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Fluid, Electrolyte, and Acid-Base Balance B260: Fundamentals of Nursing Characteristics of Body Fluids Fluid = Water that contains dissolved or suspended substances such as glucose, mineral salts, and proteins. Fluid amount = Volume. Fluid concentration = Osmolality. Fluid composition (electrolyte concentration) Degree of acidity = pH Scientific Knowledge Base : Location and Movement of Water and Electrolytes Intracellular Fluid (ICF) Extracellular Fluid (ECF) = Fluid outside of cells = Fluids within cells ~2/3 of total body water ~1/3 of total body water Three divisions: – Interstitial – Intravascular – Transcellular Hemoglobin • The hemoglobin test measures the amount of hemoglobin in blood and is a good measure of the blood’s ability to carry oxygen throughout the body. Norm Males: 13.2-17.3 g/dL Females: 11.7-15.5 g/dL Hematocrit This test measures the amount of space (volume) red bloods cells take up in the blood. The value is given as a % of RBCs in a volume of blood. For example, a hematocrit of 38 means that 38% of the blood’s volume is made of RBCs. Norm: Male: 39%-50% Females: 35%-47% Hematocrit HYPOVOLEMIA – ECF FLUID VOLUME DEFICIT Hypovolemia Causes Abnormal fluid loss Diarrhea Hemorrhage Polyuria Fever (↑ perspiration) Inadequate intake Osmotic diuresis Hypovolemia Cardiovascular Changes Respiratory Changes Mild to moderate o ↑ respiratory rate o ↑ HR o Peripheral pulses are weak, difficult to find o Change in position may cause ↑ HR or ↓ BP o Dizziness and light-headedness Severe fluid volume o ↓ BP in lying position o Pulse: weak, thready o Flattened neck veins Renal Changes o UO below 500 mL/day Neurologic Changes Alteration in Mental Status o Restlessness o Drowsiness o Lethargy o Confusion (more common in the elderly; may be first indicator of fluid balance problem) o Seizures, coma Assessment Findings Skin turgor is diminished Skin may be warm and dry with mild deficit Skin may be cool and moist with severe deficit Skin may appear dry and wrinkled Oral mucous membranes will be dry, sticky, pastelike coating Patient C/O thirst Eyes: soft, sunken Lab data: ↑ H & H; BUN; 10 Nursing Care Plan Therapeutic Interventions Restore fluid and electrolyte balance IVs and blood products as ordered; small, frequent drinks by mouth Daily weights to monitor progress of fluid replacement Loss or gain of 2.2 lbs is equal to 1 L of fluid I & O, hourly outputs Two most important assessments: HR & Output Avoid hypertonic solutions Promote comfort Frequent skin care Position: change q hr to relieve pressure meds as ordered: antiemetics, antidiarrheal 11 Nursing Care Plan Therapeutic Interventions Prevent physical injury Risk for falls due to orthostatic hypotension, dysrhythmia, muscle weakness, gait stability and level of alertness. Frequent mouth care Dry mucous membrane due to dehydration Monitor IV flow rate Observe for circulatory overload (↑ pulse, ↑ HR) Pulmonary edema (SOB) Monitor vital signs BP should be rising, ↑ LOC: more alert 12 HYPERVOLEMIA – ECF FLUID VOLUME EXCESS Causes ECF Volume Excess: Hypervolemia Excessive intake of fluids Heart failure Abnormal retention of fluids Renal failure Long-term corticosteroid therapy ECF Volume Excess: Hypervolemia Cardio Changes Respiratory Changes o ↑ Pulse: full and bounding o Full peripheral pulses o Distended neck veins o ↑ BP o ↑ respiratory rate o Shallow respirations o ↑ dyspnea with exertion or in the supine position o Pulmonary congestion and pulmonary edema o SOB o Irritative cough o Moist crackles Skin Changes o Edematous may feel cool o Skin may feel taut and hard o Edemaeyelids, facial, dependent (sacrum), pitting, peripheral extremities Neurologic Changes Other Changes o Altered LOC o Visual disturbances o Skeletal muscle weakness o Parenthesis o Cerebral edema o Headache o Confusion o Lethargy o Diminished reflexes o Seizures, coma o Urine: polyuria, nocturia o Lab data ↓Hematocrit , BUN GI Changes o Increased motility o Enlarged liver A 17-year-old high school football player has passed away after drinking too much water during practice. Zyrees Oliver, a star student and athlete at Douglas County High School in Georgia, drank two gallons of water and two gallons of Gatorade to stave off cramps last Tuesday, his relatives said. He felt better that evening but on Wednesday morning - just hours before he was set to start his first day of his senior year - he collapsed in his Douglasville home and was rushed to hospital. Doctors said Zyrees was brain dead after suffering devastating brain swelling from water intoxication http://www.dailymail.co.uk/news/article-2722957/High-school-football-player-17-dies-waterintoxication-drinking-four-gallons-fluids-stop-cramps-practice.html