Fluid Balance. General Concepts Intake = Output = Fluid Balance Intake = Output = Fluid Balance Sensible losses Sensible losses Urination Urination Defecation

Fluid BalanceFluid Balance

General ConceptsGeneral Concepts Intake = Output = Fluid BalanceIntake = Output = Fluid Balance Sensible lossesSensible losses

UrinationUrination DefecationDefecation Wound drainageWound drainage

Insensible lossesInsensible losses Evaporation from skinEvaporation from skin Respiratory loss from lungsRespiratory loss from lungs

Fluid CompartmentsFluid Compartments

Intracellular Intracellular 40% of body weight40% of body weight

ExtracellularExtracellular 20% of body weight20% of body weight Two typesTwo types

INTERSTITIALINTERSTITIAL (between) (between) INTRAVASCULARINTRAVASCULAR (inside) (inside)

Age-Related Fluid ChangesAge-Related Fluid Changes

Full-term baby - 80%Full-term baby - 80% Lean Adult Male - 60%Lean Adult Male - 60% Aged client - 40%Aged client - 40%

Fluid and Electrolyte TransportFluid and Electrolyte Transport

PASSIVE PASSIVE TRANSPORT TRANSPORT SYSTEMSSYSTEMS DiffusionDiffusion FiltrationFiltration OsmosisOsmosis

ACTIVE ACTIVE TRANSPORT TRANSPORT SYSTEMSYSTEM PumpingPumping Requires Requires

energy energy expenditureexpenditure

DiffusionDiffusion Molecules move across a biological Molecules move across a biological

membrane from an area of higher membrane from an area of higher to an area of lower concentrationto an area of lower concentration

Membrane typesMembrane types PermeablePermeable Semi-permeableSemi-permeable ImpermeableImpermeable

FiltrationFiltration Movement of solute and solvent Movement of solute and solvent

across a membrane caused by across a membrane caused by hydrostatic (water pushing) pressurehydrostatic (water pushing) pressure

Occurs at the capillary levelOccurs at the capillary level If normal pressure gradient changes If normal pressure gradient changes

(as occurs with right-sided heart (as occurs with right-sided heart failure) edema results from “third failure) edema results from “third spacing”spacing”

OsmosisOsmosis

Movement of solvent from an area Movement of solvent from an area of lower solute concentration to of lower solute concentration to one of higher concentrationone of higher concentration

Occurs through a semipermeable Occurs through a semipermeable membrane using osmotic (water membrane using osmotic (water pulling) pressurepulling) pressure

Active Transport SystemActive Transport System

Solutes can be moved against a Solutes can be moved against a

concentration gradientconcentration gradient Also called “pumping”Also called “pumping” Dependent on the presence of ATPDependent on the presence of ATP

Fluid TypesFluid Types

IsotonicIsotonic

HypotonicHypotonic

HypertonicHypertonic

Isotonic SolutionIsotonic Solution

No fluid shift because solutions No fluid shift because solutions

are equally concentratedare equally concentrated Normal saline solution (0.9% NaCl)Normal saline solution (0.9% NaCl)

Hypotonic SolutionHypotonic Solution

Lower solute concentrationLower solute concentration Fluid shifts from hypotonic solution Fluid shifts from hypotonic solution

into the more concentrated into the more concentrated

solution to create a balance (cells solution to create a balance (cells

swell)swell) Half-normal saline solution (0.45% Half-normal saline solution (0.45%

NaCl)NaCl)

Hypertonic SolutionHypertonic Solution

Higher solute concentrationHigher solute concentration

Fluid is drawn into the hypertonic Fluid is drawn into the hypertonic

solution to create a balance (cells solution to create a balance (cells

shrink)shrink)

5% dextrose in normal saline 5% dextrose in normal saline

(D5/0.9% NaCl)(D5/0.9% NaCl)

Regulatory MechanismsRegulatory Mechanisms

Baroreceptor reflexBaroreceptor reflex

Volume receptorsVolume receptors

Renin-angiotensin-aldosterone Renin-angiotensin-aldosterone

mechanismmechanism

Antidiuretic hormoneAntidiuretic hormone

Baroreceptor ReflexBaroreceptor Reflex

Respond to a fall in arterial blood Respond to a fall in arterial blood pressurepressure

