Fluid and Electrolytes Lecture August 28, 2012 *Concerning the picture that was up on the projector: If you

ou walked into a room and you saw this person - obviously we cant see the person insides like this with those eyes and the cyanosis and the diaphoresis what would you think? o You might possibly think fluid volume deficit would you be panicked? Answer: yes and you might possibly call the rapid response team (at least Prof. Magaldi would hope so!) The picture up on the projector is a classic shock picture we are talking about fluid and electrolytes in this lecture today o But if deficit is allowed to go on, it will indeed go to shock Prof. Magaldi tells most of the students that the janitor whos cleaning the floor, will be able to come in and see thats something wrong with this patient So when we get to this point, its most likely that 90% of the time somebody missed the early assessment o The patient shouldnt have to get to this point o Obviously people come into the emergency room like this from trauma, gunshots and things like that so for these patients there is no early telling or warning that something like this is going to happen and there a few instances with hospitalized patients where things happen abrubtly o But when we are talking about fluid problems they dont happen abruptly it happens over time And if you as the nurse are assessing correctly, you are going to be able to prevent that At this point, the guy in the picture if he is at this point you have to call the rapid response team Whenever there is a change a sudden change in a patient and they give you parameters in the hospital whether its tachycardia or low blood pressure essentially a sudden change that does not respond right away to whatever intervention we give then we have to call rapid response o And anyone can call rapid response because we need to save this person o We know that if you allow them to stay in this error with these symptoms that is affecting all of the organs So know that when we are talking about fluid know that it can go as severe as this (picture illustrating hypovolemic shock) o Its not simply the patient is thirsty

o If I do not respond to patients thirst, we can go from that to this (picture showing hypovolemic shock) o It doesnt happen immediately it will happen depending on how quickly they are losing fluid in other ways You need to keep this picture in mind so that when you are doing your assessment you know how critical it is to pick up on those less obvious signs thats critical and well be talking about this when we talk about shock and things like that but that is very very critical Youre assessing in preventing this this is the reason why Prof. Magaldi wanted the picture up on the projector

Looking at the Fluid and Electrolyte Imbalances Sheet: Patient scenario: first day of clinical you are going to be on the surgical floor and your instructor assigns you to a patient Information: o Age: 80 o Sex: Female o Has slight dementia and was admitted with a small bowel obstruction o Vomiting for several days o Right now has an IV running: D5 and 1/3 at 75ml/hour and has an NG tube draining dark brown fluid When you go into the room to look at this patient, she is a little lethargic its difficult to wake her up o She responds but it was difficult to get her to respond Vitals: o BP: 98/70 o Pulse: 98 o R: 23 So again you have gone in to see this patient, you have done a little of an assessment you have the vital signs what do you find concerning about this patient? o Possible concerns: Pulse Blood pressure That fact that the patient is lethargic (should be the first concern) Should be a concern if its a new patient Keep in mind: all of this could be normal for this patient thats why when you go in the room you need to know a little bit more about the patient

o Because you can say anytime I have a lethargic patient I am going to assume - unless I know better that that is new in which case I have to act quick Is it an oxygen problem? Are they diabetic? Have they had a stroke? Are they going into shock? Its almost a rapid response change in mental status we have to do something right away Point of all of this: before you go into a room we were given the history, and the assessment but not the whole assessment and before you go to do that assessment you have to go armed with a little bit more information o What is the persons normal blood pressure? Because that might make that blood pressure alarming or not o If you had a patient who is hypertensive if this patient came in and shes normally hypertensive and they put her on an IV hypertensive medication Her blood pressure is normally 150 over something and they give her this medication to bring it down and now they have switched her over to IV Sometimes when they switch to IV they dont get the exact dose or the patient has a reaction and their blood pressure drops (in Prof. Magaldis experience this happens a lot) In which case you need to know Oh this is a reaction to that medication Back to the scenario above: many of your frail elderly thats a normal blood pressure for them (below a 100) So when you are in the clinical area and when you have abnormal vital signs, you need to report it to your clinical instructor but you also need to report it including this (patient scenario above) information o Ex: my patients blood pressure is 98/70 thats what shes been running for the past few days That makes a difference of the instructor running down the hall or just say okay youve done your data collection o Same thing with the lethargy: Prof. my patient is lethargic and I cant wake them up vs my patient is lethargic and for the past few days thats how theyve been or they came from the nursing home and this is their normal level of consciousness So before you go in to assess your patient and you may or may not get a good report obviously in the beginning your instructor will give you a lot of information and towards the middle of the semester will hold back and have you data collect

