Susan Hench, RN, MSNAssistant Professor of Nursing

N102

ReviewThis section is a review of fluid

balance and IV fluid. This should not be new material.

Parenteral SolutionsIV fluidHow it works depends on how its osmolarity compares to the patient’s serum osmolarity

Involves osmotic pressureOsmolarity of body fluids is between 280 and 295

Three ways IV fluids workExpand the intravascular fluid volume

Expand the intravasular fluid volume and deplete the intracellular and interstitial fluid volume

Expand the intracellular fluid volume and deplete the intravascular fluid volume

Isotonic FluidConcentration of solute equal to that of intracellular fluid

Osmotic pressure same inside and outside cells – cells neither shrink or swell

Fluid stays in the blood vessels

Isotonic FluidExamples

0.9% Sodium Chloride (NSS)5% Dextrose In Water (D5W)0.2% Dextrose And 0.9% NACL

(1/4DNSS)5% Dextrose And 0.2% NACL

(D51/4NSS)Lactated Ringers (LR or RL)

Isotonic FluidCaution

Can cause circulatory overloadFluids do not cause shifts into other compartments

Can lower H & H and electrolytes by diluting them

Hypotonic FluidTonicity less than that of intracellular fluid

Osmotic pressure draws water into the cells from the extracellular fluid

Body fluids shift out of the blood into the interstitial areas and into the cells

Hypotonic FluidExamples

0.45% NaCL (1/2 NS)0.33% NaCL (1/3 NS)0.2% NaCL (1/4 NS)2.5% Dextrose In Water

Hypotonic FluidCaution

Infusing too much can cause intravascular fluid depletion, lower BP, cause edema, and damage cells

Use cautiously in patients with heart, renal and liver disease

Hypertonic FluidTonicity is greater than that of intracellular fluid

Shifts fluid from ICF to ECF to intravascular space so blood volume expands

Hypertonic FluidExamples

5% Dextrose In 0.45% NSS (D5 1/2NS)

5% Dextrose In NSS (D5NS)5% Dextrose In LR (D5LR)10% Dextrose In Water (D10W)

Hypertonic FluidCaution

Give slowly – use an IV pump and monitor for circulatory overload

Maintaining Fluid BalanceA number of body processes work together to maintain fluid balance

A problem in any of those processes can affect the entire fluid-maintenance system

A problem in any one of these areas can create fluid and electrolyte imbalancesKidneysPituitary GlandHypothalamusHormone

Levels

HypovolemiaFluid volume deficitIsotonic fluid loss from extracellular space to interstitial space

Children and older adults prone to this condition

HypovolemiaResults from excessive fluid loss

Bleeding with or without reduced fluid intake

VomitingExcessive diarrheaExcessive perspiration with too little

fluid intakeDrainage from wounds or burns

HypovolemiaClinical Manifestations

Weight lossOrthostatic hypotensionConfusion, irritability, thirstRapid pulse, drop in BPSkin cool and clammyDecreased urine output

FLUID AND ELECTROLYTE BALANCEHypovolemia

Diagnostic findingsIncreased urine specific gravity

Increased H & HElevated BUN

FLUID AND ELECTROLYTE BALANCEHypovolemia

Nursing implicationsProvide fluids-both PO and IVMonitor vital signs

HypovolemiaCan also result from third space fluid shiftCalled third spacingFluid shift from intravascular space into interstitial space of the peritoneal, pleural, or pericardial space causing edema

Third space fluid shiftWater and solutes in the third space are not available to maintain normal body fluid and electrolyte balances

Caused by acute bowel obstruction, ascites, pancreatitis, peritonitis

HypervolemiaFluid overloadFluid volume excessExcess of isotonic fluids in the extracellular compartment

Edema

HypervolemiaCauses

Excessive administration of oral or IV fluids

Syndrome of inappropriate antidiuretic hormone (SIADH)

Excessive water intakeHeart failureRenal failure

HypervolemiaClinical Manifestations

Cardiovascular changesRespiratory changesEdemaConfusion or altered locSkeletal muscle weakness

HypervolemiaDiagnostic Findings

H & H tend to be lowerDecreased urine specific gravityIf renal failure is the cause, electrolytes, BUN, and creatinine levels are increased because the kidneys are unable to excrete them

HypervolemiaNursing Implications

May be given diureticsFluid and/ or sodium restrictionDaily weightsI & OMonitor edema, lung sounds, vital

signsGoal is to restore fluid balance

Any Questions So Far?

