Fluid and Electrolyte Imbalance NURSE REFRESHER CLASS 2010 BY
KIM UDDO RN MN CCRN CNE MANY SLIDES BORROWED FROM ARLISHA PRATT.
MUCH THANKS.
Slide 2
Objectives Review and define concepts related to fluid movement
Discuss considerations for older adults in relation to fluid
imbalance Correctly interpreting laboratory data and diagnostic
testing indicating; fluid and electrolyte imbalances Utilizing
laboratory data, and signs and symptoms to determine the presence
of fluid and electrolyte imbalances
Slide 3
Objectives (cont) Indentify clients at risk for fluid volume
imbalances. Indentify specific assessment findings in electrolyte
imbalances. Identify priority nursing diagnosis for clients
experiencing fluid and electrolyte imbalance. Describe the
therapeutic and nursing management of clients exhibiting fluid and
electrolyte imbalances
Slide 4
Overview of Fluid Movement Intracellular Fluid- within the
cells Extracellular Fluid- outside the cells (includes the
intravascular space) Osmosis-is the movement of water only through
a selectively permeable membrane. Osmolality-concentration of
particles/kilogram Osmolarity-concentration of particles/liter
(does not have to be water)
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Overview of Fluid Movement Filtration-Movement of fluid through
a cell or blood vessel membrane Hydrostatic pressure-is the pushing
force of fluid against the walls of the space it occupies.
Diffusion-particles move from a higher concentration to an area of
lower-concentration. Oncotic pressure (colloid osmotic
pressure)-the pulling force exerted by colloids in a solution
Human serum osmolality Serum Effected by Na, Glu, and BUN
275-295 milliosmoles per kilogram of water (mOsm) If glu and Bun is
normal you can roughly multiply Na by 2 to get the osmolality
Increases in dehydration and decreases in overload Urine measured
for osmolality too
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Calculated Osmolality Estimated 2(Na) + BUN/2.8 + Blood
Glucose/18 Example 2(135) + 12/2.8 + 110/18 = 280 mOsm Some labs
will calculate with the SMA 7 Your calculation my differ from
lab
Slide 11
Human urine osmolality Like specific gravity, it is a measure
of urine concentration. Unlike specific gravity, it is NOT
concerned with the size or weight of the particles in solution,
just the number of them. So big glucose and protein molecules in
the urine do not raise the osmolality like they do the specific
gravity of urine. More sensitive test than specific gravity, temp
is controlled, can be compared to the serum osmolality.
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Urine osmolality range 500-800 mOsm 800 mOsm = 1.022 specific
gravity If the patient has a 14 hour overnight fast, they should
have a urine osmolality at least 3 x greater than the serum
osmolality. (No intake = more concentrated urine)
Slide 13
Urine specific gravity Measures the density of urine compared
to density of water Usually, the higher the number, the more
concentrated the urine Normal 1.001 1.040 If glucose or protein in
urine, false high. If no glucose or protein in urine and specific
gravity is high, urine is concentrated due to dehydration or
increased output of ADH which causes a decreased urine volume.
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Elevated secretion of ADH Trauma Stress Surgery Drugs Usually
means patient needs fluids.
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Surgical Diuresis Surgery is major trauma to the body and
activates ADH. Urine Specific Gravity gets high as result As stress
decreases, post op day 2, ADH and other hormones like
glucocorticosteroids decrease, the fluid that was held in reserve
to prevent going into shock is released The increase urine output
two days after surgery is to be expected. CABG Patient
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Serum and Urine mOsm Ratio If urine osmolality goes up and
serum is normal or elevated, we know the kidneys are conserving
water. Like in dehydration.
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Dehydration Urine and Serum Osmolality are HIGH.
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Ratios If serum osml is low or dilute and urine osmo is high,
we know that this is not a normal response. An increased level of
ADH can cause this. Think SIADH: syndrome of inappropriate anti
diuretic hormone.
