Fluid and Electrolytes Flashcards
What are the 2 main compartments of total body water and what percent of total body water do they represent?
Intracellular (65%)
Extracellular (35%)
What is the extracellular fluid composed of and by what percent?
-Plasma (8%)
-Interstitial fluid (which includes lymph fluid)- 25%
-Transcellular fluid (2%)
what comprises transcellular fluid?
Gastrointestinal, respiratory, urinary, glandular, interocular, cerebrospinal fluid
How many mL/day of fluid is intake? How many mL/day is output?
Both input and output is 2500 ml/day
What does fluid intake include (3)? Include how many mL per day
Metabolism (400 mL)
Food (500 mL)
Drinking (1600 mL)
What does fluid output include (4)? Include how many mL per day.
Feces (100mL)
Breathing (400 mL)
Skin (500 mL)
Urine (1500 mL)
How are fluids and electrolytes regulated (by what mechanisms)? (3)
- Osmosis and osmotic pressure
- Diffusion
- Filtration
Describe how osmosis regulates fluids
Regulation of intracellular and extracellular fluids is based on fluid shifts from a lower concentration of solute to higher concentration of solute through the membrane separating them
Describe how osmotic pressure regulates fluids
It’s the ability of a solution to draw water across a membrane, and is affected by the tonicity (the ability of solutes to cause an osmotic driving force that promotes the movement of water across a membrane from one compartment to another)
Describe how diffusion regulates fluid and electrolytes
Occurs as a result of the membrane transport system which assists with the passage of a specific ion or molecule through the cell membrane. Any change in concentration of electrolytes in either the interstitial fluid or plasma, the change is swiftly followed by a shift in electrolytes to restore balance in the concentration.
How does filtration regulate fluid and electrolyte balance?
The process by which water and dissolved substances (solutes) cross a membrane as a result of hydrostatic pressure.
What is hydrostatic pressure?
The pressure exerted on the walls of blood vessels by fluid (primarily water). Movement of solutes occurs from an area of high hydrostatic pressure to an area of low hydrostatic pressure
What are examples of filtration regulating fluids and electrolytes?
Glomerular filtration system of the kidneys and the arterial end of the capillary
What are the regulatory mechanisms that maintain homeostasis in fluid and electrolyte balance? (Homeostasis between fluids and regulation of input and output are achieved by what systems?) (3) AND an additional mechanism of fluid loss.
- Renal system
- Endocrine system
- Respiratory system
- Insensible losses
How does the renal system regulate fluid volume and electrolyte balance to maintain homeostasis?
Through the glomeruli and renal capillary network selective reabsorption of water and electrolytes occur maintaining homeostasis of plasma osmolality and fluid. Urine output is 1-2 L per day
What is the average urine output per day?
1-2 L per day
What is the role of the endocrine system in controlling fluid and electrolyte balance? (3)
- Renin-angiotensin-aldosterone system
- Antidiuretic hormone
- Natriuretic peptides
How does natriuretic peptide hormones influence fluid and electrolyte balance?
Released from specialized cells within the walls of the atrium (atrial natriuretic peptide) and ventricles (brain natriuretic peptide) in response to increased blood volume and blood pressure. The walls of the atrial and ventricles stretch beyond their normal size. The stretching of the atrial and ventricle walls stimulates the release of ANP and BNP which results in reabsorption of sodium and water by the kidneys and the increase in glomerular filtration rate result in increased urine output that is high in sodium
In what individuals would you see an increase in ANP and BNP? (natriuretic peptide hormones)
In response to increased circulating blood volume as seen in heart failure or a normal response to fluid volume excess
What is the role of the respiratory system in fluid and electrolyte regulation?
Fluid loss occurs from the lungs through vaporization. With exhalation the warmed humidified air (that was inspired) is released from the lungs.
How may mL of water is lost through the lungs daily? What can increase this amount?
