The document discusses fluid and electrolyte imbalances. It defines key terms related to fluids and electrolytes and describes the body's regulation of fluid compartments through processes like osmosis, active transport, filtration, and osmolarity. It discusses fluid gains and losses as well as fluid imbalances like dehydration, fluid overload, and electrolyte imbalances of sodium, potassium, and calcium. Finally, it outlines nursing assessments and interventions for various fluid and electrolyte imbalance conditions.
2. Objectives
Define Key Terms associated with Fluids and
Electrolytes
Describe the Assessment for Fluid and
Electrolytes Imbalances
Discuss the Nursing Interventions in
Maintaining Fluid and Electrolyte Homeostasis
3. Homeostasis
60% of body consists
of fluid
Intracellular space
Extracellular space
Electrolytes -active ions:
Cation positive
Anion negative
4. Regulation of Body Fluid
Compartments
Osmosis is diffusion of water caused by fluid gradient.
Diffusion is movement of a substance from area of higher
concentration to one of lower concentration.
Active Transport is movement of substance across
permeable membrane and gradient; requires energy and pump.
E.g. Sodium/potassium pump
6. Regulation of Body Fluid
Compartments (cont’d)
Filtration - the movement of water and solutes from an area
of high hydrostatic pressure to an area of low hydrostatic
pressure
Osmolality - reflects the concentration of fluid that affects
the movement of water between fluid compartments by osmosis
Osmotic pressure - the amount of hydrostatic pressure
required to stop the flow of water by osmosis
8. Osmolarity
Isotonic – same solute concentration, equal, no movement
across membrane
Hypertonic/hyper-osmotic – greater concentration
osmotic pressure water pulled into fluid to equalize
Hypotonic/hypo-osmotic – lesser concentration
osmotic pressure water pulled out of fluid to equalize
11. Gains and Losses of fluid
Gain Loss
Solid foods water and electrolytes
Drinks move in a variety of
Thirst center Ways - sensible and
Insensible.
Kidneys
Skin
Lungs
GI tract
12. Fluid Imbalances
Fluid Deficit Fluid Excess
Isotonic – fluid and Isotonic – Only ECF is
electrolytes loss equally; expanded
decline in circulating blood Hypertonic – excessive
volume Na+ intake; fluid shifts from
Hypertonic – fluid loss ICF to ECF
exceeds loss of electrolytes Hypotonic – water
Hypotonic – electrolytes intoxication; life threatening;
loss exceeds loss of water fluid moves in ICF and all
compartment expands
13. Developmental Considerations
Elderly
Skin - elasticity impaired
45% to 50% of body weight in older adults is water, loss of muscle
mass and reduced ratio of lean to total body weight
Sites for skin turgor: Forehead, Sternum, Abdomen
Renal - decrease filtration, water loss, poor excretion
Muscular – higher risk of dehydration, decrease fluid intake
Neuro - diminished reflexes such as thirst centre decreased fluid,
leading to dehydration
Endocrine - atrophy of muscle adrenal, poor Na, K regulation,
prone to hyponatraemia and hyperkalaemia
14. Nursing Assessment
Skin elasticity, oedema, skin
dryness, mucous membrane
Vital Signs -Increase respiratory
rate in response to
hypoxia, hypotension
Altered Mental status –
confusion, lethargic
Neuromuscular - assessment of
muscle tone and
strength, movement, coordinati
on, and tremors
Renal - weight loss, fluid balance
record
Lab data –elevated
haemoglobins, haematocrits, glu
cose, protein, blood urea
15. Intervention for Fluid Imbalance
Dehydration
Oral Fluid Replacement
Water, Oral Electrolytes
IV Therapy
Check closely for Fluid
Overload - Input and Output
Check vital signs
Drug Therapy
Depending on cause:
Antiemetic, Antidiarrhoea,
Antibiotic, Dysrhythmias
Oral care, artificial tears, saliva
16. Over-Hydration
Fluid Imbalance Interventions
Isotonic Over-Hydration Drug therapy
Osmotic diuretics, then Loop
Hypotonic Over-Hydration diuretic (Lasix)
Water intoxication; fluid moves Vital Signs
into ICF Check IV fluids hourly – Input and
Output
Hypertonic Over-Hydration Daily weight, serum and
Fluid pulled from ICS electrolytes level, ECG
Diet Therapy
Restrict fluid and sodium intake
17.