In our lab manual there is a mini care plan and Prof. Magaldi will actually put it up on Blackboard that kind of takes you through that step o Some instructors will use if for you to do care plans, some instructors will have you do care maps no matter what it is still a good tool for collecting the information you need to have to safely care for a patient because it will tell you their history of their medications o Prof. Magaldi will often tell her students to not enter the room unless you have the mini care plan filled out other instructors may take a different approach Know that we cant make decisions unless we know what is normal for this patient: is this a change in mental status? Is this a change in blood pressure? Is this new tachycardia their pulse is usually 60 now its 98 thats tachycardia o Their pulse is 98 and usually its 90 thats non-tachycardia So when you are looking at these assessments related to fluid and a lot of these are related to the fluid know that you have to have a baseline from where you are coming from and each patient will be individual Use fluid and electrolytes imbalances sheet as a guide

Fluid Regulators The first thing we are talking about is water and we know there are all sorts of regulators in the body that help us maintain water balance and some of them are summarized on this slide Know that the answer to the question if its included if there is a question that where the choice says increased fluids 90% of the time thats the answer o It wont be the answer for congestive heart failure, renal failure but we are not covering these two this semester The only time we have to hold water (fluid restriction) this semester is when we have dilutional hyponatremia o Everything else the answer would be to force fluid (encourage fluid) Whether it be infection, whether it be a respiratory problem we know just by the function of water if you dont have enough water, your secretions are going to dry up and in this case you are going to clog up your airways o You wont be able to cough up your secretions If you dont have enough water your immune system is affected and if you dont have enough water then your mental status is affected

So those little old ladies that were difficult to arouse Prof. Magaldi would instruct the students to wake them up because we pay attention You only have one patient so you would ask them what would they like to drink whether it would be tea or coffee or apple juice..etc o We are all supposed to be doing that o Know that when the body needs more water the normal mechanism that says you need more water is thirst With the elderly thats not always there If you have a patient that says that they are thirsty, the answer should not be youre NPO that should not be the answer o Remember that picture of the guy earlier? Somebody missed the first signs So if your patient is thirsty, you need to collect your data, you need to look at the output, you need to look at the intake, you need to look at the blood pressure you need to collect the data so that when you call the doctor you can say you know what this patient has been NPO for a procedure and this happens in hospitals where the patients get dried out o What happens is they are NPO, they are waiting for a procedure to happen 8am 8am comes and an emergency came in and so they are pushed to 10am o 10am comes and another emergency comes in so now they are pushed to 12pm o so patients are kept on NPO for too long a period and now they are dried up and thats going to cause more problems we need to respond to that symptom the doctor is not going to do anything when you say my patients thirsty can you order an IV? you need to collect the rest of the data o whats the rest of the data: the quickest way to get a doctor to order up more fluid is output data so youve got to collect enough data where the doctor has no choice but to say okay lets order some IV fluid critical data that we are looking for concerning output: less than 30mL/hour o normal output: 1mL/kg/hr o even down to 30mL/hr you are still at that conserving mode o even if the patient has 30 or 35mL/hour, theyve only put out 200mL in the last 8 hours, their mucosa are dry, they have tachycardia(normal pulse is 80 now its 98) (my own note: then most likely there is some sort of deficit occurring)

