Fluids and Electrolytes

Vesta Fairley RNC, MSN, OCN

 Fluid and Electrolyte Balance

• Internal equilibrium
• Balanced body systems
• Steady state
• Fluids, electrolytes
osmolarity are maintained
within narrow limits
 We Are in Fluid Balance
•Maintain blood volume
•Transport nutrients
•Medium for chemical
function
•Cushions, lubricates, gives
structure
•Maintain body temperature
•Eliminates waste
 “What Influences the Amount of
Body Fluid?”
Age

Gender

Body fat / elderly

 Body Fluid Compartments

Interstitial
intravascular

Extracellular Intracellular
 Body Fluid Compartments

Interstitial
intravascular

Extracellular Third space Intracellular

 Fluid and Electrolyte Balance

Intracellular • Extracellular
• Potassium (k+) • Sodium(Na+)
• Proteins ( -) • Organic Acids
• Magnesium (mg++) • Chloride (Cl-)
• Phosphates (PSO4 • Bicarbonate
=) (HCO3-)
• Sulfate (SO4 =) • Calcium (Ca++)
 Electrolyte Balance
Intracellular Cations Extracellular Cations
• Potassium 150 • Sodium 142
• Magnesium 40 • Potassium 5
• Sodium 10 • Calcium 5
• Magnesium 2

Intracellular Anions Extracellular Anions

• Phosphate/ sulfate 150 • Chloride 103
• Bicarbonate10 • Bicarbonate 26
• Proteinate 40
• Phosphate 2, Sulfate 1
• Organic acid 5
• Proteinate 17
 Electrolyte Functions
• Neuromuscular activity
• Maintain body fluid volume and
osmolality
• Regulates acid base
• Distribute body water between
compartments
 Assessment of Imbalance
• Change in behavior
• LOC, VS
• Skin turgor
• Muscle strength
• Condition of mucous membrane
• Monitor Intake and output
• Daily weight
 Evaluation of Fluid Status

• Creatinine
• Hematocrit
• Urine sodium
• Blood urea nitrogen
• Specific gravity of urine
 “Don’t Disturb Me Right Now”

Routes of Gains
• Eating and Drinking
• Parenteral fluids
• Enteral fluids
• Total Parenteral Nutrition
 Enteral Feeds
• Normal GI motility and absorption are
required

• Pancreatic enzymes and insulin

production are required

• High protein feeds can cause water

deficit through osmosis. Additional water
is needed
 Routes of Gains and Losses
• Output is approximately 1 ml of urine/ kg / hr in
all age groups

• 300 to 400 ml of water vapor is eliminated by

the lungs every day

• 100 - 200 ml per day is lost from the GI tract

 Parenteral Fluids
Isotonic - (0.9 %) NS, D5NS, D5 W, LR,
Ringers solution

Hypotonic - ½ Normal saline, ¼ Normal

saline

Hypertonic - 3% and 5% sodium solution,

Concentrated dextrose solutions, Whole
blood, albumin, TPN, lipids
 Normal Saline ( 0.9% )
• Isotonic, Osmolality of 308 mOsm / L
• Used to treat extracellular fluid deficit
• Supplies only sodium and chloride
• Can cause fluid volume excess and
hyperchloremic acidosis if given in
excessive amounts
• Only solution administered with blood
5% Dextrose in Water ( D5W )

• Isotonic - Osmolality of 252 mOsm / L

• Hypotonic when administered

• Supplies free water to aid in renal

excretion

• Corrects increased serum osmolality

• Caloric value about 170 kcal / L

 Ringers Solution

• Contains electrolytes (NA, Cl, K, Ca)

• Lactated ringers contain lactate which is

bicarbonate precursors

• Used in the treatment of hypovolemia

(fluid loss,burns,diarrhea)
 Ringers Solution
• No calories, dehydration, sodium
depletion, replacement of GI loss

• Check urine output before infusing

potassium

• Continually assess for electrolyte or

fluid imbalance
Half Strength Normal Saline
( 0.45% NS )

• Hypotonic is used to replace cellular

fluid

• Provide free water for excretion of

body waste

• Used to treat hypernatremia or other

hyperosmolar conditions
Half Strength Normal Saline
( 0.45% NS )

• Excessive infusion of hypotonic

solutions can lead to intravascular
fluid depletion, decreased blood
pressure, cellular edema and cell
damage
 Dextrose Solutions
(2.5%, 5%, 10%, 20%, 50%)
• Hypertonic, Supplies calories as carbs

• May cause peripheral circulatory collapse

and anuria in patients with sodium
deficiency

• May aggravate hypokalemia

• May irritate veins.

