1. JUDITH M. WILKINSON LESLIE S. TREAS KAREN BARNETT MABLE H. SMITH FUNDAMENTALS OF NURSING Chapter 38: Fluids & Electrolytes

2. Copyright © 2016 F.A. Davis Company Objectives Discuss the function, distribution, movement, and regulation of fluids and electrolytes in the body. Describe the body mechanisms for maintaining fluid and electrolyte balance Describe the major fluid and electrolyte balance disorders, their causes, signs and symptoms and nursing interventions Formulate appropriate nursing care plans for patients with F & E imbalances

3. Copyright © 2016 F.A. Davis Company Body Fluid Pg. 984 Water is the primary body fluid. Water content varies with age, sex, and adipose tissue. Water contains solutes. – Electrolytes – Nonelectrolytes

4. Copyright © 2016 F.A. Davis Company Body Fluid Compartments Pg. 984 Intracellular – Within the cells Extracellular – Interstitial – Intravascular – Transcellular

5. Copyright © 2016 F.A. Davis Company Movement of Fluids and Electrolytes Pg 985-986 Osmosis Diffusion Filtration Active transport

6. Copyright © 2016 F.A. Davis Company Movement of Fluids and Electrolytes  Osmosis  Water molecules move from the less concentrated area to a more concentrated area in order to equalize the concentration  Diffusion  The movement of molecules through a semi- permeable membrane from an area of higher concentration to an area of lower concentration

7. Copyright © 2016 F.A. Davis Company Movement of Fluids and Electrolytes Filtration – The movement of water and smaller particles from an area of high pressure to an area of low pressure Active transport – The movement of electrolytes (Na+ & K+) against a concentration gradient. For the movement to occur ATP requires energy expenditure

8. Copyright © 2016 F.A. Davis Company Fluid Intake Pg 987 Primarily through drinking fluids IOM recommendation: 2700 mL/day women, 3500 mL/day men 20% from food/metabolism of food Fluid intake regulated by thirst – Change in plasma osmolality – Hypothalamus

9. Copyright © 2016 F.A. Davis Company Fluid Output  Sensible losses:  Urine: 1500 mL/day  Feces: 100–200 mL/day  Skin: perspiration 300-600mlL/day  Insensible losses:  Lungs: exhalation

10. Copyright © 2016 F.A. Davis Company Hormonal Regulation Pg 988 Antidiuretic hormone (ADH) Renin-angiotensin system Aldosterone Thyroid hormone Brain naturetic factor

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12. Regulating Electrolytes Pg 988-989 Sodium Potassium Calcium Magnesium Chloride Phosphate Bicarbonate

13. Copyright © 2016 F.A. Davis Company Major Electrolytes  Sodium: (Na+) Normal levels: 135-145mEq/L Extracellular fluid (ECF): regulates fluid volume Helps maintain blood volume Stimulates conduction of nerve impulses Regulated by aldosterone & ADH levels Recommended daily intake is 1500mg Kidney reabsorbs & excretes

14. Copyright © 2016 F.A. Davis Company Major Electrolytes (also see table 38-3 & 38-5)  Potassium: K+ Normal levels: 3.5-5mEq/L Intracellular fluid (ICF): muscle contraction Regulates cardiac conduction Assists with acid/base balance Kidneys eliminate & conserve

15. Copyright © 2016 F.A. Davis Company Major Electrolytes (Cont’d)  Calcium: Ca+  Normal levels: 8.5-10.5 mg/dL Bone health; neuromuscular function; cardiac function Regulates muscle contractions Parathyroid Hormone (PTH) stimulates release & reabsorption Insufficiency leads to osteoporosis

16. Copyright © 2016 F.A. Davis Company Major Electrolytes (con’t.)  Magnesium: Mg2+  Normal levels: 1.2-1.6 mEq/L Cation found ICF and bone Many cellular functions Necessary for protein and DNA synthesis Nerve and muscle functioning Alcoholism leads to low levels  Chloride: Cl-  Normal levels: 98-106mEq/L Anion in ECF Bound to other ions (i.e. sodium chloride) Assists with acid/base balance

