management of patient with fluid and electrolyte imbalance

the presentation outlines the management of patient with electrolyte issues and how to diagnose the condition

1. Fluid and Electrolytes Balance By:

2. Objectives By the end of the session the student/learner should be able to: Describe how fluids volume & electrolytes are regulated in the body to maintain homeostasis. Define terms osmosis, diffusion, filtration, active transport

3. Obj -cont.. Identify factors affecting normal, body fluids, electrolytes and acid-base balance Identify examples of nursing diagnoses, outcomes& interventions for clients with altered fluid and electrolyte or acid base balance. Teach clients measures to maintain fluid and electrolyte balance.

4. Homeostasis State of equilibrium in body Naturally maintained by adaptive responses Body fluids and electrolytes are maintained within narrow limits

5. Why nurses need to understand fluid and electrolytes ? Important to anticipate the potential for alterations in fluid and electrolyte balance associated with certain disorders and medical therapies, to recognize the signs and symptoms of imbalances , and to intervene with the appropriate action .

6. Enhanced understanding and management of fluids and electrolytes Composition of body fluids Fluid compartments/Extracellular fluid osmolality Factors that affect movement of water and solutes Regulation of vascular volume Facilitated by clinical condition understanding, nursing assessment, lab analysis

7. Composition of body fluids (water content of body) 60% of body weight in adult 45% to 55% in older adults 70% to 80% in infants Varies with gender, body mass, and age

8. Changes in Water Content with Age Fig. 17-1

9. Mechanism for fluid and electrolyte movement osmosis diffusion filtration

10. osmosis

11. diffusion

12. diffusion

13. filtration

14. Active transport Requires metabolic activity and expenditure of energy to move substances across cell membrane. E.g Sodium and potassium pump. Sodium is pumped out of the cell and potassium pumped in against the concentration gradient

15. Regulation of body fluids Fluid intake. Hormonal controls Fluid output

16. cations

17. sodium potassium calcium magnesium

18. Electrolytes are measured milliequivalent per litre of water ( mEq / L)

19. Equivalent refers to the chemical combining power of a substance or the power of cations to unite with anions to form molecules

20. sodium

21. most abundant cat ion in the extracellular fluid sodium is regulated by Salt intake Aldosterone Urinary output

22. functions Maintain balance of extracellular fluid, thereby it controls the movements of the water between fluid compartments Transmission of nerve impulses Neuro muscular and myocardial impulse transmission

23. Normal concentration of sodium 135 to 145 mEq /L

24. POTASSIUM

25. Main intracellular cat ion Helps in maintaining fluid balance of the intracellular fluid Potassium is regulated by

26. functions Regulates neuromuscular excitability and muscle contraction Needed for glycogen formation and protein synthesis Correction of acid base imbalances. Potassium ion can be exchanged with hydrogen ion (H+)

27. Normal concentration of potassium 3.5 to 5.3 mEq /L

28. CALCIUM

29. Calcium is the most abundant element in the body Calcium is extracellular fluid Regulated by the action of Thyroid gland parathyroid gland

30. Parathyroid hormone (PTH) controls the balance among bone calcium, gastrointestinal absorption and kidney excretion of calcium. Thyrocalcitonin from the thyroid gland inhibits the release of calcium from bones, thus playing a minor role in determining serum calcium levels .

31. functions Maintenance of cell membrane, its integrity and structure Conduction of nerve impulses in the skeletal muscle Stimulation and depolarization and contraction of cardiac muscles

32. functions Aids in blood coagulation Growth and formation of bones Muscle relaxation

33. Normal concentration of calcium 4 to 5 mEq /L

34. MAGNESIUM

35. Magnesium is the second most important cat ion in the intracellular fluid It has an inhibitory effect on skeletal muscles.

36. functions Precipitation of metabolic activities of cells Enzyme activity Neuro chemical activity Muscular excitability

37. Normal concentration of magnesium 1.5 to 2.4 mEq /L

38. an ions

39. phosphate chloride bi carbonate

40. PHOSPHATE

41. Phosphate is a buffer anion in extracellular and intracellular fluid Phosphate absorption is through gastrointestinal tract in a range of 3 to 12 mg/100 ml Calcium and phosphate are inversely proportional. When one rises the other falls

42. Serum phosphate is regulated by kidneys Parathyroid hormone

43. Activated vitamin D

44. functions Promotes normal neuromuscular action Development and maintenance of bones and teeth Participates in carbohydrate metabolism Assist in acid base regulation Maintains levels of ATP ( Adenosine Triphosphate ) and thus energy levels