Located in the atrial walls, vena Located in the atrial walls, vena cava, aortic arch and carotid sinuscava, aortic arch and carotid sinus

Constricts afferent arterioles of the Constricts afferent arterioles of the kidney resulting in retention of fluidkidney resulting in retention of fluid

Volume ReceptorsVolume Receptors

Respond to fluid excess in the atria Respond to fluid excess in the atria and great vesselsand great vessels

Stimulation of these receptors Stimulation of these receptors creates a strong renal response creates a strong renal response that increases urine outputthat increases urine output

Renin-Angiotensin-AldosteroneRenin-Angiotensin-Aldosterone

ReninRenin Enzyme secreted by kidneys when Enzyme secreted by kidneys when

arterial pressure or volume dropsarterial pressure or volume drops Interacts with angiotensinogen to Interacts with angiotensinogen to

form angiotensin I form angiotensin I (vasoconstrictor)(vasoconstrictor)


AngiotensinAngiotensin Angiotensin I is converted in Angiotensin I is converted in

lungs to angiotensin II using ACE lungs to angiotensin II using ACE (angiotensin converting enzyme)(angiotensin converting enzyme)

Produces vasoconstriction to Produces vasoconstriction to elevate blood pressureelevate blood pressure

Stimulates adrenal cortex to Stimulates adrenal cortex to secrete aldosteronesecrete aldosterone


AldosteroneAldosterone Mineralocorticoid that controls Na+ Mineralocorticoid that controls Na+

and K+ blood levelsand K+ blood levels Increases Cl- and HCO3- Increases Cl- and HCO3-

concentrations and fluid volumeconcentrations and fluid volume

Aldosterone Negative Feedback Aldosterone Negative Feedback MechanismMechanism

ECF & Na+ levels drop ECF & Na+ levels drop secretion secretion

of ACTH by the anterior pituitary of ACTH by the anterior pituitary

release of aldosterone by the release of aldosterone by the

adrenal cortex adrenal cortex fluid and Na+ fluid and Na+

retentionretention

Antidiuretic HormoneAntidiuretic Hormone

Also called vasopressinAlso called vasopressin Released by posterior pituitary when Released by posterior pituitary when

there is a need to restore intravascular there is a need to restore intravascular fluid volume fluid volume

Release is triggered by osmoreceptors Release is triggered by osmoreceptors in the thirst center of the hypothalamusin the thirst center of the hypothalamus

Fluid volume excess Fluid volume excess decreased ADH decreased ADH Fluid volume deficit Fluid volume deficit increased ADH increased ADH

Fluid ImbalancesFluid Imbalances

DehydrationDehydration HypovolemiaHypovolemia HypervolemiaHypervolemia Water intoxicationWater intoxication

DehydrationDehydration

Loss of body fluids Loss of body fluids increased increased concentration of solutes in the concentration of solutes in the blood and a rise in serum Na+ blood and a rise in serum Na+ levelslevels

Fluid shifts out of cells into the Fluid shifts out of cells into the blood to restore balanceblood to restore balance

Cells shrink from fluid loss and can Cells shrink from fluid loss and can no longer function properlyno longer function properly

Clients at RiskClients at Risk

ConfusedConfused ComatoseComatose BedriddenBedridden InfantsInfants ElderlyElderly Enterally fedEnterally fed

What Do You See?What Do You See?

IrritabilityIrritability ConfusionConfusion DizzinessDizziness WeaknessWeakness Extreme thirstExtreme thirst urine outputurine output

FeverFever Dry Dry

skin/mucous skin/mucous membranesmembranes

Sunken eyesSunken eyes Poor skin turgorPoor skin turgor TachycardiaTachycardia

What Do We Do?What Do We Do?

Fluid Replacement - oral or IV over Fluid Replacement - oral or IV over 48 hrs.48 hrs.

