FLUID AND ELECTROLYTE IMBALANCE
Introduction Physiologic homeostasis
depends upon the normal fluid and electrolyte balance
electrolyte imbalance is needed to be studied to promote t he positive health outcomes. Positives outcomes are achieved throug h health promotion , healt h maintainance and health restoration strategies. Clearly water is not only responsible for bodys structure and function , it is also necessary for t he maintainance of equilibrium and of life itself. Fluid and electrolyte imbalance commonly accompany illnesses. Severe imbalances may results in deat h. Suc h imbalances affect not only t he acutely and chronically ill patients but also clients with faulty diets and those who take selected medications such as diuretics and gluccocorticoids preparations.So, every nurse must understand t he process of fluid and electrolyte balance, identify clients at risk of imbalances , intervene as appropriate and evaluate t he outcomes.
Fluids Body fluid compartments The two main fluid compartments in t he body are: 1. Intracellular fluid i.e, ICF 2. Extracellular fluid i.e,ECF 1. Intracellular fluid - It is located within the cell , constitutes about 40% of the body weight and 70% of the total water. The intracellular fluid provides the cell within the internal acqueous medium necessary for its c hemical functions . 2. Extracellular fluid It constitutes about 20% of the body weight and 30% of the total body weight . [Type text]
The extracellular fluid consist of interstitial fluid , intravasacular fluid , cerebrospinal fluid , intraocular fluid , synovial fluid , lymp hatic fluid and secretions of gastrointestinal tract . FUNCTIONS OF EXTRACELLULAR FLUID :
Transport nutrients , electrolytes , oxygen to cells and waste products for excretion .
Hydrolyzes
food for digestive process .
Regulates heat Lubricates
.
and cus hions joints and membranes .
MECHANISM
CONTROLLING FLUID AND
ELECTROLYTE MOVEMENT Many
different processes control t he movement of fluid and electrolyte between
the intracellular and extracellular spaces . DIFFUSION : Diffusion is the movement of molecules from an area of higher concentration to an area of lower concentration . FACILITATED DIFFUSION : In facilitated diffusion , one molecule moves from an area of higher concentration to an area of lower concentration with the help of some carrier . For example , glucose is transported into t he cell with the help of insulin as a carrier molecule . ACTIVE TRANSPORT : Active transport is a process in w hich molecules are moved from an area of lower concentration to an area of higher concentration and t hey require external energy for movement against the concentration gradient. OSMOSIS
: Osmosis is the flow of water between two compartments separated
by a membrane permeable to water but not to solute.
Osmosis
requires no
outside energy for movement. Water moves : from an area of low solute concentration to an area of higher concentration . from the compartment that is more diluted to side t hat is more concentrated. [Type text]
REGULATION OF FLUID ELECTROLYTE BALANCES HYPOTHALAMIC REGULATION / THIRST Water ingestion in the conscious client is regulated by t he hypothalamus . T he thirst mechanism is stimulated by hypotension and increased serum osmolality .A water deficit . Water ingestion will equal to water excretion in a client w ho has free accessible to water , a normal antidiuretic hormone ADH mechanism and a normal functioning . DECREASED VOLUME OF
INCREASED OSMOLA LITY OF
EXTR ACELLULAR FLUID
EXTACELLULAR FLUID
STIMULATES OSMORECEPTORS
DECREASED SALIVA
IN HYPOT HALAMIC
SECRETION
THIRST
CENTRE D RY
SE NSATION
OF
MOUTH
THIRST
WATER ABSORBED FROM GI TRACT
INCREASED
AMOUNT OF
EXTRACELLULAR FLUID
DECREASED OSMOLALITY OF EXTRACELLULAR FLUID
FIG. FACTOTS STIMULATING WATER INTAKE THROUGH THE THIRST MECHANISM
[Type text]
RENIN ² ANGIOTENSIN - ALDOSTERONE SYSTEM The renin- angiotensin aldosterone systemworks to maintain intravascular fluid balance and blood pressure . DECREASED RENAL PERFUSION / GLOMERULAR FILTRATION