Slide 19
Ratio Urine osmo should always be higher than serum osml unless
the patient is putting out dilute urine due to diuretics or due to
drinking an excess of fluids. Diuretic use can show a lower urine
osmolality with a normal serum osmolality.
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Diuretic Use Low urine osmolality and normal serum osmolality
What does their urine look like before the diuretic? What does
their urine look like after the diuretic?
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Something is wrong if The urine osmolality remains dilute while
the serum osmolaity starts to climb..remember a dehydrated patient
has increased urine and serum levels. We think that the patient
cannot activate their ADH DI: diabetes insipidus.pathologic lack of
ADH They look like they are unable to concentrate their urine!
Slide 22
DI vs SIADH DI. Im Dry SIADH. I float Which patient gains
weight? Which patient looses weight? What does the urine look
like?
Slide 23
Sensible & Insensible Fluid Loss OUTPUT Urine Emesis ( only
if in liquid form) Feces ( only if in liquid form) Drainage from
body cavities ( fistula/wound/ drains ) Perspiration Vaporization
through lungs INTAKE Measurable Oral intake Parenteral Fluids
Enemas Irrigation fluids Not Measurable Solid foods Metabolism
Slide 24
Hormonal/Chemical Fluid Balance Thirst Mechanism Stimulated by
thirst receptors in the hypothalamus Stimulates ADH and aldosterone
release, which promotes reabsorption of water. Depressed in older
people (> 60y/o)
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Consideration for Older Clients Older adults has less total
body water than a younger adult. They have decreased thirst
sensation Difficulty with walking or other motor skills need for
ingesting of fluids They also may take drugs such as diuretics,
antihypertensive, and laxatives that increase fluid
excretions.
Slide 26
Considerations for Obesity and Females Females have more fat
than males Obese have more fat Less water is stored in fat
Dehydrate quickly so beware.
Slide 27
Evidence Based Nursing The evidence shows that most
hospitalized patients are not offered enough water and become
dehydrated. Its a safety concern Offer water! Teach patient and
family to record accurately I& O
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Fluid Imbalances Fluid Volume Deficit Hypovolemia-Circulating
blood volume is decreased and leads to inadequate tissue perfusion.
Which can quickly lead to shock. Dehydration- Fluid intake is less
than what is needed to meet the bodys fluid needs. Can occur with
just water loss or with water and electrolyte loss.
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Dehydration What do the labs look like? Who is at risk?
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Fluid Imbalance Fluid Volume Overload Fluid overload
(overhydration)- is an excess of body fluid; can be either actual
excess of total body fluid or a relative fluid excess.
Hypervolemia-most common type of fluid overload.
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Over hydration What would the labs look like?
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Causes, Assessment, Clinical Manifestations Identify who is at
risk for fluid and electrolyte disturbances Identify S&S of
fluid volume deficit Identify S&S of fluid volume excess
Identify S&S of electrolyte disturbances Identify situations
that cause disturbances
Slide 33
Laboratory Assessment, Interventions, Patient safety Protocols
set for communication of abnormal labs Use SBAR Conduct Physical
Assessment include ECG changes Document your actions including
phone calls/ time Critical lab value stickers Get follow up lab
orders after intervention and evaluate Teach the patient!
Slide 34
Nursing Diagnosis and Case Studies Use your nursing diagnosis
list from clinical manila folder
Slide 35
Case Study #1 A 20 y/o client is admitted to the hospital for
c/o nausea, vomiting and diarrhea; and has not had an appetite in 3
days. BP 86/42, pulse 124, resp 30; While in the emergency room,
one liter of NS has infused and now D5 1/2NS is infusing at 80
mls/hr. What nursing interventions should the nurse perform and
monitor while caring for this client?
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SBAR the report to the MD Introduce yourself S B A R Any
questions for me? How long did it take?
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Case Study # 2 A 55 y/o client with Congestive heart failure is
receiving D51/2NS at 150cc/hr after surgery. The client reports
trouble breathing, and sits up in bed and coughs up moderate amount
of clear mucous. What priority nursing action and follow Up actions
are needed and why?
