fluid and electrolyte disturbance in human body

it explain about definition of fluid and electrolyte disturbance, causes and different types of fluid disturbance. diagnostic evaluation and their emergent management along with supportive management.

1. FLUID AND ELECTROLYTE IMBALANCE MS. BHARTI SHARMA NURSING TUTOR BECON, JAMMU.

2. GENERAL OBJECTIVE: At the end of the presentation the group will be able to know about the topic Fluid and Electrolyte Imbalance and can utilize that knowledge in clinical settings.

3. ELECTROLYTE Electrolytes are minerals in blood and other body fluids that carry an electric charge. Electrolytes affect the amount of water in body, the acidity of blood (pH) muscle function, and other important processes. Common electrolytes include : Chloride Magnesium Phosphorous Potassium Sodium Electrolytes can be acids, bases, and salts.

4. MINERALS: “A mineral is an element or chemical compound that is normally crystalline and that has been formed as a result of geological processes” (Nickel, E. H., 1995). “Minerals are naturally-occurring inorganic substances with a definite and predictable chemical composition and physical properties.” (O' Donoghue, 1990).

5. Fluid Balance Fluid balance is the concept of  human homeostasis   . Body fluids are mainly located in two compartments of body i.e. intracellular and extracellular spaces. 1 Intracellular spaces - ( Fluid within cells) 2 Extracellular spaces - ( fluid outside cells) It is further divided into three- Intravascular spaces- (fluid within blood vessels) Interstitial spaces- (Fluid present in interstitial spaces that surrounds the cell). Transcellular spaces - It contains approximately 1L of fluid.eg. CSF

6. SOURCES OF BODY WATER GAIN AND LOSS

7. REGULATION OF WATER AND SOLUTE LOSS

8. FLUID VOLUME DEFICIT (HYPOVOLEMIA) The state in which an individual experiences vascular, cellular, or intracellular dehydration-According to NANDA. Fluid volume deficit or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space or from a reduced fluid intake.

9. FLUID VOLUME EXCESS (HYPERVOLEMIA) The state in which an individual experiences increased fluid retention and edema -According to NANDA Fluid volume excess or hypervolemia, occurs from an increase in total body sodium content and an increase in total body fluid volume.

10. Fluid Volume Disturbances 1.Fluid Volume Deficit (Hypovolemia)- Fluid volume deficit(FVD) occurs when loss of extracellular fluid volume exceeds the intake of fluid. Etiology - decreased fluid intake . vomiting, diarrhea may occur after blood donation Trauma Risk factors include diabetes insipidus , adrenal insufficiency, osmotic diuresis , hemorrhage and coma.

11. Clinical Manifestations Acute weight loss Concentrated urine Decreased skin turgor Postural hypotension Weak , rapid heart rate Cold and clammy skin Oliguria Flattened neck veins

12. Moderate deficit Severe deficit Skin Flushed , dry Cold, Clammy Mouth Dry mucus membrane Dry, cracked tongue Eyes Soft , sunken eyeballs Cardiovascular Tachycardia , Hypotension CNS Apprehension , restlessness Lethargy , coma Blood Increased hematocrit , BUN and electrolytes Urine High specific gravity, Oliguria , concentrated Scanty amount urine Other Thirst , weight loss Thirst , weight loss and fever

13. Assessment and Diagnostic Finding History and physical examination Laboratory tests include assessment of BUN and serum creatinine concentration Hematocrit levels Serum electrolyte changes also occur- Hypokalemia occurs with GI and renal losses. Hyperkalemia occurs with adrenal insufficiency Hyponatremia occurs with increased thirst and ADH release. Hypernatremia results from increased insensible losses and diabetes insipidus .

14. Complications Hypovolemic shock Stroke Heart attack Liver failure Kidney failure Gangrene of an extremity

15. Medical Management Oral fluids that include moderate sugars and  electrolytes  are needed to replenish depleted sodium ions. Emergency oxygen should be immediately employed to increase the efficiency of the patient's remaining blood supply Isotonic electrolyte solutions eg . Lactated Ringer’s or 0.9 % sodium chloride) are frequently used to treat the hypotensive patient Blood transfusions  

16. Nursing Management Record intake and output Monitor body weight Monitor vital signs Monitor skin turgor Assess the mental functions Assess the cardiovascular functions Preventing FVD Correcting FVD

17. Fluid Volume Excess ( Hypervolemia) It refers to an isotonic expansion of the ECF caused by the abnormal retention of water and sodium in approximately the same proportion in which they normally exist in the ECF . Etiology - -heart failure, renal failure and cirrhosis of liver . -excessive amount of table salt may lead to increase in total body water -Excessive intake of fluids -Excessive administration of I.V. fluids. -Long term use of corticosteroids.