R ENIN PRODUCED
RATE
BY KIDNEYS
ANGIOTENSINOGEN IS CONVERTED TO ANGIOTENSIN I WITH
HELP OF RENIN
ANGIOTENSIN I IS CONVERTED TO ANGIOTENSIN II WITH THE
HELP OF
LUNGS
ANGIOTENSIN II : y
increases thirst
y
increases release of aldosterone
y
increases blood pressure
ALDOSTERONE :
[Type text]
y
increases absorption of sodium ions
y
increases absorption of water
y
increases excretion of potassium
y
increases excretion of hydrogen ions
ACE IN
FIG . RENIN ANGIOTENSIN ALDOSTERONE MECHANISM
ANTIDIURETIC HORMONE ² PITUITARY REGULATION Antidiuretic hormone ADH , released by the posterior pituitary gland , regulates water excretion from the kidneys . INCREASED
SERUM OSMOLALITY
MECHANICAL VENTILATION
DECREASED BLOOD PR ESSURE
INCREASE R ELEASE
ADH
INCREASES
AND
ANAETHESIA , DRUGS , PAIN ,
PRODUCTION OF
DISTAL TUBULE
,
ANTIDIURETIC
PERMEAB ILITY
HORMONE
TO REABSORPTION
decreases urine output
increases blood volume
increases blood pressure
decreases blood osmolality
[ADH]
OF
WATER
FIG. ANTIDIURETIC HORMONE [ADH] RELEASE AND EFFECT Two disorders of antidiuretic hormone [ADH] production illustrates the effect of ADH on water balance and urine output . 1. Diabetes I nspidus - due to deficient of ADH production 2. Syndrome of inappropriate antidiuretic hormone [SIAD] - due to excess release of antidiuretic hormone .
[Type text]
ADRENAL CORTICAL REGULATION Extracellular fluid volume is maintained by a combination of hormonal influences . Hormones
released by the adrenal cortex help regulate bot h water and
electrolytes . Two groups of hormones secreted by the adrenal cortex are : i.
Glucocorticoids [Cortisol] Inflammatory action and increase serum glucose level .
ii.
Mineralocorticoids
[Aldosterone] Enhances sodium and potassium
excretion . When sodium is reabsorbed , water follows as a result of osmotic changes . Many
body systems , including fluid and electrolyte balance , are affected by
stress . STRESS SIGNALS TO
ANTERIOR INCREASES OF
HYPOTHALAMUS
PITUITARY
POSTERIOR PITUITARY
SECRETION
INCREASES
ACTH
OF
SECRETION
ANTIDIURETIC HORMONE
ADRENAL CORTEX
- KIDNEYS
INCREASES
ALDOSTERONE
INCREASES
INCREASES
CORTISOL
REABSORPTION
INCREASES
SODIUM
REABSORPTION
INCR EASES POTASSIUM
[Type text]
EXCRETION
WATER
FIG. EFFECT OF STRESS ON FLUID AND ELECTROLYTE BALANCE
RENAL REGULATION ² KIDNEYS The primary organs for regulating fluid and electrolyte balance are t he kidneys . They regulate the volume and osmolality of body fluids by controlling t he excretionof water and electrolytes. The renal tubules are t he main site of action for ADH and aldosterone .
As the filtrate [plasma] moves through renal tubules , selective reabsorption of water and electrolytes and secretion of electrolytes result in the production of urine t hat is generally different in composition and concentration than plasma [filtrate] . T his helps to maintain normal plama osmolality , electrolyte balance , blood volume and acid-base balance .
Impaired
kidney function may leads to edema , potassium and p hosp horous
retention , acidosis and ot her electrolyte imbalances .
ATRIAL NATRIURETIC PEPTIDE CARDIAC ATRIA
RELEASE
ATRIAL
INHIBITS RENIN
INCREASES
URINARY EXCRETION
DECREASES BLOOD
[Type text]
VOLUME
OF
NAT RIURETIC
FACTOR [A NF]
SECRETION
SODIUM AND WATER
AND CAUSES VASODILATION
GASTROINTESTINAL REGULATION Most
of the bodys water is excreted by kidneys . A small amount of fluid is
normally eliminated by t he GI tract in faeces , but sometimes or usually diarr hoea and vomiting leads to fluid and electrolyte imbalances .
INSENSIBLE WATER LOSS INSENSIBLE
WATER
LOSS:
which is invisible vapourization from t he lungs and skin
, assists in regulating body temperature . Normally about 900ml per day is lost . SENSIBLE WATER
LOSS:
excess sweating / sensible perspiration caused by fever
or high environmental temperature may lead to large loss of water and electrolyte .