• Electrolyte free solution increases body

fluid loss
 Saline Solutions
(0.45%, 0.9%, 3%, 5%)

• No calories, fluid replacement,

dehydration, sodium depletion or
hyponatremia

• Use chloride solution with caution in

edematous patients with heart, renal or
hepatic disease
 Dextrose Saline Solutions
(5% Dextrose in 0.45% or 0.9% NS)

• Fluid replacement, calorie feeding, dehydration,

sodium depletion

• Use chloride solution with caution in patients

with compromised cardiovascular or pulmonary
status

• Continually assess for crackles, edema, and skin

turgor
“I Got the Lytes Knocked Out of Me”

Routes of Losses

• Kidneys

• Skin

• Lungs

• GI Tract
“He Said Something About a Fluid
Imbalance”
 “Hypovolemia Sounds Bad”
• Fluid and electrolytes are lost in the same
proportions
• Causes
– Vomiting and Diarrhea
– GI suctioning
– Sweating
– Decreased intake
– Fever, fistulas
– Blood loss, burns
– Fluid shifts
– Diabetes
Manifestations of Hypovolemia
• Acute wt loss and Decr skin turgor
• Oliguria / concentrated urine
• Postural hypotension and Weak rapid
pulse. Flattened neck veins
• Increased temp
• Cold clammy skin
• Thirst and Anorexia
• Muscle weakness and Cramps
 Diagnosis of Hypovolemia

• Increased
–blood urea nitrogen
– hematocrit
–sodium and potassium level
–urine specific gravity
 Management of Hypovolemia

• Give oral fluids or IV isotonic fluids

• Give hypotonic solution, when

normotensive

• Assess I&O, weight, VS, LOC, breath

sounds, skin color
Nursing Measures of Hypovolemia

• Measure I & O every 8 hrs (1 hr)

• Daily weight
• Vital signs
• Monitor skin and tongue
• Urinary concentration
• Mental function
 “Hypovolemia Sounds Bad”

• Fluid Is Lost and Electrolytes Are in

Excess

• Osmotic diuresis
• Cellular dehydration
• Circulation failure
• Buildup of waste products
• Mental changes. Disruption of brain cells
 Signs of Hypovolemia
• Weight loss

• Thirst

• Increased body temperature due to less

water for temp regulation

• Dry mouth and throat

 Management of Hypovolemia

• Give one liter of fluid / kg wt loss plus

an additional 1.5 liters of fluid to
supply current daily need.

• Replace fluid over a period of several

days

• Give IV glucose and water to replace

water loss and increase urinary flow to
excrete excess electrolytes
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 “Hypervolemia Sounds Bad Too”

• Sodium and water are retained in the

same proportions

• Causes
– CHF
– Cirrhosis of the liver
– Regulation Problem
– Renal failure
– Fluid overload
– Increased table salt
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 Manifestations of Hypervolemia

Diagnostic - Decreased BUN and hematocrit

• Weight gain • Dyspnea
• Polyuria • Tachypnea
• Distended neck • Ascites
veins • Peripheral edema
• Elevated blood • Change in mental
pressure status
• Full bounding
pulse
 Nursing Assessment
Hypervolemia
Monitor
•Daily weight
•Intake and output
•Blood pressure
•Respiratory rate
•Lab values
•Sacral edema in bedridden
patients
•Auscultate lung sounds
Management of Hypervolemia

• Treat causative factors

• Restrict fluids and sodium
• Diuretics
• Dialysis
 Hypervolemia
• Water Excess or Water Intoxication