18. Clinical manifestations Tachycardia Confusion Increased blood pressure Crackles Distended neck veins Increased urine output Shortness of breath Headache Edema

19. Assessment and Diagnostic Findings History and physical examination Laboratory test include assessment of BUN and hematocrit levels. Both of these values may be decreased because of plasma dilution. Chest X-rays can be done to reveal pulmonary congestion

20. Complications Congestive heart failure Hypervolemic hyponatremia Polyuria Non pitting edema Dysarhythmias

21. Medical Management excessive administration of sodium containing fluids, discontinue the infusion. Pharmacologic therapy- Diuretics are prescribed when dietary restriction of sodium alone is insufficient to reduce edema When pharmacological agents cannot act efficiently in case of renal impairement , Hemodialysis or peritoneal dialysis may be used to remove nitrogenous wastes. In diet, sodium restriction should be done.

22. Nursing Management

23. ELECTROLYTES IN BODY FLUIDS ELECTROLYTE: A substance that is dissolved in solution and some of its molecules spilt or dissociate into electrically charged atoms or ions. The ions formed when electrolytes dissolve and dissociate serve four general functions in the body . control the osmosis of water between fluid compartments maintain the acid base balance production of action potentials and graded potentials serve as cofactors needed for optimal activity of enzymes

24. 1.SODIUM Sodium is the abundant electrolyte in the ECF, accounting for 90% of the extracellular catoins . Its normal blood Na + concentration is 136 to 148 mEq /L. Sodium has a major role in controlling water distribution throughout the body The most common sodium imbalances are sodium deficit and sodium excess.

25. HYPONATERMIA Hyponatremia is a sodium deficit or serum sodium level of less than 135 mEq /L. 1. Increased sodium excretion Excessive diaphoresis Diuretics Renal disease 2. Inadequate sodium intake Nothing by mouth Low – salt diet 3. Dilution of serum sodium Renal failure Hyperglycemia

26. CLINICAL MANIFESTATION

27. MEDICAL MANGEMENT IV saline for patient who have hyponatremia without fluid overload. Isotonic (0.9 percent), hypertonic (3 percent). For fluid overload , diuretics restrictions to a total of 800ml in 24 hrs Such as lithium and declomycin these are antagonize anti diuretic hormone may be administered

28. NURSING MANAGEMENT Monitor cardiovascular, respiratory, neuromuscular, cerebral, renal and gastrointestinal status Instruct the client to increase oral sodium intake If the client is taking lithium monitor lithium level maintain intake and output chart assesses for signs of circulatory overload e.g. cough, dyspnea , puffy eyelids, weight gain in 24hrs. lungs should be auscultated for crackles

29. HYPERNATREMIA Hypernatremia is excess sodium in ECF or serum sodium of greater than 145 mEq /L. because the osmotic pressure of extra cellular fluid is increased.

30. CAUSES

31. Clinical manifestation

32. COMPLICATIONS- Skeletal muscles weakness Respiratory arrest LABORATORY FINDING- Serum sodium above 145 mEq / L Serum osmolality above 300 mEq /L BUN Urine specific gravity

33. MEDICAL MANAGEMENT Infusion of a hypotonic electrolyte solution e.g. 0.3% sodium chloride or dextrose 5% in water in indicated when water needs to be replaced without sodium Diuretic- Lasix If kidneys are not functioning then dialysis should be performed

34. NURSING MANAGEMENT

35. 2.POTASSIUM It is the major intracellular electrolyte, 98% of the body’s potassium is inside the cell. The remaining 2% in the ECF and is important in neuromuscular functions. The normal serum potassium concentration ranges from 3.5 to 5.0 mEq /L.

