What was the total I/O for the 24-hours? What was the patient’s balance for the day?

Break!

Electrolytes Substances in the body that carry electrical charges Necessary to transmit nerve impulses to muscles, and to contract skeletal and smooth muscles Positive-charged most plentiful (cations) Potassium, magnesium, sodium, calcium

Sodium (Na + ) Normal value mEq/L Major electrolyte that regulates body fluids Promotes transmission and conduction of nerve impulses Constantly shifts into cells while K+ shifts out of cells to maintain water balance and neuromuscular activity

Sodium Hyponatremia Hypernatremia Na < 135 mEq/L Results from vomiting, diarrhea, surgery, potent diuretics s/sx include: Weakness, headaches, lethargy, confusion, seizures, dry mucous membranes Treatment: slow correction with NS 3% NS may be used for <115mEq/L (hypertonic) Na > 145 mEq/L Results from dehydration and use of some antibiotics and cortisone medications s/sx include: Agitation, flushed & dry skin, tachycardia, muscle twitching, hyperreflexia Treatment: sodium restriction, hypotonic solutions, free water flushes

Potassium (K + ) Normal value mEq/L Necessary for transmission and conduction of nerve impulses and for contraction of skeletal, cardiac, and smooth muscles Also necessary for enzyme action for glycolysis and protein formation

Potassium Hypokalemia Hyperkalemia K+ < 3.5 mEq/L Results from cell leakage secondary to trauma, injury, surgery, shock Can also result from vomiting and diarrhea Side effect of diuretic and laxative therapies s/sx include: n/v, confusion, dysrhythmias, soft/flabby muscles Treatment: PO or IV replacement (SLOW infusion over 2 hours minimum) K+ > 5.3 mEq/L Results from renal insufficiency or large doses of potassium over time s/sx include: Nausea, abdominal cramps, tachycardia, weakness, tingling in extremities, tall peaked T-waves on ECG rhythm Treatment: kay-exalate, calcium gluconate, IV insulin + D50 amp

Calcium (Ca) Normal value: mg/dL Promotes normal nerve and muscle activity Increases contraction of myocardium Maintains normal cellular permeability and promotes blood clotting Converts prothrombin into thrombin Vit D necessary for calcium absorption in GI tract

Calcium Hypocalcemia Hypercalcemia Ca <8.5 mg/dL Results from inadequate intake, hypoparathyroidism, vitamin D deficiency, multiple blood transfusions s/sx include: Anxiety, irritability, tetany Treatment: IV or PO replacement Ca > 10.5 mg/dL Results from hyperparathy- roidism, low PO4, prolonged immobilization, multiple fx s/sx include: Flabby muscles, pain over bony areas, kidney stones Treatment: correct the underlying cause

Magnesium (Mg) Normal value: 2.0 – 3.0 mg/dL Promotes transmission of neuromuscular activity Important mediator of neural transmission in CNS Also promotes myocardial contraction Transports Na+ and K+ across cell membranes

Magnesium Hypomagnesemia Hypermagnesemia Mg < 2.0 mg/dL Frequently coincides with K+ or Ca+ deficit Generally asymptomatic until level is < 1.0 mg/dL Treatment: IV replacement Mg > 3.0 mg/dL Results from excess intake of magnesium salts (laxatives, MOM, Maalox, Mylanta) Asymptomatic Treatment: termination of mag salt intake, admin of calcium gluconate

Phosphorus (PO 4 ) Normal value: 2.0 – 2.6 mEq/L Mostly found in association with calcium Essential in bone and teeth formation, and for neuromuscular activity Important component of DNA and RNA Assists in cell energy transfer, acid-base balance, and osmotic pressure

Phosphorus Hypophosphatemia Hyperphsphatemia PO4 < 2.0 mEq/L Results from GI abnormalities, hormonal changes (shock, surgery), malabsorption s/sx include: Muscle weakness, tremors, paresthesia, bone pain Treatment: IV replacement PO4 > 2.6 mEq/L Results from renal insufficiency or failure, increased intake of phosphate medications s/sx include: Hyperreflexia, tetany (with decreased Ca), weakness, tachycardia Treatment: Treat underlying cause

NCLEX Practice The family of a client with chronic hyponatremia asks if the water restriction is a punishment for his uncooperative behavior. What is the nurse’s best response? A. “No, limiting fluid intake decreases the risk for kidney failure.” B. “No, limiting water intake prevents him from losing too much fluid by vomiting.” C. “No, limiting fluid intake keeps his blood from becoming more dilute and causing other complications.” D. “No, limiting fluid decreases his sense of thirst and prevents him from drinking liquids that contain an excess of sodium.”

NCLEX Practice A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been effective? A. Chinese take-out, including steamed rice B. A grilled cheese sandwich with tomato soup C. Slices of ham and cheese on whole grain crackers D. A chicken leg, one slice of bread with butter, and steamed carrots

NCLEX Practice The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse’s priority? A. Document the observation in the chart. B. Measure urine specific gravity and volume. C. Assess the pulse and blood pressure. D. Assess the client’s deep tendon reflexes.

Case Study/Concept Map Mrs. Hilda Beck is a 72-year-old being seen by her health care provider this morning. She fell this morning after becoming light-headed. She has had several episodes of vomiting and diarrhea over the last 2 days. She was admitted for oral and IV fluid therapy.

Case Study/Concept Map Why is Mrs. Beck likely becoming light-headed? When should you expect this to resolve? What type of fluid (isotonic, hypotonic, hypertonic) would you expect the physician to order? Mrs. Beck’s IV fluid order is 1000 ml 0.9% sodium chloride to run over 8 hours. Calculate the milliliters per hour (ml/hr) you should program into her pump.

Case Study/Concept Map You auscultate crackles in Mrs. Beck’s lung bases while her IV is infusing. What do you now suspect? The physician has diagnosed Mrs. Beck with gastroenteritis & dehydration. Create a concept map.