17. Copyright © 2016 F.A. Davis Company Major Electrolytes (Cont’d)  Phosphate: PO4-  Normal levels: 3-4.5mg/dl  (Phosphorus) ICF anion Bound with calcium in teeth and bones Inverse relationship  Bicarbonate: HCO3-  Normal levels 22-26 mEq/L ICF and ECF; acid-base balance Regulated by kidneys Produced by body to act as buffer

18. Copyright © 2016 F.A. Davis Company Fluid Imbalances Pg 992-993 Fluid volume deficit Hypovolemia Dehydration – Dry skin, dry mucous membranes – Nonelastic skin turgor – Decreased urine output and blood pressure (hypotension); increased heart rate (tachycardia); rise in temperature Weight loss

19. Copyright © 2016 F.A. Davis Company Fluid Imbalances (cont’d) Fluid volume excess Hypervolemia Overhydration – Elevated blood pressure – Bounding pulse – Pale, cool skin – Edema/ascites – Crackles

20. Copyright © 2016 F.A. Davis Company Sodium Imbalances: Hyponatremia Risk Factors Loss of Na+ – GI losses (N/V, diarrhea, GI suction) – Renal loss: kidney disease, diuretics – Skin loss: excessive perspiration, burns. Inappropriate ADH Head Injury AIDS Malignant tumors Gain of water – Hypotonic tube feeding – Excessive H2O intake – Excessive IV administration of D5W

21. Copyright © 2016 F.A. Davis Company Sodium Imbalances: Hyponatremia Clinical Manifestations Think neurological changes! Personality ∆ Lethargy, confusion, apprehension Muscle twitching or cramps Anorexia, nausea, vomiting Seizures, coma Na+ < 135 mEq/L Urine specific gravity < 1.010 Nursing Interventions Assess clinical manifestations Monitor I & O Monitor lab data (Na+, sp. gravity) Encourage food ↑ in Na+ Limit water intake as indicated Administer IV saline solutions

22. Copyright © 2016 F.A. Davis Company Sodium Imbalances: Hypernatremia Risk Factors Loss of Water – Hyperventilation or fever – Diarrhea – Water deprivation Gain of Sodium – IV saline solutions – Hypertonic tube feedings – Excessive table salt. Other Conditions Diabetes Insipidus Heat stroke

23. Copyright © 2016 F.A. Davis Company Sodium Imbalances: Hypernatremia Clinical Manifestations Thirst ↑ temperature Dry, sticky mucous membranes Red, dry, swollen tongue Na+ > 145 mEq/L Urine specific gravity > 1.030 Severe hypernatremia – Irritability – Lethargy – Disorientation/Hallucinations – Seizures Nursing Interventions Assess clinical manifestations Monitor vital signs and LOC Monitor I & O Monitor lab data (Na+, sp. gravity) Encourage fluids Monitor diet as ordered ( ↓ Na+)

24. Copyright © 2016 F.A. Davis Company Potassium Imbalances: Hypokalemia Loss of Potassium – Vomiting and gastric suction – Diarrhea – Steroid administration – Use of K+ wasting drugs (diuretics) – Poor intake of K+ – Hyperaldosteronism

25. Copyright © 2016 F.A. Davis Company Hypokalemia Clinical Manifestations Think Heart! Cardiac Dysrhythmias Flat T wave on ECG Muscle weakness, leg cramps Fatigue, lethargy Anorexia, N/V K+ < 3.5 mEq/L Nursing Interventions Monitor HR & rhythm Administer oral K+ with food Administer IV K+ slowly Teach client about food ↑ K+ Teach preventative measures

