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Fluids & Electrolytes Imbalances

Body Fluid Compartments


2/3 (65%) of TBW is intracellular fluid (ICF) 1/3 extracellular fluid (ECF)
25 % interstitial fluid (ISF) 5- 8 % in plasma [(IVF) intravascular fluid] 1- 2 % in transcellular fluids CSF, intraocular fluids, serous membranes, and in GI, respiratory and urinary tracts (third space)

Function of Body H2O


Transports nutrients, electrolytes, & O2 Excretion of Waste Products

Regulates Body Temperature


Lubrication of Joints & Muscles Medium for Food Digestion
(Kee & Paulanka, 2000, p. 2)

Movement of Fluids
Fluid compartments are separated by membranes that are freely permeable to water. Movement of fluids due to: Diffusion Osmotic pressure Active transport Hydrostatic pressure Reabsorption
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DIFFUSION
Solutes shift from an area of greater concentration to an area of higher concentration Passive process

OSMOSIS

Movement of fluid across membrane from a lower solute concentration to a higher solute concentration
Passive process

ACTIVE TRANSPORT
Solutes move from an area of lower concentration to an area of higher concentration
Process requires energy

Hydrostatic Pressure
Capillary filtration
Movement of fluid through capillaries results from blood pushing against walls of the capillary. It forces fluids and solutes through the capillary wall

REABSORPTION

Prevents too much fluid from leaving capillaries no matter how much hydrostatic static pressure is inside them

Capillary colloid osmotic pressure


Colloids do not cross the membrane and pull water into the blood stream Aka plasma expander
Albumin, plasma protein fraction, dextran, hetastarch

Interstitial hydrostatic pressure

Tissue colloid osmotic pressure


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Solutes Dissolved Particles


Electrolytes charged particles
Cations positively charged ions Na+, K+ , Ca++, H+ Anions negatively charged ions Cl-, HCO3- , PO43-

Non-electrolytes - Uncharged
Proteins (i.e. albumin), urea, glucose, O2, CO2
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Body fluids are: Electrically neutral Osmotically maintained Specific number of particles per volume of fluid

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Homeostasis maintained by:


Ion transport Water movement Kidney function

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TONICITY:
Isotonic A solution that has the same solute concentration as another solution to which its being compared i.e. sodium in blood vs. 0.9% NSS

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TONICITY:
Hypertonic - A solution that has a higher solute concentration than another solution to which its being compared Dextrose 5% in NSS
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TONICITY:
Hypotonic - A solution that has a lower solute concentration than another solution to which its being compared

0.45%NSS

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Balance
Fluid and electrolyte homeostasis is maintained in the body Neutral balance: input = output Positive balance: input > output Negative balance: input < output

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Fluid Gain & Loss


Routes of Gain and Loss:
Kidneys (urine)

Skin (perspiration)
Lungs (respiration) GI Tract (feces)
(Smeltzer et al, 2008)

Fluid Gain & Loss


Average Intake of Body H2O = 2600 ml/day
Liquid = 1500 ml Solid Foods = 800 ml Oxidation = 300 ml

(Priff, 2006, p.6)

Fluid Gain & Loss


Sensible Loss
Fluid loss that can be measured
Urination Defecation Bleeding Wound drainage Gastric drainage Vomiting
(Priff, 2006, p.6)

Fluid Gain & Loss


Insensible Loss
Fluid loss that cannot be measured
Perspiration Respiration Changes in humidity levels, respiratory rate and depth, and fever affect insensible loss

(Priff, 2006, p.6)

Fluid Gain & Loss


Average Output of Body H2O = 2600 ml/day
Urine = 1500 ml Feces = 100 ml Lungs = 400 ml Skin = 600 ml
(Priff, 2006, p.6)

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Balancing Systems
Renal System (kidneys)
RF = difficulty maintaining fluid balance Na+ & K+ are either filtered or reabsorbed via the renal system

Balancing Systems
Antidiuretic Hormone (ADH)
Water-retaining hormone Hypothalamus senses low blood volume & increased serum osmolality; triggers its release from the pituitary gland Prompts kidneys to retain H2O Increases concentration of urine

Balancing Systems
Renin-Angiotensin-Aldoseterone System (RAAS)
Release of renin triggered by low pressures Angiotensin II potent vasoconstrictor and triggers the release of aldosterone from the adrenal cortex Aldosterone = fluid retention and secretion of K+; triggers the thirst center

Balancing Systems
Atrial Natriuretic Peptide (ANP)
Released when atrial pressures increase Opposes the RAAS (shuts it off) Key Functions of ANP:
Suppresses serum renin levels Decreases aldosterone release Increases glomerular filtration rate (excretion of Na+ and H2O) Decreases ADH release Decreases vascular resistance by causing vasodilation