300 mL. This amount can be higher during hyperventilation or tachypnea or if the patient is receiving mechanical ventilization
What does insensible water loss occur through? (3)
Skin, lungs, and feces
What types of patients experience insensible water loss? (6)
Hypermetabolic states such as: trauma, burns, fever, and thyroid crisis
Via GI tract in severe diarrhea or ulcerative colitis
How does trauma and burns contribute to insensible water loss?
Fluid loss from impaired skin integrity
How does fever contribute to insensible water loss?
Increased perspiration
How does a thyroid crisis contribute to insensible water loss?
hypermetabolism
Why can insensible water loss be significant?
It is not controllable and can be significant in the total amount because of the lack of awareness of this fluid loss
What are indicators of fluid status (6)?
- Body weight
- Serum osmolality
- BUN
- Creatinine
- Urine specific gravity
- Physical assessment findings
What are common physical assessment findings indicating fluid status? (4)
- Body weight
- Oral mucous membranes
- Skin turgor
- Edema
What is a normal BUN level?
8-21 mg/dl
What physical assessment findings indicate fluid volume deficits? (3)
- Weight loss
- Dry oral mucous membranes
- Poor skin turgor (tenting)
What physical assessment findings indicate fluid volume excess? (2)
Weight gain and edema
Since BUN level varies with fluid intake and urine output, what does this reflect?
Fluid status and renal function
When do you see increased BUN? (4)
When there is decreased perfusion of kidneys seen in impaired renal function secondary to:
1. Sepsis
2. Shock
3. Stress
4. Congestive heart failure
Why is there an increased BUN level in sepsis, shock, and congestive heart failure?
There is decreased perfusion of kidneys because blood is shunted away from the kidneys to maintain perfusion to heart and brain
What conditions do you see a decreased BUN? (3)
- Syndrome of inappropriate Anti Diuretic Hormone (SIADH)
- Liver failure
- Malnutrition
Why is there a decreased BUN in Syndrome of Inappropriate Anti Diuretic Hormone (SIADH)?
Retention of water occurs diluting circulating blood volume; therefore, decreased BUN
Why is there a decreased BUN in liver failure and malnutrition?
Decrease in protein metabolism
Which is a better indicator of kidney function BUN or creatinine? Why?
Creatinine; Creatinine (the by-product of muscle creatinine phosphate metabolism) production is constant as long as muscle mass remains constant
What is the normal level of creatinine? What is the ratio of BUN to creatinine?
0.5-1.2 mg/dL
10:1 - 20:1
What does specific gravity measure? What does it reflect?
Dissolved chemicals in urine; Reflects ability of kidneys to concentrate urine
What is the normal level of SPECIFIC GRAVITY?
1.005-1.030
What factors affect normal range of specific gravity? (3)
- Hydration status
- Urine volume
- Number of particles
High values of specific gravity indicate what and can be seen in what patients?
Indicates concentrated urine
1. Decreased renal perfusion
2. Dehydration
3. Syndrome of Inappropriate Anti Diuretic Hormone (SIADH)
Low values of specific gravity indicate what and can be seen in what patients?
Indicates dilute urine
1. Diuretic use
2. Diabetes insipidus
3. Increased fluid intake
Compare fluid volume deficit and fluid volume excess for the following parameters:
1. Weight
2. Vital signs ( HR, BP, Respirations)
3. Skin turgor
4. Edema
5. Jugular vein
6. Urine output
7. Urine specific gravity
- Decreased fluid volume deficit; Increased fluid volume excess
- Heart rate is increased in both; BP: Decreased (orthostatic hypotension) in fluid volume deficit; Increased in fluid volume excess; RESPIRATIONS: Clear in fluid volume deficit; Crackles or wheezing in fluid volume excess
- Decreased skin turgor in fluid volume deficit; Increased in fluid volume excess
- No edema in fluid volume deficit; Dependent edema in fluid volume excess
- Jugular veins flat in fluid volume deficit; Possible distention in fluid volume excess
- Decreased urine output in fluid volume deficit; Normal or low in fluid volume excess
- Increased urine specific gravity in fluid volume deficit; Decreased in fluid volume excess
What are the primary intracellular electrolytes (3)
- Potassium
- Magnesium
- Phosphorus
What are the primary extracellular electrolytes (3)
- Sodium
- Chloride
- Bicarbonate
What is the normal value range for serum sodium?