Monitor symptoms and vital signsMonitor symptoms and vital signs Maintain I&OMaintain I&O Maintain IV accessMaintain IV access Daily weightsDaily weights Skin and mouth careSkin and mouth care

HypovolemiaHypovolemia

Isotonic fluid Isotonic fluid loss from the loss from the extracellular extracellular spacespace

Can progress to Can progress to hypovolemic hypovolemic shockshock

Caused by:Caused by: Excessive Excessive

fluid loss fluid loss (hemorrhage)(hemorrhage)

Decreased Decreased fluid intakefluid intake

Third space Third space fluid shiftingfluid shifting


Mental status Mental status deteriorationdeterioration

ThirstThirst TachycardiaTachycardia Delayed Delayed

capillary refillcapillary refill

Orthostatic Orthostatic hypotensionhypotension

Urine output < Urine output < 30 ml/hr30 ml/hr

Cool, pale Cool, pale extremitiesextremities

Weight lossWeight loss


Fluid Fluid replacementreplacement

Albumin Albumin replacementreplacement

Blood Blood transfusions for transfusions for hemorrhagehemorrhage

Dopamine to Dopamine to maintain BPmaintain BP

MAST trousers MAST trousers for severe for severe shockshock

Assess for fluid Assess for fluid overload with overload with treatmenttreatment

HypervolemiaHypervolemia

Excess fluid in the extracellular Excess fluid in the extracellular compartment as a result of fluid or compartment as a result of fluid or sodium retention, excessive intake, sodium retention, excessive intake, or renal failureor renal failure

Occurs when compensatory Occurs when compensatory mechanisms fail to restore fluid mechanisms fail to restore fluid balancebalance

Leads to CHF and pulmonary edemaLeads to CHF and pulmonary edema


TachypneaTachypnea DyspneaDyspnea CracklesCrackles Rapid, bounding Rapid, bounding

pulsepulse HypertensionHypertension S3 gallopS3 gallop

Increased CVP, Increased CVP, pulmonary artery pulmonary artery pressure and pressure and pulmonary artery pulmonary artery wedge pressure wedge pressure (Swan-Ganz)(Swan-Ganz)

JVDJVD Acute weight gainAcute weight gain EdemaEdema

EdemaEdema

Fluid is forced into tissues by the Fluid is forced into tissues by the hydrostatic pressurehydrostatic pressure

First seen in dependent areasFirst seen in dependent areas Anasarca - severe generalized edemaAnasarca - severe generalized edema Pitting edemaPitting edema Pulmonary edemaPulmonary edema


Fluid and Na+ Fluid and Na+ restrictionrestriction

DiureticsDiuretics Monitor vital signsMonitor vital signs Hourly I&OHourly I&O Breath soundsBreath sounds

Monitor ABGs and Monitor ABGs and labslabs

Elevate HOB and Elevate HOB and give O2 as orderedgive O2 as ordered

Maintain IV accessMaintain IV access Skin & mouth careSkin & mouth care Daily weightsDaily weights

Water IntoxicationWater Intoxication

Hypotonic Hypotonic extracellular extracellular fluid shifts into fluid shifts into cells to attempt cells to attempt to restore to restore balancebalance

Cells swellCells swell

Causes:Causes: SIADHSIADH Rapid infusion of Rapid infusion of

hypotonic solutionhypotonic solution Excessive tap Excessive tap

water NG irrigation water NG irrigation or enemasor enemas

Psychogenic Psychogenic polydipsiapolydipsia


Signs and symptoms of increased Signs and symptoms of increased

intracranial pressureintracranial pressure Early: change in LOC, N/V, muscle Early: change in LOC, N/V, muscle

weakness, twitching, crampingweakness, twitching, cramping

Late: bradycardia, widened pulse Late: bradycardia, widened pulse

pressure, seizures, comapressure, seizures, coma


Prevention is the Prevention is the

best treatmentbest treatment Assess neuro Assess neuro

statusstatus Monitor I&O and Monitor I&O and

vital signsvital signs Fluid restrictionsFluid restrictions

IV accessIV access

Daily weightsDaily weights

Monitor serum Na+Monitor serum Na+

Seizure Seizure

precautionsprecautions

ElectrolytesElectrolytes

ElectrolytesElectrolytes

Charged particles in solutionCharged particles in solution Cations (+)Cations (+) Anions (-)Anions (-) Integral part of metabolic and Integral part of metabolic and

cellular processescellular processes

Positive or Negative?Positive or Negative?