26. Copyright © 2016 F.A. Davis Company Potassium Imbalances: Hyperkalemia Decreased K+ excretion – Renal failure – Hypoaldosteronism – K+ conserving diuretics High K+ intake – Excessive use of salt substitutes – Rapid/excessive IV K+ infusion – K+ shift out of cells into plasma (trauma, burns)

27. Copyright © 2016 F.A. Davis Company Hyperkalemia Clinical Manifestations Think Heart again! Cardiac dysrhythmias ECG changes (tall T wave) Intestinal colic Muscle weakness Flaccid paralysis K+ > 5 mEq/L Nursing Interventions Monitor serum K+ levels carefully! Monitor I & O Teach client to avoid food ↑ in K+

28. Copyright © 2016 F.A. Davis Company Calcium Imbalances: Hypocalcemia Risk Factors: Surgical Removal of the parathyroid glands Certain conditions: – Hypoparathyroidism – Acute pancreatitis – Thyroid carcinoma Inadequate Vitamin D intake Malabsorption, alkalosis, ETOH abuse

29. Copyright © 2016 F.A. Davis Company Hypocalcemia Clinical Manifestations Think neuromuscular! Numbness, tingling Muscle cramps, → Tetany & convulsions Cardiac irritability + Trousseau’s & Chvostek’s Diarrhea Laryngeal spasms Ca+ <8.5 mq/dL Nursing Interventions Protect confused patient and monitor respiratory & cardiac status Administer oral and IV Ca+ as ordered Teach clients about the risk for osteoporosis and measures to take

30. Copyright © 2016 F.A. Davis Company Calcium Imbalances: Hypercalcemia Risk Factors – Prolonged immobilization – Hyperparathyroidism – Malignancy of the bone – Thiazide diuretics – Excessive calcium supplements

31. Copyright © 2016 F.A. Davis Company Hypercalcemia Clinical Manifestations Lethargy, weakness Bradycardia Bizarre behavior Anorexia, N/V Constipation Polyuria & polydipsia Kidney stones Ca+>10.5 Nursing Interventions ↑ movement & exercise ↑ fluid intake Limit food/fluids ↑ in Ca+ ↑ fiber foods Protect confused patient Monitor I & O Avoid calcium based antacids

32. Copyright © 2016 F.A. Davis Company Common Causes: Chronic Alcoholism Malabsorption Diabetic Ketoacidosis Prolonged gastric suctioning Hypomagnesemia

33. Copyright © 2016 F.A. Davis Company Clinical Manifestations Neuromuscular irritability Disorientation Mood changes Dysrhythmias Increased sensitivity to digitalis Magnesium <1.3 mEq/L Nursing Interventions Monitor I & O Encourage foods high in magnesium (whole grains, nuts, green leafy veggies, beans, broccoli, potatoes, squash) Avoid alcohol If patient is taking digoxin monitor apical pulse and observe for s/s of toxicity Hypomagnesemia

34. Copyright © 2016 F.A. Davis Company Hypermagnesemia Common Causes Renal Failure Adrenal insufficiency Excess replacement

35. Copyright © 2016 F.A. Davis Company Hypermagnesemia Clinical Manifestations Flushing and warmth of skin Hypotension Drowsiness, lethargy Hypoactive reflexes ↓ Respirations Bradycardia Magnesium >2.1 mEq/L Nursing Interventions Monitor VS and airway Monitor reflexes Avoid magnesium based products like antacids & laxatives Restrict dietary intake of foods high in magnesium (whole grains, nuts, green leafy veggies, beans, broccoli, potatoes, squash)

36. Copyright © 2016 F.A. Davis Company Hypophosphatemia Common Causes: Re-feeding after starvation Alcohol withdrawal Diabetic ketoacidosis Respiratory acidosis

37. Copyright © 2016 F.A. Davis Company Hypophosphatemia Clinical Manifestations Paresthesia Joint stiffness Seizures Cardiomyopathy Impaired tissue oxygenation Phosphate <2.5 mEq/L Nursing Interventions Monitor serum phosphorus levels Monitor calcium levels as phosphate is replaced Start TPN slowly to avoid a drop in phosphate level

