Susan Hench, RN, MSN Assistant Professor of Nursing N102

Review This section is a review of fluid balance and IV fluid. This should not be new material.

Parenteral Solutions IV fluid How it works depends on how its osmolarity compares to the patient’s serum osmolarity Involves osmotic pressure Osmolarity of body fluids is between 280 and 295

Three ways IV fluids work Expand the intravascular fluid volume Expand the intravasular fluid volume and deplete the intracellular and interstitial fluid volume Expand the intracellular fluid volume and deplete the intravascular fluid volume

Isotonic Fluid Concentration of solute equal to that of intracellular fluid Osmotic pressure same inside and outside cells – cells neither shrink or swell Fluid stays in the blood vessels

Isotonic Fluid Examples 0.9% Sodium Chloride (NSS) 5% Dextrose In Water (D5W) 0.2% Dextrose And 0.9% NACL (1/4DNSS) 5% Dextrose And 0.2% NACL (D51/4NSS) Lactated Ringers (LR or RL )

Isotonic Fluid Caution Can cause circulatory overload Fluids do not cause shifts into other compartments Can lower H & H and electrolytes by diluting them

Hypotonic Fluid Tonicity less than that of intracellular fluid Osmotic pressure draws water into the cells from the extracellular fluid Body fluids shift out of the blood into the interstitial areas and into the cells

Hypotonic Fluid Examples 0.45% NaCL (1/2 NS) 0.33% NaCL (1/3 NS) 0.2% NaCL (1/4 NS) 2.5% Dextrose In Water

Hypotonic Fluid Caution Infusing too much can cause intravascular fluid depletion, lower BP, cause edema, and damage cells Use cautiously in patients with heart, renal and liver disease

Hypertonic Fluid Tonicity is greater than that of intracellular fluid Shifts fluid from ICF to ECF to intravascular space so blood volume expands

Hypertonic Fluid Examples 5% Dextrose In 0.45% NSS (D5 1/2NS) 5% Dextrose In NSS (D5NS) 5% Dextrose In LR (D5LR) 10% Dextrose In Water (D10W)

Hypertonic Fluid Caution Give slowly – use an IV pump and monitor for circulatory overload

Maintaining Fluid Balance A number of body processes work together to maintain fluid balance A problem in any of those processes can affect the entire fluid- maintenance system

A problem in any one of these areas can create fluid and electrolyte imbalances Kidneys Pituitary Gland Hypothalamus Hormone Levels

Hypovolemia Fluid volume deficit Isotonic fluid loss from extracellular space to interstitial space Children and older adults prone to this condition

Hypovolemia Results from excessive fluid loss Bleeding with or without reduced fluid intake Vomiting Excessive diarrhea Excessive perspiration with too little fluid intake Drainage from wounds or burns

Hypovolemia Clinical Manifestations Weight loss Orthostatic hypotension Confusion, irritability, thirst Rapid pulse, drop in BP Skin cool and clammy Decreased urine output

FLUID AND ELECTROLYTE BALANCE Hypovolemia Diagnostic findings Increased urine specific gravity Increased H & H Elevated BUN

FLUID AND ELECTROLYTE BALANCE Hypovolemia Nursing implications Provide fluids-both PO and IV Monitor vital signs

Hypovolemia Can also result from third space fluid shift Called third spacing Fluid shift from intravascular space into interstitial space of the peritoneal, pleural, or pericardial space causing edema

Third space fluid shift Water and solutes in the third space are not available to maintain normal body fluid and electrolyte balances Caused by acute bowel obstruction, ascites, pancreatitis, peritonitis

Hypervolemia Fluid overload Fluid volume excess Excess of isotonic fluids in the extracellular compartment Edema

Hypervolemia Causes Excessive administration of oral or IV fluids Syndrome of inappropriate antidiuretic hormone (SIADH) Excessive water intake Heart failure Renal failure

Hypervolemia Clinical Manifestations Cardiovascular changes Respiratory changes Edema Confusion or altered loc Skeletal muscle weakness

Hypervolemia Diagnostic Findings H & H tend to be lower Decreased urine specific gravity If renal failure is the cause, electrolytes, BUN, and creatinine levels are increased because the kidneys are unable to excrete them

Hypervolemia Nursing Implications May be given diuretics Fluid and/ or sodium restriction Daily weights I & O Monitor edema, lung sounds, vital signs Goal is to restore fluid balance

Any Questions So Far?

