Pathophysiology (NUR 190) Carmen Corder, MSN, RN Chapter 24 Fluids and Electrolyte Balance Body fluids are present

in 1. cells 2. spaces between cells & outside blood vessels(interstitial spaces) 3. blood that fills the vascular compartment Functions of Body Fluid Serves as lubricant for tissues Transports gases, nutrients, wastes Generates electrical activity for body function Transforms food into energy (metabolism) Fluid Compartments 1.Intracellular (ICF) or inside the cell 2.Extracellular (ECF) or outside the cell a. Interstitial fluid (tissue spaces) b. Intravascular fluid-fluid portion of blood (blood plasma) c. Transcellular fluid-fluid in body spaces such as CSF, peritoneal, pleural, and pericardial cavities **also referred to as third spaces See Figure 24-1 on page 593 Distribution of body water Total Body Water (total water in all fluid compartments) Muscle contains more H2O than fat Adult male 60% TBW Adult female (more fat/less TBW)

Obese adults 45% TBW Elderly adults 45% TBW d/t natural loss of muscle mass with age **Less TBW = more susceptible to dehydration Intracellular Fluid Compartment Contains 2/3 of total body water in healthy adults **Potassium is major intracellular cation(+) Extracellular Fluid Compartment Contains 1/3 of body water in healthy adults **Sodium is major extracellular (+) cation Chloride is main ECF (-) anion The ECF electrolyte levels are the levels which are drawn and measured clinically (Basic Metabolic Panel). Extracellular fluid compartment- blood plasma Extracellular fluid- interstitial fluid Extracellular fluid- Ex. pleural effusion Water Balance (fluid homeostasis) Total body water is mainly regulated by the processes of fluid intake, absorption, distribution, and excretion. Fluid homeostasis Fluid intake- eating and drinking. Fluid absorption- occurs in the GI tract and partially depends on osmotic forces of particles. Fluid distribution- the net result of the processes causing movement of water (osmosis, hydrostatic pressure, colloidal osmotic pressure). Fluid excretion- urinary tract, bowels, lungs, and skin; ADH (released by the posterior pituitary). Osmolality Concentration of molecules per weight of water (the amount of stuff present in the water)

 Stuff= electrolytes, proteins, glucose, etc.; anything which cannot pass through a semi-permeable membrane such as a capillary wall. Serum (blood) osmolality 280-295 mOsm/kg - increases with fluid volume deficits -decreases with fluid volume excesses Why would serum osmolality increase with fluid volume deficits and decrease with fluid volume excesses? Fluid distribution: Movement of water Osmosis Hydrostatic pressure Colloid Osmotic pressure Osmosis Fluid moves across a semi-permeable membrane. Moves from area of higher water concentration to area of lower water concentration. Hydrostatic Pressure Hydrostatic pressure is the pushing force of a fluid. Colloid Osmotic pressure Osmotic pressure is the pulling force created by the particles; the stuff that cannot pass through the pores of the capillary membrane attracts fluid. Osmolality refers to the stuff and this refers to the pulling force of the stuff. Alterations in H20 balance Extracellular volume deficit Causes: Vomiting, diarrhea, excessive diuretic use, hemorrhage, third spacing Signs/ symptoms: weight loss, decreased UOP, tachycardia, flattened neck veins, orthostatic hypotension

Alterations in fluid balance Clinical dehydration- A combination of an extracellular fluid volume deficit and hypernatremia. Alterations in H2o balance Extracellular volume excess Causes: excessive infusion of IV fluids, heart failure, renal failure. Signs/ symptoms: weight gain, decreased H&H and plasma proteins; bounding pulse, JVD; may lead to pulmonary edema. Lab values: altered fluid balance ANP and BNP (p. 596)- Elevated in fluid volume excess. Urine specific gravity- Elevated in fluid volume deficits; decreased in fluid volume excess. Urine osmolality- more accurate reflection of the concentration of particles in urine. BUN (blood urea nitrogen)- Falsely elevated in dehydration. Tonicity of IV fluids Isotonic or iso-osmolar Hypertonic or hyper-osmolar Hypotonic or hypo-osmolar The higher the osmolality (amount of stuff) of a solution, the greater its pulling power for water. Tonicity of intravenous Fluids Isotonic IVF Concentration of dissolved particles equal to ICF and/or ECF. Hypertonic IVF Concentration of dissolved particles greater than ICF (cells shrink b/c theres more stuff in the IVF than in the cells). Hypotonic IVF