Balancing Systems
Thirst Mechanism
Simplest mechanism in maintaining fluid balance Increases after even small fluid loss Increase in salty foods dries mucous membranes, which stimulates the thirst center in the hypothalamus

Hypovolemia
A decreased blood volume that may be caused by internal or external bleeding, fluid losses, or inadequate fluid intake. (Tabers Online Dictionary, 2007)

A.K.A. Fluid Volume Deficit (FVD) or Extracellular Fluid Volume Deficit (ECFVD)

Hypovolemia
FVD occurs when the loss of ECF exceeds the intake of fluid. (Smeltzer et al, 2008)

Hypovolemia or FVD dehydration


Dehydration is loss of H2O only!! FVD Fluid Loss = Electrolyte Loss Ratio Remains the Same (usually)

Hypovolemia
Signs & Symptoms Weight Loss Decreased Skin Turgor Oliguria Concentrate Urine Postural Hypotension Weak, rapid pulse Flattened Neck Veins Signs & Symptoms Increased Temp Cool, clammy skin Thirst Anorexia Nausea Muscle Weakness Muscle Cramps

Hypovolemia
Treatment:
Infusion of Isotonic IV solutions for hypotensive patients Infusion of Hypotonic IV solutions for normotensive patients Hypovolemia d/t blood loss blood transfusion

Hypervolemia
ECF H2O gain is balanced with retention of sodium Usually secondary to retention of sodium

Concentration of sodium to H2O is balanced serum sodium levels usually WNL A.K.A. Extracellular Fluid Volume Excess (ECFVE)

Hypervolemia
Hormonal Imbalances - ADH Can occur secondary to heart failure, renal failure, or cirrhosis of liver Fluid overload related to administration of excessive IV fluids Dietary: Excessive sodium intake

Hypervolemia
Signs & Symptoms
JVD Edema Crackles Tachycardia Elevated B/P Weight Gain Increased Urine Output SOB/Wheezing

Hypervolemia
Treatment:
Treat the underlying cause!!!

Renal Failure dialysis Heart Failure diuretics, etc. Dietary low-salt diet and/or fluid restriction Discontinuation of IV infusions

Intracellular Fluid Volume Excess


A.K.A. Water Intoxication
An excess of H2O or decrease in solute concentration in the intravascular space (Kee & Paulanka, 2000, p.34)

Causes cellular edema


Usually occurs in cerebral cells first

Intracellular Fluid Volume Excess


Causes:
Excessive non-solute water intake Solute deficit (electrolyte & protein) Increased secretion of ADH

Kidney Dysfunction

Intracellular Fluid Volume Excess


Signs & Symptoms
Headaches & Perspiration (early s/s) Apprehension, irritability Confusion, disorientation Increase ICP B/P, HR, RR Nausea/vomiting Weight Gain

Intracellular Fluid Volume Excess


Treatment:
Goal: Decrease excess H2O intake and promote H2O excretion

Extracellular Fluid Volume Shift


A.K.A. Third-spacing

Permanent fluid shift from intravascular space to interstitial space Nonfunctional fluid shift & physiologically useless

Extracellular Fluid Volume Shift


Simple: Blister or Sprain

Serious: Massive injuries, burns, ascites, abdominal surgery

ELECTROLYTES

ELECTROLYTES
Compounds, that when placed in a solution, conduct an electric current and emit dissociated particles of electrolytes (ions) that carry either a positive charge (cation) or negative charge (anion)
(Kee & Paulanka, 2000, p. 42)

ELECTROLYTES
Na+ & Cl- ECF K+ ICF Mg+ = ICF

Ca+ almost equal in ICF & ECF


(Kee & Paulanka, 2000, p. 42)

ELECTROLYTES
Terms:

Anabolism formation of new tissue

Catabolism tissue breakdown

(Kee & Paulanka, 2000, p. 46)

Potassium

Reference Range: 3.5 5.1 mEq/L

Potassium
Potassium is gained by intake and lost by excretion. If either is altered, hyperkalemia or hypokalemia may result! Regulated by aldosterone and insulin

Potassium
Potassium levels directly affect cell, nerve, & muscle function:
Maintains the electrical neutrality and osmolality of cells Aids in neuromuscular transmission of nerve impulses Assists skeletal and cardiac muscle

contraction and electrical conductivity

Affects acid-base balance in relationship to hydrogen (another cation)

Potassium

Hypokalemia is K+ < 3.5


Hyperkalemia is K+ > 5.1

Hypokalemia
Levels < 3.5 Mildly Low Levels usually asymptomatic
If level < 3.2, usually accompanied by symptoms

Hypokalemia
Causes of Hypokalemia: Increased Urine Output Malnutrition Vomiting and/or Diarrhea Hypomagnesemia DKA

Hypokalemia
May be a result of acid-base imbalances = alkalosis In alkalosis, potassium moves into the cell to maintain balance, which may lead to hypokalemia