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SBAR the report to the MD Introduce yourself S B A R Do you
have any additional questions for me? How long did it take?
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Safety Measures Orient client to the environment (especially
the older adult) Monitor for falls Assess the client muscle
strengths, gait stability Instruct the client to get up slowly from
a lying sitting and standing position Assist the client from the
bed to chair Monitor for any skin breakdown Change positions q2
hours
Electrolyte Balance and Imbalances Potassium Main cation in the
ICF Regulate intercellular osmolarity Maintenance of electrical
membrane excitability Maintenance of plasma acid-base balance
Sodium Main cation in the ECF Maintenance of plasma &
interstitial osmolarity Maintenance of acid-base balance Generation
and transmission of nerve impulses
Slide 42
Electrolyte Balance and Imbalances Hyponatremia (< 135mEq/L)
Water shift from the ECF to the ICF; resulting in circulating
plasma volume & intracellular fluid. Causing cellular swelling
Hypernatremia (> 145mEq/L) Water shift from the ICF to the ECF,
which result in cellular shrinkage/dehydration
Slide 43
Case Study # 3 The nurse is assigned to a client who is NPO and
on prolong intermittent nasogastric suctioning. What will the nurse
monitor for and why?
Slide 44
Case Study # 4 In caring for a client with Hypernatremia, what
should the nurse do to help ensure client safety? Note: when sodium
levels change, think about how the fluid shift has changed.
Slide 45
Causes of Hypernatremia Dehydration / water loss Too much IV or
po saline/salt Many blood bank units of blood Impaired renal
function Large increase in sodium intake without proportional water
intake (rare cuz this makes you thirsty) Large amount of water loss
without salt loss (more commondiarrhea, vomiting) Sometimes one can
looses both sodium and water =
Slide 46
Who is at risk for hypernatremia? Elderly Patients on fluid
restrictions Diuretic therapy Receiving hypertonic IVs or tube
feeding Diabetes Mellitus (HHNKD) Dehydration
Slide 47
Youtube: Dehydration Video
http://www.youtube.com/watch?v=rOGS6PhE4wI
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Treat hypernatremia Drink water Change IV to isotonic solution
Give IV fluids Dialysis Strict I&Os Check Labs
Slide 49
Isotonic dehydration Lose equal parts sodium and water (infants
do this with vomiting and diarrhea)
Slide 50
Hypertonic dehydration Loose more water than sodium: Also
called- Hyperosmolar dehydration By the time serum sodium is
elevated, the compensory shift of water has left the cells and
interstitial spaces has entered the blood stream and dehydrated the
cells. The patient is dehydrated at the cellular level when we see
elevated serum sodium levels. The water exits via the kidneys and
the patient is severely dehydrated intracellularlly and
intravascularlly.
Slide 51
Symptoms of hypernatremia Thirst Dry membranes, tenting Little
or no urine output High specific gravity Hematocrit increased
Hyperactivity/ seizures Increase 3meq above normal = I liter fluid
loss 1 liter fluid loss = 1 kg in body weight Weight Loss: do daily
weights!!!!!!
Slide 52
Edema By the time edema is evident, the patient has already
gained 3 liters of fluid Weight gain is the best indicator of fluid
retention and weight loss is the best indicator of fluid loss.
Slide 53
Electrolyte Balance and Imbalances Hypokalemia (< 3.5 mEq/L)
When K+ moves into the ICF, it causes hypokalemia, in turn hydrogen
moves out of the cell. Making the ECF more normalized or acidotic.
Hyperkalemia ( > 5.0 mEq/L) Hydrogen moves into the cells,
causing the ECF to become more normalized or alkalotic, In turn, K+
and Na+ move out of the cell.