36. HYPOKALEMIA HYPOKALEMIA is a potassium deficit or a serum potassium level of less than 3.5mEq/L. CAUSES Actual total body potassium loss Inadequate potassium intake Dilution of serum potassium Water intoxication Intravenous therapy with potassium poor solution

37. CLINICAL MANIFETSTION

38. COMPLICATIONS- Dysarrhythmias Respiratory failure coma LABORATORY FINDINGS- Serum potassium below 3.5mEq/L Arterial blood gases may show alkalosis T wave flattering and ST segment depression on ECG PH of blood will increase 7.4

39. MEDICAL MANAGEMENT provide the food high in potassium the adult recommended allowance for potassium is 1875 to 5625mg/day oral potassium therapy for mild hypokalemia ( 3.3 to 3.5mEq/l) Severe hypokalemia require IV intervention. A clients level with 3 and 3.4 mEq /l needs 100 to 200mEq of IV potassium for to increase 1mEq/l. if it is less than 3 then client need 200 to 400 mEq /l

40. NURSING MANAGEMENT

41. HYPERKALEMIA Hyperkalemia is a serum potassium level that exceeds 5.1mEq/L. It can lead to cardiac arrest . CAUSES

42. CLINICAL MANIFESTATION

43. MEDICAL MANAGEMENT If plasma potassium level is less than 5.5 mEq /l restrict the diet that is rich in potassium If level is higher the provide the potassium wasting diuretics to improve urine output. If hyperkalemia is severe then infusion of IV calcium gluconate to decrease the effect of potassium excess on the myocardium. As hyperkalemia increase then sodium polystyrene sulfonate may be given orally. In marked renal failure peritoneal dialysis or hemodialysis may be needed.

44. NURSING MANAGEMENT Take the dietary history of the patient. Check the vital signs bowel functions, urine output, lung sounds (crackles) and peripheral edema every 4 to 8 hours, in severe hyperkalcemia performs hourly checks of vital signs including apical pulse. Nurse should monitor the cardiovascular, respiratory, neuromuscular, renal and gastrointestinal status, place on a cardiac monitor. ECG changes should be monitored continuously . Prepare for the IV administration of glucose with regular insulin to move excess potassium into the cells. Instruct the client to avoid the use of use salt substitutes or other potassium containing substance.

45. 3.CALCIUM 99% of the calcium is found in the bones. Its normal value 8.6 to 10.0mg/dl. The most important regulator of calcium concentration in blood plasma is parathyroid hormone (PTH). A low level of calcium in blood plasma promotes release of more PTH, which stimulates osteoclasts in bone tissue to release calcium from bone extracellular matrix.

46. HYPOCALCEMIA

47. CLINICAL MANIFESTATION

48. LABORATORY FINDINGS

49. MEDICAL MANAGEMENT Provide the calcium gluconate , calcium lactate or calcium chloride. Calcium supplement should be given with a glass of milk with meals. Vitamin D in the milk promotes calcium absorption. Mild hypocalcemia can be treated to give the diet high in calcium like dairy products- cheese, ice cream, milk IV calcium chloride or calcium gluconate must be given slowly to avoid hypotension and bradycardia. Use D5 solutions when dilution is necessary; avoid saline solutions because they promote calcium loss.

50. NURSING MANAGEMENT Take the history of the client current and chronic illness, diet intake and medications, identify the risks for calcium deficit Monitor cardiovascular, respiratory, neuromuscular and gastrointestinal status; place the client on cardiac table. when administering calcium intravenously , warm injection to body temperature before administering , administer slowly, monitor for electrocardiogram changes, observe for infiltration monitor for hypocalcemia Move the client carefully and monitor for signs of a fracture. Keep 10% calcium gluconate available for treatment of acute calcium deficit. Instruct the client to consume foods high in calcium like cheese, milk and Soya milk, spinach, low fat etc

51. HYPERCALCEMIA Hypercalcemia is a total serum calcium level greater than 10.5 mg/dl, it most often occurs when calcium is mobilized from the bony skeleton. It may occur in any age group. It is a common disorder that can have serious physical complications.