Cations (+)Cations (+) SodiumSodium PotassiumPotassium CalciumCalcium MagnesiumMagnesium

Anions (-)Anions (-) ChlorideChloride BicarbonateBicarbonate PhosphatePhosphate SulfateSulfate

Major CationsMajor Cations

EXTRACELLULAR EXTRACELLULAR SODIUM (Na+)SODIUM (Na+)

INTRACELLULARINTRACELLULAR POTASSIUM POTASSIUM

(K+)(K+)

Electrolyte ImbalancesElectrolyte Imbalances

Hyponatremia/ Hyponatremia/

hypernatremiahypernatremia

Hypokalemia/ Hypokalemia/

HyperkalemiaHyperkalemia

Hypomagnesemia/ Hypomagnesemia/

HypermagnesemiaHypermagnesemia

Hypocalcemia/ Hypocalcemia/

HypercalcemiaHypercalcemia

Hypophosphatemia/ Hypophosphatemia/

HyperphosphatemiaHyperphosphatemia

Hypochloremia/ Hypochloremia/

HyperchloremiaHyperchloremia

SodiumSodium

Major extracellular cationMajor extracellular cation

Attracts fluid and helps preserve fluid Attracts fluid and helps preserve fluid

volumevolume

Combines with chloride and bicarbonate to Combines with chloride and bicarbonate to

help regulate acid-base balancehelp regulate acid-base balance

Normal range of serum sodium 135 - 145 Normal range of serum sodium 135 - 145

mEq/LmEq/L

Sodium and WaterSodium and Water

If sodium intake suddenly increases, If sodium intake suddenly increases, extracellular fluid concentration also extracellular fluid concentration also risesrises

Increased serum Na+ increases thirst Increased serum Na+ increases thirst and the release of ADH, which and the release of ADH, which triggers kidneys to retain watertriggers kidneys to retain water

Aldosterone also has a function in Aldosterone also has a function in water and sodium conservation when water and sodium conservation when serum Na+ levels are lowserum Na+ levels are low

Sodium-Potassium PumpSodium-Potassium Pump

Sodium (abundant Sodium (abundant outside cells) tries to outside cells) tries to get into cellsget into cells

Potassium (abundant Potassium (abundant inside cells) tries to inside cells) tries to get out of cellsget out of cells

Sodium-potassium Sodium-potassium pump maintains pump maintains normal normal concentrationsconcentrations

Pump uses ATP, Pump uses ATP, magnesium and an magnesium and an enzyme to maintain enzyme to maintain sodium-potassium sodium-potassium concentrationsconcentrations

Pump prevents cell Pump prevents cell swelling and swelling and creates an creates an electrical charge electrical charge allowing allowing neuromuscular neuromuscular impulse impulse transmissiontransmission

HyponatremiaHyponatremia Serum Na+ level < 135 mEq/LSerum Na+ level < 135 mEq/L Deficiency in Na+ related to amount of Deficiency in Na+ related to amount of

body fluidbody fluid Several typesSeveral types

DilutionalDilutional DepletionalDepletional HypovolemicHypovolemic HypervolemicHypervolemic IsovolemicIsovolemic

Types of HyponatremiaTypes of Hyponatremia Dilutional - results from Na+ loss, water Dilutional - results from Na+ loss, water

gaingain Depletional - insufficient Na+ intakeDepletional - insufficient Na+ intake Hypovolemic - Na+ loss is greater than Hypovolemic - Na+ loss is greater than

water loss; can be renal (diuretic use) water loss; can be renal (diuretic use) or non-renal (vomiting)or non-renal (vomiting)

Hypervolemic - water gain is greater Hypervolemic - water gain is greater than Na+ gain; edema occursthan Na+ gain; edema occurs

Isovolumic - normal Na+ level, too Isovolumic - normal Na+ level, too much fluidmuch fluid

What Do You See?What Do You See? Primarily neurologic symptomsPrimarily neurologic symptoms

Headache, N/V, muscle twitching, Headache, N/V, muscle twitching, altered mental status, stupor, altered mental status, stupor, seizures, comaseizures, coma

Hypovolemia - poor skin turgor, Hypovolemia - poor skin turgor, tachycardia, decreased BP, tachycardia, decreased BP, orthostatic hypotensionorthostatic hypotension

