Fluid and Electrolytes ( Hurst) PDF

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Review of Fluids and Electrolytes. Hurst review...

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Fluid Balance Fluid Excess/Hypervolemia Definition: Too much fluid in the vascular space ( any vein or artery including the heart) Causes: 1. Heart Failure: heart weak  decreased cardiac decreased kidney perfusion  decreased output *volume stays in vascular space and builds up 2. Renal Failure: kidneys aren’t working therefore there is no diuresis 3. Hypernatremia: a. Effervescent soluble medications b. Canned/processed foods c. IVF with sodium Hormone Regulation of Fluid Volume Aldosterone (steroid/mineralocorticoid) Anti-diuretic Hormone (ADH) Location: Adrenal glands (cortex) Location: is found in the pituitary (brain) Action: when blood volume is low (i.e. vomiting, Action: works to retain water hemorrhage, trauma, sx)… Aldosterone secretion Imbalances increases  retention of sodium/water (not just Too Much (SIADH) Too Little (DI) fluids) and blood volume increases Diurese water Retain Water Imbalances: Fluid volume deficit Fluid Volue excess 1. To HIGH: Cushing’s (too many of all Urine is concentrated Diabetes Insipidus steroids) & Hyperaldosteronism (conns Di – Diuresis – shock Blood diluted syndrome) Urine dilute 2. To LOW: Addison’s (too low steroids) Blood concentrated Atrial Natriuretic Peptide (ANP) Causes of Imbalances: increased ICP ( head injury Location: found in atrium of the heart and is surgery, craniotomy, etc) as pituitary is situated in brain released when heart stretches with fluid volume  Another name for ADH is vasopressin excess ( Frank Starlings law) (different from vasopressors) the drug Action: works opposite of aldosterone: acts on vasopressin (pitressin) may be used as ADH kidneys to excrete sodium and water replacement in diabetes insipidus. 1. Distended neck veins/peripheral veins: vessels are full Signs and Symptoms 2. Peripheral edema/third spacing: vessels cant hold any more, so they start to leak 3. Central Venus Pressure (measured in R. Atrium) as volume rises so does pressure 4. Lung sounds: crackles 5. Polyuria: Kidney’s are trying to help Diurese (except with ADH problems) 6. Increased HR; heart wants to move fluid forward: if it does not go forward it goes backward into lungs. Increased volume  increased workload  HF  pulmonary edeam 7. Increased blood pressure 8. Weight increase; any sudden weight gain or loss is related to fluid Treatment DIET: Low sodium diet and fluid restrictions Fluid Balance: monitor I & O and record daily weights ( weight must be done at the same time on the same scale each day) Diuretics: 1. Loop Diuretics: furosemide (bumetanide may be given if furosemide doesn’t work) 2. Potassium Sparing: spironolactone Bed Rest: nduces diuresis by release of AN and, decreases production of ADH Physical Assessment: focus on pertinent signs and symptoms Med Administration: Give IVFs slowly to the elderly and very young

Fluid Volume Deficit/ Hypovolemia Causes: A. Loss of fluids from anywhere: thoracentesis, paracentesis, vomiting, diarrhea, hemorrhage, trauma, sx) B. Third Spacing: (when fluid is in a palce that does you no good)  Burns: tissues  Ascitis: Peritoneum: measure abdominal girth q24h as it pushes on diaphragm and can cause trouble breathing. C. Diseases with polyuria (diabetes) or oliguria/anuria (worry about kidney failure) Signs and Symptoms - Weight decrease - Decreased skin turgour - Dry mucous membranes 9swlle tongue) - Decreased output (kidney’s aren’t being perfused or they are trying to hold on to fluid to compensate) - Decreased BP: - Increased Heart Rate - Increased RR - Decreased CVP - Peripheral veins/neck veins vasoconstrict - Cool extremities (peripheral vasoconstriction an effort to shunt blood to the vital organs) - Urine specific gravity increases. If putting out any urine at all it will be very concentrated. IV Fluids Isotonic Solutions

Treatment a. Prevent further losses (tx underlying cause) b. Replace volume: ( mild deficit with PO fluids, severe deficit with IV fludis) *** see below for fluid administration c. Safety precautions: high risk for falls d/t/ decreased LOC. Also monitor for overload.

Hypotonic Solutions

Goes into the Vascular space and Goes into the fascular space and then shifts out into the cells to stays there! replace cellular fluid! Examples: D5W, NS, LR, D5 ¼ NS Examples: D2.5W, ½ NS, 1/3 NS Indications: used in patients that Indications: used on clients who have lost fluids through N/V, have HTN, renal or cardiac burns, sweating, trauma, & Sx disease, and need fluid (replenishing vascular space) replacement because of N/V, burs, or hemorrhage Alert: do not use isotonic * Also used for dilution when a solutions in clients with HTN Cardiac disease or Kidney disease client has hypernatremia and for as these solutions can cause FVE, cellular dehydration. Alert: watch for cellular edema HTN, or hypernatremia (only an because this fluid is moving out alert when administering to the cells which can lead to solutions with sodium) fluid volume deficit and decreased BP

Hypertonic Solutions Volume expanders that will draw fuid into the vascular space from the cells! Examples: D10, 3%NS, 5% NS, D5LR, D5 ½ NS, D5NS, TPN, Albumin, Mg Sulfate Indications: hyponatremic patients or patients who have shifted large amounts of vascular volume to a 3rd space or have severe edema, burns or ascites Alert: Watch for fluid volume excess. Monitor in an ICU setting with frequent monitoring of blood pressure, pulse, and CVO if they are receiving 3% NS or 5% NS. (HT, wet lungs)