Slide 54
Case Study # 5 A 55 year old client is admitted to the hospital
with complaint of diarrhea for three days. The client reports being
weak and feels like his/her heart is racing What questions should
the nurse ask about the clients medical hx? What other s/s maybe
present What labs maybe ordered What orders would the nurse expect
this client to receive?
Slide 55
Nursing Diagnosis Decreased cardiac output r/t dysrhythmia
2ndary to electrolyte imbalance (K, Mag, Cal) Impaired physical
mobility r/t skeletal muscle Imbalance nutrition r/t decreased
renal function or poor dietary intake 2ndary to renal failure
anorexia or NPO status or Risk for injury r/t muscle weakness and
seizures 2ndary to electrolyte imbalance Impaired safety r/t
confusion or altered LOC 2ndary to hyponatremia
Slide 56
Electrolyte Balance and Imbalances Phosphorus Activate vitamins
and enzymes Forming ATP Assisting in cellular growth and
metabolism. Acid-base balance Calcium homeostasis Calcium Maintain
strong bone and teeth Transmission of nerve impulses Allow blood
clotting Regulate BP Control by the PTH, Vit D and calcitronin
Slide 57
Electrolyte Balance and Imbalances Hypocalcemia (< 9.0
mg/dl) Abnormally low calcium level or decreased availablity of
ionized calcium; any condition that cause a decrease in PTH
production. Hypercalcemia (> 11.0 mg/dl) An Anbormally elevated
serum calcium level; symptoms may not appear until the serum
calcium is >12mg/dl
Slide 58
Case Study # 6 A 54y/o client with a diagnosis of multiple
myeloma has been admitted to your unit. The client has a c/o of
increasing fatigue, muscle weakness, and bone pain. What do you
think is the cause of these symptoms What is the nurse priority
nursing intervention How will you evaluate if therapy has been
effective. What exactly is multiple myeloma?
Slide 59
What is it? Lets check the web.
http://www.nlm.nih.gov/medlineplus/multiplemyelo ma.html
http://www.nlm.nih.gov/medlineplus/multiplemyelo ma.html Excellent
resource http://www.nlm.nih.gov/medlineplus/tutorials/multi
plemyeloma/htm/_yes_50_no_0.htm
http://www.nlm.nih.gov/medlineplus/tutorials/multi
plemyeloma/htm/_yes_50_no_0.htm Awesome movie explaining
X-plain.com
Slide 60
Electrolyte Balance and Imbalances Hypophosphatemia (< 2.5
mEq/L) An abnormal decrease in serum phosphorus level.
Hyperphosphatemia (> 4.5 mEq/L) An abnormal increase in serum
phosphorus level. Phosphorus shifts from the ICF to the ECF which
causes serum level to increase
Slide 61
Case Study # 7 Mr. G is a 56 y/o client with newly diagnosed
chronic renal failure as a complication of diabetes mellitus. He is
receiving hemodialysis 3 times a week and will continue this
therapy when discharged. Which electrolyte imbalance the nurse
would expect (hypo/hyperphosphatemia) Why? What dietary
modifications would be necessary? What role will dialysis play in
managing the imbalance?
http://www.merck.com/mmhe/sec11/ch143/ch143c.html
Slide 62
Electrolyte Balance and Imbalances Chloride Aids in cellular
integrity by maintaining balance. Serves as a buffer in exchange of
O2/CO2 Regulates the pH of the stomach Magnesium Powers the sodium-
potassium pump Activates enzymes Important for skeletal muscle
relaxation Aids in converting ATP for energy release
Slide 63
Electrolyte Balance and Imbalances Hypomagnesemia ( < 1.5
mEq/L) Abnormal secretion of magnesium in the blood. Can cause
lethal torsades dysrhythmias Hypermagnesmia ( > 2.5mEq/L) Rare
electrolyte imbalance, occur to excessive intake of magnesium and
decreased renal excretion.
Slide 64
Case Study # 8 A 25y/o client during a clinic visit reports to
the nurse that she has been experiencing; chest pains and frequent
cramps in her legs and hands for the past week. Her vital signs are
BP 110/72, P 98, resp 18. What other data is necessary to gather?