Treatment
Oral or IV Potassium Chloride Replacement D/C or adjust medications that may cause hypokalemia Reverse alkalosis, if cause Monitor closely for arrhythmias Monitor Respiratory Status Monitor LOC Monitor GI symptoms

Hyperkalemia
Levels > 5.1 Mildly elevated levels usually asymptomatic

Hyperkalemia
Causes of Hyperkalemia: Renal Failure Meds (ACEIs, ARBs, K+ sparing diuretics, NSAIDs) Addisons Disease Aldosterone Insufficiencies Dig Overdose Beta-Blocker Therapy

Hyperkalemia
May be a result of acid-base imbalances = acidosis In acidosis, excess hydrogen ions move into cells and push potassium into ECF, which may lead to hyperkalemia as potassium moves out of the cell to maintain balance.

Treatment
Medications:
Cation-exchange resins (bind with K+ and excreted via feces) IVP insulin and glucose (K+ binds to insulin) IV Ca++ (protect the heart from the effects of hyperkalemia) Sodium bicarbonate (to reverse acidosis) Diuretics (non-K+ sparing) Beta2 Adrenergic agonists (epinephrine, albuterol)

D/C meds that may cause hyperkalemia Restrict foods with K+ Dialysis for renal failure Monitor closely for arrhythmias Monitor Blood Pressure Monitor GI symptoms

Sodium

Reference Range: 136 145 mEq/L

Sodium
Accounts for 90% of ECF cations Almost all Na+ is found in ECF; 10% in ICF Na+ attracts fluid and helps preserve ECF volume and fluid distribution Na+ helps transmit impulses in nerve and muscle fibers and combines w/ Clabd HCO3 to regular acid-base balance

Sodium
Excreted mainly via the kindeys (GU)
Also via the GI tract and perspiration

Increased Na+ levels trigger thirst and the ADH Sodium-Potassium pump helps maintain normal Na+ levels
Pump also creates an electrical charge for both cardiac and neuromuscular function

Sodium

Hyponatremia is Na+ < 136

Hypernatremia is Na+ > 145

Hyponatremia

Causes an osmotic fluid shift from plasma into brain cells

Hyponatremia
Signs & Symptoms:
Nausea/Vomiting Headache Malaise Confusion Diminished Reflexes Confusion Convulsions Stupor or Coma

Hyponatremia
Causes of Hyponatremia: Vasopressin/ADH SIADH Adrenal Insufficiency Diuretics Hypervolemia Liver Failure Heart Failure

Treatment
Administration of oral or IV Na+ (3%) Supplements Encourage foods high in Na+ Fluid restriction Monitor Neuro Status Monitor for Arrhythmias Normovolemic hyponatremia
Vaprisol (conivaptan) IV infusion Samsca (tolvaptan) - PO

Hypernatremia
Causes

Dehydration/Hypovolemia Diabetes Insipidus Ingestion of Hypertonic Solutions IV Infusion of Hypertonic Solutions Cushings Syndrome Hyperaldosteronism Loss of pure water
(excessive sweating or respiratory infections)

Signs & Symptoms


Thirst Lethargy Neurologic Dysfuntion
Due to dehydration of brain cells Irritablility Weakness Seizures Coma

Edema Decreased vascular volume

Treatment
Administration of IV Fluids
(Isotonic Salt-Free)

Encourage foods low in Na+ Push P.O. Fluids Monitor Neuro Status Monitor for Arrhythmias

Magnesium

Reference Range: 1.8 2.4 mEq/L

Magnesium
2nd most abundant ICF cation (K+ #1) 60% Mg+ found in bones, < 1% ECF Mg+ performs the following functions:
Promotes enzyme reactions in carbohydrate metabolism Helps produce ADP (adenosine triphosphate) Helps with protein synthesis Influences vasodilation (normal CV function) Helps Na+ and K+ ions cross cell membranes

Magnesium
Mg+ performs the following functions:
Regulates muscle contractions Affects irritability and contractility of

cardiac and skeletal muscle


maintain Ca++ levels in ECF

Influences Ca++ levels

Magnesium

Hypomagnesemia is Mg+ < 1.8

Hypermagnesemia is Mg+ > 2.4

Hypomagnesemia
Results in cardiac dysrhythmias and irritates the nervous system (tetany)

Hypomagnesemia
Causes of Hypomagnesia: Malnutrition Chronic Diarrhea Malabsorption ETOH Abuse Diuretics AMI Pancreatitis

Hypomagnesemia
Does not produce specific EKG changes May contribute to arrhythmias caused by digoxin toxicity, ischemia, or potassium imbalances

(Woods et al, 2005, p. 358)

Hypomagnesemia
Replacement of Mg PO or IV PO = Mg Oxide 400mg tabs

MgSo4 IV administration is usually given at a rate of 1 gram/hr (1 gram/100 ml)


