Adult Clients with Changes in Fluids and Electrolytes Unit 2 – Chapter 10 (p. 224)
o Review of key concepts: Fluids and Electrolytes
Fluid:
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Essential for homeostasis
Approx 60% of adult weight is fluid
Children have more fluid than adults
Men have more fluid than women (Men are generally bigger in stature than women)
Most of the liquid is Intracellular Fluid (ICF)
ECF:
○ Intravascular- Plasma
○ Interstitial- Lymph
○ Transcellular- Cerebral spinal fluid, pericardial
Excess ICF to ECF- Cellular dehydration
Excess ECF to ICF- Cellular swelling
Third Space Fluid:
○ Fluid loss from ECF that does not go to ICF
■ Examples:
● Angioedema
● Pericardial effusion
● Ascites
■ Symptoms:
● Decreased urine output - because, fluid is going somewhere else
● Increased HR
● Decreased BP
● Edema
● Increased weight
Electrolytes:
● Active chemicals that carry cations (+) and anion (-) charges
○ Memory Trick: ca+ions the “t” is a plus sign so its positive
○ Cations: Na, Ca, K, Mg, H
○ Anions: Cl, HCO3, PO4
○ High “Na+” in ECF
■ Sodium regulates regulates body fluid volume
○ ICF has high “K+” concentration
■ Changes in potassium can cause cardiac issues
Gains vs Losses:
● Gain:
○ Eating and drinking
○ Daily I&O’s of water should be equal
● Loss:
○ Kidney- Urine
○ Skin- Sweat
■ Na, Cl, K
○ Lungs- Water vapor
○ GI- Waste and reabsorption into bloodstream
Insensible fluid→ Fluid lost through sweat, respiratory system→ NOT MEASURABLE!
FVD (Fluid Volume Deficit): AKA :Hypovolemia
● Loss of water and electrolytes
● Decrease ECF
● Decreased fluid intake
● Third space fluid
○ In anemia and trauma patients
● Diffuse edema is a major symptom
● Intervention:
○ Constant I&O’s
○ Daily weight
○ Administration of fluids (Oral, Parenteral)
Fluid Volume Excess:
● “Too much extracellular fluid”
● Decreased albumin production
● Caused
○ HF, kidney injury, liver issues
● Symptoms:
○ Edema
○ Distended neck veins
○ Crackles
● Intervention:
○ Assess lung sounds
○ Monitor medication responses- diuretics and parenteral fluids
○ Avoid excess sodium
○ I&Os
○ Daily weights
Electrolyte Imbalances:
● Sodium (Na)
○ Normal: 135-145 mEq/L
○ Hyponatremia- Less than 135 mEq/L
■ Symptoms:
● Confusion/Headache
● Seizures
● Coma
● Poor skin turgor
■ Treatment:
● Lactated Ringers Solution
● Isotonic Saline (0.9% sodium chloride)
● Water restriction
○ Hypernatremia: Greater than 145 mEq/L
■ Symptoms:
● Thirsty
● Fever
● Edema: Peripheral and pitting
● Memory Trick: “Na” I’m so hype, that my BP is high. I just can’t
pee because I'm so confused about why my legs are so swollen.
■ Treatment:
● Monitor I&O’s and body weight
● 0.45% NaCl IV- Safer
● Dextrose 5% in water
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Chloride (Cl)- NOT ON EXAM
○ Normal: 96-106 mEq/L
○ Sodium and Chloride have a direct relationship
○ Hypochloremia: Less than 96
■ Due to:
● Cystic Fibrosis
● Metabolic Alkalosis
● Vomiting
● Decreased HCl
■ Symptoms:
● Same as Hyponatremia
○ Hyperchloremia: More than 106
■ Due to:
● Decreased Bicarb
○ Watch for increased Sodium and decreased Bicarb→
Too much Chloride
■ Symptoms:
● Same as Hypernatremia
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Potassium (K)
○ Potassium & Sodium have an inverse relationship
○ Normal: 3.5-5 mEq/L
○ Hypokalemia: Less than 3.5 mEq/L
■ Symptoms:
● Orthostatic Hypotension
● Arrhythmias - ECG changes (ST depression)
● Weakness/Fatigue
● Alkalosis
■ Treatment:
● Potassium supplements
● NEVER IV PUSH!