What imbalance may this client be experiencing according to the
above data? What collaborate measures should be considered?
Slide 65
Renal function BUN BUN : Creatinine Ratio UUN BUN:Creatinine
Ratio Serum Creatinine Creatinine clearance
Slide 66
Blood Urea Nitrogen BUN Urea is a waste product from protein
metabolism. It is formed in the liver and travels to the kidneys
for elimination from the body. Since the kidneys excrete this, it
is a good lab to determine kidney function. Normal 8 25 mg/dL
Dehydration, malnutrion with protein wasting, liver failure, and
over hydration can mask the renal function on this test.
Slide 67
Elevated BUN Kidney failure Poor perfusion to kidneys due to
shock or CHF High protein tube feedings Dehydration Bleeding in the
GI tract (blood is protein)
Slide 68
Decreased BUN Over hydration
Slide 69
UUN 1 gram of nitrogen in each 6 grams of protein We loose 4
grams of Nitrogen each day in stool Nitrogen balance= g of pro
intake/6.25 (24 hour UUN +4) If the number is less than 0 the
patient is not wasting or loosing protein. A patient with a
negative protein balance needs extra protein in diet.
Slide 70
Serum Creatinine Waste product of creatinine phosphate from
skeletal muscle Normal men 0.6-1.5 mg/dL Normal women 0.6-1.1 mg/dL
Elevated in nephron damage
Slide 71
Bun to Creatinine Ratio About 10: 1 is normal 15:1 dehydration
or protein breakdown (ratio goes up) Look at together. Kidney
failure both will be elevated. If BUN elevated and not creatinine,
look for dehydration or protein stores
Slide 72
Uric Acid Proteins and muscle breaks down into purines and are
excreted by kidneys as uric acid waste. Feel joint pain.
Hyperuricemia: due to renal impairment, drugs, pre- eclampsia,
Allopurinol is the medication to correct this.
Slide 73
ALBUMIN Albumin (3.5-5 g/dl) Long half lifeonly get ever two
weeks Prealbumin (19.5-35 mg/dl) Shorter half life.more sensitive
indicator in changes in nutrition. Hypoalbuminemia= think leaking
capillaries in blood vessels and lungs! Loss of colloid
pressure.
Slide 74
CBC RBC Count (4.7-6 males/ 4.2-5.4 females) Hematocrit (42-52%
males/ 37-47 %) Hemoglobin (14-18 g/dl males / 12-16 g/dl females)
WBC Count with differential (5-10 x 10 to the 9 th )
Slide 75
WBC Neutrophils and bands :neutrophilia (bact. Infec) Nomal
bands less than 3% decreased neutrophil count: neutropenia (viral
infec) Increased eosinophil count: eosinophilia (asthma) Decreased
eosinophil count: (steroid use) Basophil count changes (infec and
steriods) Increased lumphocyte count: lymphocytosis (CD
numbers)(infections lymphocytic leukemia) Decreased lymphocyte
count: lymphopenia (HIV)
Slide 76
Coagulation Tests Activated clotting time (180-570 sec) D-dimer
Screen (less than 500 ng/ml)(high w clot) Fibrinogen(200-400mg/dl)
(2-4 g/liter)(low in DIC) Fibrinogen Degradation Products(fsp)(high
in DIC) Partial Thromboplastin time (PTT)(therapy 1.5-2x) Activated
PTT (30-40 sec) Platelet count (150-400 x 10 9 th per liter) (20
severe) Prothrombin time (PT)(10-14sec)(therapy 1.5-2.5x)
International Normalized Ratio (INR)
Slide 77
DIC Disseminated intravascular clotting in microcirculationuse
up all the clotting factors.bleedsee a drop in platelets Ddimer
positive = clot somewhere Abruptio placentae D dimer negative = r/o
pulmonary embolus
Slide 78
Therapeutic Levels On heparin drip post op MVR (PTT 1.5 2x
normal) 60 x 2.5 = 150 On Coumadin by mouth for chronic afib
(1.5-2.5 normal) so 10 x 2.5 = 25 sec INR: 2-3 for chronic afib
