Assessment and Care of Patients with Fluid and Electrolyte Imbalances

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solvent

water portion of fluids

solute

particles dissolved or suspended in water

hydrostatic pressure

the force that pushes water outward from a confined space through a membrane

viscous

"thickness" of a fluid

equilibrium

no pressure differences between the two spaces due to equal hydrostatic pressure

disequilibrium

occurs when a gradient of unequal pressures exist across a membrane

Average amount of urine per day

1.5 L

Filtration

movement of fluid through a cell or blood vessel membrane due to hydrostatic pressure differences on both sides of the membrane

How is blood pressure an example of hydrostatic filtering force?

It moves whole blood from the heart to capillaries where filtration can occur to exchange water, nutrients, and waste products between the blood and tissues

Edema develops when...

increases in venous capillary pressure rise and force fluid into the interstitial tissues

Diffusion

free movement of particles across a permeable membrane from an area of high concentration to low concentration

Osmosis

-movement of water through a semi-permeable membrane
-Water moves from low to high concentration to achieve homeostasis

What is the thirst mechanism?

The feeling of thirst is caused by the activation of cell in the brain that responds to changes in the ECF osmolarity

Normal Osmolarity

270-300 mOsm/L

Lymph

-fluid left in interstitial tissue following a movement of fluids from the capillary at it's arterial end and back to venous capillary system
-Lymph flow is slower than blood flow

What is lymph flow enhanced by?

-skeletal muscle contractions
-breathing
-lymphatic peristalsis

What is flood intake regulated by?

thirst drive

What triggers the thirst drive?

increased osmolarity
decreased blood volume

Measurable fluid intake

oral fluids
parenteral fluids
enemas
irrigation fluids

Non measurable intake

solid foods
metabolism

Minimum amount of urine needed to excrete toxic waste products

400-600 mL/day

Insensible water loss

fluid loss through skin, lungs, and stool
cannot be controlled or measured

average water loss for healthy adult

500-1000 mL/day

Aldosterone

secreted by adrenal cortex when sodium level in ECF in decreased
prevents both water and sodium loss

Antidiuretic hormone (ADH)

stored in posterior pituitary gland
acts on renal tubules in response to changes in blood osmolarity causing water retention

Natriuretic peptides

hormones secreted by special cells in the atria (ANP) and ventricles (BNP) of the heart in response to increased blood volume and pressure
***Opposite of aldosterone- increases urine output to reduce circulating blood volume

When does BNP increase?

CHF

Dehydration

Fluid intake is less than what is needed to meet the body's fluid needs, resulting in fluid volume deficit

Actual dehydration

decrease in total body water

Relative Dehydration

intravascular water shifts out of circulating blood volume into the interstitial (extravascular) space

Where do you assess skin turgor in older adults?

skin over sternum or on forehead

Assessment for DEHYDRATION

I&O record
fever
sweating
diarrhea
diuretics
laxatives
vomiting

Physical assessment & clinical manifestations of DEHYDRATION

orthostatic hypotension
flattened neck veins in supine position
tachypnea
decreased turgor
decreased moisture
dry mucous membranes
change in mental status
concentrated urine (increased spec. grav.)
decreased urine output (<500 mL/day cause for concern)

Lab assessment for DEHYDRATION

INCREASED
Hgb, Hct, Serum Osmolality, glucose, protein, BUN, and electrolytes
(All increased because decreased extracellular volume)

Fluid overload

excess of body fluid
-most common causes are related to fluid volume excess in the vascular space or to dilution of specific electrolytes and blood components

Assessment of FLUID OVERLOAD

pitting edema
weight gain (EARLIEST INDICATOR)
tachycardia
bounding pulses
hypertension
distended neck veins
tachypnea
AMS
hepatomegaly
(Report >3 lb weight gain/week OR >1-2 lbs in 24 hrs.

Sodium normal range

136-145 mmol/L

Nursing care priority for hyponatremia

monitor pts. response to therapy and prevent hypernatremia and fluid overload

Normal potassium range

3.5-5.0 mEq/L

ECG changes in HYPOkalemia

flattened T wave, appearance of U wave

Nursing care for HYPOkalemia

ensures adequate oxygenation, patient safety for falls prevention, prevent injury from potassium administration, monitor pts. response to therapy

Most severe problems from HYPERkalemia

Cardiovascular changes due to ECG changes
Major cause of death in hyperkalemia
(ventricular ectopy, heart block, systole, or ventricular fibrillation)

Normal CALCIUM range

9.0-10.5 mg/dL

Trousseau's sign

palmar spasm with arterial occlusion with BP cuff for 1-4 min.

Chvostek's sign

tap the face in front and below ear to assess for twitching

Musculoskeletal weakness in HYPOphospatemia may progress to...

rhabdomyolosis

Normal Phosphorus levels

3.0-4.5 mg/dL

What does it mean when CALCIUM and PHOSPHORUS are in a balanced reciprocal relationship?