○ Hyperkalemia: More than 5 mEq/L
■ Symptoms: (MURDER)
● Muscle cramps
● Urine abnormalities
● Respiratory distress
● Decreased BP and HR
● EKG changes- Flat P waves, Prolonged PR, Widened QRS
● Reflexes- Increased DTR
■ Treatment:
● Monitor EKG
● Potassium excreting diuretics
● Avoid Potassium rich foods
● Prepare for dialysis
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Calcium (Ca)
○ Calcium and Phosphate have an inverse relationship
○ Normal: 9-10.5 mEq/L
○ Hypocalcemia: Less than 9
■ Symptoms: (CANT)
● Convulsion
● Arrhythmias
● Numbness in fingers, face & limbs
● Trousseau and Chvostek
■ Treatment:
● Calcium supplements
● High Calcium diet
● Administer aluminum hydroxide & Vit D
○ Hypercalcemia: More than 10.5
■ Symptoms: (BACK ME)
● Bone pain
○ Ca is being taken away from bones
● Arrhythmias
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● Cardiac arrest
● Kidney stones
● Muscle weakness- Decrease in DTR
● Excessive urination
Treatment:
● D/C Calcium IV/ PO & Thiazide diuretics
● Give Phosphorus
● Avoid high calcium diet
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Magnesium (Mg)
○ Magnesium is a sedative!
○ Ca and Mg have a direct relationship
○ Normal: 1.3-2.1 mEq/L
○ Hypomagnesemia: Less than 1.3
■ Symptoms: Everything is high (Non-sedating)
● High HR/BP
● Increased DTR
● Confusion
● Shallow respirations
● Trousseau & Chvostek
■ Treatment:
● Magnesium sulfate IV/ PO
● Seizure precautions
● High Magnesium diet
○ Hypermagnesemia: More than 2.1
■ Symptoms: Everything is low (Sedative)
● Low energy
● Low HR/BP/RR
● Decreased respirations/ bowel sounds/ DTR’s
■ Treatment:
● Diuretics
● Avoid laxatives & antacids that contain Magnesium
● Avoid magnesium containing foods
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Phosphate (P)
○ Normal: 2.8-4.5 mEq/L
○ Calcium and Phosphate have an inverse relationship
○ Hypophosphatemia: Less than 2.8
■ Symptoms:
● Constipation
● Muscle weakness
● Decreased bowel sounds→ Constipation
● Coma
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Hyperphosphatemia: More than 4.5
■ Usually seen in renal failure
■ Symptoms:
● Acidosis
○ Due to loss of Bicarb (Basic)
● Massive Blood Transfusion
● Renal failure
● Hypocalcemia
● Hyperthyroidism
Acid-Base Balance:
● Kidneys regulate Bicarb (Metabolic)
● Lungs regulate CO2 (Respiratory)
● ABG
○ pH: 7.35-7.45
○ PaCO2: 35-45 mm Hg
○ HCO3: 22-26 mEq/L
■ In order to be a metabolic issue, value must be less than 22
○ PaO2: 80-100 mmHg
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Metabolic Acidosis:
○ Causes:
■ Diabetic Ketoacidosis (DKA)
■ Renal failure
■ Severe Diarrhea
■ Shock
○ Symptoms:
■ Kussmaul Respirations (Hyperventilation)
■ Hyperkalemia
■ N/V/D
■ Vasodilation→ Warm, flushed skin
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Metabolic Alkalosis:
○ Causes:
■ Increased Bicarb
■ Decreased Hydrogen
○ Symptoms:
■ Tachycardia- because of decreased Potassium