so you have to collect all of the data that tells the physician that this is what they need to do they need to order IV fluid and the physicians have become better at doing that o you just cant call up one piece of data so whenever you want to do an order for your patient because youve assessed that: the patient says they are thirsty, you should be doing vital signs, you should be looking at urine output, you should be looking at the skin turgor, etc o all of that information will be conveyed to the doctor so that we can order IV if the patient is not able to take PO o if the patient is thirsty and they are taking PO, get the patient what they need to drink the other thing that happens in the hospital is: youve got patients that are sitting in the bed and their pitcher of water is on the other side of the room so very basic things like making sure its available to the patient where its right there so that they can access it o for our dementia patients who doesnt know how to respond to their thirst or doesnt have the thirst: make sure to encourage fluid intake everytime you go into the room there should be a cup of water on their tray make them take a sip for you when things go wrong, its usually because basic principles have been overlooked whether its related to fluid or infection control thats usually when the patient gets into problems o all of the higher end things are being done but the basic things are not being done as far as this slide goes(Fluid Regulators slide) this is a review of anatomy and physiology but just remember that aldosterone which is secreted by the adrenals and think of that in terms of steroids which do the same thing retains water o if the body needs more water, aldosterone will be released so that the body retains more water o the downside of that is when we retain more water, we get the ability to retain more sodium, getting rid of the potassium most of your patients in the hospital that are little fluid deprived because they are NPO are going to have low potassium the other reason besides this aldosterone is what happens during stress: stress hormones get released o stress hormones also retain water and as a result get rid of potassium (because of the retention of sodium)

o so every patient in the hospital that is stressed and any student in the hospital that is stressed is at risk for potassium loss o so unless they are eating, they are going to have that hypokalemia so right now we are talking about fluids but remember this when we are talking about aldosterone so we know there are compensatory things that go on in the body to help us retain the fluid we know when we get to the point where look like the guy in the picture that was put up what compensatory measures have been used up when we are talking about weight loss or fluid volume deficit, how quickly it occurs really will be determined by what caused it o so if we have someone who is vomiting and is vomiting every hour, it might occur very quickly because they are not taking anything in if we had put an NG tube down someone we are sucking out their secretions and we are noticing 150mL, 200mL/hour its going to occur very quickly o unless we are giving them an IV, that is at least equal to what we are taking out o so you have to take that into account when you are looking at your patient so if we are calling the doctor for the person we think is fluid deprived and they have an NG tube, one of things we are including is the urine output is only 20 or 30mL/hour and their NG drainage is 150mL/hour you are going to give all of that data when we talk about fluid volume deficit, many times we can see the loss and that makes it easier o patient is vomiting or hemorrhaging so you can see their actual losses a lot of times when we are talking about our surgical patient, we are not going to actually see the loss o any of the -itis is inflammation anytime you have inflammation, you will have third space fluid loss o so if you have an infection on your hand or on your leg, one of the things you notice right away is besides the pain and maybe the redness is swelling you will not notice that in the abdominal cavity (peritonitis) its going to take a lot of third space loss before you notice anything so its almost like an invisible third space loss

o so whenever you hear -itis think inflammation and think possibility of third spacing o ex: Prof. Magaldi had twins and one of them at 2 years old got up one day, complained of his stomach vomited once and laid down on the couch o Prof. Magaldi thought hey this isnt normal hes lethargic and so off they went to the emergency room because she was responding to the change in mental status He wasnt active, he wasnt playing around o Remember he only vomited once it wasnt as if he was vomiting all day long or had diarrhea or anything like that nothing It was just a little stomach pain, vomiting once, and then laying down o When Prof. Magaldi and the son arrived at the hospital, they had to give him a bunch of IV fluid and it was going on in his abdominal cavity he was losing some fluid o He was in the emergency room for about 8 hours never vomited again, never had any diarrhea again but whatever was going on he had some inflammation going on He wasnt able to tell Prof. Magaldi exactly what was going on but there was some pain we can only assume it was some itis so there was some third space fluid loss o so where did he lose the fluid? Answer: into the interstitial space thats what happens it leaks out o once he received some fluid after 8 hours, he was sent home so keep that in mind when you are taking care of these patients when you ask yourself well why are they fluid deprived? they are getting IV fluid at 75mL/hr they arent losing it well they might be losing it so you have to assess o the best assessment is looking at that urine output: is it dark? Is it concentrated? Is it decreased in the amount? o The kidneys are the window to perfusion so Prof. Magaldi will always ask the students what is the urine output because that tells you whats going on One more story: Prof. Magaldi was an educator in the ER and a little old lady came in from the nursing home and she came in for infection/change in mental status o Couldnt get a blood pressure reading on her arm Whats the assumption when you cant get a blood pressure? Answer: dehydration and shock

