1 Disorders of Fluid & Electrolyte Balance University of San Francisco Dr. M. Maag ©2003 Margaret Maag
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Disorders of Fluid &Electrolyte Balance
University of San FranciscoDr. M. Maag©2003 Margaret Maag
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Class 6 Objectives
n Upon completion of this lesson, the student willbe able to
n describe the outcomes associated with hypoand hypervolemia.
n distinguish between the different etiologies ofmajor electrolyte imbalances.
n list the manifestations of electrolyte imbalances.n identify normal distribution of ICF and ECF.n state the normal serum values for Na, K, Cl,
Mg, PO4 ,Ca.
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Starling’s Law of the Capillary
n Fluids leave (filtration) or enter (re-absorption)the capillaries depending on how the pressurein the capillary and interstitial spaces relate toone another
n Volume re-absorbed is similar to volumefiltered: “A net equilibrium”
n Regulates relative volumes of blood &interstitial fluid
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Capillary Exchangen The 5% of blood in the systemic capillaries =
the bulk of blood that exchanges materialswith systemic tissue cells
n Substances that pass through thin capillarywalls into interstitial fluid and then into cellsare: nutrients & oxygen
n Substances that are secreted by tissue cellsand removed from them are: wastes & CO2
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Fluids
n Distribution of total body water (TBW)n 60% of adult body weight is fluid
• Gender, body mass & age considerationsn Intracellular (ICF, within cells = 40% of body
weight)n Extracellular (ECF, plasma, interstitial & lymph
=20% of body weight)n 1 Litre water = 2.2lb or 1 kg
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Developmental Differences
n Infants & young childrenn Four areas of immature functioning
• Increased fluid intake and output relative to size• Total body fluid is 20% more than adults
• Greater surface area relative to size: > water lossthrough skin
• Increased metabolic rate up to 2 years• Immature kidney function
• requires more fluid to excrete wastes
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Fluid Shifts“Third Spacing”
qExcess fluid in interstitial spaces andconnective tissues between cells [edema]
ORn Excess fluid in potential spaces [effusion]
• peritoneal cavity• pericardial sac• synovial cavities of joints• alveoli or intra-pleural spaces
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Fluid Shifts“Third Spacing”
n Etiologyn Caused by an increase in filtration and/or decrease in
reabsorption due to altered capillary forcesn Pathophysiology
n Lymph edeman Angioedema
Mechanisms causing third spacing & edeman massive inflammationn venous obstructionn increased blood volumen low serum albumin
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Hypovolemia
n A decrease in the ECF volumen Intravascular and interstitial volume
n Isotonic volume deficit may be due tonDecreased intake of isotonic fluidsnOr excessive
• vomiting or diarrhea• hemorrhage• urine output
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Hypovolemian Hematocrit (Hct) is sensitive to fluid shifts
n volume (%) of erythrocytes in whole bloodn 40-54 mL/dL malesn 37-47 mL/dL femalesn 11.2-16.5 mL/dL children
n BUN will be elevated d/t < volumen 11-23 mg/dL
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Hypovolemia: manifestationsn Decreased tissue perfusionn Check capillary refill time
n Decreased blood volumen Hypotension, tachycardia, oliguria
n Tissue dehydrationn Loss of skin turgorn Possible temperature elevation
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Hypovolemian Nursing Responsibilities:
n calculate I & O frequently• minimal urinary output = 30cc/hr• check urine specific gravity
n check O2 saturationsn draw & analyze blood gasesn auscultate lungs (side to side)n check temperature distal from heartn give isotonic solutions (oral or IV)
