Fluid and Electrolyte Balance, Student Notes(4) - Fundamentals of Nursing: the Art and Science of Nursing Care PDF

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Fluid and Electrolyte Balance, Student Notes NURS 303 Fluid and Electrolyte Balance Overview 

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Body Fluid Composition o Water  Primary component of body fluids  Provides medium for  Transport and exchange of nutrients and substances to and from cells and metabolic reactions between cells  Assists in regulating temp  Perspire  Don’t want to elevate too quickly  Helps cell maintain shape o Electrolytes  Chemical compound of body fluids that dissociates into particles  Become charged particles:  Cation  Anion  Function of electrolytes  Water balance o Sodium especially cause sodium holds on to water o Too much sodium then too much water  Acid base balance o Kidneys wont function properly  Contributes to enzyme reaction  Necessary for neuromuscular function and cardiovascular Body Fluid Distribution: body fluid is classified by its location o Intracellular: inside the cells o Extracellular: outside the cells (need to know where we are trying to get the water)  Interstitial: in between the cells  CHF or ascites.  Intravascular: in veins arteries or capillaries  Important when talking about blood volume, pressure, and CV  Transcellular: random. Urine, digestive secretion, spinal fluid, pericardial fluids Body Fluid Movement: Four major components (must function properly to maintain balance) o Osmosis: Water movement across a semi-permeable membrane  Osmolarity: the concentration of the solution; the number of solutes per kilogram of water  Drawn to higher solute concentration places  Ex: serum osmolarity or UA  Dependent on sodium, glucose, and urea

Fluid and Electrolyte Balance, Student Notes NURS 303 

Osmotic Pressure and Tonicity:  Pressure: power of a solution to draw water across membrane o Maintains balance between interstitial and intravascular spaces and keeps water in vascular system  Tonicity: effect solution has on the movement of water o Isotonic: have the same concentration of solutes as surrounding plasma  Description  Example Fluid  Example Scenario  Equal in concentration of solutes as the surrounding plasma  Use this primarily for volume  Cells wont shrink or swell  Ex: normal saline (0.9% sodium chloride) and some others  Ex: use: if there is a bleed. Cause if we lose blood volume we lose blood pressure. Then heart rate will increase o Hemorrhage or GI suctioning o Hypertonic: Greater concentration of solutes than surrounding plasma  Description  When cells are surrounded by hypertonic solution the cells shrink as water is drawn out  Can become dehydrated  Short term  Watch carefully  Example Fluid  3% sodium chloride and there are other things to memorize  Example Scenario  Seizures related to ICP (intracranial pressure) o Hypotonic: have a lower concentration of solutes than plasma  Description: moves water into the cells and causes them to swell  Example Fluid  0.45% sodium chloride  Example Scenario  Dehydration

Fluid and Electrolyte Balance, Student Notes NURS 303 Diffusion: process of solutes moving across the membrane from an area of high solute concentration into lower solute concentration through protein channels o Filtration: water and dissolved soluties move from area of increased hydrostatic pressure to and area of lower hydrostatic pressure  Typically occurs in capillary membranes  Hydrostatic pressure: created when the heart pumps and when gravity pushes against capillary membrane  Heart beats pushes water away then when relaxed water comes back o Active Transport: allow molecules to move across the membrane even in areas of high concentration  Ex: sodium-potassium pump Body Fluid Regulation o Thirst  Primary regulator of water intake  Maintains fluid balance and prevents dehydration  Thirst center stimulated with drop in volume or increased serum osmolarity o Kidneys  Prime regulator of fluid volume and electrolyte balance in the body  Selectively reabsorb water and electrolytes o Renin Angiotensin Aldosterone System: helps maintain intravascular fluid balance and blood pressure  Renin stimulates angiotensin 1 angiotensin 2.  Angiotensin 2 increases aldosterone and ADH  Hold on to sodium and water o Antidiuretic Hormone  Fall in bp or increase in serum osmolarity stimulates ADH  Promotes water reabsorption in distal tubule o Atrial Natriuretic Peptide  Blocks RAA system  Promotes sodium wasting and increases urine output Normal Fluid Balance o Intake:2500 ml/day o Urine output: 1500 ml/day o Insensible loss: 1000ml/day  30ml/hour at least (50,60,70 for most people)  These include feces skin(perspire) lungs Factors That Influence Fluid Balance o Age  Young and old.  Not developed kidneys or not working as well o environment o

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Fluid and Electrolyte Balance, Student Notes NURS 303  o