Electrolytes: Magnesium and Calcium (Normal Lab Values: Mg: 0.65 – 1.05 mmol/L Ca: 2.25 – 2.62 mmol/L) Magnesium *Signs/Symptoms that re To High: common in a pt. with Causes: Renal Failure (Mg. is excreted via kidneys), Antacids Signs and Symptoms: Flushing, warmth (Magnesium makes you vasodilate) hyper magnesium or hyper-excitability of the heart. hypercalcemia - DTRs weak Treatment: a. Ventilator: if RR is < 12 (diaphragm/lungs are muscle) - muscle tone flaccid b. Dialysis (since kidneys are failing - arrhythmias high risk c. Calcium gluconate: is administered IVP very slowly (antidote for mg) - LOC decreased d. Safety Precaution’s: Calcium has an inverse relationship with phosphorus - Pulse decreased - Respirations Too Low: decreased Causes: diarrhea (lots of Mg in intestines), not eating or drinking, Alcoholism (alcohol suppresses ADH and it’s hypertonic Signs and Symptoms of Signs and Symptoms: see to right both hypoMG, and Treatment: HypoCa… 1. Give Magnesium: Check Kidney function - Muscle tone is tight before and during IV Magnesium ( only give if you know they can excrete and rigid it) . If patient reports flushing and sweating stop Mg immediately. - Risk of seizures - Stridor/laryngospasm 2. Seizure precautions : airway = smooth 3. Increase Mg intake: foods (spinach, halibut, turnip, kale, celery, seeds. muscle Calcium - Chvostek’s – tap To High cheek Causes: hyperparathyroidism (PTH  calcium released from bones into - Trousseau’s blood), Thiazides (retain calcium i.e. HCTZ), Immobilization (you have to bear - Arrhythmias – heart weight to keep Ca in the bones) is muscle QRS Signs and Symptoms: Bones are brittle, kidney stones (majority made of complex widens calcium) - DTRs – hyper reflexive Treatment: - Mind Changes: a. ACT QUICKLY wired/manic/ b. Fluids: prevent kidney stones depressed c. Calcium has inverse relationship with phosphorus (add protein to diet as - Swallowing problems: protein has phosphorus in it once it breaks down) esophagus is smooth d. Steroids : cause loss of Calcium in GI muscle (may cause e. Mediations that decrease serum Calcium… Bisphosphates (Etridonate) or aspiration. calcitonin (used for osteoporosis) Too Low: Causes: Hypoparathyroidism or surgery that may decrease parathyroid function (i.e. radical neck dissection/thyroidectomy) all of these = not enough sedative Treatment: a. PO calcium b. IV calcium (GIVE SLOWLY) and always use cardiac monitor c. Vitamin D  causes absorption in stomach d. Phosphate binders: sevelamer hydrochloride

Sodium (Normal Lab Values: 135-145 mmol/L) The Sodium level in your blood is totally dependent on how much water you have in the blood. Hypernatremia = Dehydration Hyponatremia Definition: Too much water, not enough sodium Definition: too much sodium, not enough water. Causes: drinking water for fluid replacement Causes: Hyperventilation (insensible fluid loss after vomiting/sweating 9need salt with h2o) with breathing) heat stroke, diabetes insipidus. psychogenic polydipsia (excessive h2o intake), Feeding tube clients tend to get Hypernatremic SIADH, replacing with D5W (dehydrated. Signs and Symptoms: headache, seizure, coma Signs and Symptoms: Dry mouth, thirsty – already dehydrated by the time your thirsty, Treatment (NEEDS Na but not H20) 1. If having neuro problems administer swollen tongue (for severe) hypertonic saline Treatment: 1. Restrict Sodium 2. Dilute client with fluids: Diluting makes sodium go down (hypotonic solution) 3. Daily weights 4. I & O: if you have a sodium problem you have a fluid problem 5. Lab work Potassium: (Normal Lab values 3.5 – 5 mmol/L) Potassium is excreted by the kidneys. If the kidneys are not working well the serum potassium will go up. Hyperkalemia: common causes include kidney failure or the use of potassium sparing diuretics such as spironolactone ( retains potassium) Signs and Symptoms --- Begins with muscle twitching, then proceeds to muscle weekness and then flaccid paralysis ECG changes with Treatment hyperkalemia: a. Dialysis (kidneys aren’t working) bradycardia, tall, and b. Calcium gluconate decreases potential for arrhythmias peaked t waves, c. Glucose and insulin: insulin carries glucose and potassium into the cell. prolonged PR Anytime you give IV insulin, watch for hypoglycemia and hypokalemia intervals, flat/absent p d. Sodium polystyrene sulfonate (Kayexalate) only give with hyperkalemia waves, wide QRS, conduction blocks and Hypokalemia: common causes include vomiting, NG suction (we have lots of K v-fib. in our stomach), Diuretics, Not eating (we get it from our diet) ECG changes with Signs and Symptoms --- Muscle cramps and muscle weakness hypokalemia: U Treatment: waves, PVCs, and a. Give potassium: assess output before/during IV K. Always put in pump ventricular and mix well. This burns on infusion. Problem with PO K = GI upset. tachycardia b. Spironolactone to help client retain potassium c. Eat more potassium: spinach, kale, Brussel sprouts, tomatoes, banana, tuna, kiwi, potatoes, cabbage etc....