Fluid & Electrolytes ATI PDF

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ATI 57 & 58 Chapter 57: Fluid Imbalance Fluid Volume Deficit/ Hypovolemia EX: Hypovolemia & Dehydration

Risk Factors:  GI loss- vomiting, NG suction, diarrhea  Diaphoresis  Diuretics, diabetes insipidus, CKD  Peritonitis, intestinal obstruction, ascites, burns  Excessive loss from wound  Hemorrhage  Altered intake Dehydration:  Hyperventilation  Prolonged fever  DKA  Enteral feeding w/o water  *Older adults @ risk-> decrease in ability to detect thirst Expected Findings: VS:  Hypothermia  Tachycardia  Thready pulse  Hypotension  Orthostatic Hypotension  Decrease CVP  Tachypnea  Hypoxia Others:  Dizziness, syncope, confusion, weakness, fatigue  Thirst, dry mm, dry tongue, n/v/anorexia, weight loss  Oliguria  Diminished cap refill, cool clammy skin, diaphoresis, flattened neck veins, decreased skin turgor  Older adults* skin turgor not as reliable bc loss of elasticity

Fluid Volume Excess/ Hypervolemia EX: Hypervolemia & Overhydration *Can lead to pulmonary edema and heart failure* Risk Factors:  Kidney failure  Age related changes in cardiovascular and kidney function  Excessive sodium intake from IV fluids, diet, or medications Overhydration:  Water replacement without electrolyte replacement  Syndrome of inappropriate antidiuretic hormone (SIADH) (excess ADH)  Head injuries  Barbiturates  Anesthetics Expected Findings: VS:  Tachycardia  Bounding Pulse  Hypertension  Increased CVP  Tachypnea Others:  Confusion  Muscle weakness  Weight gain  Ascites  Dyspnea  Orthopnea  Crackles  Edema  Distended neck veins

Labs:  Increase serum osmolarity  Increased Urine specific gravity: > 1.030  Increased sodium: >145

Labs:  Decreased serum osmolarity: hypotension  Check neurological status to determine level of consciousness  Assess heart rhythm  Isotonic Infusions: 0.9% NS, LR, D5W  I&O; encourage fluids  Alert if Cell shrinks; hypertonicity Complications: coma, seizures, resp arrest Risk Factors: Risk Factors:  Deficient ECF volume  Water deprivation (NPO)

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GI loss: vomiting, NG suctioning, diarrhea, tap water enemas  Renal losses: diuretics, kidney disease, adrenal insufficiency excessive sweating  Skin losses: burns, wound drainage, edema  Excessive oral water intake, SIADH  Heart failure, cirrhosis, nephrotic syndrome  Excessive hypotonic fluids  Inadequate sodium intake (NPO status)  Hyperglycemia  Age related : older adults, use of diuretics Findings:  Hypothermia  Tachycardia  Rapid thread pulse  Hypotension  Orthostatic hypotension  Headache  Confusion  Lethargy  Muscle weakness  Fatigue  Decreased DTRs  Seizures  Coma  Hyperactive bowel sounds  Abdominal cramping  n/v/a 

Labs:  < 135 Sodium  Decreased serum osmolarity < 280  Decreased Urine specific gravity: altered thirst mechanism r/t altered thirst mechanism

Findings:  Hyperthermia  Tachycardia  Orthostatic hypotension  Restlessness  Disorientation  Irritability  Muscle twitching  Muscle weakness  Seizures  Decreased LOC  Reduced to absent DTR  Thirst, dry mm  Dry and swollen tongue  Hyperactive bowel sounds  Abdominal cramping, nausea  Edema  Oliguria  Warm flushed skin Labs:  >145 Sodium  Increased osmolarity > 295  Increased USG: > 1.030 Patient Care: LOC and ensure safety

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Oral hygiene to decrease thirst

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Fluid restrictions prescribed Monitor respiratory status if muscle weakness is present Restrict water intake if fluid overload Hypertonic IV therapy: >0.9 NS