o So ER was hanging bags of IV fluids up and before they did that Prof. Magaldi put in the foley catheter in and Prof. Magaldi said I dont think she is dehydrated o Her urine output: she had tons of urine output and it was nice and clear o The family called and they said to them we are having difficulty getting the blood pressure their response: no one is ever able to get a blood pressure in her arm! so again: if they are putting out urine, it tells you that usually they have enough fluid o again look at the color of the urine should be clear and light colored shouldnt be described as dark yellow color should be a light pale yellow color that tells you that they have enough fluid o look at the specific gravity you have to memorize the specific gravity: 1.010 WINS range is actually from 1.010 to 1.030 so when you are doing your patient teaching: o with the parents: make sure the child has wet diapers this tells us whether they are hydrated besides looking at the other things

Fluid Volume Deficit looking at the handout on fluid volume deficit: o you can have a fluid volume deficit all by itself or you can have an electrolyte imbalance with it also so when we are talking about these things, we are going to talk about each one individually but know that you can have a fluid volume deficit and you can have a high sodium you could have a fluid volume deficit and you could have a little sodium it can go either way but right now we are just talking about fluid volume deficit for the elderly, anytime there is a change in mental status with the elderly one of the first things we think of is fluid volume deficit o thats probably every disease state we are going to talk about this semester o everytime we talk about a disease and then we say the classic symptoms are this.. but with the elderly it will be change in mental status o just know that thats the answer

o so the answer to many questions is: increased fluids and the other answer is what are the signs and symptoms in the elderly? Answer: change in mental status thats a sign of hypoxia, its a sign of infection, its a sign of fluid volume deficit, etc you are going to see that more in the elderly we talk about the infants: depressed fontanelle

o o up until 18 months the anterior fontanelle is open, so if there is a fluid volume deficit, then they call it the pediatric handshake pediatric handshake: where assessing the baby, you run the palm of your hand over the top of their head you are looking for bulging or depression which could say fluid volume deficit again this is with other things no wet diapers, no tears there is not just one thing we are looking for

Interventions/Patient Teaching o Know that 2.2lbs = 1 liter of fluid o One of the ways we assess fluid gain or fluid loss is by weighing the patient Youre going to see this very clearly in pediatrics because most of the infants with fluid volume deficit (an adult can stay home and take care of it there) are brought in and are usually admitted

Going to weigh the child to assess whether they are gaining weight or losing weight Fluid volume deficit is something we can respond to Clinical Manifestations o Know that tachycardia-weak pulse - well talk about this more when we get to shock: When you are having difficulty getting a pulse for you it may be because we are new at taking pulses There are automatic BP machines out there but this semester we are to focus on feeling, touching, and using the old fashioned blood pressure machine if you can one Reason: what happens is when technology fails we have to go back to the old way The other thing is: when you are taking a pulse, and you put your hand to feel a pulse, theres much more information you get when you take the pulse that way o You can find out about the skin and whether it is warm or not Tells us something about fluid status or if they are very warm it can tell us whether they have a fever or not o You can find out about the rhythm if the rhythm is irregular take an apical pulse o You can also find out about the quality: if you know youve got somebody whos got enough fluid volume or too much fluid volume its going to be easy to get that pulse because it is going to be bounding We know that if we are putting our hand and we are feeling that it comes and goes comes and goes, you are thinking vasoconstriction If the vessels are very tight, its very difficult to feel that pulse o So it gives you more information if you put your hands on that patient and you should be doing it Vital signs