Nursing Care Plan Therapeutic Interventions Maintain oxygen to all cells Position: sim-Fowler’s or Fowler’s to facilitate improved gas exchange. Vital signs; q 4 hrs and PRN Tachycardia ↑ BP (overload) and ↓ BP (fluid deficit) Fluid restriction: I & O Promote excretion of excess fluid Meds as ordered: diuretics Monitor electrolytes, esp. Mg and K 17 Nursing Care Plan Therapeutic Interventions Obtain/maintain fluid balance Wt gain is the best indicator of fluid retention and overload Weight daily; 2.2 lbs = 1 Liter (1000 ml) Measure: all edematous parts, abdominal girth, I & O: fluid restriction Limit fluids by mouth, IVs per doctors orders Strict monitoring of IV fluids Prevent tissue injury Skin and mouth care as needed Evaluate feet for edema and discoloration when client is OOB Observe suture line on surgical clients (Potential for evisceration due to excess fluid retention) 18 Sodium Hypernatremia and Hyponatremia Functions of Sodium • Regulates osmolality • ICF: 14 mmol/L & ECF: 135-145 mmol/L • Helps maintain blood pressure by balancing the volume of water in the body • Works with other electrolytes to promote nerves, muscles and other body tissues to work properly. 20 Hypernatremia Hypernatremia –Water Loss Causes Signs & Symptoms • Inadequate water intake • Unconscious or cognitively impaired individuals • NPO status • Excessive water loss • ↑ insensible water loss • High fever • Diuretic therapy • Watery diarrhea • Disease states • Uncontrolled diabetes mellitus • Restlessness, agitation, twitching, confusion • Seizures*, Coma • Intense thirst • Dry, swollen tongue • Sticky mucous membranes • Weight loss • Weakness, lethargy • Postural hypotension Hyponatremia Hypernatremia – Na Gain Causes Signs & Symptoms • Na intake • IV fluids: hypertonic NaCl, excessive isotonic NaCl • Hypertonic tube feeding with out water supplement • Use of Na containing drugs • corticosteroids • Diseases • Renal failure • Restlessness, agitation, twitching • Seizures, Coma • Intense thirst • Flushed skin • Weight gain • Peripheral and pulmonary edema • ↑ BP Hyponatremia – Dilution (Water Gain) Causes Signs & Symptoms • Use of hypotonic irrigation solution • Tap water enemas • Excessive water gain • Excessive hypotonic IV fluid • Headache, apathy, confusion • Nausea, vomiting, anorexia • Lethargy • Weakness • Muscle spasms, seizures, coma • Diarrhea, Abdominal cramps • Weight gain • ↑ BP Hyponatremia – Na Loss Causes Signs & Symptoms • GI • Vomiting • Diarrhea • NG suctioning • NPO Status • Kidney • Diuretic • Skin • Burns • Wounds • Excessive diaphoresis • Irritability, apprehension, confusion • Dizziness • Personality changes • Tremors, seizures, coma • Dry mucous membranes • Postural hypotension • Tachycardia, thread pulse • Cold & clammy skin Potassium Hyperkalemia and Hypokalemia Functions of Potassium • Maintains fluid balance in the cells • Contributes to intracellular osmotic pressure • Direct effect on excitability of nerves and muscles • Skeletal, cardiac, and smooth muscle contraction • Regulates glucose use and storage 28 Hyperkalemia Hyperkalemia Causes • Most cases of hyperkalemia occur in hospitalized patients and in those undergoing medical treatment. • Those at greatest risk for hyperkalemia are • Chronically ill patients • Debilitated patients • Older adult • Excess potassium Intake • Excessive or rapid parenteral administration • Shift of potassium Out of Cells • Acidosis • Crushing injury • Tissue catabolism (fever, sepsis, burns) • Failure to Eliminate Potassium • Renal disease • Potassium-sparing diuretics • ACE inhibitors Signs & Symptoms • Clinical Manifestations • Irritability • Abdominal cramping, diarrhea • Weakness of lower extremities • Irregular pulse • Cardiac arrest if hyperkalemia sudden or severe • Electrocardiogram Changes • Ventricular fibrillation • Ventricular standstill Hypokalemia Hypokalemia Causes • Potassium Loss • GI losses: diarrhea, vomiting, fistulas, NG suction, NPO status • Renal losses: diuretics, • Skin losses: diaphoresis • Dialysis • Shift of Potassium into Cells • Lack of Potassium Intake • Starvation • Diet low in K • Failure to include K in parenteral fluids if NPO • TPN Signs & Symptoms • Clinical Manifestations • Fatigue • Muscle weakness, leg cramps • Nausea, vomiting, paralytic ileus • Soft, flabby muscles • Paresthesias, decreased reflexes • Weak, irregular pulse • Irregular heartbeat • Electrocardiogram Changes • Ventricular dysrhythmias (e.g., PVCs) • Bradycardia Hypokalemia - Medical Management Administration of KCl supplements K may be given orally (K chloride, K gluconate, K citrate) or IV KCl should be administered IV at a rate of 10 to 20 mEq/L