Hypervolemia - edema, hypertension, Hypervolemia - edema, hypertension, weight gain, bounding tachycardiaweight gain, bounding tachycardia


MILD CASEMILD CASE Restrict fluid intake Restrict fluid intake

for for hyper/isovolemic hyper/isovolemic hyponatremiahyponatremia

IV fluids and/or IV fluids and/or increased po Na+ increased po Na+ intake for intake for hypovolemic hypovolemic hyponatremiahyponatremia

SEVERE CASESEVERE CASE Infuse hypertonic Infuse hypertonic

NaCl solution (3% NaCl solution (3% or 5% NaCl)or 5% NaCl)

Furosemide to Furosemide to remove excess fluidremove excess fluid

Monitor client in Monitor client in ICUICU

HypernatremiaHypernatremia

Excess Na+ relative to body waterExcess Na+ relative to body water Occurs less often than hyponatremiaOccurs less often than hyponatremia Thirst is the body’s main defenseThirst is the body’s main defense When hypernatremia occurs, fluid shifts When hypernatremia occurs, fluid shifts

outside the cellsoutside the cells May be caused by water deficit or over-May be caused by water deficit or over-

ingestion of Na+ingestion of Na+ Also may result from diabetes insipidusAlso may result from diabetes insipidus


Think Think S-A-L-TS-A-L-T SSkin flushedkin flushed AAgitationgitation LLow grade feverow grade fever TThirsthirst

Neurological symptomsNeurological symptoms Signs of hypovolemiaSigns of hypovolemia


Correct underlying Correct underlying disorderdisorder

Gradual fluid Gradual fluid replacementreplacement

Monitor for s/s of Monitor for s/s of cerebral edemacerebral edema

Monitor serum Na+ Monitor serum Na+ levellevel

Seizure Seizure precautionsprecautions

PotassiumPotassium

Major intracellular cationMajor intracellular cation Untreated changes in K+ levels can Untreated changes in K+ levels can

lead to serious neuromuscular and lead to serious neuromuscular and

cardiac problemscardiac problems Normal K+ levels = 3.5 - 5 mEq/LNormal K+ levels = 3.5 - 5 mEq/L

Balancing PotassiumBalancing Potassium

Most K+ ingested is excreted by the Most K+ ingested is excreted by the kidneyskidneys

Three other influential factors in K+ Three other influential factors in K+ balance :balance : Na+/K+ pumpNa+/K+ pump Renal regulationRenal regulation pH levelpH level

Sodium/Potassium PumpSodium/Potassium Pump

Uses ATP to pump potassium into Uses ATP to pump potassium into cellscells

Pumps sodium out of cellsPumps sodium out of cells Creates a balanceCreates a balance

Renal RegulationRenal Regulation

Increased K+ levels Increased K+ levels increased K+ increased K+ loss in urineloss in urine

Aldosterone secretion causes Na+ Aldosterone secretion causes Na+ reabsorption and K+ excretionreabsorption and K+ excretion

pHpH

Potassium ions and hydrogen ions Potassium ions and hydrogen ions exchange freely across cell exchange freely across cell membranesmembranes

Acidosis Acidosis hyperkalemia (K+ moves hyperkalemia (K+ moves out of cells)out of cells)

Alkalosis Alkalosis hypokalemia (K+ moves hypokalemia (K+ moves into cells)into cells)

HypokalemiaHypokalemia

Serum K+ < 3.5 mEq/LSerum K+ < 3.5 mEq/L Can be caused by GI losses, diarrhea, Can be caused by GI losses, diarrhea,

insufficient intake, non-K+ sparing insufficient intake, non-K+ sparing

diuretics (thiazide, furosemide)diuretics (thiazide, furosemide)


Think Think S-U-C-T-I-O-NS-U-C-T-I-O-N SSkeletal muscle weaknesskeletal muscle weakness UU wave (EKG changes) wave (EKG changes) CConstipation, ileusonstipation, ileus TToxicity of digitalis glycosidesoxicity of digitalis glycosides IIrregular, weak pulserregular, weak pulse OOrthostatic hypotensionrthostatic hypotension NNumbness (paresthesias)umbness (paresthesias)