135-145
What is the normal value range for serum chloride?
97-107
What is the normal value range for serum potassium?
3.5-5.3
What is the normal value range for serum magnesium?
1.6-2.2
What is the normal value range for total serum calcium?
8.2-10.2
What is the normal value range for ionized calcium?
4.6-5.3
What is the normal value range for serum phosphorus?
2.5-4.5
What are the 3 main causes of hypovolemia (fluid volume deficit)?
- Excessive loss of fluids
- Insufficient intake of fluids
- Fluid shifts into interstitial space (3rd spacing) from vascular space
What causes excessive loss of fluids? (7)
- GI loss through vomiting, diarrhea, and NG suctioning
- Increased perspiration during exercise or extreme heat without adequate fluid replacement
- Hemorrhage
- Diabetes insipidus
- DKA
- Adrenal insufficiency
- Aggressive treatment of fluid volume excess with diuretics
What conditions do you see third spacing? (4) Third spacing is often related to what?
- trauma
- burns
- cirrhosis
- right sided heart failure
Often related to decreased oncotic pressure
With 3rd spacing, fluid can shift into (4)? Name space and condition name
- Abdomen (ascites)
- pleural space (pleural effusion
- soft tissues (peripheral edema)
- lost through disrupted skin integrity as with burn injuries
What are the normal values of hemoglobin for men and women?
Men: 14-17.3
Women: 11.7-15.5
What are the normal values of hematocrit for men and women?
Men: 42-52%
Women: 36-48%
What lab values do you evaluate for hypovolemia? (6)
- Electrolytes (specifically sodium and potassium)
- Hemoglobin and hematocrit
- Serum osmolality
- BUN in relation to creatinine
- Urine specific gravity
- Urine osmolality
What labs are increased in hypovolemia? (6)
- Sodium
- Hemoglobin and hematocrit (however, it is decreased if fluid volume deficit is secondary to hemorrhage)
- Serum osmolality
- BUN in relation to creatinine
- urine specific gravity
- urine osmolality
Why is BUN: Creatinine elevated in hypovolemia?
Due to decreased renal perfusion and function which occur in shock or fluid volume deficit
Why could potassium be low in hypovolemia?
In severe GI fluid loss such as diarrhea because of the rapid passage of stool through the colon
What electrolytes do GI fluids contain? (4)
- Sodium
- Potassium
- Bicarbonate
- Chloride
What are the clinical manifestations of hypovolemia? (6)
- Weight loss
- Decreased skin turgor
- Concentrated urine
- Oliguria (low urine output)
- Thirst
- Dry mucous membranes
What additional clinical manifestations are seen with significant fluid loss? (6)
- Weak, rapid peripheral pulses
- Flattened neck veins
- Hypotension
- Anxiety
- Restlessness
- Cool, clammy, skin
What conditions do you see severe rapid, fluid loss? (3)
- Hemorrhage
- Burns
- Extensive loss from GI tract
What is the medical management of hypovolemia? What is the goal?
-ID fluid loss
-Intake of oral fluids (preferred method of water replacement if deficit isn’t severe)
-IV isotonic solutions (0.9% normal saline) or Lactated Ringers
Expands plasma volume and corrects hypotension
Once hypotension has been corrected, what IV solutions are administered and why?
D5 0.45% NaCl or 0.45% NaCl can replace deficits in total body water and are used as maintenance fluids
After administering IV fluids, what is the medical management of hypovolemia?
Assess VS, pulmonary and neuro function, urine output
What does improvement in neuro status include?
Decreased restlessness and increased mental status
What are the clinical manifestations of fluid overload (4)?