Encourage foods high in magnesium

Hypomagnesia
Monitor
Monitor EKG for Arrhythmias Monitor for muscle cramps

Hypermagnesemia
Severe hypermagnesemia is associated with AV blocks and intraventricular conduction disturbances

Calcium

Reference Range: 8.5 10.1 mg/dl

Calcium
99% Ca++ in bones; 1% in serum & soft tissue (measured in blood serum levels) Is found in both ECF and ICF Can be measured in 2 ways:
Total serum calcium (total Ca++in blood) Ionized calcium level (various forms of Ca++ in ECF)

41% ECF Ca++ is bound to protein; 9% bound to citrate or other organic ions

Calcium
Ca++ functions in the following ways:
Responsible for formation of bones and teeth Helps maintain cell structure & function Plays a role in cell membrane permeability and

impulse transmission Affects contraction of cardiac muscle, smooth muscle, and skeletal muscle Participates in blood-clotting process

Calcium
Calcium helps potassium & sodium move into and out cells in the sodiumpotassium pump mechanism

Hypocalcemia
Causes:
Vitamin D Deficiency
Vitamin D promotes Ca++ absorption in intestines, resorption from bones, and kidney resorption all of which raise Ca++ levels

Deficiency of parathyroid hormone Inefficient parathyroid hormone

Hypocalcemia
Causes:
Deficiency of parathyroid hormone (PTH)
Calcitonin, secreted by PTH, helps regulate Ca++ Decreases absorption of Ca++ and enhances its excretion by the kidneys

Hypocalcemia
Hypocalcemia May Cause
Laryngospasm Cardiac Arrhythmias EKG s prolonged QT interval

Hypocalcemia
Management
PO or IV calcium replacement (depends on severity of symptoms or deficiency)

Vitamin D supplement
Encourage foods high in calcium

Hypercalcemia
Causes of Hypercalcemia:
Excessive calcium release Increased intestinal calcium absorption

** Decreased renal calcium excretion **

Hypercalcemia
Hypercalcemia May Cause Cardiac Arrhythmias EKG s shortened QT interval

Hypercalcemia
Severe Hypercalcemia (> 15mg/dl) is a

Medical Emergency
May result in Coma or Cardiac Arrest

Hypercalcemia
Signs & Symptoms
Fatigue Depression Confusion Anorexia N/V Constipation Pancreatitis Increased Urination

Hypercalcemia
Treatment
Hydration Increased Salt Intake Diuretics Dialysis (renal failure) Glucocorticoids

Renal Function

Renal Function
The main function of the renal system is to excrete biowaste, regulate water and electrolyte levels, and release of hormones that affect RBC production, bone metabolism, and hypertension.

Renal Function
Minimal urine output = 30 ml/hr Output affected by fluid intake, hormones, & medications Renal impairment causes imbalances of both fluids and electrolytes

Blood Urea Nitrogen


Reference Range: 5 -20 mg/dl An end-product of protein metabolism

Excreted by the kidneys


Elevated levels are indicators of possible dehydration, pre-renal failure, or renal failure

Blood Urea Nitrogen


Reference Range: 5 -20 mg/dl

If BUN (up to 35 mg/dl) but the creatinine is WNL = DEHYDRATION Usually as a result of Diarrhea, vomiting, and/or inadequate fluid intake
BUN WNL after hydration. If not, may indicate pre-renal or renal failure

Creatinine
Reference Range: 0.8 1.3 mg/dl A by-product of muscle catabolism

Excreted by glomerular filtration More specific indicator of renal failure


Not influenced by diet or fluid intake

Creatinine
Reference Range: 0.7 1.5 mg/dl If creatinine (> 2.5 mg/dl) this could be indicative of renal impairment IF both BUN and creatinine are elevated, then renal disorder is present

BUN/Creatinine Ratio
Reference Range: 10 - 20 Low Suspect acute tubular necrosis, malnutrition, low protein intake, pregnancy, liver disease, hemodialysis High Reduced renal perfusion (dehydration, heart failure), glomerular disease, tissue or muscle destruction, high protein intake, azotemia (elevated urea levels)

References
Kee, J. L. (2005). Laboratory and diagnostic tests with nursing implications (7th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Kee, J. L. & Paulanka, B. J. (2000). Handbook of fluid, electrolyte, and acid-base imbalances. Scarborough, Canada: Delmar Publishers. Priff, N. (ed.). (2006). Nurses quick check: Fluids and electrolytes. Ambler, PA: Lippincott, Wilkins, and Williams.

Smeltzer, S. C. et al. (2008). Brunner and suddarths textbook of medical-surgical nursing (11th ed.). Philadelphia, PA: Lippincott Williams and Wilkins. Tabers On-Line Medical Dictionary

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