FLUID IMBALANCES EXTRACELLULAR FLUID VOLUME DEFICIT DEFINITION : Extrcellular fluid volume deficit is commonly called dehydration or decrease in intravascular and interstitial fluid . CAUSES : Lack
of fluid intake due tp impaired t hirst mechanism .
Excessive fluid output t hrough diaphoresis , GI suction , blood loss , burns , deceased antidiuretic hormone .
Alteration in any of the regulators of fluid balances .
Stimulants result in increased Renin-Angiotensin-Aldosterone response t hat causes sodium retention .
CLINICAL FEATURES :
[Type text]
Loss
of body weight .
Changes in intake and output i.e, t hirst and urine output decreases .
Changes in vital signs : systolic blood pressure decreases , weak pulse , C VP decreases , pulmonary capillary wedge pressure decreases , heart rate increases ,
flat jugular vein .
Mouth
mucous membrane becomes dry .
Sunken eyes .
Cracked lips .
Furrows on tongue .
Tenting of skin [decreasedskin turgor] .
Muscle
weakness .
Decreased and hard faeces .
Hallucinations
and confusion .
DIAGNOSTIC EVALUATION : Hypernatremia Osmolality Plasma
: > 295 mOsm/kg
sodium : > 145 mEq/ L
BUN : > 25mg/dl
Plasma
glucose : > 120 mg/dl
Hematocrit
: .55%
MANAGEMENT
1.
ORAL REHYDRATION
Oral glucose replacement solution are palatable , a
good source of fluid , glucose and electrolytes and even t hey are absorbed quickly. 2.
INTRAVENOUS R EHYDRATION
I ntravenous fluids are used for replacement
. The volume of fluid is calculated on basis of clients weig ht and other factors. y
[Type text]
Isotonic
ECFVD is treated with isotonic solution .
3.
y
Hypertonic
y
Hypotonic
Monitoring
ECFVD is treated with hypotonic solution .
ECFVD is treated with hypertonic solution .
for complications of fluid restoration A client wit h severe
ECFVD is accompanied by severe heart , pulmonary , liver or kidney disease cannot tolerate large volume of fluid or sodium wit hout the risk for developmemt of heart failure . For unstable client , monitors are used to detect increasing pressure from fluid . If
deficit has existedfor more than 24hrs , it is dangerous
to correct this deficit too rapidly . Urine output , body weig ht and laboratory volumes of sodium , osmolality , BU N and potassium are monitored closely . 4. Correction of underlying problem : y
Antiemetics
y
Antidiarrhoeals
y
Antibiotics
y
Antipyretics
NURSING MANAGEMENT
1. Deficit fluid volume y
Restore
oral fluid intake .
y
Restore
fluid by intravenous .
y
Reduce
risk of deficit fluid volume .
y
Control of underlying problems .
y
Monitor
for complications .
2. Impaired oral mucous membrane
3.
y
Oral
y
Apply lip moisturizer.
y
Rinse
y
Examine clients mout h with penlig ht for debris .
Risk
[Type text]
care regularly 2-4 hourly . clients mout h every 1-2 hourly .
for injury
y
Provide
y
Place
safety through step progression position c hange .
alarm monitors on clients bedside .
y
Restraints
sometimes may be needed .
EXTRACELLULAR FLUID VOLUME EXCESS DEFINITION : Extarcellular fluid volume excess is a fluid overload or overhydration. CAUSES :
Compromised regulation of fluid movement and excretion , example Hypothtroidism
, Renal disorder , Decreased plasma protein .
Excessive ingestion of fluids or foods containing sodium , example Excessive amount of saline intravenous , I ngestion of high sodium food , Excessive use of enema wit h sodium .
Increased
ADH and aldosterone , example Certain barbiturates , narcotics
, Cushing syndrome , Glucocortiods , S IADH . CLINICAL FEATURES :
Cough , Dypnea , Crackles , can be ausculcated over t he lung area .
Pallor
, Cyanosis , Deceased tissue perfusion , Increased carbon dioxide
blood gases abnormalities .
Systematic venous engorgement
Jugular
vein distension .
