Fluids and Electrolytes

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Fluid balance: Fluid mostly shifts between the intravascular and interstial spaces to maintain balance.
Third-spacing or Third-space fluid shift: Loss of ECF into a space that does not contribute to equilibrium between ICF and ECF.
Cations (+): Sodium, Potassium, Calcium, Magnesium and Hydrogen ion
Anions (-): Chloride, bicarbonate, Phosphate, Sulfate, Proteinate ions
Osmosis: The diffusion of water by a fluid concentration gradient through a membrane
Diffusion: The natural tendancy of a substance to move from an area of high concentration to an area of lower concentration.
Filtration: Hydrostatic pressure in the capillaries tends to filter fluid out of the vascular compartment into the interstitial fluid
-Ex: filtration of water and electrolytes from the arterial capillary bed to the interstial fluid (hydrostatic pressure is supplied by the pumping heart)
Active Transport: Implies that energy must be expanded for the movement to occur against the concentration gradient
-Ex: sodium/potassium pump in the cell membrane
Routes of gains and losses: -Kidney: urine 1ml/kg per hour, abour 1-2L daily for adults
-Skin: Visible loss (sweat) 0-1L, Not visible (evaporation) 600mL per day
-Lungs: water vapor 400mL per day
-GI tract: 100-200mL per day
Urine Specific Gravity: Measures the kidneys ability to excrete or conserve water
Blood Urea Nitrogen (BUN): Urea, an end product of protein metabolism
Creatine: An end product of muscle metabolism
Hematocrit: Measures the volume percentage of RBCs in whole blood
Hypovolemia: -D/T: abnormal losses through kidneys, skin, GI tract, decreased intake, bleeding, 3rd spacing shift
-S/S: increased HR, decreased B/P, reduced urine output, dizziness, weakness, dry mucus memebranes, increased specif gravity
-Tx: Isotonic fluids (LR, NS) are used if patient is hypotensive, hypotonic fluids are given once normotension is reached (1/2NS)
Hypervolemia: D/T: body retaining water and electrolytes in ECF, often occurs with CHF, renal failure, cirrhosis, steroid use
S/S: edema, pulmonary edema, low HGB, increased HR, increased B/P
Tx: low Na, restrict fluids, normal saline IV
Respiratory Acidosis: -D/T: pneumonia, pulmonary edema, drowning, asthma, cystic fibrosis, emphysema, CNS depression, inadequate excretion of CO2 (H2CO3 excess)
-S/S: increased pulse and resp. and B/P, SOB, confusion, lethargy
Lab: reduced pH (<7.35, PaCO2 > 45)
Tx: Improving ventilation, hydrate
Respiratory Alkalosis: -D/T: H2CO3 deficit, excessive loss of CO2, anxiety, fever, hyperventilation
-S/S: hyperventilation, difficulty concentrating, tingling
-Labs: pH > 7.45, PaCO2 < 35
-Tx: Breathing into paper bag, antianxiety drugs, reduce fever
Metabolic Acidosis: -D/T: HCO3 deficit, products from renal impairment (excessive acid), Diabetes Mellitus, starvation, loss of bicarbonate d/t diarrhea, excessive infusion of NaCl (IV)
-S/S: fruity breath, rapid and deep breathing, lethargy and weakness
-Labs: pH < 7.35, HCO3 < 21
-Tx: Na bicarb through IV push, restore F&E, correct underlying problem ie diarrhea...