Causes
• Sodium deficit
• Water intake excessive
• Intake of electrolyte free fluids
• Increased secretion of antidiuretic
hormone
• Inadequate output of urine
 Signs of Hypervolemia

• Change in behavior
• Hyperventilation
• Sudden weight gain
• Warm, moist skin
• Increased intracranial pressure
• Peripheral edema, usually not marked
 Management of Hypervolemia

• Water restriction
• Lasix and hypertonic saline (5%)
• Obtain hourly intake and output
• Obtain body weight
• Auscultate breath sounds
• Obtain serum sodium levels
• Assess neurological status
• Assure patient safety
Have you lost
your
electrolytes?
 Sodium
Imbalance
 Sodium
• (135 - 145 meq/ L)

• Extracellular
• Regulates fluid balance
• Essential for glucose to be
transported into the cells
• Necessary for muscle and nerve
action
• Helps maintain acid base balance
Causes of Sodium Imbalance

• Diuretics
• Restricted sodium intake
• GI or biliary drainage, draining fistulas
• Disease interfering with aldosterone
secretions
• Third spacing, heavy perspiration, fever
• Chronic renal disease
 Manifestations of Sodium
Imbalance
Hyponatremia Hypernatremia
• Headache • Swollen tongue and
• Anorexia and N & thirst
V • Sticky mucous
• Muscle cramps membranes
• Exhaustion • Deep tendon reflexes
• Postural HTN
• Peripheral edema
• Weight loss
 Manifestations of Sodium
Imbalance
Hyponatremia Hypernatremia
• Increased • Pulmonary edema
pressure
• Postural hypotension
• Mental
• Increased muscle tone
confusion
• Flushed skin
• Delirium
• Neurological changes
• Shock related to cellular
• Coma dehydration
 Diagnostic of Sodium Imbalance
Hyponatremia Hypernatreamia
• Decreased sodium level • Serum level greater
135 / L than 145 meq / l

• Decreased serum • Serum osmolality

osmolality greater than 295
mOsm/kg
• Urinary sodium content
changes depending on • Increased urinary
cause specific gravity
Management of Sodium Imbalance
Hyponatremia
• Shock – rapid infusion of normal saline
• Replacement of potassium, calcium
bicarbonate
• Increase sodium PO, GA, IV
• Safety measures
– Fluid restriction (treatment of choice)
– If neurologic symptoms, administers
hypertonic solution
Management of Sodium Imbalance
Hypernatremia - Increase fluid, Hydrate
cautiously, Diuretics, Dialysis
Potassium
Imbalance
 Potassium
• Normal value 3.5 - 5.5 meq / l
• 98% inside cell, 2% outside cell
• 80 % excreted by kidneys
• 20% excreted in bowels and sweat
glands
• Responsible for muscle and cardiac
activity
• Potentiates digitalis
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 Causes of Potassium Imbalance
Hypokalemia Hyperkalemia
• Decreased food and • Decreased renal
fluids intake function
• Failure to replace • Corticosteroids
losses deficiency
• Alterations in acid • NSAIDS, captopril, K
base sparing diuretics,
• Hyperaldosteronism aged blood
 Causes of Potassium Imbalance
Hypokalemia Hypokalemia

• Potassium losing • Acidosis

diuretics • Tissue damage and
• Digitalis toxicity, if trauma, infection
person becomes
hypokalemic
• Kidney and heart
damage
Clinical Signs of Potassium Imbalance

Deficit Excess
• Nausea and
• EKG changes
Vomiting
• Excessive urination • Cardiac arrest
• Cardiac arrest • Skeletal muscle
• Respiratory arrest weakness
• Dysrythmias • Muscle spasms
Clinical Signs of Potassium Imbalance

Deficit Excess
• Fatigue, muscle
• Paralysis
weakness
• Paralytic ileus • Nausea
• Abdominal • Intestinal colic
distention • Diarrhea
• Anorexia
• Leg cramps
 Diagnostics of Potassium
Imbalance