Peripheral
vein filling time greater t han 5 seconds .
Bounding pulse .
Elevated blood pressure .
Increased
right atrial CVP and PCWP .
DIAGNOSTIC EVALUATION : Plasma
osmolality : < 275 mOsm/kg
Plasma
sodium : < 135 mEq/ L
Hematocrit
: < 45%
Specific gravity : < 1.010
[Type text]
BUN : < 8 mg/dl
MANAGEMENT
:
Restriction
of sodium and fluids : Because sodium retains water , sodium
intake is commonly restricted especially in t hose clients with renal or heart failure . Promoting
urine output : Mild diuretics and digitalis promote fluid loss and
diuretics also causes excretion of magnesium and potassium loss in urine . NURSING MANAGEMENT
:
1. Excess fluid volume y
Reduce
sodium and fluid intake .
y
Mobilize
y
Reduce
fluid electrolye imbalances .
complications like digitalis toxic effects , cerebral.
INTRACELLULAR FLUID VOLUME DEFICIT DEFINITION : Intracellular fluid volume deficit is decrease in fluid wit hin the cells. CAUSES :
Excessive fluid loss .
Insufficient
fluid intake .
Failure of regulatory mec hanism .
Loss
of GI fluid from vomitting , diarro hea , gastrointestinal suctioning ,
intestinal fistula and intestinal drainage .
Haemorr hage
.
Chronic abuse of laxatives and enemas .
Water and sodium losses during sweating from exercise or increased environmental temperature .
Excessive renal losses of water and sodium from diuretic t herapy .
CLINICAL FEATURES : [Type text]
Dry and sticky mucous membrane .
Decreased urine output .
Anxiety and confusion .
Diminished skin turgor .
Dry , pale and cool extremities .
Orthostatic hypotension
.
Decrease capillary refill .
Increase
body temperature .
Weight loss .
Thirst .
DIAGNOSTIC EVALUATION :
Serum electrolyte : sodium increases and potassium decreases .
Serum osmolality : osmolality is high .
Hematocrit
: high .
Urine specific gravity : high .
Central venous pressure : low .
MANGEMENT
1.
Oral
:
rehydration : It is the safest and most effective treatment for fluid
volume deficit in alert clients w ho are able to take oral fluids . Adults requires minimum of approximately 30ml per kg body weig ht for maintainence . 2. Intravenous therapy : When fluid deficit is severe or client is unable to ingest fluid , the intravenous route is used to administer replacement fluid. Isotonic
: 5% dextrose in water D5W . 0.9% sodium chloride . 5% dextrose and 0.45% sodium c hloride . Ringers
solution .
Lactated Hypertonic
ringers solution .
: 10% dextrose in water .
20% dextrose in water . 50% dextrose in water . [Type text]
3% sodium chloride . Hypotonic
: 0.45% sodium c hloride .
3. Fluid c hallenge : A fluid c hallenge , the rapid administration of a designated amount of intravenous fluid may be performed to evaluate fluid volume when urine output is low and cardiac or renal functioning is questionable . NURSING MANAGEMENT
:
1. Deficit fluid volume . y
Assess intake and output regularly .
y
Monitor
y
Assess vital signs , C VP , peripheral pulse .
y
Weight the client daily .
y
Adminster intravenous fluids .
y
Monitor
fluid balances regularly .
laboratory values : electrolytes , serum osmolality , BU N and
hematocrit
.
2. Ineffective tissue perfusion .
3.
y
Monitor
c hanges in level of consciousness .
y
Monitor
serum creatinine , BUN , cardiac enzymes .
y
Change position 2 hourly .
Risk
for injury .
y
Keep side rails of bed up .
y
Slowly raise the client from supine to sitting t hen to standing position.
INTRACELLULAR FLUID VOLUME EXCESS DEFINITION : When sodium and water are retained wit hin the cells i.e, known as intracellular fluid volume excess . CAUSES : [Type text]
Fluid overload i.e, water and sodium retention .
Administration of excessive amount of hypo-osmolar intravenous fluid .
Clients continuously receiving 5% dextrose in water.
Impaired homeostasis
mechanism .
Stress condition causes increase in release of ADH and aldosterone .
Psychiatric
disorders like sc hizophrenia .