• Normal saline; dextrose, Ringer’s lactaten give a fluid bolus as ordered
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Hypervolemia
n Excess of isotonic fluid in the intravascularand interstitial spacesn Isotonic fluid retention
• Olguric state r/t renal failuren Secondary Hyperaldosteronism
• Inappropriate renal reabsorption of water andsodium,and increased renal secretion of potassium
n Iatrogenic hypervolemia
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Hypervolemia
n Pathon An excess in blood volume results in
elevated CHP and third spacingn Clinical manifestations
• Edema• Hypertension• Bounding pulse• Increased urinary output
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Major Electrolytes
n Electrolytesn Na+, K+, Ca++, Mg+ = cationsn HCO-3, Cl-, PO-4 = anions
n ICF = K+n ECF = Na+
n osmosisn osmolarityn capillary dynamics
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Hyponatremia(Na+ < 135 mEq/L)
n Low sodium determined by blood chemistryn The most common electrolyte imbalance:
• 2.5% of hospitalized patientsn Sodium supports neuron transmission
n Mechanism and examplesn Free water gainn Deficient sodium intaken Renal sodium loss in excess of watern Water in excess of sodium gain
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Hyponatremia(Na+ < 135 mEq/L)
n Manifestationsn Water excess fi rapid weight gainn Na+ loss fi neurological symptoms
• irritability, seizures, < LOCn Muscle crampsn Anorexia/ Nausea/Vomiting (subtle signs)
n Treat water excessn Fluid restriction (I&O)
n Treat sodium loss• Oral or IV sodium
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Hypernatremia(Na+ >145 mEq/L)
Etiologyn Water loss or sodium gains
n Elderly / or comatose patientsn Na+ intake > water intaken Diabetes insipidus (excessive fluid loss) fi < production of
ADHn Damage to hypothalamic thirst center?
• Tumor or CVA?n Manifestations
n Thirst, dry tonguen Restlessness; < LOC; Coma; Intracranial bleedsn Weight changes
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Hypernatremia(Na+ >145 mEq/L)
Treatment (Rx)
n Dilute Na+ and promote secretionn Fluids (5% D/W) and diureticsn Always check LOC
n loose alertness & orientation• sepsis, head injury, intracranial bleed
n Sodium pulls fluid to cause blood vessels toburst
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Potassium (K+)3.5-5.0 mEq/L
n Primarily an intracellular ion; small amount inplasma is essential for normal neuromuscular ancardiac function
n Maintained by the cellular sodium-potassium pumpn K+ changes fi altered excitability of musclesn Eliminated by kidneys
n renal problems causes hyperkalemian Insulin: causes K+ to move from ECF fi ICFn Acidosis, trauma to cells, and exercise
• cause K+ to move from ICF fi ECF:
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HyperkalemiaK+ > 5.5 mEq/L
n Major Causesn Increased potassium intake
• excess or rapid delivery of K+• penicillin containing K+• Massive blood transfusion with irradiated packed red cells
Buntain and Pabari (1999)
n Shift of K+ from the ICF to ECF• Acidosis, uncontrolled DM• increased cell lysis (e.g. cytotoxic drugs)
n Decreased renal excretion• Digitalis toxicity, renal failure, overuse of potassium sparing
diuretics (spiroaldactone)
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HyperkalemiaK+ > 5.5 mEq/L
n Mainfestations:n weak skeletal muscles/ paralysis > 8 mEq/Ln paresthesiasn irritabilityn abdominal cramping with diarrhean irregular pulse fi EKG changes fi cardiac standstilln EKG changes
• peaked T-waves and a shortened QT interval occur• Depressed ST segment and widened QRS interval
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HyperkalemiaK+ > 5.5 mEq/L
Managementn Eliminate K+
n Diuretics (Lasix)n Dialysisn Kayexalaten Increased fluids
n IV insulinn Cardiac monitor
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HypokalemiaK+ < 3.5 mEq
n Major causesn < intake of potassium or > cellular uptake of