- Increased respiratory rate
- Cough
- Development of crackles
- Decreased oxygen saturation
How does urine output evaluate fluid status?
If urine output continues to be low, further evaluation of fluid status and renal perfusion assists in determining if additional fluid is required
What are the complications of hypovolemia? (3)
- Hypovolemic shock
- Decreased LOC
- Tachypnea
What are the signs and symptoms of hypovolemic shock? (3)
- hypotension
- tachypnea
3.signs of organ hypoperfusion
What are the signs of organ hypoperfusion? (2)
- Cool, clammy skin 2. oliguria progressing to anuria (lack of urine output)
What is the nursing management of hypovolemia?(4)
- Health history
2, Physical assessment - Review of diagnostic results
- Calculating I & O’s
What are the clinical signs and symptoms of hypovolemia identified during the physical assessment ? (9)
- Dry mucous membranes
- Poor skin turgor
- Weak peripheral pulses
- Change in VS: HR >100 BPM and hypotension can indicate significant fluid volume deficit
- Weight loss
- Urine specific gravity, color and volume
- Hypotension (especially hypotension)
- Tachycardia with weak thready pulse
- Monitor VS to assess patient’s response to treatment
What is asked during the health assessment for hypovolemia?
Onset and duration of clinical manifestations, recent illness, medication use
What lab data indicates hypovolemia? (3)
Increased:
1. Hemoglobin and hematocrit
2. Sodium
3. BUN
What physical assessment findings can the nurse identify as signs of correction for hypovolemia? (3)
- Moist mucous membranes
- Increased skin turgor
3.Increased urine output
What does the nurse monitor to evaluate a patient’s response to treatment for hypovolemia? (3)
- Physical assessment (moist mucous membranes, increased skin turgor, and increased urine output)
- Monitor I&O’s (hourly)
- Monitor lab results (serum electrolytes, osmolality and hemoglobin and hematocrit
What is hypervolemia and what does it lead to?
Increased water and sodium retention. An increase in sodium always results in an increase in water retention to maintain equilibrium. the presence of excess fluid can lead to increased intravascular fluid volume and interstitial fluid or edema
What are causes of hypervolemia? (7)
- Cirrhosis
- Heart failure
- Stress conditions resulting in a release of ADH and aldosterone
- Adrenal gland disorders
- Use of corticosteroids
- Receiving sodium containing fluids in excess
- Ingestion of excessive amounts of salt in the diet
What lab values are evaluated for hypervolemia? (5)
1.Serum electrolytes (DECREASED)
2. Hematocrit (DECREASED)
3. BUN (DECREASED)
4. Serum osmolality (DECREASED)
5. Albumin (decreased in cirrhosis)
What happens to the hematocrit in hypervolemia? Why?
Decreased secondary to dilution
What happens to serum electrolytes in hypervolemia? Why?
Decreased- hyponatremia may be present in chronic renal failure because of dilution of blood volume
What happens to BUN in hypervolemia? Why?
Decreased, secondary to dilution
What happens to serum osmolality in hypervolemia? Why?
May be decreased in chronic renal failure because of dilution of blood volume
What happens to albumin in hypervolemia? Why?
Decreased in cirrhosis because of alteration in protein synthesis secondary to liver dysfunction
what are the clinical manifestations of hypervolemia? (6)
- Weight gain
- Ascites
- Edema
- Cardiac manifestations (HTN, tachycardia, increased central venous pressure, development of S3 heart sounds, jugular vein distention)
- Increased urinary output
- Respiratory symptoms ( Cough, tachypnea, adventitious lung sounds- crackles or wheezing, orthopnea, decreased oxygen saturation
what are the respiratory symptoms of hypervolemia? (5)
- Cough
- Tachypnea
- Crackles or wheezing
- orthopnea
- decreased oxygen saturation
What are the cardiac manifestations of hypervolemia? (5)
- HTN
- Tachycardia
- Increased central venous pressure
- Development of S3 heart sound
- Jugular vein distention
Why is these increased venous pressure in hypervolemia?