52. CAUSES

53. CLINICAL MANIFESTATION

54. MEDICAL MANAGEMENT Administer the IV normal saline, rapidly with furosemide to prevent fluid over load Administer medications as prescribed that inhibit calcium reabsorption from the bone like aspirin, nonsteroidal anti-inflammatory drugs. Corticosteroids drugs decrease calcium level

55. NURSING MANAGEMENT Take the history of the patient and identify the high risk patient. Assess the vital signs, apical pulses, and ECG every 1 to 8 hours. Check the bowel sounds, renal function and hydration status should be assessed every 8 hours. If flank pain arises, strain all urine to capture renal calculi for analysis. Report urine output of less than 0.5ml/kg/ hr for 2 hours. Advise the patient to take sodium unless it is contraindicated to promote calcium loss through the kidneys Advise the patient to report the clinical manifestation of renal calculi such as flank pain, hematuria or cardiacdysfunctions Instruct the client to avoid foods high in calcium like cheese, milk and soy milk Spinach , low fat.

56. 4.MAGNESIUM It’s normal value 1.6 to 2.6mg/dl. In adults, about 54% of the total body magnesium is part of bone matrix as magnesium salts. Magnesium is a cofactor for certain enzymes needed for the metabolism of carbohydrates and proteins and for the sodium-potassium pump.

57. HYPOMAGNESEMIA Hypomagnesemia Is a serum magnesium level less than 1.6 mg/dl CAUSES

58. CLINICAL MANIFESTATION

59. MANAGEMENT Monitor the cardiovascular, gastrointestinal, respiratory, neuromuscular and central nervous system, place the patient on cardiac monitor Restore the calcium level because hypocalcemia frequently accompanies hypomagnesemia Administer magnesium sulfate by the IV route in severe cases( intramuscular injections pain and tissue damage) monitor serum magnesium levels frequently. Oral preparations of magnesium may cause diarrhea and increase magnesium loss Instruct the client to increase the intake of foods that contain magnesium like cauliflower, green leafy vegetable such as spinach, milk, potatoes

60. HYPERMAGNESEMIA Hypermagnesemia is a serum magnesium level that exceeds 2.6 mg/ dl.   CAUSES - Increased magnesium intake magnesium – containing antacids and laxatives excessive administration of magnesium intravenously Decreased renal excretion of magnesium as a result of renal insufficiency

61. CLINICAL MANIFESTATION

62. MANAGEMENT Monitor cardiovascular , respiratory, neuromuscular and central nervous system status, place client on cardiac monitor Administer diuretic that are prescribed by physician to increase renal excretion of magnesium Intravenously administered calcium chloride or calcium gluconate may be prescribed to reverse the effects of magnesium on cardiac muscles Instruct the client to restrict dietary intake of magnesium containing foods like cauliflower, green leafy vegetables such as spinash I nstruct the client to avoid the use of laxatives and antacids containing magnesium.

63. 5.PHOSPHATE About 85% of the phosphate in adults is present as calcium phosphate salts, which are structural components of bone and teeth. The normal blood plasma concentration of ionized phosphate is only 1.7mEq/ liter .Although some are free, most phosphate ions are covalently bound to organic molecules such as lipids, proteins, carbohydrates, nucleic acids, and adenosine triphosphate(ATP).

64. HYPOPHOSPHATEMIA The normal value of phosphorus is 2.7 to 4.5mg/dl, when their amount is less than 2.7mg/dl is called hypophosphatemia. CAUSES

65. CLINICAL MANIFESTATION

66. MANAGEMENT Monitor cardiovascular, respiratory, neuromuscular, central nervous and hematological status. Administer phosphorus orally along with a vitamin D supplement Administer phosphorus intravenously only when serum phosphorus level fall below 1 mg/dl and when the client experience critical clinical manifestation. Administer phosphorus intravenously slowly because of the risks associated with hyerphosphatemia Assess renal system before administering phosphorus Instruct client to increase intake of phosphorus containing foods while decreasing the intake of calcium containing foods like fish, nuts, whole grain breads and cereals.

67. HYPERPHOSPHATEMIA Hyperphosphatemia is a serum phosphorus level that exceeds 4.5mg/dl, most body systems tolerating elevated serum phosphorus level well. An increase in the serum phosphorus level is accompanied by a decrease in the serum calcium level . CAUSES- Decreased renal excretion resulting from renal insufficiency Tumor lysis syndrome Increased intake of phosphorus including dietary intake or overuse of phosphate containing laxatives or enemas.