Disturbance in the electrolyte balance is common in clients requiring nursing care

Electrolytes Electrically charged solutes in body fluids Necessary to maintain balance Also called ions Anions have a negative charge Cations have a positive charge

Functions of Electrolytes Maintain acid-base balance Promote neuromuscular activity Maintain body fluid osmolarity Regulate and distribute body fluids among the compartments

SODIUM MEQ/L Very important, a major cation Most abundant in ECF Helps transmit impulses in nerve and muscle fibers Comines with chloride and bicarbonate to regulate acid-base balance Regulated by the kidneys

Hyponatremia Sodium deficit Dilutional – loss of sodium or excessive water gain Depletional – not taking in enough sodium

Hyponatremia Causes Prolonged diuretic therapy Excessive diaphoresis Insufficient sodium intake Excessive sodium loss from trauma Severe fluid loss

Hyponatremia Causes Administration of hypotonic solutions Compulsive water drinking Labor induction with oxytocin SIADH – Syndrome of Inappropriate Anti-Diuretic Hormone secretion

Hyponatremia Clinical Manifestations General – abdominal cramps, nausea, headache, altered loc, muscle twitching, tremors, and weakness Depletional – orthostatic hypotension, poor skin turgor, dry mucous membranes, tachycardia Dilutional – hypertension, weight gain, bounding pulse

Hyponatremia Diagnostic Findings Serum sodium levels low Serum chloride levels may be low Urine specific gravity less than 1.010

Hyponatremia Nursing Implications Monitor clients at risk Monitor VS Monitor neurological status I & O, daily weight Monitor labs May restrict fluid Client and family teaching

Hypernatremia Sodium excess Happens less frequently than hyponatremia

Hypernatremia Causes Inadequate intake or excessive loss of water Administration of hypertonic solutions High intake of sodium Enteral nutrition TPN

Hypernatremia Causes Severe watery diarrhea Severe insensible water loss Severe burns Diabetes Insipidus Cushing’s Syndrome Severe renal failure

Hypernatremia Diagnosis Serum sodium levels above 145 Urine specific gravity above Treatment Administer hypotonic solutions

Hypernatremia Clinical manifestations Extreme thirst Tachycardia Neuromuscular signs Hyperactive deep tendon reflexes Hypertension Low-grade temperature Oliguria or anuria

Hypernatremia Nursing implications Monitor I & O Daily weights Assess for mental function Monitor labs Provide good oral hygiene Teach family and client about low sodium diet

Potassium 3.5 to 5.0 mEq/L-narrow range Major cation in the ICF Affects nerve impulse transmission Affects skeletal and cardiac muscle contraction and conductivity Affects acid-base balance The body cannot conserve potassium as it can sodium

Hypokalemia Causes of low serum potassium: Drug therapy Inadequate K intake Severe GI fluid losses Excessive diaphoresis High stress

Hypokalemia Other causes High blood glucose levels Cushing’s Syndrome Alkalosis Hepatic disease Alcoholism Heart failure Nephritis

Hypokalemia Clinical Manifestations Skeletal muscle weakness Paresthesias and leg cramps Deep tendon reflexes may be decreased or absent Anorexia, N/V Drowsiness, lethargy Cardiac arrhythmias

Hypokalemia Diagnostic Findings Serum K levels below 3.5 Elevated blood pH and bicarbonate levels EKG changes

Hypokalemia Nursing Implications Identify clients at risk Monitor VS, labs, EKG Assess for signs of metabolic alkalosis Monitor I & O Provide safe environment Provide teaching

Hyperkalemia Serum levels over 5.0 Not as common as hypokalemia

Hyperkalemia Causes Most common related health problem is renal failure Excessive oral or parenteral administration of K Severe widespread cell damage (from burns, trauma, crushing injuries) that causes K to leak from cells into bloodstream Certain meds – Beta Blockers, some types of chemotherapy Metabolic acidosis Addison’s Disease

Hyperkalemia Clinical manifestations Skeletal weakness that may lead to flaccid paralysis Muscle hyperactivity in the GI tract N/V and abdominal cramping Cardiac complications Arrhythmias, bradycardia, hypotension, cardiac failure Confusion, slurred speech Decreased deep tendon reflexes

Hyperkalemia Diagnostic Findings Serum potassium above 5 Decreased arterial pH EKG abnormalities

Hyperkalemia Nursing Implications Emergency therapy Hypertonic solution Kayexalate Monitor VS, Labs, EKG May give loop diuretics Monitor neuro status Monitor for S/S of acidosis Monitor meds Diet teaching – avoid foods high in potassium