How hot or cold is it

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 how much sodium/protein are you taking in stress  increases metabolism and tells body to hold onto sodium o illness  Fluid imbalances come with Tests and Indicators of Fluid and Electrolyte Imbalance o Labs:  Osmolality: normal=280-300 mOm  Refers to concentration of solution  Specific gravity of urine: normal =1.010-1.030  Hematocrit: normal = 40%  BUN: normal = 5-20  Sodium: normal =135-145 o Other Indicators  Daily weight: increase/decrease reflects gains and losses  Chf can gain 20-30 pound in a night  Use this to see if treatment is effective  I&O  Low output can be cause holding on to electrolytes  can cause fluid volume excess or be due to dehydration  Edema  Fluid shifts from intravascular to interstitial  Skin turgor  Poor and tenting  Mucous membranes  Dry o

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Intravenous Access and Fluids: Nursing Responsibilities 

Assessment o Part of your head to toe o Size  Note the color of the catheter to determine the size  Certain things have to use a larger or smaller IV  Insertion date- change every 3  Surrounding area  Color and temp  IV fluids and tubing  Need to match what they are supposed to be getting  Fluids are only good for 24 hours

Fluid and Electrolyte Balance, Student Notes NURS 303 

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 Tubing is good for 72 hours unless otherwise specified Complications o Infiltration  Fluid you are giving has gone into the interstitial space. See swelling proximal to insertion site  Cool and pale o Thrombophlebitis  Vein is irritated  Red, swollen, and warm  Meds that are known to cause this the site will be changed often Systemic Complications o Circulatory overload:  BP increases  Respiratory (dyspnea or crackling in lung)  JVD  Edema  Bounding pulse o Air embolism  More common in central line  Central line ends at the heart so there are no nodes to catch an air bubbles  Signs of shock:low BP, tachycardia  Place on left side and in trendelenburg  So that the bubble is stuck in ventricle and will eventually get reabsorbed and wont get into the lung o Allergic reaction Types of lines/access o Peripheral Line  In someones arm  Could also mean lower extremity but someone specially trained puts this in  The cannula is only about an inch or inch and a half under the skin  Clean dressing changes o Central Line  Ends at patients heart  Can have the central line in the chest  Line is tunneled under the skin  Lasts much longer up to months  For cancer patients, the port can be left in for a long time after as long as they maintain it  You can draw blood from a central line

Fluid and Electrolyte Balance, Student Notes NURS 303 o o

 Sterile dressing changes PICC Line Triple Lumen Catheter (TLC)  A lot of critical care patients need lots of meds at once  Some of these meds cant mix

FLUID CLASSIFICATION Isotonic

Hypotonic

NAME AND COMMON USES OF FLUIDS Lactated Ringers (LR): a balance electrolyte formula(puts some electrolytes in us), commonly used for surgical patients. Caution with renal patients because they cant get rid of potassium well. Lactated: helps reverse acidosis after surgery

0.45% Normal Saline (1/2NS): Treats cellular dehydration and promotes waste elimination by kidneys. If BP is really low then give NS first to increase blood volume then the 1/2NS to help with the dehydration. If you continue to use this, the cells

Normal Saline (0.9%NS): used for vascular volume expansion and fluid resuscitation. Stays in the blood and is used for shock Common in ER and for BP elevation

5% Dextrose (D5W): Can become free water when dextrose metabolizes; expand intracellular and interstitial fluids. Short term only. (can lower the sodium and make the blood cells lyse/eventually washes the cell out) Give when patients need dextrose for blood sugar (diabetic patients)

Fluid and Electrolyte Balance, Student Notes NURS 303 can swell

Hypertonic

5% Dextrose and 0.45% Sodium Chloride (D51/2NS):Draws fluid into the vasculature from interstitial and intracellular compartments.

3% Sodium Chloride (3%NS): Prevents seizures from severe hyponatremia.only used when at risk of seizures from brain edema . associate with head injury or stroke

5%Dextrose and Lactated Ringers (D5LR): Electrolyte formula used for patients with draining wounds.

5% Dextrose and Normal Saline (D5NS): provides calories to prevent catabolism when NPO

Total Parenteral Nutrition (TPN): Used when patient is NPO more than 5 days or have extensive caloric needs (burns, GI surgery)

TPN (Total Parenteral Nutrition)    

Large bag of hyperosmolar (hypertonic) solution Contains fats, proteins, glucose, vitamins, and electrolytes Provides items necessary to sustain life Not a tube feeding o Indications  Patient can eat but isn’t getting enough  Bowel system is off limits o Administration  Give via central line  One bag hung daily usually in the evening  So dieticians and docs and can make decisions during the day  Will check blood sugar often  Hanging TPN  Change the entire bag and all tubing with the next TPN ($5000 a bag) o Nursing Care  Hang bag at exact time ordered  Discard old bag and any fluid left in it  Monitor patient’s BS every 6 hours  Two rns must verify before bag is hung  If new bag is not there and old bag is out hang D10 at same rate until new bag comes  Tubing and tpn have 24 hour hang limit o Complications  Hyperglycemia: check blood sugar at least qid.