potassium• Insulin: promotes K+ uptake by muscle & liver cells• When insulin is given: K+ goes into ICF fi < serum K+
leveln Uncontrolled diabetes mellitus:
• > Glucose: osmotic diuretic fi > potassium viaurinary excretion
• Diabetic Ketoacidosis: › H+ ions in ECF fiexchange across cell membranes fi K+ is firstelevated and then K+ stores are excreted via urine
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HypokalemiaK+ < 3.5 mEq
n Epinephrine: promotes uptake into cells• stress, acute illness, hypoglycemia
n Excessive GI loss: diarrhea & ng suction fimetabolic alkalosis
n Diuretics: Lasix (watch K+ levels)n Excessive renal excretion fi elevated
aldosterone fi diuresis
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HypokalemiaK+ < 3.5 mEq
n Signs & Symptomsn Muscle weakness: hypotonian Cardiac dysrhytmias (T-wave inversion or PVCs)n Atony of smooth muscle
• intestinal distention• constipation• paralytic ileus• urinary retention
n Confusion or disorientation
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HypokalemiaK+ < 3.5 mEqManagement
n Administer KCL slowly and accuratelyn dilute properly with other IV fluids
• 10 mEqs/1 hourn can cause pain and necrosis of veins
• use central IV line for large rapid amountsn Bring pt out of immediate danger & restore
graduallyn Consider discontinuing diuretic therapyn Consider chloride for metabolic alkalosis
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Calcium8.8 - 10 mg/dL
n Major functions:n Transmission of nerve impulsesn Cardiac muscle contractionsn Blood clotting factorn Formation of teeth & bonen Muscle contraction
n Requires:n Vitamin Dn Parathyroid hormone (PTH)n Calcitonin from thyroid gland
29http://lpi.oregonstate.edu/infocenter/minerals/calcium/capth.html
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HypocalcemiaCa+ < 8.5 mg/dL
n Nutritional deficiency of calcium or Vitamin Dn Parathyroid deficiency d/t surgical removaln Children & elderly d/t dietary deficiencyn Bone cancer: excess bone formation
n “Hungry Tumor” syndromen Treatment of prostrate cancer with estrogen depletes
ECF calcium levelsn Blood transfusions
n preserve blood with citrate & this binds with calcium
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HypocalcemiaCa+ < 8.5 mg/dL
n Manifestations:n Chvostek’s signn Trousseau’s signn Dysrythmias:< threshold for depolarization in
cardiac cellsn Paresthesias: “pins & needles”n Abdominal cramping & diarrhean Tetany, Seizures (severe hypocalcemia)
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HypercalcemiaCa+ > 10.5 mg/dL
n Malignancies or hyperparathyroidismn PTH secreting tumor (adenoma)
n Skeletal calcium secreted into bloodstreamn Metastatic breast cancer & multiple myeloma
n Prolonged immobility: loose Ca+ from bone into bloodn Osteoporosis: Ca+ is liberated into bloodstreamn Manifestations:n lethargy/ weakness/fatigue/constipationn pathogenic fractures fi calcium loss from bone
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Phosphate (PO4 -) 3.0 - 4.5mg/dL or 1.8 - 2.6 mEq/L
n Stored with Ca+ in bones & teethn PO-4 & Ca+ are equilibrated
• > Ca+ = < PO-4• excreted by kidneys
n Hypophosphatemia: < 2.7 mg/dLn clinical manifestations
• confusion, weakness, seizures, numbness, coman Hyperphosphatemia: > 4.5 mg/dL
n common in renal failure
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Magnesium (Mg+)1.5 - 2.5 mEq/L
n Second most abundant ICF cationn essential for neuromuscular functionn changes in serum Mg+ levels effect other
electrolytesn Hypermagnesemia: > 2.5mEq/L
n muscle weakness, bradycardia, hypotension,nausea & vomiting
n Hypomagnesemia:< 1.5mEq/Ln increased neuromuscular irritability
• Muscle spasms, tetany, seizures
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References
n Braxmeyer, D. L. & Keyes, J. L. (1996). Thepathophysiology of potassium balance. CriticalCare Nurse, 16(5), 59-71.
n Hansen, M. (1998). Pathophysiology:Foundations of disease and clinicalintervention. Philadelphia: Saunders.
n Huether, S. E., & McCance, K. L. (2002).Pathophysiology. St. Louis: Mosby.