CLINICAL FEATURES : Peripheral Increase
or generalized oedema .
in total body water causes weig ht gain .
Circulatory overload causes y
Full , bounding pulse .
y
Distended neck and perip heral vein .
y
Increased
y
Cough , dyspnoea , ort hopenea .
y
Moist
y
Pulmonary
y
Increased
y
Ascites .
CVP .
crackles in lungs . edema if severe ICFVE .
urine output .
Altered mental status and anxiety .
Confusion and unknown fear .
DIAGNOSTIC EVALUATION Plasma
sodium : < 125mgEq/L
Hematocrit MANAGEMENT
1.
: decreases
:
Medication
: Diuretics are commonly used to treat fluid volume excess .
They inhibit sodium and water reabsorption , increasing urine output . LOOP
DIURETICS :Furosemide [Lasix] .
THIAZIDE
LIKE
POTASSIUM
[Type text]
DIURETICS : Chlorothiazide [Diuril] .
SPARING DIURETICS : Spironolactone [Aldactone] .
2. Fluid Management : Fluid intake may be restricted to client having fluid volume excess . The amount of fluid allowed per day is prescribed by primary care provider . All fluid must be calculated , including meals and thatis used to administer medication orally or intravenously . 3. Dietary management : Because sodium retention is a primary cause of fluid volume excess , so sodium restriction diet is often prescribed . NURSING MANAGEMENT
:
1. Excess fluid volume y
Assess vital signs , heart sounds , CVP , and volume of peripheral arteries .
y
Assess for the presence of edema .
y
Obtain
y
Provide
y
Teach client about sodium restricted diet .
y
Report
y
Administer oral fluids cautiously , ad hering to any prescribed fluid
weight daily at same time of day . oral hygiene 2hourly .
significant changes in serum electrolytes .
retention . y
2.
Risk
Administer diuretics as prescribed . for impaired skin integrity
y
Assess skin in pressure area and over bony prominences .
y
Change position of client 2 hourly .
y
Provide
alterating pressure mattress , foot cradle , heel protectors
, to reduce pressure on tissues . 3.
[Type text]
Risk
for impaired gas exc hange
y
Ausculcate lungs for presence of w heezes and crackles .
y
Place
y
Monitor
y
Administer oxygen as indicated .
y
Ausculcate heart for extra heart sounds .
in fowlers position if having dysponea or ort hopenea . oxygen saturation level and ABGs .
EXTRACELLULAR FLUID VOLUME SHIFT [ THIRST SPACING ] DEFINITION : Extracellular fluid volume s hift is a change in the location of Extracellular fluid between intravascular and interstitial space . Fluids shifts are of types : 1.
Vascular
fluid shifts to interstitial space .
2. Interstitial fluid s hift to vascular space . Fluid that shifts into interstitial space and remains t here is known as third spacing. Common sites for t hird spacing are : Pleural
cavity .
Peritoneal
cavity .
Pericardial
sac .
ETIOLOGY : Increased hyrostatic Increased
pressure .
capillary permeability .
Decreased serum protein level .
Obstruction
of venous portion of capillary or non functional lymphatic
drainage system . Pathologic
process that triggers the inflammatory process .
Decreased protein intake production , storage or increased loss in PEM and liver or kidneys .
Altered lymphatic function / Venous thrombosis impairs fluid return to right atrium , thus producingfluid s hifting .
Peritoneal
cavity impaired protein synt hesis , decreased colloidal osmotic
pressure . CLINICAL FEATURES : Pallor [Type text]
, cold limbs , weak and rapid pulse .
Hypotension
, oliguria , decreased level of consciousness .
Bounding pulse .
Engorgement of peripheral and jugular vein .
DIAGNOSTIC EVALUATION :
Serum sodium : increased .
BUN : increased .
Urine specific gravity : increased .
MANAGEMENT
Replace
fluid :
y
Intravenous
fluid administration to replace intravascular volume .
y
Albumin given to replace protein loss from trauma .
y
Fluids are titrated to maintain adequate blood pressure , C VP , PCWP, urine output .
Stabilize other problems : y
Intravenous
antibiotics are given to prevent sepsis .
y
Vasodilators
are given to maintain blood pressure .
y
Steroids are given for inflammatory disorders .