■ Hypoventilation
■ Tremors/muscle cramps and tingling
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Respiratory Acidosis: (CO2 retention)
○ Causes: (Basically any disease that makes it hard to breathe)
■ Decreased respiratory stimuli
● Anesthesia
● Drug overdose
■ COPD
■ Pneumonia
■ Atelectasis
○ Symptoms:
■ Hypoventilation→ Hypoxia
■ Vasodilation→ Decreased BP
■ Hyperkalemia
■ Dysrhythmias- because of increased Potassium
■ Increased DTR
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Respiratory Alkalosis: (Too much CO2 loss)
○ Causes:
■ Hyperventilation
■ Mechanical ventilation
○ Symptoms:
■ Tachycardia
■ Hypokalemia
■ Paresthesia
■ Seizures
■ Decreased or Normal BP
Endocrine:
● Each hormone has a target
● Major hormones:
○ Amines
○ Peptides
○ Steroids
● Kidneys produce erythropoietin
○ Stimulates bone marrow to produce RBC
● WBC produce cytokines
○ For inflammatory responses
● Negative Feedback Loop
○ Hormone concentration increases→ hormone function is inhibited
Pituitary Gland Disorders:
● Hyperpituitarism
○ Acromegaly (Growth hormone) - NOT ON TEST
■ Andre the Giant
■ Excess growth hormone
■ Causes:
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■ Symptoms:
● Enlarged/ elongated limbs/ body features
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■ Treatment:
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○ SIADH (ADH)- Opposite of Diabetes Insipidus
■ Soaked Inside- Water retention
■ Causes:
● Pneumonia
● Pneumothorax
● Head injury (pituitary gland)
● Meds
■ (6 S’s)
■ Symptoms:
● Sodium low in blood (Hyponatremia)
○ No edema
● Stops urine output
○ Urine has increased salt concentration
■ Sticky Dark and thick urine
● Seizures
● Severely high BP
■ Treatment:
● Stop all fluid and increase salt intake and diuretic
● Treat underlying causes
● Hypertonic saline 3% or D10 IV
● Administer demeclocycline
○ Cushing syndrome (ACTH)
■ “Too much steroids in body”
■ Causes:
● Endogenous: Pituitary cancer
● Exogenous: Outside source affecting pituitary gland
■ Diagnosis:
● 24 hr urine sample
■ Symptoms:
● Hyperglycemia
● Thin extremities
● Na & fluid retention
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Osteoporosis
Female:
○ Amenorrhea- She’s screaming amen cause she's a man”
■ Increased body and facial hair
■ Menstrual cycle stops
● Male:
○ Gynecomastia- “Moobs”
■ Treatment:
● Treat underlying cause
● Chemo/Radiation
● Pituitary removal
● Monitor mental status
○ Dr. G’s mom was on steroids and she went crazy
● Na and Fluid restrictions
● Increased insulin for DM patients
● Fall precautions
Hypopituitarism
○ Dwarfism (Growth hormone) NOT ON TEST
■ Midgets
■ Limited growth hormone in body
■ Causes:
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○ Diabetes Insipidus (ADH)- Opposite of SIADH
■ Dry Inside- Dehydration
■ “DI”= DIE ADH
■ (7D’s)
■ Causes:
● Primary: Defect in hypothalamus/pituitary gland
● Secondary: Head trauma etc.
