Transcript Causes

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?