Hypokalemia
• Potassium is less than 3.5 meq / L
• Sensitivity to digitalis
• Alkalotic (metabolic)

Hyperkalemia
• Elevated potassium level
• EKG changes
• Acidotic (Metabolic)
 Management of Hypokalemia
• Oral or IV potassium
• IV must be on a pump
• Schlerose and burns veins Rapid rise in
potassium can
• 20 meq / hr rate be lethal
• Concentration < 40 meq/ l
• Agitate solution to mix well
• Must have adequate urine
output
• Monitor potassium level
Management of Potassium Excess
• EKG and serum potassium level
• No oral intake of foods high in
potassium
• D 10 with regular insulin
• Kayexelate
• Dialysis
• Calcium gluconate IV or sodium
bicarbonate
• Bedrest
 Calcium
Imbalance
 Calcium
Serum calcium level 9.0 – 11.0 mg / dl
Functions
• Blood coagulation
• Smooth skeletal functions
• Cardiac muscle function
• Nerve function
• Bone and teeth formation
 Hypocalcemia
Causes
• Inadequate intake or vitamin D deficiency
• Hypoparathyroidism
• Pancreatic disease
• Excess loss through intestinal fistulas
• Hyperphosphatemia
• Magnesium deficiency
• Medications
 Hypocalcemia

Clinical Manifestations
• Tetany
• Numbness and tingling of the nose, fingers, and
toes
• Muscle spasm and muscle pain
• Seizures
• Mental changes such as depression, confusion,
hallucinations
Trousseau’s Sign
 Hypocalcemia
• Diagnostics
• Decreased corrected calcium
• Increased ph
• Decreased parathyroid hormone
• Decreased magnesium
• Decrease phosphorus
 Hypocalcemia

Management
• Increase calcium in diet or oral calcium
salts
• 10 % calcium gluconate IV
• Vitamin D or parathyroid hormone
• Give aluminum hydrate
 Hypercalcemia
Serum calcium level > 11mg / dl
Causes
• Malignant neoplastic disease
• Hyperthyroid disease
• Immobilization
• Thiazide diuretics
 Hypercalcemia

• Mild
– Polyuria
– Severe thirst
– Anorexia
– Nausea and vomiting
– Constipation
 Hypercalcemia

Progressive
Lethargy
Confusion
Comatose
Bone pain
 Hypercalcemia

Crisis
•17 mg / dl or higher
•Intractable N & V
•Dehydration
•Stupor
•Coma
•Azotemia
•Cardiac arrest
 Hypercalcemia
Diagnosis
• Serum calcium level > 11 mg / dl
• Increased parathyroid hormone
levels
• Potassium
• Sodium
• Phosphorus
• Urine bun and creatinine
• Cardiovascular changes
 Hypercalcemia
Treatment
• Remove the cause
• IV saline and diuretics
• Calcitonin
• Mitramycin, aredia, didronel
• Glucocorticoids if cause is cancer
• Increase fluid intake to 3 – 4 L / d to reduce
calculi formation
Magnesium
Imbalance
 Magnesium
Functions
• Level 1.5 – 2.5 meq/l

• Activates enzyme reaction especially

carbohydrates and proteins

• Prevent convulsions in toxemia in pregnancy

• Acts as a vasodilator which decreases blood

pressure

• Similar to calcium in muscular and nerve

function
 Hypomagnesemia
Causes
• Calcium deficit
• Loss of intestinal fluids through draining
fistulas, diarrhea, stetorrhea and GI suctioning
• Alcoholism or prolonged malnutrition
• Drug therapy with aminoglycosides and loop
diuretics
• Endocrine disorders such as increase
secretion of antidiuretic hormone aldosterone
and thyroid hormone
 Hypomagnesemia
Clinical Manifestations

• Confusion • Increased reflexes

• Hallucinations • Tremors
• Weakness • Muscle spasms
• Convulsions • Trousseau's sign and
• Depression chvostek's sign
 Hypomagnesemia
Diagnostics
• Serum albumin < 1.5 meq / l
• Decreased potassium and calcium level