45. Normal concentration of phosphate 2.5 to 4.5 mEq /L

46. chloride

47. Chlorides are found in extracellular and intracellular fluids The chloride ion balances the cati ons within the extracellular fluid The ion exchange helps to maintain the electrical neutrality

48. Chloride is regulated through kidneys The dietary intake of chloride and the amount excreted in urine are closely related

49. Normal concentration of chloride 100 to 106 mEq /L

50. bicarbonate

51. Bicarbonate is found in extracellular and intracellular fluids It is a major chemical buffer in the body Regulation is through kidneys It is an essential component of the carbonic acid-bicarbonate buffering system essential to acid base balance

52. Normal arterial bicarbonate value 22 to 26 mEq /L

53. Normal venous bicarbonate value 24 to 30 mEq /L In venous blood, bicarbonate is measured as carbondioxide content

54. FLUID VOLUME DISTURBANCE S

55. Fluid volume deficit H ypovolemia

56. Fluid Volume Deficit Mild – 2% of body weight loss Moderate – 5% of body weight loss Severe – 8% or more of body weight loss

57. Pathophysiology results from loss of body fluids and occurs more rapidly when coupled with decreased fluid intake

58. Clinical manifestations Acute Weight loss Decreased skin turgor

59. Concentrated urine flattened neck veins Postural hypotension

60. Weak, rapid, heart rate Oliguria Increased temperature Decreased central venous pressur e

61. Nursing Diagnosis Fluid volume Deficit r/t Insufficient intake, vomiting, diarrhea, hemorrage , m/b dry mucous membranes

62. Nursing management Restore fluids by oral or IV Treat underlying cause Monitor I & O at least every 8 hours Daily weight Vital signs Skin turgor Urine concentration

63. Fluid volume excess H ypervolemia

64. Pathophysiology may be related to fluid overload or diminished function of the homeostatic mechanisms responsible for regulating fluid balance

65. Contributing factors

66. Clinical manifestations Edema Distended neck vein s

67. Tachycardia Increased blood Pressure

68. Increased weight crackles

69. Nursing Diagnosis Fluid volume excess r/t CHF, excess sodium intake, renal failure

70. Nursing management Preventing FVE Detecting and Controlling FVE Teaching patients about edema

71. Electrolyte Imbalances

72. SODIUM

73. Sodium Normal range – 135 to 145 mEq /L Primary regulator of ECF volume (a loss or gain of sodium is usually accompanied by a loss or gain of water)

74. HYPONATREMIA Sodium level less than 135 mEq /L

75. causes Vomiting Diarrhea

76. Sweating Diuretics

77. Clinical manifestations Poor skin turgor Decreased saliva production Dry mucosa Anorexia vomiting

78. Clinical manifestations Orthostatic hypotension Altered mental status Nausea/ abdominal cramping Confusion & lethargy

79. Nursing interventions Assess clinical manifestations Monitor fluid intake and output, vital signs and lab data . Encourage food and fluids high in Na Limit water intake .

80. HYPERNATREMIA Sodium level more than 145 mEq /L

81. CAUSES Loss of fluids Water deprivatio n Excessive salt intake Conditions like Diabetes insipidus , heatstroke

82. Pathophysiology Fluid deprivation in patients who cannot perceive, respond to, or communicate their thirst Most often affects very old, very young, and cognitively impaired patients

83. Clinical manifestations Thirst Sticky mucous membranes Flushed skin Postural hypotension Dry, swollen tongue

84. Nursing interventions Monitor intake and output Monitor behavioural changes Monitor lab findings Encourage fluids Monitor diet as ordered(salt restriction)

85. POTASSIUM

86. Normal serum potassium concentration is 3.5 to 5.5 mEq /L Major Intracellular electrolyte and 98% of the body’s potassium is inside the cells

87. HYPOKALEMIA Potassium level less than 3.5 mEq /L

88. CAUSES Loss of K+ in the form of vomitings ,GI suction poor K intake diuretics steroid administration

89. Clinical manifestations Muscle weakness Leg cramps Fatigue Lethargy Anorexia Nausea , vomiting Decreased bowel sounds Decreased bowel motility Cardiac dysrrhythmias Depressed deep tendon reflex

90. Nursing interventions Monitor heart rate and rhythm Monitor clients receiving DIGITALIS Administer oral K+ as ordered with food /fluids Administer IV K+ as ordered ,flow rate not more than 10-20 meq /hr Teach patients about potassium rich diet and to reduce potassium wastage

91. HYPERKALEMIA Potassium level more than 5.5 mEq /L

92. Causes Decreased renal potassium excretion as seen with renal failure and oliguria High potassium intake Renal insufficiency Shift of potassium out of the cell as seen in acidosis