Metabolic Alkalosis: -D/T: HCO3 excess, loss of acid through vomiting, GI suction, diuretic, K loss (Lasix), excessive base intake (antacids, IV bicarb, baking soda)
-Labs: HCO3 > 26, pH > 7.45
-S/S: decreased resp. rate and depth, dizziness, tetany-like symptoms, irritability, confusion
Tx: IV admin of K, treat vomiting, rid body of excess bicarb and retain CO2
Sodium: -Normal: 135-145
-Fx: controls and regulates water balance, conduction of nerves and muscles, stimulates thirst
-Most abundant electrolyte in ECF
-increase or loss in Na is almost always accompanied by and increase or loss in water
Hyponatremia: -Na < 135mEq/L
-Causes water to move out of vascular space into intracellular space (cell size increases)
-D/T: Losses through GI tract (diarrhea), profuse sweating, diuretics, drinking too much water, head injury, craniotomy, or stroke
-S/S: dry mucosa, cerebral edema, edema, hypotension, lethargy, confusion, muscle cramps, N/V, anorexia, poor skin turgor
-Tx: Encourage high Na diet, monitor I&Os, fluid restrictions, LR, or NS
Hypernatremia: -Na > 145
-Pulls water from the cells into the vascular space (dehydrating the cells)
-D/T: loss of fluids through diarrhea, hyperventilation, increased Na intake, Diabetes Insipidus, heat stroke, water deprivation
-S/S: thrist, dry mucus membranes, fatigue, disorientation, agitation, red tounge
-Tx: Restrict Na intake, administer diuretics, D5W or 1/2NS, I&Os monitored
Potassium: -Normal: 3.5 - 5.0
-Major intracellular electrolyte
-Regulated by the kidneys
-Effects all body systems, escpecially cardiac and neuromuscular
-Plays a role in acid base balance (K losses in metabolic alkalosis)
Hypokalemia: -K < 3.5 mEq/L
-D/T: losses through vomiting, GI suction, diarrhea, drugs that cause K loss (lasix), low intake (alcoholic, anorexia, debilitaed pts), excessive loss through kidneys
-S/S: muscle weakness, leg cramps, anorexia, N/V, decreased bowel motility, cardiac arrhthmias, decreased deep tendon reflexes, increased pH and bicarbonate
Tx: admin of KCl (IV or PO), (K can burn the veins and is very upsetting to the stomach), encourage intake of potassium rich foods
Hyperkalemia: -K > 5.0mEq/L
-D/T: Decreased losses through kindeys due to renal failure, hypoaldosteronism, K sparing diuretics, increased K intake, movement out of cells due to burns, tissue trauma
S/S: muscle weakness, cardiac arrhythmias, confusion, numbness in extremities, abscence of reflexes
Tx: Sodium bicarbonate (due to high K causing acidosis), Kayexalate, dialysis, avoid high K foods, Ca gluconate, IV glucose (pushes K back into cell)
Calcium: -Normal: 8.5 - 10.5
-Controlled by the parathyroid
-Affects bone reabsorption and is found primarily in bones
-Fx: bone formation, transmission of nerve impulses, muscle contraction, and blood coagulation
-Calcium is bound primarily to albumin but is binds to phosphate, citrate, and carbonate
Hypocalcemia: -Ca < 8.5mEq/L
-D/T: parathyroid or thyroid dysfunction, inadequate intake of Vitamin D, Excessive loss of intestinal secretions, alcohol abuse
S/S: numbness, tingling, muscle tremors, cardiac arrhythmias, tetany, seizures, hyperactive deep tendon reflexes, + Trousseau's and Chvostek's sign
Tx: IV Ca gluconate, Vit D supplement, Phoslo (Vit D and Ca), increase diet in vit D and Ca
Hypercalcemia: -Ca > 10.5
-D/T: Prolonged immobilization, parathyroid and thyroid conditions, ingestion of antacids, bone malignancy
-S/S: Flank pain, urinary calculi, weakness, reduced muscle tone, depressed deep tendon reflexes, cardiac arrest
-Tx: Hydrate pt to dilute calcium and promote excretion, lasix, calcitonin
Magnesium: -Normal: 1.5 - 2.5
-Controlled by the parathyroid, kidneys, and K concentration
Fx: neuromuscular activity, metabolism of carbohydrates and proteins, influences vasodilation
Hypomagnesemia: -Mg < 1.5mEq/L
-D/T: Excessive losses through GI suctioning, diarrhea, fisula draining, diuretics, chemotherapy, alcoholism, renal disease, burns
-S/S: 3T's (tremors, twitching, tetany), increased reflexes, seizures, + Trousseau's and Chvostek's sign
-Tx: MgSO4 IV (watch for hypotension), monitor for reduced HR, seizure precautions
Hypermagnesemia: -Mg > 2.5mEq/L
-D/T: Retention d/t renal failure, increased intake (antacids)
-S/S: lethargy, coma, muscle weakness, hypotension, impaired respirations, depressed deep tendon reflexes
-Tx: Hemodialysis, diuretics, 1/2NS, Ca gluconate

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