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I&O Hypotonic IV fluids: 5.0 Risk Factors: Risk Factors:  IV potassium admin, salt substitutes,  Hyperaldosteronism  Vomiting, ng suctioning, diarrhea, blood transfusions excessive laxative  Insufficient insulin, DKA  Furosemide (diuretics that lose K)  Uncontrolled diabetes  Kidney failure, severe dehydration, K  Diaphoresis, wound losses  Metabolic alkalosis sparing diuretics, ACE inhibitors,  Tissue repair of burns, trauma, adrenal insufficiency  Older adult-> decreased kidney starvation  TPN function Findings: Findings:  Hyperthermia  Slow, irregular pulse  Weak irregular pulse  Hypotension  Hypotension  Irritability, confusion, weakness w/  Orthostatic hypotension ascending flaccid paralysis  Respiratory distress  Paresthesia  Bilateral muscle weakness w/  Lack of reflexes respiratory collapse and paralysis  V. Fib, peaked T waves, widened QRS, cardiac arrest  Muscle cramping  Decreased muscle tone + hypoactive  Diarrhea reflexes  Abdominal cramps, hyperactive bowel sounds  Mental confusion  PVCs, bradycardia, blocks ventricular tachycardia, flattening T waves, and ST depression  Hypoactive bowel sounds, abdominal distension, constipation, ileus, nausea, vomiting, anorexia  Anxiety Labs: Labs:  < 3.5 Potassium  > 5.0 potassium

 Metabolic alkalosis  EKG needed Patient Care:  Replace potassium  Monitor for urine output  Monitor breathing  Monitor cardiac rhythm  Monitor clients receiving digoxin bc of digoxin toxicity  LOC  IV potassium supplementation  Dilute to 1mEq-10 mL and infuse slowly no faster than 10 mEq/hr  Monitor for phlebitis  Never IV bolus bc cardiac arrest risk

 Metabolic acidosis  EKG needed Patient Care:  Decrease K intake: stop infusion of IV potassium hold PO potassium, K restricted diet  IV fluids with dextrose and regular insulin  Monitor cardiac rhythm  Prepare for dialysis if needed Meds: Loop diuretics-> furosemide (if good kidney function) Sodium polystyrene sulfonate (Kayexalate)-> poop the K out

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 Calcium 9- 10.5 mg/dL o Function of cardiovascular, neuromuscular, endocrine, blood clotting, bone and teeth formation -> NEED Vit D to absorb the Calcium!! Hypocalcemia: < 9 Hypercalcemia: >10.5 Risk Factors: Risk Factors:  Thiazide diuretics  Chronic diarrhea  Steatorrhea  Increased calcium intake and absorption  Malabsorption syndromes: Crohn’s  Vit D Deficiency  Hyperparathyroidism  Rapid infusion of blood  Bone cancer  Post thyroidectomy  Paget’s disease  Hypoparathyroidism  Chronic immobility  Long term glucocorticoid use  Hyperthyroidism Findings: Findings:  Decreased reflexes Muscle Twitches/ Tetany  Bone pain  Numbness & Tingling around mouth  Flank pain if renal calculi and fingers  Frequent painful muscle spasms  Dysrhythmias  Hyperactive DTR  Increased risk for blood clot  n/v/a/constipation  Positive Chvostek’s sign (tapping on facial nerve triggering the twitch)  weakness, lethargy  confusion, decreased LOC  Positive Trousseau’s sign (hand/finger spasms with sustained blood pressure cuff inhalation)  Laryngospasm

Cardiovascular:  Weak, thread pulse  Prolonged QT interval and ST segments Others:  Diarrhea, abdominal cramping  Seizures due to the overstim of CNS Labs:  < 9 calcium Patient Care:  Oral or IV calcium supplements-> monitor respiratory and cardiovascular status  Initiate seizure precautions (padded beds, suctioning nearby, position to prevent aspiration, protect head)  Keep emergency equipment on standby  Encourage foods high in calcium: dairy, dark green vegetables

Labs:  > 10.5 Patient Care: Increase the activity level

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 Magnesium: 1.3-2.1 mEq/L o Small amount in ECF Hypomagnesemia: 2.1 Risk Factors:  CKD, AKI  Adrenal insufficiency  Laxatives or antacids

Findings:  Diminished DTRs  Muscle paralysis  Shallow respirations, decreased respiratory rate  Bradycardia, hypotension  Dysrhythmias, cardiac arrest  lethargy

Patient Care:  Frequent focused assessments* Notify provider of changes or absent

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Oral can cause diarrhea and increase MG depletion ; IV is best Monitor DTRs for hyper magnesia Whole grains and dark green vegetables Implement seizure precautions

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reflexes Monitor resp and cardiac Admin loop diuretics and magnesium free IV fluids Administer calcium for severe cardiac changes...