93. Clinical manifestations Skeletal muscle weakness/paralysis ECG changes – such as peaked T wa ves, widened QRS complexes Heart block

94. Nursing interventions Monitor ECG changes – telemetry Administer Calcium solutions to neutralize the potassium Monitor muscle tone Give Kayexelate Give Insulin and D50W

95. CALCIUM

96. Normal serum calcium level is 4 to 5 mEq /L More than 99% of the body’s calcium is located in the skeletal system

97. HYPOCALCEMIA Calcium level less than 4 mEq /L

98. Causes Vitamin D/Calcium deficiency Primary/surgical hyperparathyroidism Pancreatitis Renal failure

99. Clinical Manifestations Tetany and cramps in muscles of extremities

100. Trousseau’s sign – carpal spasms

101. Chvostek’s sign – cheek twitching

102. Seizures, mental changes

103. ECG shows prolonged QT intervals

104. Nursing interventions IV/PO Calcium Carbonate or Calcium Gluconate Encourage increased dietary intake of Calcium Monitor neurological status Establish seizure precautions

105. HYPERCALCEMIA Calcium level more than 5 mEq /L

106. Causes Hyperparathyroidism Prolonged immobilization Thiazide diuretics Large doses of Vitamin A and D

107. Clinical manifestations Muscle weakness, nausea and vomiting Lethargy and confusion Constipation Cardiac Arrest (high level)

108. Nursing interventions Eliminate Calcium from diet Monitor neurological status Increase fluids (IV or PO) Calcitonin

109. MAGNESIUM

110. Normal serum magnesium level is 1.5 to 2.4 mEq /L Thought to have a direct effect on peripheral arteries and arterioles

111. HYPOMAGNESEMIA magnesium level less than 1.5 mEq /L

112. TPN - Diabetic ketoacidosis

113. Clinical manifestations Neuromuscular irritability Positive Chvostek’s and Trousseau’s sign EKG changes with prolonged QRS, depressed ST segment, and cardiac dysrrhythmias May occur with hypocalcemia and hypokalemia

114. Starved – possible cause of hypomagnesemia Seizures Tetany Anorexia and arrhythmias Rapid heart rate Vomiting Emotional lability Deep tendon reflexes increased

115. Nursing interventions IV/PO Magnesium replacement, including Magnesium Sulfate Give Calcium Gluconate if accompanied by hypocalcemia Monitor for dysphagia , give soft foods Measure vital signs closely

116. Foods high in Magnesium : Green leafy vegetables

117. Nuts Legumes

118. Seafood Chocolate

119. HYPERMAGNESEMIA magnesium level more than 2.4 mEq /L

120. Causes Renal failure Untreated diabetic ketoacidosis Excessive use of antacids and laxatives

121. Clinical manifestations Flushed face and skin warmth Mild hypotension Heart block and cardiac arrest Muscle weakness and even paralysis

122. RENAL R eflexes decreased (plus weakness and paralysis) E CG changes ( bradycardia and hypotension) N ausea and vomiting A ppearance flushed L ethargy (plus drowsiness and coma)

123. Nursing interventions Monitor Mg levels Monitor respiratory rate Monitor cardiac rhythm Increase fluids IV calcium for emergencies

124. PHOSPHORUS

125. Normal serum phosphorus level is 2.5 to 4.5 mg/100 ml Phosphate levels vary inversely to calcium levels High Calcium = Low Phosphate

126. HYPO PHOSPHOTEMIA Phosphorus level less than 2.5 mEq /L

127. Causes Most likely to occurs with overzealous intake or administration of simple carbohydrates Severe protein-calorie malnutrition (anorexia or alcoholism)

128. Clinical manifestations Muscle weakness Seizures and coma Irritability Fatigue Confusion Numbness

129. Nursing interventions Prevention is the goal IV Phosphorus for severe Prevention of infection Monitor phosphorus levels Increase oral intake of phosphorus rich foods

130. Foods rich in phosphorus Milk and milk products Poultry Whole grains Organ meats Nuts Fish

131. HYPER PHOSPHOTEMIA Phosphorus level more than 4.5 mEq /L

132. Causes Renal failure Chemotherapy Hypoparathyroidism High phosphate intake

133. Clinical manifestations Tetany Muscle weakness Similar to Hypocalcemia because of reciprocal relationship

134. Nursing interventions Treat underlying cause Avoid phosphorus rich foods

135. references https://www.nursingtimes.net/Journals/1/Files/2011/8/1/Fluid%20balanceCorr.pdf.pdf