Monitor the
followings regularly :
y
Abdominal girth 8 hourly .
y
Limb
y
Skin integrity to prevent skin breakdown of edematous area .
y
Urine output 8 hourly .
y
Plasma
circumferences .
sodium , BU N and creatinine level .
ELECTROLYTES Electrolytes are substances whose molecules dissociates or splits into ions w hen placed in water .
[Type text]
IONS
: Ions are electrically c harged particles .
CATIONS : Cations are positively c harged particles . For example
Na+
, K+ etc .
ANIONS : Anions are negatively c harged particles . For example Cl- etc. NON-ELECTROLYTE
: Non electrolyte are substances that do not dissociate into
ions in solution .For example Glucose and urea . OSMOLA LITY
: A measure of the total substance [solute] concentration per
kilogram of solvent . OSMOLARITY
: A measure of the total substance [solute] concentration per litre of
the solvent . SOLUTE : Substance that is dissolved in solvent . SOLUTION : Homogenous mixture of solutes dissolved in a solvent . SOLVENT : Substances that is capable of dissolving a solute .
MEASUREMENT OF
ELECTROLYTES
Electrolytes can be measured by weight or combining power . T he unit of weig ht is milligram per deciliter [mg/dl] and combining power is miliequivalents per litre [mEq/L] . Milliequivalents equals weig ht [in milligrams ] divided by atomic weight and multiplied by the valence .
SODIUM IMBALANCES Sodium is t he most plentiful electrolyte in extracellular fluid [ECF]. Sodium is t he primary regulator of volume , osmolality and distribution of ECF . Normal
serum sodium : 135 145 mEq/ L
[Type text]
EXTRACELLULAR
EXTRACELLULAR EXPANSION
CONTRACTION
VOLUME
DEFICIT
RESULTING
FROM: VOLUME
Water deficiency : Hypernatremia
FROM :
Sodium deficiency : Hyponatremia Isotonic
EXCESS RESULTING
Water excess : Hyponatremia
ECF deficit : Normal sodium
Sodium excess : Hypernatremia Isotonic
ECF excess : Normal sodium
FIG . DIFFERENTIAL ASSESS MENT OF EXTRACELLULAR FLUID VOLUME HYPO-OSMOLAR
HYPER-OSMOLAR
IMBALANCE
IMBALANCE
Na+Loss>water loss
OSMOLAR
ISOTONIC LOSS
Na+
ISOT ONIC
BALANCE
HYPO-OSMOLAR
IMBALANCE
[Type text]
OSMOLAR
Water gain>Na+gain
HYPER-OSMOLAR
FLUID COMPARTMENTS
GAIN
BALANCE
Water loss>Na+loss
FIG. ISOTONIC GAINS AND LOSSES AFFECT
Gain>water gain
BALANCE MAINLY
THE EXTRACELLULAR
HYPONATRENMIA
: When sodium levels are low , water is drawn into t he cells of
the body , causing t hem to swell. HYPERNATREMIA
: High levels of sodium in extracellular fluid , draw water out of
body cells , causing them to shrink . [Type text]
REGULATION OF SODIUM BALANCE IN THE BODY :
Kidneys are the primary regulator of sodium balance in t he body . Mechanisms are : Renin
Angiotensin A ldosterone System : Promotes the renal tubules to
reabsorb sodium .
Antidiuretic hormone is released from posterior pituitary AD H promotes sodium and water reabsorption in t he distal tubules of kidneys .
HYPONATREMIA DEFINITION : Hyponatremia is a serum sodium level less t han 135 mEq/dl . It may
result from a loss of sodium from the body , but it may also be caused by water gain than dilute ECF . ETIOLOGICAL FACTORS : Inappropriate
use of sodium free or hypotonic
IV
fluids after surgery or
trauma .
Administration of fluids in patients wit h renal failure or psyc hiatric disorders .
SIADH will result in dilutional hyponatremia .
Loss
of sodium rich body fluid from G IT , kidneys or skin directly .
Excessive hypotonic solutions .