Disturbance in the electrolyte balance is common in clients requiring nursing care

ElectrolytesElectrically charged solutes in body fluids

Necessary to maintain balanceAlso called ions

Anions have a negative chargeCations have a positive charge

Functions of ElectrolytesMaintain acid-base balancePromote neuromuscular activityMaintain body fluid osmolarityRegulate and distribute body fluids among the compartments

SODIUM136-145 MEQ/LVery important, a major cationMost abundant in ECF Helps transmit impulses in nerve and

muscle fibersComines with chloride and bicarbonate

to regulate acid-base balanceRegulated by the kidneys

HyponatremiaSodium deficitDilutional – loss of sodium or excessive water gain

Depletional – not taking in enough sodium

HyponatremiaCauses

Prolonged diuretic therapyExcessive diaphoresisInsufficient sodium intakeExcessive sodium loss from trauma

Severe fluid loss

HyponatremiaCauses

Administration of hypotonic solutions

Compulsive water drinkingLabor induction with oxytocinSIADH – Syndrome of Inappropriate Anti-Diuretic Hormone secretion

HyponatremiaClinical Manifestations

General – abdominal cramps, nausea, headache, altered loc, muscle twitching, tremors, and weakness

Depletional – orthostatic hypotension, poor skin turgor, dry mucous membranes, tachycardia

Dilutional – hypertension, weight gain, bounding pulse

HyponatremiaDiagnostic Findings

Serum sodium levels lowSerum chloride levels may be lowUrine specific gravity less than

1.010

HyponatremiaNursing Implications

Monitor clients at riskMonitor VSMonitor neurological statusI & O, daily weightMonitor labsMay restrict fluidClient and family teaching

HypernatremiaSodium excessHappens less frequently than hyponatremia

HypernatremiaCauses

Inadequate intake or excessive loss of water

Administration of hypertonic solutionsHigh intake of sodiumEnteral nutritionTPN

HypernatremiaCauses

Severe watery diarrheaSevere insensible water lossSevere burnsDiabetes InsipidusCushing’s SyndromeSevere renal failure

HypernatremiaDiagnosis

Serum sodium levels above 145Urine specific gravity above 1.030

TreatmentAdminister hypotonic solutions

HypernatremiaClinical manifestations

Extreme thirstTachycardiaNeuromuscular signsHyperactive deep tendon reflexesHypertensionLow-grade temperatureOliguria or anuria

HypernatremiaNursing implications

Monitor I & ODaily weightsAssess for mental function Monitor labs Provide good oral hygieneTeach family and client about low sodium diet

Potassium3.5 to 5.0 mEq/L-narrow rangeMajor cation in the ICFAffects nerve impulse transmissionAffects skeletal and cardiac muscle

contraction and conductivityAffects acid-base balanceThe body cannot conserve potassium as

it can sodium

HypokalemiaCauses of low serum potassium:

Drug therapyInadequate K intakeSevere GI fluid lossesExcessive diaphoresisHigh stress

HypokalemiaOther causes

High blood glucose levelsCushing’s SyndromeAlkalosisHepatic diseaseAlcoholismHeart failureNephritis

HypokalemiaClinical Manifestations

Skeletal muscle weaknessParesthesias and leg crampsDeep tendon reflexes may be

decreased or absentAnorexia, N/VDrowsiness, lethargyCardiac arrhythmias

HypokalemiaDiagnostic Findings

Serum K levels below 3.5Elevated blood pH and bicarbonate levels

EKG changes

HypokalemiaNursing Implications

Identify clients at riskMonitor VS, labs, EKGAssess for signs of metabolic alkalosisMonitor I & OProvide safe environmentProvide teaching

HyperkalemiaSerum levels over 5.0Not as common as hypokalemia

HyperkalemiaCauses

Most common related health problem is renal failure

Excessive oral or parenteral administration of K

Severe widespread cell damage (from burns, trauma, crushing injuries) that causes K to leak from cells into bloodstream

Certain meds – Beta Blockers, some types of chemotherapy

Metabolic acidosisAddison’s Disease

HyperkalemiaClinical manifestations

Skeletal weakness that may lead to flaccid paralysis

Muscle hyperactivity in the GI tract N/V and abdominal cramping

Cardiac complicationsArrhythmias, bradycardia, hypotension,

cardiac failureConfusion, slurred speechDecreased deep tendon reflexes

HyperkalemiaDiagnostic Findings

Serum potassium above 5Decreased arterial pHEKG abnormalities

HyperkalemiaNursing Implications

Emergency therapyHypertonic solutionKayexalate

Monitor VS, Labs, EKGMay give loop diureticsMonitor neuro statusMonitor for S/S of acidosisMonitor medsDiet teaching – avoid foods high in potassium