Increase dietary K+Increase dietary K+ Oral KCl supplementsOral KCl supplements IV K+ replacementIV K+ replacement Change to K+-sparing diureticChange to K+-sparing diuretic Monitor EKG changesMonitor EKG changes

IV K+ ReplacementIV K+ Replacement Mix well when Mix well when

adding to an IV adding to an IV solution bagsolution bag

Concentrations Concentrations should not should not exceed 40-60 exceed 40-60 mEq/LmEq/L

Rates usually Rates usually 10-20 mEq/hr10-20 mEq/hr

NEVER GIVE IV NEVER GIVE IV PUSH PUSH

POTASSIUMPOTASSIUM

HyperkalemiaHyperkalemia

Serum K+ > 5 Serum K+ > 5

mEq/LmEq/L

Less common than Less common than

hypokalemiahypokalemia

Caused by altered Caused by altered

kidney function, kidney function,

increased intake increased intake

(salt substitutes), (salt substitutes),

blood transfusions, blood transfusions,

meds (K+-sparing meds (K+-sparing

diuretics), cell diuretics), cell

death (trauma)death (trauma)

What Do You See?What Do You See? IrritabilityIrritability ParesthesiaParesthesia Muscle weakness (especially legs)Muscle weakness (especially legs) EKG changes (tented T wave)EKG changes (tented T wave) Irregular pulseIrregular pulse HypotensionHypotension Nausea, abdominal cramps, diarrheaNausea, abdominal cramps, diarrhea


MildMild Loop diuretics Loop diuretics

(Lasix)(Lasix) Dietary restrictionDietary restriction

ModerateModerate KayexalateKayexalate

EmergencyEmergency 10% calcium 10% calcium

gluconate for gluconate for

cardiac effectscardiac effects Sodium bicarbonate Sodium bicarbonate

for acidosisfor acidosis

MagnesiumMagnesium

Helps produce ATPHelps produce ATP Role in protein synthesis & Role in protein synthesis &

carbohydrate metabolismcarbohydrate metabolism Helps cardiovascular system Helps cardiovascular system

function (vasodilation)function (vasodilation) Regulates muscle contractionsRegulates muscle contractions

HypomagnesemiaHypomagnesemia

Serum Mg++ level Serum Mg++ level < 1.5 mEq/L< 1.5 mEq/L

Caused by poor Caused by poor dietary intake, dietary intake, poor GI absorption, poor GI absorption, excessive excessive GI/urinary lossesGI/urinary losses

High risk clientsHigh risk clients Chronic alcoholismChronic alcoholism MalabsorptionMalabsorption GI/urinary system GI/urinary system

disordersdisorders SepsisSepsis BurnsBurns Wounds needing Wounds needing

debridementdebridement


CNSCNS Altered LOCAltered LOC ConfusionConfusion HallucinationsHallucinations


NeuromuscularNeuromuscular Muscle weaknessMuscle weakness Leg/foot crampsLeg/foot cramps Hyper DTRsHyper DTRs TetanyTetany Chvostek’s & Trousseau’s signsChvostek’s & Trousseau’s signs


CardiovascularCardiovascular TachycardiaTachycardia

HypertensionHypertension

EKG changesEKG changes


GastrointestinalGastrointestinal DysphagiaDysphagia

AnorexiaAnorexia

Nausea/vomitingNausea/vomiting


MildMild Dietary replacementDietary replacement

SevereSevere IV or IM magnesium sulfateIV or IM magnesium sulfate

MonitorMonitor Neuro statusNeuro status Cardiac statusCardiac status SafetySafety

Mag Sulfate InfusionMag Sulfate Infusion Use infusion pump - no faster than Use infusion pump - no faster than

150 mg/min150 mg/min Monitor vital signs for hypotension Monitor vital signs for hypotension

and respiratory distressand respiratory distress Monitor serum Mg++ level q6hMonitor serum Mg++ level q6h Cardiac monitoringCardiac monitoring Calcium gluconate as an antidote Calcium gluconate as an antidote

for overdosagefor overdosage

HypermagnesemiaHypermagnesemia Serum Mg++ level > 2.5 mEq/LSerum Mg++ level > 2.5 mEq/L Not commonNot common Renal dysfunction is most common Renal dysfunction is most common

causecause Renal failureRenal failure Addison’s diseaseAddison’s disease Adrenocortical insufficiencyAdrenocortical insufficiency Untreated DKAUntreated DKA