o Dont take vitals on a patient more than twice because you make them nervous o You dont want the patient being anxious thinking she doesnt know or he doesnt know what they are doing get them out of here o Postural hypotension = orthostatic hypotension You would know if someone had orthostatic changes if the patient complains of dizziness (when moving from one position to another) If you have a patient who complains of dizziness, the first thing you do is sit them down and stay with them Always think what is the safest thing to do? The safest thing in this instance is NOT to run down the hall to find the instructor You can always use the call bell if you need assistance in the room use the call bell to say my patient needs assistance shes feeling a little dizzy Now the complaints of dizziness could also be related to the BP medication in which case you would educate the patient about getting up slowly and changing positions slowly Could also be from fluid volume deficit in which case they need more fluid whether it be PO fluid or IV fluid o We are going to be taking care of patients with tube feedings if you think somebody on a tube feeding needs more fluid: Suppose they are receiving a tube feeding of 30mL/hour, and you think that the patient is a little lethargic, and the urine output has gotten a little bit dark you would just give more fluid Unless they were on fluid restriction; the same way you would give someone taking PO fluid more fluids if they were thirsty, you would just give the patient receiving tube feedings more fluid You dont need a doctors order for that the only time you are going to need a doctors order is if the patient is on fluid restrictions o But if they are not on fluid restrictions, and the patient is on a clear liquid diet and they finish their tray and they want another glass of juice, you can give it to them

So the patient on tube feeding they cant tell you that maybe they are thirsty but if you are looking at their urine and it looks concentrated, you can sort of get an idea These are things you need to think about and incorporate it into your interventions This is why Prof. Magaldi wants nursing students to wake up patients because they recognize that after receiving the cup of water the patient is sitting up where yesterday they were lethargic because no one paid attention to that you dont need a doctors order for that as long as they are getting fluid o Provide oral care o If the patient is NPO and they are complaining of thirst, you want to collect the rest of the data usually you dont give ice chips unless the doctor specifically requests it But you want to collect the rest of your data and possibly order an IV o Labs: Hemoglobin (Hgb), BUN, and Hematocrit (Hct) are increased when you have a fluid volume deficit You need to pay attention to these you can tell if its a fluid volume deficit if the BUN levels are up but the creatinine levels are normal This usually indicates that its not renal failure its fluid volume deficit Hematocrit and hemoglobin we may not notice it as being elevated because what usually happens is the patient started out maybe as anemic and now when you look at their blood work they have a fluid volume deficit their levels are right in the normal range so you may not even pick it up until we correct the fluid volume deficit So it might look like its in the normal range but usually with the fluid volume deficit we will usually have increased hemoglobin and hematocrit Fluid Volume Excess A patient with congestive heart failure (CHF) is weighed in order to know whether they need more medication o One of the things we have the patient do is everyday they weigh themselves at the same time and if their weight is going up too

quickly, the doctor might say on that day take 1 tablets your diuretic o If the weight has gone down too much then the doctor might say hold the diuretic for one day along with other symptoms We will talk about fluid volume excess a lot during next semester when we talk about renal failure We need to be very aware of fluid volume excess when we are giving our patients fluids especially in our patients who have a history of renal failure or some sort of problem with fluid People need fluid so its not like a patient with congestive heart failure shouldnt receive fluid we are just more careful with assessing them afterwards You might have a patient who has an it is an appendicitis that turned into a peritonitis so remember they have all of that third space fluid loss as you get better from an itis what the body does is it pulls o Now what happen to that patient is maybe in the OR and they gave the patient lots of fluids and things like that because they had a natural fluid volume deficit o What happens with that patient day 2, day 3 on the surgical unit - and youre caring for them they are on antibiotic therapy the itis is resolving o So what happens as the itis resolves is that fluid that was lost is pulled back into the vascular system o for us, we are going to go back and forth to the bathroom every hour to get rid of that extra fluid that our body is reclaiming in the elderly, or patients who have a little bit of congestive heart failure: all of a sudden the patient is pulling back this fluid and the heart of this patient is saying hey! Where is this coming from?! so we need to keep a watch on that because it usually happens day 2 day 3 where they reclaim some of this fluid now you may be asking yourself why is the patient now having respiratory difficulty? Answer: because of the extra fluid treatment: possibly a diuretic you just need to do your assessments and so for that person maybe their urine output is still a little bit low but we know we are giving them enough fluid and they are having signs and symptoms of fluid overload most of the signs and symptoms of fluid overload will be related to the respiratory system:

o patient will have difficulty breathing, we may hear a little crackles so we are going to call the doctor for that person and they are probably going to give them some diuretic therapy to see if they can get rid of some of this fluid your assessment is critical and your knowledge of underlying disease with this patient is critical also so its not that we withhold fluid its that we very carefully assess the patient while we are giving it other signs of symptoms of fluid volume excess: o bounding pulse o increased blood pressure o increased pulse pressure (systolic diastolic) normal range is 40 it will decrease with fluid volume deficit and increase with fluid volume excess and thats usually related to the diastolic pressure Interventions/Patient Teaching o Weigh the patient daily Labs: decreased sodium, BUN, Hct Treatment o Sometimes sodium and fluid restriction o One of the things we are going to do is restrict the fluids So this might be the patient that we are going to see only a 1,000mL per day We have to be very very careful and we have to make sure the patient understands what that means o These patients are usually edemadous so you have to do frequent skin assessments and make sure to turn the patients every 2 hours because the skin will break down very easily o So we can do nursing care but what is really going to help the patient are diuretics and possibly hemodialysis

IV Fluids we give hypotonic, hypertonic and isotonic solutions when we are talking about fluid volume deficit we usually give a isotonic solution o isotonic solution is the same consistency of the blood o when we think about isotonic we think about normal saline, we think about Lactated Ringers and we think that it says where we put it

so we are going to put this fluid into the person and its going to stay there in the vascular system for the most part its going to expand the vascular system surgical solutions(prof. magaldi calls them surgical solutions because thats what the surgeons seem to know what to write for because they are used to itis) such as D5 NS and D5 1/3 are slightly hypertonic o hypertonic solutions pulls the fluid anything that has a high osmolarity it pulls fluid to there are solutions that are very hypertonic: o the high glucose concentrations so the TPN solutions are considered hypertonic o manitol or albumin albumin is sometimes given to people who have a low albumin and are very malnourished albumin will pull fluid back into the vascular system hypertonic solutions we give with caution we know that a complication of hypertonic solution is an overload of the fluid into the vascular system so we are always assessing our patient looking very carefully at the respiratory system

Sodium 135 145 mEq/L where sodium goes water follows o this tells you that whenever you have a sodium problem you usually have a water problem o memorize that sodium is needed for nerve impulse transmission and skeletal and cardiac contraction because if you memorize that you will know that when we are asked what are the signs and symptoms related to this sodium imbalance, we are going to think nerve it has something to do with the nervous system o if you know what it does, you can almost identify what the symptoms will be Hypernatremia | Na>145 think dehydration we know that if the sodium is high it pulls the fluid out of the cell think of that desert (on the handout) and think about what happens to your skin when you are out in that hot sun it shrivels up o thats what happens to your brain cells and thats why the person when talking about fluid volume deficit (and sometimes FVD has components of hypernatremia) we see a change in mental status

those brain cells all of the water is just depleted from them so just think of everything shriveling up when the patient sticks out their tongue the tongue is going to look like it shriveled up hypernatremia can be caused by several factors: o most of the time it is caused by water deprivation client is unable to respond to thirst or physical disability they just cant get to their fluid and their sodium o could also be caused by sodium gain in excess of water that could be caused by excessive hypertonic IV solution or concentrated formulas now the concentrated formula could either be an infant formula its much more economical for a mother to give her baby formula to buy the powdered version and mix it with water to create the right consistency but she needs to follow directions o if it is too concentrated it can cause this hypernatremia o same thing with patients who are on tube feedings: when first start a patient on tube feeding the start them a low concentration (about 20 t 30mL/hour) and it goes up gradually o every 8 hours or 9 hours the nurse will do her assessments and if the patient is tolerating the formula they will then increase it by 10mL the next time around o it might take 3 or 4 days before they reach their target goal when you see a bag of tube feedings we usually see next to it a bag of water if the patient is getting 35mL/hr of the tube feeding then will get 25mL of flush which is extra fluid because the formula is so concentrated think of that brain being deprived of fluid because its being pulled Signs and Symptoms: o Initially the patient will be thirsty