68. CLINICAL MANIFESTSTION

69. MANAGEMENT Administer phosphate binding medications that increase fecal excretion of phosphorus from food in the gastrointestinal tract. Instruct client to avoid the laxatives and enemas Advise the patient to decrease the intake of food that are rich in phosphorus like fish, beef chicken etc. Instruct client in how to take phosphate binding medications, emphasizing that they should be taken with meals or immediately after meal.

70. RISK FACTORS FOR FLUID , ELECTROLYTE ANDACID BASE IMBALANCE Pathophysiology of lungs and chest wall Renal Pathophysiology Diabetes mellitus Other endocrine pathophysiology Prolonged vomiting or gastric suction Newborn Older people

71. ASSESSMENT AND DIAGNOSTIC FINDING FOR FLUID AND ELECTROLYTE IMBALANCE

72. INTRAVENOUS FLUID THERAPY PURPOSES Provide water, electrolytes and nutrients when people cannot ingest enough orally Provide vascular access for infusion of medication or blood component Allow vascular access for monitoring devices.

73. INTRAVENOUS SOLUTIONS Isotonic Solution 0.9 % NaCl Na + = 154 mEq /L, Cl - = 154 mEq / L Lactated Ringer’s Solution- (Hartmann’s solution ) Na + = 130 mEq /L K + = 4 mEq /L Ca 2+ = 3 mEq /L Cl - = 109 mEq /L Lactate= 28 mEq /L 5% dextrose in water ( D 5 W )- No electrolytes. 50 g of dextrose

74. INTRAVENOUS SOLUTIONS Hypotonic Solution- 0.45%NaCl Composition Na + = 77 mEq /L Cl - = 77 mEq /L Hypertonic Solutions- 3% NaCl , 5% Nacl Composition- Na + = 513 mEq /L Cl - = 513 mEq /L

75. BLOOD TRANSFUSION A blood transfusion is a process that involves taking blood from one person (the donor) and giving it to someone else   INDICATIONS- To replace blood lost To treat anaemia To treat the certain disorders

76. Home based and community based care

77. RESEARCH STUDY AN EXPERIMENTAL STUDY ON FLUID AND ELECTROLYTE IMBALANCE AND ITS CORRECTIVE MEASURES AMONG CHILDREN ABSTRACT OF RESEARCH FINDINGS Fluid and electrolyte imbalance is most commonly associated with diarrhea among children (3-5 yr ). Among all the disease conditions encountered in children, diarrhea is the most common causing the highest morbidity and mortality. Dehydration and acidosis are the most common cause of death in diarrheic children. The present study was carried out on 24 children including six clinically healthy and 18 diarrheic children. Physiological, Hematological, blood biochemical and electrocardiographic changes were monitored in control as well as diarrheic children. Efficacy of fluid therapy regimen i.e. ORS was evaluated in treating fluid and electrolyte imbalance in diarrheic children during the period of study.

78. CONTI… RESULTS : Following the administration of fluid therapy regimen i.e. ORS, the physiological, (HR, RR) hematological ( Hb , PCV and TEC), plasma biochemical (total protein, glucose, sodium, potassium, chloride and phosphorus) and electrocardiographic parameters exhibited a trend towards restoration to normal by the 3rd to 5th day of treatment. O RS was found to be more efficacious and rapid in correcting fluid and electrolyte imbalance in the diarrheic children.

79. CONCLUSION The ORS used in the present study, may be recommended for clinical and field trials for correcting fluid and electrolyte imbalance in mildly to moderately dehydrated diarrheic children. A further study needs to be undertaken, on the combined use of oral and parenteral hypertonic solutions for treating severe dehydration in children.

80. SUMMARIZATION ELECTROLYTES MINERALS FLUID BALANCE FLUID VOLUME DISTURBANCES: HYPERVOLEMIA HYPOVOLEMIA ELECTROLYTE IMBALANCE: SODIUM IMBALANCE POTASSIUM IMBALANCE CALCIUM IMBALANCE MAGNESIUM IMBALANCE PHOSPHATE IMBALANCE INTRAVENOUS FLUID THERAPY