Concentration of dissolved particles less than ICF (cells swell like a hippo b/c theres less stuff in the IVF than in the cells). Isotonic fluids Cell size remains the same The amount of stuff in the IVF = to amount of stuff in the cell 0.9% NaCl(referred to simply as Normal Saline in the hospital- 0.9% is the baseline for % of solutes in IVF) Lactated ringers (LR) Hypertonic Fluids Cells shrink Water moves from ICF (cells) to ECF (blood) b/c theres more stuff in the IVF than in the cell **The percentages of solutes in these IVF will be higher than the baseline of 0.9% 3% Saline (3% NS) Dextrose 5% in 0.45% NS (D5W in NS) Dextrose 10% in water (D10W) Hypotonic fluids Draws water into ICF (cells) from ECF (blood) Cells swell like a hippo b/c there is less stuff in the IVF than in the cell **The percentages of solutes in these IVF will be less than the baseline of 0.9% Isotonic IVF Uses: Usually first fluid ordered for emergency volume replacement Dehydration Most types of shock 0.45% Saline (1/2 NS) D5W (Dextrose 5% in water)

Hypertonic IVF Uses: Expand ECF volume and decrease cellular swelling. May be used in patients with increased intracranial pressure secondary to stroke or head trauma (will decrease cerebral edema).

Hypotonic IVF Uses: Cellular dehydration resulting from excessive diuresis Hypernatremic dehydration Absolute contraindication: Increased intracranial pressure, cerebral edema!!!!

????????Questions?????????? Which type of IVF is most commonly used to treat isotonic dehydration? Which type of IVF would have the highest potential to lead to intravascular fluid volume overload? ?????????Questions?????????? -What nursing assessments would be critical to monitor for complications related to hypertonic IV solutions? -Name the most important contra-indication to hypotonic IVF. Edema Accumulation of excess fluid within the interstitial spaces causing palpable swelling. Edema cannot be visually observed until interstitial fluid volume has increased 2.5 to 3 liters. edema Causes of edema (Fig 24-9) Increased capillary hydrostatic pressure fluid volume excesses, venous obstruction (thrombophlebitis) Decreased capillary osmotic pressure- starvation, liver failure (decreased intake/production of plasma proteins) Increased capillary permeability- trauma, burns, inflammation Obstruction of lymph flow- cancer of lymph structures Types of Edema

Localized- Ex: edema associated with hives Generalized- usually a result of fluid volume excesses (common in CHF) Pulmonary- fluid accumulating around the lungs (CHF- left sided heart failure) Dependent- fluid accumulates in LE usually d/t prolonged standing Lymphedema- lymph channels blocked or surgically removed DependentEdema Assessment for edema Daily weights (wt. gain of 2.2 lbs. in 24 hours is significant) Visual assessment Is & Os Measurement of affected part (thrombophlebitis) Application of finger pressure to assess pitting edema Auscultate lung sounds Critical thinking questions Your patient has new audible crackles, a non-productive cough, and a respiratory rate of 35bpm. What specific type of edema is this patient experiencing? What specific interventions will you perform for this patient? Name a possible cause for this type of edema. Case Study You are caring for a patient with a severe closed head injury. He is intubated and being mechanically ventilated as he is completely unresponsive at this time. Upon admission his blood pressure was only 85/40. The MD orders fluid resuscitation. Which type of IVF do you anticipate will be ordered and why? _____________________________________________________________________________________ _________________________________________________________________________________ Third Space Accumulation When fluid is trapped in serous cavities of the body such as the pericardial sac, the peritoneal cavity, or the pleural cavity.

Ie: ascites, pleural effusion Dissociation of electrolytes Electrolytes- ionized salts dissolved in water The distribution of electrolytes depends on their charge, as (+) ions are always accompanied by (-) ions and vice-versa in order to maintain a neutral charge. **In addition, any (+) ion may be exchanged for another (+) ion to maintain neutrality; and the same is true for (-) ions. Sodium Balance Sodium (Na+) is the most abundant (+) ion in the body Normal serum Na+ is 135-145 Think quick- is it mainly in the ICF or ECF????? Sodium (Na+) Important regulator of osmolality Helps regulate acid base balance b/c it is part of the Na-bicarb molecule Conducts nerve impulses Sodium Balance Regulated by renin-angiotensin-aldosterone system When blood pressure is low, the kidneys secrete renin Renin stimulates secretion of Angiotnesin I which converts to Angiotnesin II (vasoconstriction) Angiotensin II stimulates the release of aldosterone by the adrenal cortex Sodium balance Aldosterone causes the kidneys to reabsorb Na+ and water and excrete K+. Aldosterone = salt water hormone End result of all reactions in increased blood pressure. Hyponatremia Serum sodium less than 135 mEq/L