INR: 2.5-3.5 for mechanical heart valve replacement
Slide 79
Acid Base Balance ABGs Anion gap Serum CO2 Electrolytes shift
Metabolic acidosis Metabolic alkalosis Respiratory acidosis
Respiratory alkalosis
Slide 80
ABGs Great online tutorials pH 7.35 7.45
Slide 81
Anion Gap (8-16 +/- 4) Acid base lab Think of conditions that
create acid DKA Lactate lactic acidosis from shock and sepsis Gap =
higher number Differentiates the types of acidosis Lactic acid =
gap High chloride no gap
Slide 82
Serum Co2 High levels think high base binding ability Carbon
dioxide binding power or total CO2 is an indirect measurement of
serum bicarbonate. If anion gap is high, this will be low And vice
versa
Slide 83
CO2 Base Excess Extra buffering base on board to compensate for
losses of H ions, K, and Cl Common cause: GI suctioning induced
loss of gastic contents. COPD compensation
Slide 84
CO2 Base Deficit Less buffer binding availability Compensation
to acidosis buffers used up Or due to Chloride elevated Or due to
kidneys loosing bicarbonate
Slide 85
Electrolyte Shift What happens to K during acidosis event? What
happens to K during alkalosis event? Chloride Elevated acidosis (no
anion gap)
Slide 86
Relationships We rarely ever just look at one lab value. We
look at relationships between the labs. Inverse relationships
Proportional relationships.
Slide 87
Inverse Relationship Acidic Environment Alkaline Environment
Serum co2 decreases Potassium increases Serum co2 increases
Potassium decreases
Slide 88
Proportional Relationship Calcium Albumin Calcium travels on
albumin If albumin levels are low calcium will be low. Expect this
finding Indicates nutritional status If you want to improve the
calcium level, think about feeding the patient protein. Normal 3.5
5.2 g/dl
Slide 89
Corrected Calcium For every gram decrease in albumin calcium
will decrease 0.8. This is our coeffiencient. Mid normal Albumin is
4.0 0.8 (4.0 current albumin) = x X + calcium level= corrected
calcium level
Slide 90
Example Lab report shows calcium level to be 7.5 The nurse
knows that if albumin is low, calcium will also probably be low.
But how low? Albumin is 3.0 0.8 (4.0-3.0)= 0.8 0.8 + 7.5 = 8.3 The
corrected calcium is low. If the patient is showing physical
symptoms, they probably will be given IV calcium gluconate
Trousseaus and Chvostecks sign classic & tremors
Slide 91
Example Calcium is 7.5 Albumin is 2.8
Slide 92
Patient Populations Pancreatitis Diabetes/ DKA/ DI Hemorrhage/
thrombocytopenia Post op CABG Liver Failure/ ETOH Abuse
Malnutrition Homework: Post on Wiki
Slide 93
Each population What labs should you follow? What do the labs
look like in this condition? What is the goal (expected outcomes)
for our labs? What interventions do we do?
Slide 94
Questions
Slide 95
Lipoprotein panel A lipoprotein panel gives information about
your: Total cholesterol. LDL ("bad") cholesterol. This is the main
source of cholesterol buildup and blockages in the arteries. (For
more information about blockages in the arteries, go to the
Diseases and Conditions Index Atherosclerosis
article.)Atherosclerosis HDL ("good") cholesterol. This type of
cholesterol helps decrease blockages in the arteries.
Triglycerides. Triglycerides are a type of fat in your blood. A
lipoprotein panel measures the levels of LDL and HDL cholesterol
and triglycerides in your blood. Abnormal cholesterol and
triglyceride levels may be signs of increased risk for CHD. Most
people will need to fast for 9 to 12 hours before a lipoprotein
panel