Calcium9.0-10.5 MG/DL (some tests 11.0)Most abundant ion in the bodyCation in ICF and ECFResponsible for formation and structure

of bones and teethMaintains cell structure and functionAffects all muscle types Participates in blood clotting

HypocalcemiaCalcium deficit with serum levels below 8.9

Risk factorsPoor dietary intakeElderlyCertain diseases

HypocalcemiaCauses

Poor PO intakeProlonged immobilityStressProlonged diarrheaThyroidectomyGI tract problems

HypocalcemiaCauses

Pancreatic insufficiencyMedicationsHypomagnesiaHyperphosphatemiaAlkalosisClients receiving massive blood

transfusions

HypocalcemiaClinical Manifestations

Muscle cramps, spasms, or tremorsHyperactive deep tendon reflexesTetanyPositive Trousseau’ signPositive Chvostek’s signConfusion, memory lossArrhythmiasSeizures

HypocalcemiaDiagnostic Findings

Serum levels less than 8.9EKG changes

HypocalcemiaNursing Implications

Mild to moderate-educate client to consume food high in Ca and take a supplement

If recovering from parathyroid or thyroid surgery keep Ca gluconate at the bedsideMay have a rapid drop in Ca and need

immediate replacementMonitor persons at risk – eg those receiving

blood transfusions

HypocalcemiaNursing Implications

Monitor VS and EKGBe prepared in the event of laryngospasm

Keep airway at bedsideSeizure precautions may be necessaryEvaluate for Chvostek or Trousseau Signs

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HypercalcemiaSerum calcium above 11.0Calcium excesses are not commonOccurs when the rate of Ca entry into

the ECF exceeds the rate of renal Ca excretion

Risk factorsRenal abnormalitiesMetastatic cancers – especially those

involving bone

HypercalcemiaCauses

Excessive intake of Ca supplements or vitamin D

Excessive use of Ca containing antacids

Piaget’s DiseaseHyperparathyroidismThyrotoxicosisMultiple fractures and prolonged

immobilizationUse of lithium or thiazide diuretics

HypercalcemiaClinical manifestations

Muscle weakness or flaccidityPersonality changes progressing to psychosesAnorexia, nausea and vomitingExtreme thirstConstipationPolyuria, renal calculiCardiac changesPathologic fracturesAltered LOC, impaired memory – can lead to

coma

HypercalcemiaDiagnostic Findings

Serum levels of Ca greater than 11.0 mg/dL

Digitalis toxicity if on digoxinEKG changesX-rays revealing pathologic fractures

HypercalcemiaNursing Implications

Monitor clients with parathyroid disorders, cancer

Immobile clientsMonitor I & O, IV fluid = NS Observe for signs of digoxin toxicitySafety precautionsClient and family teaching

Magnesium1.2 – 2.0 mEq/LMost abundant cation in ICF after

potassiumSupplied in dietFunctions include

Promoting enzyme reactions within cellsProtein synthesisRegulates muscle contractionsInfluences body’s calcium level

HypomagnesemiaMagnesium deficitRelatively commonMost common cause in the United States is chronic alcoholism

HypomagnesemiaCauses

Chronic alcoholismLoss from GI tract – vomiting,

diarrhea, NG suctioningLoop and thiazide diureticsBurnsSepsisPancreatitis

HypomagnesemiaClinical manifestations

Tremors, seizuresConfusionWeakness, ataxiaCardiac dysrhythmiasTetanyPositive Chvostek’s and Trousseau’s

signs

HypomagnesemiaDiagnostic Findings

Below normal serum levels of MgBelow normal serum levels of K or Ca

EKG changes

HypomagnesemiaNursing Implications

Treatment depends on the causeOral supplementsIf severe, IV or IM administration

Identify at risk patientsDietary changesThorough assessmentMonitor VS, EKG, and labsPatient and family education

HypermagnesemiaHigher than normal serum levels

Less common than hypomagnesemia

More common in adults with advanced renal failure

HypermagnesemiaCauses

Advanced renal failureExcessive intake

Example – overuse of antacidsTPN with too much magnesiumTreatment of toxemia with Mg

HypermagnesemiaClinical manifestations

Drowsiness, sedationLethargyRespiratory depressionMuscle weaknessSevere hypotension concurrent with

nausea and vomiting

HypermagnesemiaDiagnostic Findings

Above normal serum levels of MgEKG changes

HypermagnesemiaNursing Implications

Increase renal excretionLots of PO and IV fluid

Administer diureticsAdminister calcium gluconate (given IV in

emergency situations)Monitor labs, EKG, VSDiet changesPatient and family teaching

QUESTIONS ??