Blood backs up in right side of heart
Why is there the development of the S3 heart sound in hypervolemia?
Due to large blood volume entering ventricles during diastole
In patients with heart failure cardiac output is not able to meet the oxygen demands of the body. How does the body compensate?
To meet demands sympathetic NS is activated which increase heart rate and cardiac contractility (both increase blood pressure). As a result of decreased tissue perfusion activation of RAS, where angiotensin II stimulates release of aldosterone (increased sodium and water reabsorption by kidneys) further increasing circulating blood volume
How do respiratory symptoms develop in patients with hypervolemia?
Respiratory symptoms develop from leaking from pulmonary capillaries into alveoli because of increased circulating blood volume and inability of left side of heart to pump blood volume forward into circulatory system
what is the medical management of hypervolemia? (6)
- Prevent, correct/manage underlying cause
- Treat clinical manifestations
- limit daily intake of fluid and sodium for at risk patients
- Daily weights (for early recognition of fluid overload)
- Stopping or decreasing infusion rate of sodium containing IV fluids
- Diuretics (if patient with renal compromise don’t respond—renal dialysis
What are the complications of hypervolemia?
Worsening heart failure and pulmonary edema
What is pulmonary edema?
Fluid accumulates in interstitial spaces of lungs and in alveoli
What is progressive pulmonary edema due to?
Acute exacerbation of heart failure, acute MI, chronic renal failure
What are the emergent interventions for pulmonary edema? (4)
- Oxygen therapy
- Diuretics
- morphine
- Vasodilators (Nitroglycerin or nitroprusside (Nipride) IV)
What type of oxygen therapy is administered for pulmonary edema?
They type of intervention is determined by the patient’s arterial blood gas (ABG) results, signs of respiratory distress, and oxygen saturation of less than 94%
Why is morphine administered for pulmonary edema?
-Promotes peripheral venous dilation which decreased preload by redistributing blood volume in the periphery and less blood to the heart, which can decrease fluid overload of pulmonary edema
-Decreases anxiety
What is preload?
Amount of blood in ventricles at the end of diastole
What is treatment plan for the complications of fluid overload? (6)
- Emergent interventions for pulmonary edema (oxygen therapy, diuretics, morphine, vasodilators)
- Administer IV diuretics (i.e. furosemide Lasix)
- Close monitoring of urine output to evaluate response
- Electrolyte values (especially potassium because of diuretics–either potassium sparing or potassium wasting
- Patients with renal failure may require emergency dialysis
- Vasodilators (Nitroglycerin or nitroprusside (NIpride) via IV- closely monitor BP
Why are vasodilators administered for fluid overload?
To promote venous dilation and decrease preload
what is the nursing management for hypervolemia? (6)
- Health history (onset and duration of symptoms, recent illness, current medicine use and compliance
- physical assessment
- Lab data
- Monitor weights- obtain weight on admission for baseline data
- Calculate I&Os
- patient education
What physical assessment data are indicative of hypervolemia? (6)
1.Crackles
2. Extra heart sound (S3)
3. Abdominal distention or ascites
4. peripheral edema
5. Distended jugular vein
6. Altered mental status
What are patients educated about in hypervolemia? (4)
Education regarding medicines such as diuretics, limiting intake of sodium and fluid; importance of daily weights; specific criteria for the patient to contact health care provider regarding clinical manifestations
What is the safety alert for patients with significant fluid volume deficits? what does the nurse need to monito closely?
Risk for orthostatic and postural hypotension. The nurse needs to monitor the patient closely when changing the patient’s position, particularly when sitting or standing, because the patient is at risk for dizziness and falls secondary to decreasing blood pressure
What is the most prevalent electrolyte in the ECF?
Sodium 95% of physiologically active sodium located in ECF
What electrolyte is a key determinant of osmolality of ECF and controls distribution of water with the body?
sodium
What is the most common electrolyte disorder?
hyponatremia
What is the recommended daily intake of sodium
Less than 2,300 mg with the goal to limit sodium intake
What is the serum sodium value for hyponatremia?