Etiologies Water retention (hemodilution) **most common cause Na+ loss through skin, GI tract, kidneys Increased Na+ shifting into cells when there is a cellular potassium deficit Diuretic therapy Signs and symptoms of hyponatremia Cells ability to depolarize and repolarize is affected Mainly behavioral and neuro changes- confusion, depressed reflexes, seizures coma Dilutional hyponatremias will cause s/s associated with fluid volume excess Treatment of hyponatremia Depends on severity and cause Water restriction and/or loop diuretics if caused by fluid volume excess Oral or IV saline solution Nursing Implications: Monitor serum Na+ levels, accurate Is&Os, monitor V.S. closely. ????????Questions??????????? If hyponatremia is caused by hemodilution, how will you expect the MD to treat this?________________________________________________________________________________ If hyponatremia is also accompanied by severe dehydration, how will you expect the MD will treat this? ____________________________________________________________________________________ Case Study 64 year old male presents to the ER with SOB, fatigue, and generalized edema. He has a long history of coronary artery disease and underwent coronary artery bypass graft surgery 3 years ago. Which of the following is the most likely Na+ disorder for this patient? A. Isotonic hyponatremia B. Hypertonic hypernatremia

C. Isotonic hypernatremia D. Hypervolemic hyponatremia Case study How should the patient in the previous scenario be treated? A. 3 % Sodium chloride solution B. IV normal saline and loop diuretics C. Implement fluid restriction and loop diuretics D. Start high doses of beta blockers Hypernatremia Sodium level greater than 145 mEq/L Etiologies Net gain of Na+ OR net loss of water (hemoconcentration) Rapid infusion or ingestion of Na+ w/out time for adequate water ingestion Thirst defect/inability to communicate thirst or drink water Loss of excessive amts. of body fluids w/ low Na+ concentrations: heavy sweating during exercise, watery diarrhea Hypernatremia Normally, when there is an excess of Na+ OR a deficit of water, thirst intake occurs. and water

Hyper-Na+ is more likely to occur in babies and those with a decreased LOC. Hypodipsia (impaired thirst), prevalent among elderly. Signs and symptoms of hypernatremia Hypernatremia increases serum osmolality; therefore leading to cellular dehydration- dry skin and MMs, salivation and tearing decreased If caused by hemoconcentration/ dehydration, s/s will be associated with fluid volume deficit Neuro-Restlessness, aggitation, HA, disorientation Seizures and coma if hypernatremia severe

Hypernatremia Treatment of hypernatremia Treat underlying cause Sodium restriction If caused from dehydration, oral or intravenous fluids may be given; oral route preferable Nursing Implications: Instruct client to avoid foods rich in salt (canned goods, lunch meats), monitor serum Na+ levels, monitor V.S. closely, lung sounds, check for LE edema ?????????Questions??????????? Hypernatremia as a result of hemoconcentration will be treated how? ____________________________ How will mild hypernatremia in the absence of dehydration be treated? __________________________ Potassium (K+) Normal serum level 3.5 to 5.5 mEq/L The major (+) ion of the ICF About 65-75% of K+ is in muscle cells, so total body K+ decreases with age d/t muscle mass loss. Functions Aids in transmission of nerve impulses Assists in skeletal and cardiac muscle contractions and electrical conductivity Affects acid base balance Regulation of Potassium Balance Aldosterone- stimulates Na+ reabsorption and K+ excretion by the kidneys Insulin- causes K+ to move from ECF (blood) back into the cells Na+/K+ pump high amts. of K+ and low amts. of Na+ inside the cell maintains the resting potential

K+/Hydrogen ion exchange system- when serum K+ levels are high, K+ is excreted in urine and is replaced by reabsorption of hydrogen(*one (+) ion exchanged for another) Hypokalemia Serum potassium (K) less than 3.5 mEq/L Etiologies (Box 24-6) Inadequate nutritional intake Excess losses through GI system (vomiting, GI suctioning), or skin (sweating, burns) Diuretics (esp. loop diuretics like Lasix) **most common Metabolic Alkalosis- promotes movement of K+ into the cells in exchange for hydrogen Signs and symptoms of hypokalemia -Cardiac- Postural hypotension, ECG changes, & dysrhythmias; K+ is abundant in cardiac muscle -Muscle weakness & cramps -Decreased GI motility Treatment of hypokalemia Remove or treat underlying cause Increase intake of high potassium foods Oral potassium supplements Intravenous potassium chloride (KCL)- usually 40 MeQ diluted in 100 mL of diluent Nursing Implications: Monitor V.S. and ECG closely, monitor serum K+ levels, dilute oral K+ supplements as directed, NEVER give IV K+ as a push, instruct client on foods rich in K+ (fresh fruits & veggies, salt substitutes) Question A patient is admitted with a K+ level of 2.9. Which of the following treatments is written correctly? A. KCL 40 MeQ/10mL IVP over 4 minutes B. KCL 40 mEQ/100mL hung over 1 hour at 100 mL/hr.