Decreased neuromuscular activityDecreased neuromuscular activity

Hypoactive DTRsHypoactive DTRs

Generalized weaknessGeneralized weakness

Occasionally nausea/vomitingOccasionally nausea/vomiting


Increased fluids if renal function Increased fluids if renal function normalnormal

Loop diuretic if no response to fluidsLoop diuretic if no response to fluids Calcium gluconate for toxicityCalcium gluconate for toxicity Mechanical ventilation for Mechanical ventilation for

respiratory depressionrespiratory depression Hemodialysis (Mg++-free dialysate)Hemodialysis (Mg++-free dialysate)

CalciumCalcium

99% in bones, 1% in serum and soft 99% in bones, 1% in serum and soft tissue (measured by serum Ca++)tissue (measured by serum Ca++)

Works with phosphorus to form bones Works with phosphorus to form bones and teethand teeth

Role in cell membrane permeabilityRole in cell membrane permeability Affects cardiac muscle contractionAffects cardiac muscle contraction Participates in blood clottingParticipates in blood clotting

Calcium RegulationCalcium Regulation Affected by body stores of Ca++ and Affected by body stores of Ca++ and

by dietary intake & Vitamin D intakeby dietary intake & Vitamin D intake Parathyroid hormone draws Ca++ Parathyroid hormone draws Ca++

from bones increasing low serum from bones increasing low serum levels levels (Parathyroid pulls)(Parathyroid pulls)

With high Ca++ levels, calcitonin is With high Ca++ levels, calcitonin is released by the thyroid to inhibit released by the thyroid to inhibit calcium loss from bone calcium loss from bone (Calcitonin (Calcitonin keeps)keeps)

HypocalcemiaHypocalcemia

Serum calcium < 8.9 mg/dlSerum calcium < 8.9 mg/dl Ionized calcium level < 4.5 mg/DlIonized calcium level < 4.5 mg/Dl Caused by inadequate intake, Caused by inadequate intake,

malabsorption, pancreatitis, thyroid malabsorption, pancreatitis, thyroid or parathyroid surgery, loop or parathyroid surgery, loop diuretics, low magnesium levelsdiuretics, low magnesium levels


NeuromuscularNeuromuscular Anxiety, confusion, irritability, muscle Anxiety, confusion, irritability, muscle

twitching, paresthesias (mouth, twitching, paresthesias (mouth, fingers, toes), tetanyfingers, toes), tetany

FracturesFractures DiarrheaDiarrhea Diminished response to digoxinDiminished response to digoxin EKG changes EKG changes


Calcium gluconate for postop thyroid Calcium gluconate for postop thyroid

or parathyroid clientor parathyroid client

Cardiac monitoringCardiac monitoring

Oral or IV calcium replacementOral or IV calcium replacement

HypercalcemiaHypercalcemia

Serum calcium > 10.1 mg/dlSerum calcium > 10.1 mg/dl Ionized calcium > 5.1 mg/dlIonized calcium > 5.1 mg/dl Two major causesTwo major causes

CancerCancer HyperparathyroidismHyperparathyroidism


Fatigue, confusion, lethargy, comaFatigue, confusion, lethargy, coma Muscle weakness, hyporeflexiaMuscle weakness, hyporeflexia Bradycardia Bradycardia cardiac arrest cardiac arrest Anorexia, nausea/vomiting, Anorexia, nausea/vomiting,

decreased bowel sounds, decreased bowel sounds, constipationconstipation

Polyuria, renal calculi, renal failurePolyuria, renal calculi, renal failure


If asymptomatic, treat underlying If asymptomatic, treat underlying

causecause Hydrate the patient to encourage Hydrate the patient to encourage

diuresisdiuresis Loop diureticsLoop diuretics CorticosteroidsCorticosteroids

PhosphorusPhosphorus

The primary anion in the intracellular The primary anion in the intracellular fluidfluid

Crucial to cell membrane integrity, Crucial to cell membrane integrity, muscle function, neurologic function and muscle function, neurologic function and metabolism of carbs, fats and proteinmetabolism of carbs, fats and protein