Management
• Correction of the underlying problem
• Mild cases can be corrected by diet alone
• Oral magnesium salts
• IV magnesium sulfate (calcium gluconate must be
readily available
 Hypermagnesemia

Causes
• Can result from frequent use of
magnesium containing antacids
• Can be caused by renal failure
• Can be caused by a adrenocortical
insufficiency
 Hypermagnesemia
Clinical Manifestations

Mild
• Decreased blood pressure
• Facial flushing
• Sense of heat
• Thirst
• Nausea and vomiting
 Hypermagnesemia
Clinical Manifestations
Moderate
•Lethargy
•Difficulty speaking
•Drowsiness
•Loss of deep tendon reflexes
•Muscle weakness
•Paralysis
•Respiratory depression
 Hypermagnesemia
Diagnostic
• Level > 2.5 mg / dl
Management
• Calcium gluconate (temporary treatment)
• Hemodialysis with a magnesium free
dialysate
• Duretics and 0.45% NACL to enhance
excretion
Phosphorus
Imbalance
 Phosphorus
Normal serum level 2.5 - 4.5 meq / dl
Functions
•RBC formation (ATP)
•Metabolism of carbohydrates, fats and
proteins
•Maintenance of acid base balance

•Nerve and muscle function

•Support of bones and teeth

 Hypophosphoremia
Causes
• Overzealous intake of carbohydrates
• Anorexia nervosa
• Alcoholism or alcohol withdrawal
• Poor dietary intake
• Thermal burns
• Vitamin D deficiency
• Diabetic ketoacidiosis

Diagnostics - Level < 2.5 mg / dl

 Hypophosphoremia
Clinical manifestations
• Irritability • Seizures
• Apprehension • Coma
• Weakness • Tissue anoxia
• Numbness • Bruising
• Confusion • Bleeding

Management
•Oral phosphorus replacement
•IV phosphorus
 Hyperphosphoremia

Causes
• Decreased excretion of phosphorus
• Increase phosphorus intake of absorption
• Muscle necrosis

Diagnostics
• Level > 4.5 mg / dl
• Abnormal bone development
 Hyperphosphoremia

Clinical manifestations
– Complication of joint calcification
– Tetany - tingling of fingers and toes
– Anorexia
– Nausea
– Vomiting
– Muscle weakness
 Hyperphosphoremia

Management
– Treat underlying disorder
– Allopurinol
– Restrict dietary phosphorus
– Dialysis
– Phosphate binding gels
Total Parenteral Nutrition
 Total Parenteral Nutrition
Method of giving highly concentrated solutions
Intravenously to maintain a patient’s nutritional
Balance when oral or enteral nutrition is not
Possible

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 Total Parenteral Nutrition
Indications
– Major GI diseases
– Fistulas and inflammatory disease
– Severe trauma or burns
– Severe GI side effects from radiation or
chemotherapy
– Congenital malformations of the GI tract
– Severe malnutrition

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 Contents of All TPN
• Water
• Proteins • Dextrose 25% – 35%
• • Amino acids 3% – 5%
Carbohydrates
• Fat • Electrolytes
• Vitamins • Minerals
• Trace elements
• Vitamins
• Fat emulsions 10% – 20%

12
 Total Parenteral Nutrition
Administration

• Must be on a pump
• If TPN is stopped for any reason, hang D10 or D5
as ordered
• Only lipids can be hung with TPN
• Lipids are unfiltered, TPN is filtered

12
 Total Parenteral Nutrition
Administration

• Must be on a pump
• If TPN is stopped for any reason, hang D10 or D5
as ordered
• Only lipids can be hung with TPN
• Lipids are unfiltered, TPN is filtered

12
 Total Parenteral Nutrition
Administration

• Must be through a central line

• D 10 or less can be administered
through a peripheral IV

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 Total Parenteral Nutrition
Administration

• Maintain strict aseptic technique

• May be unrefrigerated < 30 minutes

prior to admin

• Use within 24 hours after mixing

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 Total Parenteral Nutrition
Administration