C. KCL 20 MEQ/50 mL IVBP over 25 minutes D. KCL 40 meQ/100mL hung over 4 hours at 25 mL/hr Hyperkalemia Serum potassium greater than 5.5 mEq/L Etiologies (Box 24-7) Decreased renal elimination (renal failure) **most common Cellular injury causing K+ to be released into the blood from the cells Metabolic acidosis think about the relationship between K+ and hydrogen Rapid administration of intravenous potassium! Signs and symptoms of hyperkalemia Earliest symptom- Paresthesia Generalized muscle weakness/dyspnea Cardiac dysrhythmias and ECG changes Treatment of Hyperkalemia Prevent complications and treat underlying cause Potassium restriction - *major ingredient in salt substitutes is KCL so these should not be given to patients w/ hyperkalemia/severe renal failure Diuretics- esp. loop diuretics Kayexalate Hemodialysis Emergency tx: Insulin and Glucose Treatment of hyperkalemia Nursing Implications: Monitor V.S. and ECG strips closely, monitor serum K+ levels, accurate Is&Os, teach clients to avoid foods w/ high amounts of K+ (orange juice, yogurt) Calcium (Ca+) Normal serum level 8.5 to 10.5 mg/dl

Functions (Calcium calms) Forms bone and teeth (99% of body Ca found in bone & teeth) Assist in cell membrane permeability Assists in impulse transmission Affects muscular contractions- cardiac, smooth, and skeletal Promotes blood clotting Plasma calcium

Ca+ in plasma is present in 3 forms: 1. Bound to plasma proteins such as albumin. 2. Bound to small organic ions such as citrate. 3. Unbound- **only physiologically active form of Ca+. Calcium Regulators Parathyroid hormone (PTH)- secreted in response to low serum Ca+ levels; increases serum Ca+ Albumin almost serum Ca+ bound to albumin (the remaining 50% of serum Ca+ is unbound and referred to as ionized Ca+) Calcitonin- removes Ca+ from circulation & puts it in bone; decreases serum Ca+ Vitamin D- needed in order to absorb Ca+ Phosphorus- inverse relationship w/ Ca+ Hypocalcemia Calcium level less than 8.5 mg/dl Etiologies Inadequate intake Renal failure- d/t inability of kidneys to produce Vit. D and increased levels of phosphorus Hypoparathyroidism- d/t decreased levels of PTH

Diarrhea Lack of Vitamin D Diuretics Signs and symptoms of hypocalcemia Neuromuscular- paresthesia, twitching, tetany, **laryngeal spasms Cardiovascular- dysrythmias Musculoskeletal- pathologic fractures and bone pain w/ chronic deficiency; osteoporosis Hematologic- increased risk for bleeding d/t lack of prothrombin

Tetany +Trousseaus sign (carpopedal spasm) +Chvosteks sign

Treatment of Hypocalcemia Determine and correct underlying cause If tetany present, IV Ca+; GIVE SLOWLY Increase oral intake Oral calcium supplements & Vitamin D Nursing Implications: Monitor serum Ca+ levels, V.S., and ECG, give oral Ca+ supplements at least 30 minutes prior to a meal to enhance intestinal absorption, teach clients to eat foods high in Ca+ & Vitamin D, check for prolonged bleeding times Case study Mr. J is a 65 year old male who underwent a subtotal parathyroidectomy yesterday morning. This morning he is complaining of pins and needles in his hands and feet and difficulty getting his breath. What type of electrolyte imbalance do you suspect with Mr. Js signs and symptoms? _____________________

What is the cause for Mr. Js imbalance? ____________________________________________________ Hypercalcemia Serum calcium greater than 10.5 mg/dl Etiologies Hyperparathyroidism Cancer some malignancies produce ectopic PTH Prolonged immobilization Overuse of Ca+ containing antacids/supplements Signs and symptoms of hypercalcemia Decreased neuromuscular excitability; dulling of consciousnessstupor Bradycardia and dysrythmias Constipation Formation of kidney stones Treatment of Hypercalcemia Hydration/ loop diuretics (Why is hydration so important?) Nursing Implications: Monitor serum Ca+ levels, V.S., and ECG; promote ROM for bedridden clients, maintaining hydration, avoidance of foods high in Ca+ Magnesium Normal serum magnesium 1.5 to 2.5 mg/dl. See boxes 24-10 and 24-11 for common causes of Mg+ imbalances. Functions Assists sodium-potassium pump Causes neuromuscular excitability Smooth muscle contraction and relaxation Phosphorus Normal serum phosphorus level is 2.5-4.5 mg/dl.

See boxes 24-12 and 24-13 for common causes of phosphorus imbalances. Functions Important component of ATP, the major source of energy for cellular processes. Phosphorus has inverse relationship with calcium.