18. Electrolyte Imbalances
Hypo and Hypernatraemia (Na+)
135-146 mmol/L
Hypo and Hyperkalaemia (K+)
3.5 - 5.0 mmol/L
Hypo and Hypercalcaemia (Ca+)
2.2 – 2.67mmol/L
19. Electrolytes
Basic Principles in Treatment
Electrolyte Deficits Electrolyte Excess
Drug Supplements Antagonist – block
Foods absorption
Hydration
Assess – Vital signs, Cease foods or
ECG changes medications high in
Remove the cause electrolytes
Assess – Vital signs,
ECG changes
Remove the cause
20. Sodium Electrolyte Imbalances
Hyponatraemia N+ Hypernatraemia
Clinical Manifestation Clinical Manifestation
Irritability, confusion, dizziness, tremors, Restlessness, intense thirst, dry swollen
seizures, coma, dry mucous tongue, twitching, weight
membrane, cold, clammy skin, weight loss, lethargy, seizures, coma, flushed
gain, muscle spasms, nausea, vomiting skin, peripheral/pulmonary oedema
Assess mental, muscle weakness, GI Assess mental status, muscle twitching
distress, hypovolaemia, fluid and irregular muscle contractions, Vital
input/output, Vital Signs Signs, BP in hypovolaemia, BP with
bounding pulses in hypervolaemia, fluid
Notify MO input/output
Replace Na+ slowly, Saline IV infusions
Notify MO
Check ADH levels
If fluid loss - hypotonic IV fluids
Monitor electrolytes if Na+ K+ If fluid and Na+ loss - isotonic IV fluid
Diet therapy Restrict Na+
21. Potassium Electrolyte Imbalances
Hypokalaemia K+ Hyperkalaemia
Clinical Manifestation Clinical Manifestation
Hand grasp weak, hyporeflexia, paresthesia, GI upset, irritability,
muscle weakness, shallow irregular pulse
respirations, pulse thready and
weak, dysrhythmia, lethargic, Assess ECG changes, Vital Signs,
confusion, coma, GI upset, hypo Fibre/Fluid intake
activity
Notify MO
Assess Vital Signs, ECG changes; Stop K+ - oral or IV
Fibre and Fluid intake Administer K+ excreting diuretics (lasix)
and Kayexlate
Notify MO
Dialysis if severe
Administer K+ oral or IV
Monitor lab results
25. Complications of
Intravenous Therapy
Systemic Complications Local Complications
Fluid overload Infiltration and Extravasations
Air embolism –Dyspnoea, Cyanosis Phlebitis
Thrombophlebitis
Septicemia and other infection Hematoma
Clotting and Obstruction
Cease IV Fluids
Notify MO Stop infusion at once
Warm or cold compresses
Notify MO
Homeostasis – a tendency of biological systems to maintain stability while continually adjusting to conditions that are optimal for survival.
Osmosisis diffusion of water caused by fluid gradient.Diffusionis movement of a substance from area of higher concentration to one of lower concentration.Active Transport is movement of substance across permeable membrane and gradient; requires energy and pump. E.g. Sodium/potassium pump
Sodium-Potassium PumpSodium concentration is higher in ECF than ICFSodium enters cell by diffusionPotassium exits cell into ECF
Filtration- the movement of water and solutes from an area of high hydrostatic pressure to an area of low hydrostatic pressureOsmolality - reflects the concentration of fluid that affects the movement of water between fluid compartments by osmosisOsmotic pressure - the amount of hydrostatic pressure required to stop the flow of water by osmosis
Isotonic– same solute concentration, equal, no movement across membraneHypertonic/hyper-osmotic– greater concentration osmotic pressure water pulled intofluid to equalizeHypotonic/hypo-osmotic– lesser concentration osmotic pressure water pulled outof fluid to equalize
Gain - solid foods, Drinks, thirst centerLoss - water and electrolytesmove in a variety ofWays - sensible andInsensible.KidneysSkinLungsGI tract
Fluid DeficitIsotonic – fluid and electrolytes loss equally; decline in circulating blood volumeHypertonic – fluid loss exceeds loss of electrolytesHypotonic – electrolytes loss exceeds loss of waterFluid ExcessIsotonic – Only ECF is expandedHypertonic – excessive Na+ intake; fluid shifts from ICF to ECFHypotonic – water intoxication; life threatening; fluid moves in ICF and all compartment expands
Skin – elasticity; Renal – decrease filtration; increase water loss; poor excretion of waste products;Muscle mass – lean – greater risk of dehydration and decrease fluid intake;Neuro – diminished reflexes such as the thirst center; decrease fluid, risk of dehydration;Endocrine – atrophy of muscle and adrenal; regulation of Na and K poor; prone to hyponatraemia and hyperkalaemia