• Dressing change every 72 hours if

central line or every 48 hours if
peripheral line

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 Total Parenteral Nutrition
Administration
• Although the bags are
numbered, pay attention to the
expiration date

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 Total Parenteral Nutrition
Administration
•Start administration slowly about 25 cc / hr

•Gradually increase rate about every 4 hrs in

25 cc increments until ordered rate is reached

•When discontinuing, gradually taper off over

about 6 hours

•Monitor blood glucose levels every 4 hours

12
 Total Parenteral Nutrition

Mechanical complications

– Pneumothorax
– Hemothorax
– Air embolism
– Catheter misplacement
– Thromboembolism

13
 Mechanical Complications
Pneumothorax, hemothorax

– Needle tip penetrated the pleura of the lung which

usually occurs in thin malnourished patients

– Pneumothorax is characterized by a sudden sharp

pain around the area where the needle was
inserted, coughing, chest pain, cyanosis or
becomes hypotensive

13
Mechanical Complications
Air Embolism

– Occurs when changing the

tubing or when the tubing is
separated

– 100 - 200 cc of air is fatal

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 Characteristics of Air Embolism

• Dyspnea • Sharp pain

• Cyanosis • Distended neck
• Tachycardic veins
• Elevated venous • Hypotension
pressure • Depressed
mental status

13
Management of Air Embolism

• Place in trendelenburg
• Lay on left side
• Perform the valsava maneuver, while
disconnecting the tubing

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 Mechanical Complications

Thromboembolism

Predisposition
– Venous stasis
– Hypercoagulable state
– Local trauma

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 Prevention of
Thromboembolism
• Heparin added to the solution

• Thrombosis may be asymptomatic

• Signs of pulmonary embolism may

be the first sign of thrombosis
13
 Catheter Related Sepsis
– Catheter contamination is the major source
of TPN sepsis

– Catheter sepsis can be minimized by aseptic

technique in the maintenance as well as
insertion and restricted use of catheter for
nutrition use only

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 Metabolic Complications

Glucose intolerance
– Hypoglycemia can result from sudden
withdrawal of a prolonged infusion
– Symptoms include diaphoresis, confusion
and agitation
– Treatment include frequently monitoring of
glucose levels and reinstitution an infusion
of 10% dextrose in water

13
 Metabolic Complications

Glucose intolerance
– Hyperglycemia infusion rate too fast for
the patient's insulin response

– Treatment for a patient with

hyperglycemia is to increase the
percentage of calories provided by fat,
infusing glucose infusions slowly, and
providing insulin when necessary

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 Metabolic Compensation
Hypomagnesemia
– Symptoms include apathy, weakness,
seizures, arrhythmia hallucinations,
hyperreflexia

– Symptoms resolve rapidly with

magnesium replacement
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 Metabolic Complications
Hypophosphatemia
– Signs and symptoms include tremor,
paresthesias. Ataxia, decreased platelet
and erythrocyte survival, impaired
leukocyte function and weakness

– Treated with 10 - 15 mmol of phosphate per

liter of solution

13
Complication Fluid Imbalance

• Volume infused is excessive

• Treatment consist of decreasing the

rate of fluid and optimizing cardiac and
renal function
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 Complications Acidosis
– Acidosis occurs when carbohydrates are
broken down

– The increased production of carbon

dioxide can induce respiratory distress

– Abnormal neurological symptoms include

disorientation, lethargy , stupor, and
convulsions which can lead to coma and
death
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 Administration of Lipid
Emulsions

Lipids can be piggybacked in the

TPN but it has to be below the

filter preferably close to the

insertion site
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 Administration of Lipid
Emulsions
• The rate is usually 30 - 60 ml/hr
• 10% emulsion - 30 ml / hr for 30
min
• 20% emulsion - 15 ml / hour for 30
min
• Gradually increased to prescribed
dose if no reaction
 Administration of Lipid
Emulsions

• Lipids can be given peripherally

• Lipids can be given to a patient who

is glucose intolerant
 Complications From
Administration of Lipid Emulsions

• Pulmonary embolus

• Fat overload
“WOW I’m Glad This Is Over”