Functions in ATP formation, Functions in ATP formation, phagocytosis, platelet function and phagocytosis, platelet function and formation of bones and teethformation of bones and teeth

HypophosphatemiaHypophosphatemia

Serum phosphorus < 2.5 mg/dlSerum phosphorus < 2.5 mg/dl Can lead to organ system failureCan lead to organ system failure Caused by respiratory alkalosis Caused by respiratory alkalosis

(hyperventilation), insulin release, (hyperventilation), insulin release, malabsorption, diuretics, DKA, malabsorption, diuretics, DKA, elevated parathyroid hormone levels, elevated parathyroid hormone levels, extensive burnsextensive burns

What Do You See?What Do You See? MusculoskeletalMusculoskeletal

muscle weaknessmuscle weakness respiratory muscle respiratory muscle

failurefailure osteomalaciaosteomalacia pathological pathological

fracturesfractures CNSCNS

confusion, confusion, anxiety, seizures, anxiety, seizures, comacoma

CardiacCardiac hypotensionhypotension decreased cardiac decreased cardiac

outputoutput HematologicHematologic

hemolytic anemiahemolytic anemia easy bruisingeasy bruising infection riskinfection risk


MILD/MODERATEMILD/MODERATE Dietary Dietary

interventionsinterventions

Oral supplementsOral supplements

SEVERESEVERE IV replacement IV replacement

using potassium using potassium

phosphate or phosphate or

sodium phosphatesodium phosphate

HyperphosphatemiaHyperphosphatemia

Serum phosphorus > 4.5 mg/dlSerum phosphorus > 4.5 mg/dl

Caused by impaired kidney function, Caused by impaired kidney function,

cell damage, hypoparathyroidism, cell damage, hypoparathyroidism,

respiratory acidosis, DKA, increased respiratory acidosis, DKA, increased

dietary intakedietary intake


Think Think C-H-E-M-OC-H-E-M-O CCardiac irregularitiesardiac irregularities HHyperreflexiayperreflexia EEating poorlyating poorly MMuscle weaknessuscle weakness OOligurialiguria


Low-phosphorus dietLow-phosphorus diet Decrease absorption with antacids Decrease absorption with antacids

that bind phosphorusthat bind phosphorus Treat underlying cause of Treat underlying cause of

respiratory acidosis or DKArespiratory acidosis or DKA IV saline for severe IV saline for severe

hyperphosphatemia in patients hyperphosphatemia in patients with good kidney functionwith good kidney function

ChlorideChloride

Major extracellular anionMajor extracellular anion Sodium and chloride maintain water Sodium and chloride maintain water

balancebalance Secreted in the stomach as Secreted in the stomach as

hydrochloric acidhydrochloric acid Aids carbon dioxide transport in Aids carbon dioxide transport in

bloodblood

HypochloremiaHypochloremia

Serum chloride < 96 mEq/LSerum chloride < 96 mEq/L

Caused by decreased intake or Caused by decreased intake or

decreased absorption, metabolic decreased absorption, metabolic

alkalosis, and loop, osmotic or alkalosis, and loop, osmotic or

thiazide diureticsthiazide diuretics


Agitation, irritabilityAgitation, irritability Hyperactive DTRs, tetanyHyperactive DTRs, tetany Muscle cramps, hypertonicityMuscle cramps, hypertonicity Shallow, slow respirationsShallow, slow respirations Seizures, comaSeizures, coma ArrhythmiasArrhythmias


Treat underlying causeTreat underlying cause

Oral or IV replacement in a sodium Oral or IV replacement in a sodium

chloride or potassium chloride chloride or potassium chloride

solutionsolution

HyperchloremiaHyperchloremia

Serum chloride > 106 mEq/LSerum chloride > 106 mEq/L Rarely occurs aloneRarely occurs alone Caused by dehydration, renal failure, Caused by dehydration, renal failure,

respiratory alkalosis, salicylate respiratory alkalosis, salicylate toxicity, hyperpara-thyroidism, toxicity, hyperpara-thyroidism, hyperaldosteronism, hypernatremiahyperaldosteronism, hypernatremia

Documents

Fluid Balance. General Concepts Intake = Output = Fluid Balance Intake = Output = Fluid Balance Sensible losses Sensible losses Urination Urination Defecation