Nursing AssessmentSkin elasticity, oedema, skin dryness, mucous membraneVital Signs -Increase respiratory rate in response to hypoxia, hypotensionAltered Mental status – confusion, lethargicNeuromuscular - assessment of muscle tone and strength, movement, coordination, and tremorsRenal - weight loss, fluid balance recordLab data –elevated haemoglobins, haematocrits, glucose, protein, blood urea
Intervention for Fluid ImbalanceDehydrationOral Fluid ReplacementWater, Oral ElectrolytesIV TherapyCheck closely for FluidOverload - Input and OutputCheck vital signsDrug TherapyDepending on cause:Antiemetic, Antidiarrhoea,Antibiotic, DysrhythmiasOral care, artificial tears, saliva
Over-HydrationFluidImbalanceIsotonic Over-HydrationHypotonic Over-Hydration Water intoxication; fluid moves into ICFHypertonic Over-Hydration Fluid pulled from ICSInterventionsDrug therapyOsmotic diuretics, then Loop diuretic (Lasix)Vital Signs Check IV fluids hourly – Input and OutputDaily weight, serum and electrolytes level, ECGDiet TherapyRestrict fluid and sodium intakeNotify MO
Hypo and Hypermagnesaemia (Mg+)Hypo and Hyperphosphataemia (Phos+)Hypo and Hyperchloraemia (Cl-)
Excessive – Hyper electrolytes; Antagonist – medication to block absorption, or binders to electrolytes that excrete the excess electrolytes via renal or GI system; last resort is dialysis.Complications – heart rate, dysrhythmias, ECG, Vital Signs
Assess mental status, cardiovascular, Neuromuscular, GI; Vital signs, weights, I &O if fluid excess or loss and needs monitoring.GI distress – increase motility, nausea, diarrhea, and abdominal cramping; bowel sounds hyperactive; bowels watery and frequent; Hyponatraemia with hypovolaemia – rapid weak, thready pulse, neck veins flat, severe hypotension (diastolic down); Hypervolaemia – Blood pressure normal or high; pulses difficult to palpate if edema.In hypernatraemia – irritability – overexcited tissues; mental status – seizures, memory impaired and possible attention span delay, lethargic, drowsy. Cardiovascular – If hypovolaemia – faint peripheral pulses, hypotension, orthostatic hypertension, pulse pressure is reduced.Diuretics if excess fluids,
K+ - cause major cell excitability, in particular nerve and muscle, and cellular processes; increase cell uptake of K+(hypo K+) in metabolic alkalosis and insulin use. GI – decreased peristalsis, constipation, abdominal distention- paralytic ileus;Mental status – loss problem solving ability;EKG – ST- segment depressed, T wave flat or inverted and increase U wave; dysrhythmias can be fatal.IV K+ - severely irritating to tissues – never given SQ or IM, and given in 1 liter; Oral potassium – liquid, unpleasant taste. But with protocol and frequent lab monitoring, it does well to raise K+ levels.In treatment – for constipation – fiber, fluids; asses for respiratory distress – hypoxemia ( decrease blood oxygen levels or hypercapnia – increase CO2 levels)K sparing diuretics, foods high in K+; Older adults at risk due to meds, mental status, physiological changes.Hyperkalaemia – Tall, peak T waves, prolong PR intervals, flat or absent P waves and wide QRS’ high K+ levels – complete heart block, asystole and ventricular fibrillation; paresthesia – tingling numbness in hands and feet and around mouth; treat with sodium polystyrene sulfonate
Hypocalcaemia - seizuresHypocalcaemia – excitable tissues – heart, muscles, nerves, and intestinal smooth muscles. Blood-clotting requires calcium in excessive calcium may have increase clotting especially if viscosity of blood.EKG – changes in T wave and QT intervalsCalcium binders – to lower serum calcium levels – drugs that interfere with calcium uptake – NSAID, ( calcium inhibitor - reabsorption to bones).
Trousseau’s sign – Carpal spasm can be extracted by compressing the upper arm causing ischaemia to the nerves distallyHoman’s sign – Pain obtained in the calf when the foot is dorsiflexed, symptomatic of venous thrombosisChvosteck’s sign – a spasm of the facial muscles which occurs in tetany.
Isotonic - Lactated Ringers Solution or Normal SalineHypotonic - .45% NaClHypertonic – 5 or 10% Dextrose ( concentration)Common complication or problem with IV fluids – infectionLocal complications – Infiltration and extravasations – escape of fluid from its normal course into surrounding tissues. Phlebitis inflammation of vein; Thrombophlebitis – inflammation with blood clot. HaematomaAir embolism – another complication – dyspnoea, cyanosis, weak, hypotension, unresponsiveness. Omit starting IV and peripheral and central and midline catheters