If Calcium increases, Phosphorus decreases
If Calcium decreases, Phosphorus increases

Normal Magnesium levels

1.3-2.1 mg/dL

What is a major nursing intervention for HYPERmagnesemia?

Discontinue all oral and parenteral magnesium

Normal Chloride levels

98-106 mEq/L

Most common reasons for Infusion Therapy

-maintain or correct fluid balance
-maintain or correct electrolyte or acid-base balance
-Administer medications
-Replace blood or blood products

Normal serum osmolarity for adults

270-300 mOsm/L

Parenteral solutions within normal range are...

Isotonic

Fluids greater than 300 mOsm/L are...

hypertonic

Fluids less than 270 mOsm/L are...

hypotonic

Patient's receiving ISOTONIC solutions are at risk for...
WHY?

fluid overload
-when isotonic infusions are used, water does not move into or out of the body's cells

3-5% NS

HYPERTONIC

D5NS

HYPERTONIC

D5LR

HYPERTONIC

How do HYPERTONIC infusions work?

move water out of the body's cells (ICF) by osmosis and into the bloodstream (ECF)
LESS WATER, MORE SALT

Complications with HYPERTONIC infusions

vascular overload (increased ECF)
pulmonary edema
cellular dehydration (decreased ICF)

1/4 NS

HYPOTONIC

0.45% NS

HYPOTONIC

Complications with HYPOTONIC infusions

causes cells to burst or lyse (increased ICF)
serum (decreased ECF) dehydration
increased serum electrolytes due to hemoconcentration

Vascular Access Device (VAD)
-Where are they used?
-How long can they dwell in a vein?

superficial veins of the hand and forearm
dwell for 72 to 96 hours and then require removal

How do you remove a PICC line?

1-2" at a time, over 1-2 minutes (relaxes, prevents vasospasm, breakage)
MEASURE CATHETER*** make sure you take as much as you gave

Tunneled Central Catheter

portion of catheter lying in a subcutaneous tunnel separates the point at which the catheter enters the vein from where it exits the skin

used for infusion therapy that is frequent and long-term

Implanted Ports

A subcutaneous pocket is surgically created to house the port body
Port is usually placed in the upper chest or the upper extremity
Port needs to be flushed after each use and at least once a month between courses of therapy
(Most facilities require a heparin-lock flush upon discontinuing infusions

Dialysis Catheters

Lumens are very large to accommodate the hemodialysis procedure or a pheresis procedure that harvests specific blood cells
Should not be used for administration of other fluids or medications, except in an emergency

What type of administration set is used when no primary line is present?
Ex: Antibiotic without continuous infusion line

Intermittent

Needleless connection devices

Used to minimize risk for needle sticks

Slip-lock add-on system

Memorial has them, male and female end

Luer-lock add-on system

threaded end that screw together

Circulatory overload

homeostasis disruption due to excess fluid

Speed shock

rapid infusion of drugs or bolus infusion that causes shock or cardiac arrest due to introduction of a foreign substance

Allergic reaction

may be to tape, cleansing agent, solution, or IV device

Catheter embolism

Piece of catheter breaks off causing it to freely float in the blood vessel

Arterial therapy

Used for pressure monitoring, repeated blood gases, & to infuse some chemotherapy agents

Intraperitoneal infusion

placement of chemotherapy agents into the peritoneal cavity

Suncutaneous infusion
HYPODERMOCLYSIS

slow infusion of isotonic fluids into the subcutaneous tissue, short term fluid replacement
torso preferred site

Intraspinal infusion

Administration of opioids and anesthetics for regional pain relief, also steroids and antispasmodics

Ex: Epidural, Subarachnoid injection

Intraosseous therapy

Easy access in the proximal tibia or sternum
Used mostly in pediatric population
Now used for trauma, burn, or cardiac arrest victims
Short duration (24 hours), but as effective as peripheral or central IVs for large volume infusions

What does a "pins and needles" sensation indicate?

nerve puncture

aldosterone

adrenal gland hormone that causes kidneys to reabsorb sodium into the blood, causing more water to be reabsorbed by osmosis

hemodilution

condition in which that plasma is more dilute than normal

hypovolemia

a state of fluid volume excess or overload in the blood stream

Osmolality

concentration of solute per kilogram of water, which creates the pulling power of that solution for water

Osmolarity

concentration of solute per liter of solution, which creates the pulling power of that solution for water

vascular space

space within the blood vessels

euvolemia

normal fluid volume in the body

relative hyperkalemia

movement of potassium from the intercellular fluid to the extracellular fluid, leading to elevated serum potassium levels without a true body increase of K+, such as occurs with acidosis

relative hypokalemia

movement of potassium fro the ECF to the ICF, leading to lowered K+ levels without a true decrease of K+ in the body, such as occurs with insulin therapy

ECG changes for hyperkalemia

wide QRS, tall tented T-wave, ST segment depression

ECG changes for hypokalemia

Flattened T wave, Normal QRS, ST segment depression

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