Calcium MG/DL (some tests 11.0) Most abundant ion in the body Cation in ICF and ECF Responsible for formation and structure of bones and teeth Maintains cell structure and function Affects all muscle types Participates in blood clotting

Hypocalcemia Calcium deficit with serum levels below 8.9 Risk factors Poor dietary intake Elderly Certain diseases

Hypocalcemia Causes Poor PO intake Prolonged immobility Stress Prolonged diarrhea Thyroidectomy GI tract problems

Hypocalcemia Causes Pancreatic insufficiency Medications Hypomagnesia Hyperphosphatemia Alkalosis Clients receiving massive blood transfusions

Hypocalcemia Clinical Manifestations Muscle cramps, spasms, or tremors Hyperactive deep tendon reflexes Tetany Positive Trousseau’ sign Positive Chvostek’s sign Confusion, memory loss Arrhythmias Seizures

Hypocalcemia Diagnostic Findings Serum levels less than 8.9 EKG changes

Hypocalcemia Nursing Implications Mild to moderate-educate client to consume food high in Ca and take a supplement If recovering from parathyroid or thyroid surgery keep Ca gluconate at the bedside May have a rapid drop in Ca and need immediate replacement Monitor persons at risk – eg those receiving blood transfusions

Hypocalcemia Nursing Implications Monitor VS and EKG Be prepared in the event of laryngospasm Keep airway at bedside Seizure precautions may be necessary Evaluate for Chvostek or Trousseau Signs

Hypercalcemia Serum calcium above 11.0 Calcium excesses are not common Occurs when the rate of Ca entry into the ECF exceeds the rate of renal Ca excretion Risk factors Renal abnormalities Metastatic cancers – especially those involving bone

Hypercalcemia Causes Excessive intake of Ca supplements or vitamin D Excessive use of Ca containing antacids Piaget’s Disease Hyperparathyroidism Thyrotoxicosis Multiple fractures and prolonged immobilization Use of lithium or thiazide diuretics

Hypercalcemia Clinical manifestations Muscle weakness or flaccidity Personality changes progressing to psychoses Anorexia, nausea and vomiting Extreme thirst Constipation Polyuria, renal calculi Cardiac changes Pathologic fractures Altered LOC, impaired memory – can lead to coma

Hypercalcemia Diagnostic Findings Serum levels of Ca greater than 11.0 mg/dL Digitalis toxicity if on digoxin EKG changes X-rays revealing pathologic fractures

Hypercalcemia Nursing Implications Monitor clients with parathyroid disorders, cancer Immobile clients Monitor I & O, IV fluid = NS Observe for signs of digoxin toxicity Safety precautions Client and family teaching

Magnesium 1.2 – 2.0 mEq/L Most abundant cation in ICF after potassium Supplied in diet Functions include Promoting enzyme reactions within cells Protein synthesis Regulates muscle contractions Influences body’s calcium level

Hypomagnesemia Magnesium deficit Relatively common Most common cause in the United States is chronic alcoholism

Hypomagnesemia Causes Chronic alcoholism Loss from GI tract – vomiting, diarrhea, NG suctioning Loop and thiazide diuretics Burns Sepsis Pancreatitis

Hypomagnesemia Clinical manifestations Tremors, seizures Confusion Weakness, ataxia Cardiac dysrhythmias Tetany Positive Chvostek’s and Trousseau’s signs

Hypomagnesemia Diagnostic Findings Below normal serum levels of Mg Below normal serum levels of K or Ca EKG changes

Hypomagnesemia Nursing Implications Treatment depends on the cause Oral supplements If severe, IV or IM administration Identify at risk patients Dietary changes Thorough assessment Monitor VS, EKG, and labs Patient and family education

Hypermagnesemia Higher than normal serum levels Less common than hypomagnesemia More common in adults with advanced renal failure

Hypermagnesemia Causes Advanced renal failure Excessive intake Example – overuse of antacids TPN with too much magnesium Treatment of toxemia with Mg

Hypermagnesemia Clinical manifestations Drowsiness, sedation Lethargy Respiratory depression Muscle weakness Severe hypotension concurrent with nausea and vomiting

Hypermagnesemia Diagnostic Findings Above normal serum levels of Mg EKG changes

Hypermagnesemia Nursing Implications Increase renal excretion Lots of PO and IV fluid Administer diuretics Administer calcium gluconate (given IV in emergency situations) Monitor labs, EKG, VS Diet changes Patient and family teaching

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