PATHOPHYSIOLOGY
Due to etilogical factors Decreased osmolality of intracellular fluid Cells swelled [water s hift from ECF into intracellular fluid ] Drops serum osmolality Hyponatremia
[Type text]
CLINICAL FEATURES : NEUROLOGIC MANIFESTATION y
Cellular edema
y
Headache
, lethargy
y
Irritability
, confusion
y
Personality changes
y
Tremors , seizures , coma
y
Hyperrflexia
y
Depression , dulled sensorium
, muscle spasm
MUSCULAR MANIFESTATIONS
:
y
Muscle
y
Weakness
y
Fatigue
:
cramps
GASTROINTESTINAL
MA NIFESTATIONS
y
Anorexia
y
Nausea
y
Weight loss
y
Dry mucous membrane
y
Abdominal cramping
y
Diarrhoea
:
, vomitting
CARDIOVASCULAR MANIFESTATIONS : y
Postural hypotension
y
Tachycardia
y
Rapid
y
Decreased CVP and jugular venous filling
, thready pulse
DIAGNOSTIC EVALUATION : Health history
[Type text]
:
y
Current manifestations
y
Precipitating
y
Chief complaints
factors
Physical y
assessment :
Head
to toe examination for detecting the clinical features or any
abnormality in body functioning .
Diagnostic tests : y
Serum potassium : < 135 mEq/ L .
y
Serum osmolality : < 275 m Osm/kg .
y
24 hour urine specimen to evaluate sodium excretion .
MANAGEMENT
1.
Medications
:
y
Sodium containing fluids are given .
y
Fluids like Isotonic Ringers solution or Isotonic saline is recommemded .
y
Loop
diuretics are given .
y
Drugs related to sign and symptoms are given .
2. Fluid and dietary management y
NURSING
1.
2.
Risk
If hyponatremia
is mild , increase intake of sodium ric h diet .
MANAGEMENT
for imbalanced fluid volume
y
Monitor
y
Weight daily .
y
Use IV flow control devices .
y
Explain and clear doubts of client and his family .
Risk
intake and output .
for ineffective cerebral tissue perfusion
y
Monitor
serum electrolytes and serum osmolality .
y
Assess neurological c hanges .
y
Monitor
y
Assess muscle strength and tone and deep tendon reflexes .
mental status and orientation .
HYPERNATREMIA [Type text]
DEFINITION : Hypernatremia is a serum sodium level greater t han 145 mEq/L . ETIOLOGICAL FACTORS :
Altered thirst .
Inability
to respond to thirst sensation or obtain water .
Decreased synthesis of ADH from posterior pituitary gland .
Excessive sweating.
Diarrhea .
Diabetes inspidus .
Oral
electrolyte solutions or hyperosmolar tube-feeding formulas .
Excessive IV fluid suc h as normal saline , 3% or 5% sodium c hloride , or sodium bicarbonate .
Primary hyperaldosteronism [ hypersecretion
of aldosterone ].
PATHOPHYSIOLOGY
Two regulatory mechanisms protect the body from hypernatremia : i.
Excess sodium in ECF stimulates t he release of ADH , so more water is retained by the kidneys .
ii.
Thirst mechanism is stimulated to increase t he intake of water .
CLINICAL FEATURES NEUROLOGICAL MANIFESTATIONS
y
Lethargy
, weakness .
y
Irritability
y
Seizures , coma and death .
y
Altered mental status .
y
Decreased level of consciousness .
y
Muscle
.
twitching .
Dry and sticky mucous membrane .
DIAGNOSTIC EVALUATION Health history [Type text]
:
:
y
Current manifestations .
y
Precipitating
y
Chief complaints .
Physical y
factors .
assessment :
Head
to toe examination for detecting the clinical features or any
abnormality in body functioning .
Diagnostic evaluation : y
Seum sodium : > 145mEq/ L .
y
Serum osmolality : > 295m Osm/kg .
y
Water deprivation test is performed .
MANAGEMENT
MEDICATIONS
:
y
Oral
or intravenous water replacement .
y
Hypotonic
intravenous fluid[0.45% sodium c hloride or 5% dextrose in
water ]. y
Diureticsgiven to increase sodium excretion.
NURSING
1.
Risk
MANGEMENT
for injury
y
Maintain
y
Monitor
serum sodium and osmolality .
y
Monitor
neurologic functioning .
y
Institute
safety precautions as necessary.
y
Make
P OTASSIUM
[Type text]
fluid replacement .
client oriented to time , place and person .
IMBALANCES
[Type text]
[Type text]
[Type text]