over an hour. Rapid infusion could cause cardiac arrest IV K solutions irritate veins and cause phlebitis. Check IV site q 2 hrs. Discontinue IV if infiltrate to prevent necrotic and slough of tissue 33 Calcium Hypercalcemia & Hypocalcemia Functions of Calcium • Helps maintain muscle tone • Contributes to regulation of blood pressure by maintaining cardiac contractility • Necessary for nerve transmission and contraction of skeletal and cardiac muscle 35 Hypercalcemia Hypercalcemia Causes • Increased Total Calcium • Prolonged immobilization • Thiazide diuretics • Dehydration • Renal failure Signs & Symptoms • Clinical Manifestations • Lethargy, weakness • Depressed reflexes (DTR) • Decreased memory • Confusion, personality changes, psychosis • Anorexia, nausea, vomiting, constipation • Bone pain, fractures • Electrocardiogram Changes • Ventricular dysrhythmias • Hypertension Hypocalcemia Hypocalcemia Causes Signs & Symptoms • Decreased Total Calcium • Chronic renal failure • Loop diuretics (e.g., furosemide [Lasix]) • Chronic alcoholism • Diarrhea • Decreased Ionized Calcium • Excess administration of citrated blood • Clinical Manifestations • Easy fatigability • Depression, anxiety, confusion • Numbness and tingling in extremities and region around mouth • Hyperreflexia, muscle cramps • Chvostek’s sign & Trousseau’s sign • Laryngeal spasm • Tetany, seizures • Electrocardiogram Changes • Ventricular tachycardia Magnesium Hypermagnesemia & Hypomagnesaemia Functions of Magnesium • Cofactor in clotting cascade • Acts directly on myoneural junction, affecting muscular irritability and contractions • Maintains strong and healthy bones 41 Hypermagnesemia Hypermagnesemia Causes • Renal failure • Diabetes Mellitus • Clients who ingest large amounts of Mg-containing antacids such as Tums, Maalox, Mylanta, or laxatives such as MOM are also in ↑ risk for developing hypermagnesemia Signs & Symptoms • Bradycardia and hypotension • Severe hypermagnesemia: cardiac arrest • Drowsy or lethargic • Coma • Deep tendon reflexes are reduced or absent • Skeletal muscle contractions become progressively weaker and finally stop Hypomagnesemia Hypomagnesemia Causes • Malabsorption disorders • Inflammatory bowel disease (IBD) • Bowel resection • Bariatric population who undergoes gastric bypass surgery • Alcoholism • Prolonged diarrhea • Draining GI fistulas • Diuretics Signs & Symptoms • Confusion • Hyperactive deep tendon reflexes • Tremors • Seizures • Hypertension • Neuromuscular changes • Hyperactive deep tendon reflexes • Numbness and tingling • Painful muscle contractions Nursing Knowledge Base • Use the scientific knowledge base in clinical decision making to provide safe, optimal fluid therapy. • Apply knowledge of risk factors for fluid imbalances and physiology of normal aging when assessing older adults, knowing that this age group is at high risk for fluid imbalances. • Ask questions to elicit risk factors for fluid, electrolyte, and acid-base imbalances. • Perform clinical assessments for signs and symptoms of these imbalances. Nursing Process: Assessment • Nursing history • Age: very young and old at risk • Environment: excessively hot? • Dietary intake: fluids, salt, foods rich in potassium, calcium, and magnesium • Lifestyle: alcohol intake history • Medications: include over-thecounter (OTC) and herbal, in addition to prescription medications Nursing Process: Assessment • Medical history • Recent surgery (physiological stress) • Gastrointestinal output • Acute illness or trauma • Respiratory disorders • Burns • Trauma • Chronic illness • Cancer • Heart failure • Oliguric renal disease Physical Assessment • Daily weights • Indicator of fluid status • Use same conditions. • Fluid intake and output (I&O) • 24-hour I&O: compare intake versus output • Intake includes all liquids eaten, drunk, or received through IV. • Output = Urine, diarrhea, vomitus, gastric suction, wound drainage • Laboratory studies Nursing Interventions • Interventions for electrolyte imbalances • Support prescribed medical therapies • Aim to reverse the existing acid-base imbalance • Provide for patient safety Implementation • Health promotion • Fluid replacement education • Teach patients with chronic conditions about risk factors and signs and symptoms of imbalances. • Acute care • Enteral replacement of fluids • Restriction of fluids • Parenteral replacement of fluids and electrolytes • Total parenteral nutrition • Crystalloids (electrolytes) • Colloids (blood and blood components) Implementation • Restorative care • Home intravenous therapy • Nutrition support • Medication safety • Medications • OTC drugs • Herbal preparations Evaluation 1. Are the goals met? 2. How do we know?