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Sepsis: infection in blood stream due to sugar in TPN and central line: change bag and lines accordingly Fluid overload: due to increase osmolality of solution  Monitor for S/S of overload: lung sounds, resp rate, edema

Fluid Imbalances 

Fluid Volume Deficit o o o

An decrease in intravascular, interstitial, and/or intercellular fluid in the body Causes: excessive fluid loss, insufficient fluid intake, or failure of regulatory mechanisms and fluid shifts within the body Types: Hyperosmolar and Isotonic  Hyperosmolar Volume Deficit:  Description o Blood becomes hypertonic o The water moves out of the cells to dilute the extracellular tissue causing the cells to shrivel and become dehydrated. o Even though water is moving out into the vascular system it is not enough  Causes o Decreased fluid intake  Older people may forget  Cant retain fluids o Increased water loss  Diuretics o Hyperosmolar dietary intake  High amounts of protein and salt they will start losing a lot of fluids  Water is drawn to the salt in the blood o Build-up of solutes due to disease  Renal failure  DKA o Sequestration of body fluids  Major shift. Fluid is going somewhere not acceptable  Pleural effusions or edema  Isotonic Volume Deficit  Description o Loss of water and solutes from extracellular spaces o Balanced loss o Balances osmolarity  Causes

Fluid and Electrolyte Balance, Student Notes NURS 303 o o o

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Hemorrhage Excessive sweating GI loss  N/v  NGT drainage  Ileostomy  Higher in bowel so nutrients and water aren’t being absorbed as well

Signs and Symptoms:  Skin  Dry, flushed, poor turgor   Mouth  Dry mucous membrane  Eyes  Sunken eyes  May lose ability to make tears  CNS  Wake, restless, confused  CV  Orthostatic or postural hypotension  Pulse pressure will decrease o Difference between systolic and diastolic pressure  Ex: 130/70 then 120/90  Could go into irreversible shock  Other  Thirsty, weight loss  Urine  Decreased uop  Labs  Iso is normal labs  Hyper o Everything increases  BUN creatinine hematocrit, urine osmolality and specific gravity, plasma osmolarity increase Treatment: Fluid replacement and rehydration  Hyperosmolar Replacement  Hypotonic solution is patient normotensive  Isotonic solution if patient is hypotensive (so low BP start with iso)  Isotonic Replacement  Isotonic solution

Fluid and Electrolyte Balance, Student Notes NURS 303 o

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Nursing Care  Assessment:  Health history, meds (diuretics), exercise  Physical assessment:  Weight, v/s, heart rate (if they become tacchycardic), urine output  Careful I&O Nursing Diagnosis  Deficient fluid volume  Ineffective tissue perfusion  Risk for injury  Orthostatic hypotension

Fluid Volume Excess: Typically results from conditions in which sodium and water are retained o o

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Types: Hypotonic and Isotonic Hypotonic causes  Renal failure- decreased renal output related to failure or disease  Pump failure- CHF or renal perfusion deficit.  Oral hydration overload- psychogenic polydipsia (no control over how much they drink)  SIADH- syndrome of inappropriate ADH  Retaining water but it is an all over rention.  Wont notice distinct edema  Sodium levels start to drop o When drop below 120 the CNS symptoms will come o Intracranial pressure increases o Give 3% (noted from above) Isotonic causes  Increased venous pressure  Obstruction from DVT  Increased aldosterone  Cushings disease: salt and water reabsorption  Cirrhosis- decreases in aldosterone metabolism  Decreased capillary oncotic pressure  Loss of protein- burns, liver disease, nephrotic syndrome o Excess protein is in the urine  Increased interstitial oncotic pressure  Blocked lymphocytes Symptoms:  Skin  Dependent edema, tight and cool skin