38. Copyright © 2016 F.A. Davis Company Hyperphosphatemia Common Causes: Renal failure Hyperthyroidism Chemotherapy Excess use of phosphate based laxatives

39. Copyright © 2016 F.A. Davis Company Hyperphosphatemia Clinical Manifestations Short term: tetany symptoms- tingling of extremities and cramping Phosphate >4.5 mEq/L Long term: Calcification in soft tissue Nursing Interventions Monitor serum phosphorus levels Monitor for tetany If sever administer aluminum hydroxide with meals as it binds to phosphorus and gets excreted

40. Copyright © 2016 F.A. Davis Company Nursing Assessment: Fluid & Electrolyte Imbalances Pg 999  Health History  Head-to-toe physical assessment  Vital signs: temperature, pulse, respirations, blood pressure  Daily weights  Fluid intake/output  Laboratory studies  CBC (hematocrit), electrolytes, osmolarity, urine specific gravity, urine pH, ABG’s

41. Copyright © 2016 F.A. Davis Company NANDA Nursing Diagnoses Deficient Fluid Volume Excess Fluid Volume Risk for Imbalanced Fluid Volume Risk for Deficient Fluid volume

42. Copyright © 2016 F.A. Davis Company Nsg Dx related to Fluid Imbalances Impaired Oral Mucous Membrane Impaired Skin Integrity Decreased Cardiac Output Ineffective Tissue Perfusion Activity Intolerance Risk for Injury Acute Confusion

43. Copyright © 2016 F.A. Davis Company Planning (goals in general terms) Maintain or restore normal fluid balance Maintain or restore normal balance of electrolytes Prevent associated risks – Tissue breakdown, decreased cardiac output, confusion, other neurologic signs

44. Copyright © 2016 F.A. Davis Company Nursing Interventions Pg 1002  Dietary teaching  Oral electrolyte supplements  Limiting or facilitating oral fluid intake  Parenteral replacement of fluids and/or electrolytes

45. Copyright © 2016 F.A. Davis Company Promoting Fluid and Electrolyte Balance Consume at least 8-10 glasses of water daily Avoid foods with excess salt, sugar, caffeine Eat well-balanced diet Limit alcohol intake Increase fluid intake before, during, after strenuous exercise Replace lost electrolytes Maintain normal body weight Learn about, monitor, manage side effects of medications Recognize risk factors Seek professional health care for notable signs of fluid imbalances

46. Copyright © 2016 F.A. Davis Company Implementing: Facilitating Fluid Intake Pg 1003 Explain reason for required intake and amount needed Establish 24 hour plan for ingesting fluids Set short term goals Identify fluids client likes and use those Help clients select foods that become liquid at room temperature Supply cups, glasses, straws Serve fluids at proper temperature Encourage participation in recording intake Be alert to cultural implications

47. Copyright © 2016 F.A. Davis Company Implementing: Restricting Fluid Intake Pg 1003 Explain reason and amount of restriction Help client establish ingestion schedule Identify preferences and obtain Set short term goals; place fluids in small containers Offer ice chips and mouth care Teach avoidance of ingesting chewy, salty, sweet foods or fluids Encourage participation in recording intake

48. Copyright © 2016 F.A. Davis Company Think Like a Nurse Five members of the LaGuardia family have come to the emergency department complaining of nausea, vomiting, and diarrhea related to severe gastroenteritis, a viral intestinal disorder. The family members include 8-month-old Jason, grandson of Jackson 26-year-old Susanna, Jackson’s daughter and Jason’s mother 60-year-old Jackson 58-year-old Gemma, Jackson’s wife 82-year-old Martha, Jackson’s mother Based on the information you have learned about the major electrolytes of the body, which electrolytes are most likely to be out of balance in members of the LaGuardia family? Explain your answer.