Less than 135
Hyponatremia often results from what?
disturbances in water
what is hypovolemic hyponatremia?
Decrease in total body water and total body sodium in ECF as a result of renal loss
What are the causes of hypovolemic hyponatremia? (5)
Loss of sodium and water
1.The use of thiazide diuretics
2. Diarrhea
3. Vomiting
4. Hyperglycemia with glycosuria
5. perspiration
What are the clinical manifestations of hypovolemic hyponatremia? (5)
1.Weight loss
2. Orthostatic hypotension
3. Tachycardia
4. Abdominal cramps
5. Polydipsia (increased thirst)
What is EUVOLEMIC HYPONATREMIA?
Increase in total body water with no evidence of edema or hypovolemia
What patients do you see euvolemic hyponatremia? (4)
- Syndrome of ineffective anti-diuretic hormone (SIADH)
- Severe hypothyroidism
- Adrenal insufficiency
- psychotic polydipsia (excessive thirst)
Why is euvolemic hyponatremia seen in patients with severe hypothyroidism or adrenal insufficiency?
Impairs water excretion
What is psychotic polydipsia?
Excessive thirst due to antipsychotic meds which have an anticholinergic effect causing dry mouth and increased thirst
what is hypervolemic hyponatremia?
Increase in extracellular fluid and occurs secondary to increases in total body water
What patients do you see hypervolemic hyponatremia? (3)
- Heart failure
- Cirrhosis
- Nephrotic syndrome
how does heart failure contribute to hypervolemic hyponatremia?
Hypoperfusion results in activation of renin-angiotensin-aldosterone, norepinephrine and ADH compensation mechanism leading to water and sodium retention
How does hypoalbuminemia from cirrhosis or nephrotic syndrome result in hypervolemic hyponatremia?
Results in decreased osmotic pressure of the intravascular volume allowing fluid shifts to interstitial space
What is the blood serum level for acute hyponatremia? Describe how treatment needs to be started and why.
<120 develops in <48 hours. Tx needs to be started quickly to prevent cerebral edema and neurological decline. Pt is at greatest risk for neuro complications such as cerebral edema and death
Describe the symptoms of a patient with a slow decline in sodium (hyponatremia). How do you treat this patient?
Slow decline may delay onset of symptoms. Treat more conservatively than an acute onset
Describe the symptoms of a patient with chronic hyponatremia
Brain cells are adapted to new osmotic equilibrium causing fewer symptoms
With the acute onset of sodium levels less than 120 what is the patient at high risk for? Why? What must be done to prevent?
Life-threatening neurological changes. These can occur due to brain swelling and intracranial hypertension that can result in brainstem herniation and respiratory arrest. If not treated quickly this can result in permanent brain damage or death
What are the neurological clinical manifestation of hyponatremia? (10)
- Lethargy
- Headache
- Confusion
- Gait disorders
- Nausea
- Vomiting
- Seizures
- Coma
- Permanent brain damage
- DEATH
What are the neuro clinical manifestations of hyponatremia caused by cerebral edema that is severe and not treated? (4)
- Seizure
- Coma
- Permanent brain damage
- Death
What is the tx for hyponatremia based on? (3)
- Etiology
- Speed of development
- Assessment for potential cause
What is the initial treatment for hyponatremia?
-Replace sodium via oral, enteral, or parenterally
-Restrict fluid intake
-If able, intake of regular diet
How do you treat hypovolemic hyponatremia?
-Replacement of volume with isotonic saline (0.9% NaCl)
How do you treat euvolemic hyponatremia?
Restrict water to less than 1 L per day
How do you treat chronic hyponatremia?
Slowly correct to prevent osmotic demyelination
How do you treat hypervolemic hyponatremia?
-Decrease circulating volume through use of loop diuretics
-Sodium restriction
-Treat underlying cause
How do you treat patients with cirrhosis that have hyponatremia?