Fluid and Electrolyte Balance, Student Notes NURS 303 CNS  Lethargy and confusion  Respiratory  Sob crackles, increased respiration dyspnea at rest  CV  Full bounding pulse, hypertension, distended neck weins, tachycardia  Labs  Normal with isotonics. Hypotonic: decreased sodium, hct, osmolality, and BUN. UA decreased osmolality and specific gravity Type of edema  Increased hydrostatic pressure: pressure in blood causes fluid to shift into tissues  Pitting edema o Ankle/dependent edema, CHF, pregnancy o Pregnant women cause baby is putting pressure on the vena cava  Pulmonary edema o Blood isn’t pumping out fast enough and is in lungs  Ascites: cirrhosis o Liver scarring prevents portal blood from going into liver  Edema caused by electrolyte imbalance: cerebral edema  Where we start giving 3%  Steroids to decrease inflammation  Mannitol  Fluid shifts from blood into brain  Low protein edema  Non pitting  Caused by low albumin  Often seen with burn victims and malnourished o Just increase protein  Edema caused by lymphatic problems  Lymph nodes have been removed  Congential defect that impairs one’s ability to filter and move fluids appropriately o Say axillary lymph nodes was blocked, the whole arm could swell o Another example could be people with breast cancer who have had those nodes removed Treatment of fluid volume excess  Diuretics: potassium sparing vs non potassium sparing  Fluid restriction 

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Fluid and Electrolyte Balance, Student Notes NURS 303  Divided up throughout the day Sodium restriction  No added sodium on meal trays plus high sodium foods removed from diet  Elevation of HOB/FOB depending on symptoms  Lymphedema  Elevation of extremity, jobst sleeve (like spanx for arm or leg), ted hose Nursing Care  Health assessment: history, recent weight gain, diet. Complaints of SOB, dyspnea at rest, coughing, or edema  Physical assessment: weight, vital signs, lung sounds, urine output, level of consciousness Nursing Diagnosis  Fluid volume excess  Risk for impaired skin integrity  Impaired gas exchange 

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Electrolyte Imbalance: Sodium, Normal Range: 135-145.     

Primary regulator of volume, osmolality, and distribution of extracellular fluid Helps in maintaining neuromuscular activity Imbalance affect osmolality of ECF and water distribution between fluid compartments Low sodium=water drawn into cells of the body, causing them to swell High sodium=water drawn out of cells, causing them to shrink

Hyponatremia o

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Causes:  Diuretics  Causing them to lose sodium with water  Kidney disease  Adrenal insufficiency  Vomiting  Severe will start out at an isotonic situation but then turns to an electrolyte issue  Diarrhea  GI suctioning  Excessive sweating Symptoms  BP decrease  Cause no sodium to hold onto volume  Could go into shock

Fluid and Electrolyte Balance, Student Notes NURS 303 Muscle cramps Weakness Headache  Typically cause of brain edema  Brain edema: lethargy, stupor, coma  Very extreme confusion  Ex: 40 yr old man who sat on floor and cried Treatment  If dilution is the cause, restrict intake and give diuretics  If Hypotensive give NS to balance that out  Patient has CNS symptoms: give 3% saline and or mannitol  3% has to be given very slowly  If too fast it demyelinizes the myelin shift  Should be scared when giving this and be very careful  Loop diuretics  for people with normal pressure  ignore the thiazide diuretics cause you will just lose more sodium Nursing Care  High sodium diet if it is a true loss  Monitor neuro status and pad rails  Weigh daily  Accurate I&O  Monitor VS  Monitor electrolytes   

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Hypernatremia o

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Causes  Hypertonic dehydration  Fluid loss with electrolyte loss  Certain diuretics  Water is drawn out of cells  Serious in brain cells because the cells shrink and cause neurological issues  Brain vessels contract and they can tear  Medication related to sodium rention : cortisone, PCN  Increased intake of salt Symptoms  Excessive thirst  Lethargy, weakness, irritability  Coma, seizures, death  Weight gain  Dry mucous membranes

Fluid and Electrolyte Balance, Student Notes NURS 303 o

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Treatment  Hypotonic fluids1/2 NS  Or D5W  Diuretics (thiazide)  To get rid of fluid and sodium Nursing Care  Fluid replacement  Assessment of neurological function  Safety precautions

Electrolyte Imbalance: Potassium (Normal Range: 3.5-5.3)   

Primary intracellular cation Vital in cell metabolism, cardiac and neuromuscular function Maintenance of nerve impulses, normal cardiac rhythms, and muscle contraction

Hypokalemia o

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Causes  Inadequate intake  Excessive losses, intestinal, or skin losses  Redistribution between the ICF and ECF  Diabetic ketoacidosis  Secondary loss from medications: loop diuretics, corticosteroids, certain antibiotics  GI/GU losses  Diarrhea ,suction Symptoms  Confusion, lethargy  Dysrhythmias, irregular pulse, ECG abnormalities, cardiac arrest  Nausea/vomiting, diarrhea  Fatigue, muscle cramps, muscle weakness, parathesia (numbness and tingling)  Paralytic ileus due to decreased muscle activity in smooth muscle  When hypokalemic muscle activity decreases including in your bowels Treatment  Medications  IVF with potassium added, oral and or parenteral supplements  If potassium is going as a secondary IVF it can cause pain...