● Kidney issues (nephrogenic)
● Meds
■ Symptoms:
● Hypovolemic (Dehydration/Dry)
○ Increased Na→ Hypernatremia
○ Everything tested in blood is high
● Diurese (High urine output)
○ Clear and diluted
○ Everything tested in urine is low
● Dry skin
● Decrease in BP
■ Treatment/Management:
● Fall precautions
● Monitor I&O daily
● Administer a vasoconstrictor- Vasopressin (Desmopressin)
○ Made to decrease urine output
● Drink a lot of water
● Replace ADH
● Meds
○ Lithium
○ Declomycin
○ Addison Disease (ACTH)
■ Low steroids in the body
■ Add steroids
● Fixes hyponatremia and hyperkalemia
■ Causes:
● Primary:
○ Autoimmune disease
● Secondary:
○ Withdrawal from steroids abruptly
■ Symptoms:
● Weight loss
● Weakness
● Hypoglycemia
● Bronze pigmentation
● Postural hypotension
■ Adrenal Crisis:
● Fatigue
● Dehydration
● Hyponatremia and Hyperkalemia
● Renal failure
● Symptoms:
○ Decreased BP
○ Cyanosis
○ Fever
○ N/V
■ Treatment:
● Give steroids
Thyroid Gland:
● Thyroid hormones
○ T3
○ T4
○ Calcitonin
● Iodine is a thyroid hormone is essential for hormone production
● Meds that affect thyroid function:
○ Anticonvulsants
○ Propranolol
○ Diazepam
● B/C of negative feedback
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Increase TSH= Hypothyroidism= Decreased T3 & T4
Decreased TSH= Hyperthyroidism= Increased T3 & T4
Hypothyroidism:
○ *More common in women than men*
○ Causes:
■ Hoshimoto’s ( seen in kids)
■ Thyroid atrophy
■ Iodine deficiency/excess
■ Radiation
■ Tx of hyperthyroidism
○ Symptoms:
■ Intolerance to cold
■ Thick tongue & Slowed speech- Hashimoto’s
■ Anorexia
● Trouble losing weight
● Low appetite
■ Menstrual disturbances
■ Cardiac complications:
● Bradycardia
■ Weight gain
■ Hair loss
○ Treatment:
■ Eval T3 and T4
■ Give thyroid hormone
● Cynthroide
○ On empty stomach @ least 30 mins before eating
● On meds FOREVER
○ Diseases of Hypothyroidism:
■ Myxedema Coma
● Fatigue will gradually increase to a coma
● Treatment:
○ Give IV thyroid hormone
Hyperthyroidism:
○ Causes:
■ Grave’s disease
■ Treatment of hypothyroidism
○ Symptoms:
■ Intolerance to heat
■ Tachycardia
■ Amenorrhea
■ Tremors
■ Bulging eyes (Exophthalmos)
■ Localized edema
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■ Weight/muscle loss
Treatment:
■ Eval T3 and T4
■ Give radioactive iodine
■ Thyroidectomy
● Increased risk for hyperthyroidism
■ Meds:
● Propylthiouracil (PTU)
○ Blocks secretion of thyroid hormone
● Dexamethasone (steroid)
Diseases of hyperthyroidism:
■ Thyroid storm:
● Fatal
● Symptoms:
○ Diaphoresis
○ Tachycardia
○ Delirium/Coma
○ HF
○ Mood swings
● Treatment:
○ Tylenol
○ IV fluids
○ Steroids
○ Iodine
○ PTU
Radioactive Iodine Therapy:
● Goal: Eliminate the hyperthyroid state
○ Results in hypothyroidism
● Contraindicated in pregnancy
Thyroidectomy:
● Monitor airway - #1 nursing intervention
Hypoparathyroidism:
● Cause:
○ Removal of thyroid
○ Vit D deficiency
○ Autoimmune disease
○ Decreased Calcium and Increased Phosphorus
● Symptoms:
○ Cardiac arrhythmias
○ Muscle cramps/twitching
○ Paresthesia
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○ Irritability
○ Depression
○ Neck stiffness
Intervention:
○ Phenobarbital
■ Decreases irritability
○ Give parathyroid hormone
○ Diet:
■ Increase Calcium ( calcium gluconate) & Vit D
■ Decrease Phosphorus
Hyperparathyroidism:
● Cause:
○ Elevated thyroid levels
○ Thyroid tumor
○ Anything that causes hyperthyroidism
○ Excess Calcium and Decreased Phosphorus
● Symptoms:
○ Osteoporosis
○ Depression
○ Weakness
○ Gout
● Intervention:
○ Increased fluid intake
○ Parathyroidectomy
○ Decrease Calcium intake
Diabetes:
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Manifestations:
○ Polyuria
○ Polydispia
○ Polyphasia
○ Vision changes
○ N/T in peripheries
○ Recurrent infections
Findings:
○ Fasting: Greater than 126 mg/dL more than once
■ Fasting for at least 8 hours
○ Random: Greater than 200 mg/dL
○ A1C: 7+
■ 3 month average of blood sugar
○ Glucose level increases with age
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Type 1 DM:
○ Decreased insulin production
○ Born with it
○ Risk Factors:
■ Genetic predisposition
■ Environmental
■ Immunological
○ Managed with meds
Type 2 DM: (most common)
○ Insulin resistance
■ Impaired secretion of insulin
○ Can go on for years without detection
○ Risk Factors:
■ Modifiable risk factors:
● Obesity
● HTN
● HDL/ LDL/ Triglycerides
■ Non-Modifiable risk factors:
● Babies over 9 lbs
● Age
○ Manageable with lifestyle changes
■ Diet
■ Exercise
Insulin Therapy:
○ Rapid acting (Humalog, Novolog, Apidra)
■ Given before every meal
○ Short acting (HumalogR, NovolinR, IIetin II R)
■ Drugs are about the same as rapid except add an R at the end
○ Intermediate acting ( NPH, HumulinN, IIIetin II Lente, IIIetin II NPH, Novolin N)
■ Drugs are about the same as short except replace with N at the end
■ Taken at night
○ Very long acting ( Lantus, Levemir)
■ 1x/day before bed
○ Short-rapid: less than 15- 20 minutes
○ Short slower: 30-60 minutes
○ Long acting: 60 minutes
○ PEAK is where they are at risk for HYPOglycemia
○ HYPERglycemia is more at risk at the end of the duration
Morning Hyperglycemia:
○ Insulin Waning
■ Progressive rise throughout the night to morning
■ Treatment:
● Increase evening dose of intermediate or long acting insulin
○ Dawn Phenomenon:
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Normal blood glucose until 3 am then it increases
Treatment:
● Change injection time to evening
○ Somogyi Effect:
■ Normal/elevated blood glucose at bedtime, decreases at 2-3 am with
hypoglycemic levels.
■ Treatment:
● Decrease evening dose
● Give a bedtime snack
Oral antidiabetic agents:
○ Type 2 DM who need more than lifestyle changes
○ Side effect:
■ Hypoglycemia
○ Intervention:
■ Monitor blood glucose for hypoglycemia
Complications:
○ Hypoglycemia: Blood sugar less than 70
■ Symptoms:
● Tremors
● Tachycardia
● Slurred speech
● Confusion
● Seizures
● Death
■ Management:
● Assess patient
● A&O
○ Give glucose gel/tablets
○ OJ/Soda
○ Reassess in 15 minutes/ if Blood sugar is low then repeat
○ If normal- give protein / carb
● Unconscious
○ 50% dextrose injections /IV
○ Then flush with ~ 20 cc of saline
○ Reassess in 15 minutes/ if Blood sugar is low then repeat
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○ DKA:
■ Absence of insulin
■ Most common in type 1 DM
■ 600+ blood sugar levels
■ Symptoms:
● Hyperglycemia
● Dehydration
● Acidosis
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HSS:
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○ Low pH & Low HCO3
○ Kussmaul respirations
○ Elevated electrolytes
Treatment:
○ Assess
○ Rehydration
○ Insulin infusion
○ Reverse acidosis
○ Restore electrolytes
Metabolic disorder caused by lack of insulin
Most common in type 2 DM or people that dont have DM at all
Symptoms are the same as DKA except NO ACIDOSIS!
Treatment:
● Assess
● Rehydration
● Insulin infusion
● Restore electrolytes