o The patient with FVD has cool skin | the patient with hypernatremia has flushed, warm skin they almost look good and maybe a slight temperature You are not going to notice that temperature unless you are looking at it very carefully o The big thing here is the change in mental status o Increase in urine specific gravity and the dark urine Interventions Hyponatremia Whenever we are talking about sodium imbalances, we correct them slowly We might give hypotonic solutions to people that have hypernatremia so that might be someone that would get D5W or NaCl o NaCl is classically given to the diabetic patient in the hospital o classically when we give a diabetic patient an IV solution, we dont usually hang dextrose on them although its a possibility - but usually its not hung if they are in the hospital because they had a problem they had an elevated blood glucose many times what you will see hanging is NaCl reason: diabetics when they have a high blood sugar, their osmolarity is elevated it goes up what happens with high osmolarity? Answer: it pulls water away from the cells so a diabetic that has high sugars has cellular dehydration fluid has been pulled out of their cells so the treatment is along with insulin and everything else hydrating those cells pushing fluid back into those cells one of the ways you will do it is give them a hypotonic solution a diabetic at home whose sugar is high: drink, drink, drink have to drink a lot of fluid water = hypotonic o so when you see someone who has an IV running NaCl its usually because they have cellular dehydration usually caused by high glucose Hyponatremia anytime the sodium is less than 135

again think about the CNS (central nervous system) it can be caused by a loss of sodium o it could be someone who is running maybe running a marathon who only replaces fluid without replacing electrolytes o so anyone that is doing activity or if you have a child who is vomiting etc, - we dont just tell the mother to just give water they have to give an electrolyte-balanced solution for the adults: Gatorade for children: Pedialyte Dilutional hyponatremia o A gain of more water than sodium o The sodium level is the same o If you take a teaspoon of salt and you put it in a cup of water and you take that same teaspoon of salt and you put it in a gallon of water which one is going to taste more salty? Answer: the cup of water o Its not that there isnt enough salt its too much fluid o When you are thinking of dilutional hyponatremia think theres too much fluid Salts okay theres just too much fluid The treatment for both of these: you need to know whats going on with the patient you just dont get a sodium level o You need to know: Is it a sodium level in the presence of fluid volume excess? Or is this just a sodium level where the fluid level is fine they just lost sodium o Because the treatment is completely different You are going to have to replace the sodium hyponatremia In the other you are going to have to hold fluid dilutional hyponatremia so whenever we have dilutional hyponatremia we have to restrict fluid how would you distinguish the two? Signs and Symptoms o if the patient has dilutional hyponatremia: weight gain maybe they will have some respiratory symptoms there are going to be other symptoms that will tell you that the patient has too much fluid hyponatremia can be caused by irrigating a body cavity with tap water whenever you are irrigating a body cavity you need to irrigate with normal saline

o remember that tap water is hypotonic the symptoms despite the cause will be the same: think of the CNS before when we had dehydration we had that shriveled up brain now we have a brain where its swollen what happens when your brain gets swollen: you complain of headaches early symptoms might be: o muscle cramps o weakness o fatigue o anorexia o vomiting o diarrhea you might have some of these symptoms but as it goes on, and it becomes more severe, you will complain of CNS symptoms such as: o headache o depression o personality changes o muscle twitching and trembling we can cause dilutional hyponatremia by infusing the wrong fluid o when you put up an IV fluid know that its a medication so remember all of your checks have to check it 3 times o too quickly people take IV bags and throw them up we can cause severe problems with the patients if we infuse hypotonic solution and the hypotonic solution that is dangerous is D5W o so if you put a 1000mL bag of D5W and you are supposed to put up normal saline, you can cause dilutional hyponatremia