-Sodium and water restriction
-Aldosterone antagonists (spironolactone (Aldactone)) treats hyponatremia by causing kidneys to eliminate unneeded water and sodium
How do you treat patients with neuro symptoms from hyponatremia? What are these patients at risk for?
-Hypertonic saline (3% or 5% NaCl) at 1 ml/kg/hr (may be infused at 2-3 ml/kg/hr for the first few hours if seizures are present or the patient is exhibiting signs of brain herniation).
-Hypertonic saline saline is administered until the resolution of neuro symptoms, and then
-treatment focuses on management of the underlying disease process causing the hyponatremia
RISK: Developing fluid overload
How do you administer hypertonic saline solution (3% or 5% NaCl) for hyponatremia with neuro symptoms? (4)
- Requires cardiac monitoring
- Frequent assessments for improvement in severe neuro symptoms and fluid volume overload
- Infused via central line and IV pump
- Terminate before reaching normal serum sodium levels (because overcorrection can lead to excessive water diuresis resulting in HYPERNATREMIA
What are the pharmacological interventions for hyponatremia? (3)
- demeclocycline (Delomycin)
- Lithium (Eskalith)
- vasopressin-receptor antagonist (conivaptan and tolvaptan)
What does demeclocycline (Delomycin) and lithium (Eskalith) do to help treat hyponatremia?
Inhibition of kidneys response to vasopressin. BOTH inhibit reabsorption of water
What do the vasopressin-receptor antagonists conivaptan and tolvaptan do to help treat hyponatremia?
Increases excretion of water by blocking V2 receptors in renal tubules (—vaptans)
What are complications from hyponatremia? (9)
1.Lethargy
2. confusion
3. weakness
4. fatigue
5. muscle cramps
6. postural hypotension
7. seizure
8. coma
9. Death
what are the nursing interventions for hyponatremia? (4)
- ID patients at risk for developing hyponatremia and monitoring sodium levels
- Monitor fluid status through daily weights and measure I&O’s to assist with early detection of water balance issues - can serve as a warning sign of sodium imbalance
- Monitor urine osmolality and specific gravity to assist with monitoring sodium and water balance
- Patient education
What is the patient education for hyponatremia? (3)
- Educate on the importance of fluid and sodium intake compliance
- Sodium intake increases reabsorption of water increasing risk of hyponatremia
- Educate family about clinical manifestations and sodium content in food
what is the serum sodium level of hypernatremia?
Greater than 145
What is hypernatremia a result of?
Water loss and/or loss of sodium and water
How can water loss occur that results in hypernatremia? (9)
- Diabetes insipidus
- Hyperglycemia
- neoplasms- can affect hypothalamic osmoreceptors that regulate thirst
- hypercalcemia
- hyperkalemia secondary to nephrogenic diabetes insipidus or medications such as lithium, SSRIs (especially during first month), demeclocycline and amphotericin B
6.Increase in insensible water loss through respiratory tract which may be secondary to hyperventilation and tracheobronchitis - Burn injuries
- Fever
- Exercise
what 3 ways is fluid lost through the skin that may result in hypernatremia?
1.Burn injuries
2. Fever
3. Exercise
what elevates sodium? (2) How can you minimize the risk of developing hypernatremia?
- Excessive ingestion of sodium
- Use of sodium bicarbonate to correct metabolic acidosis and CPR
-Close monitoring of sodium levels and prompt termination of sodium bicarbonate infusions after correction of metabolic acidosis minimizes risk of developing hypernatremia
what are the clinical manifestations of hypernatremia? (8)
- Neuromuscular irritability
- Agitation
- Restlessness
- Lethargy
- Coma
- Seizure
- Signs of dehydration
- thirst- serves as mechanism to prevent development of hypernatremia
What additional symptoms are seen in severe hypernatremia? (3)
- hallucinations
- delusions
- disorientation
What are signs of dehydration in hypernatremia? (5)
- Tachycardia
- dry mucus membranes
- flushed skin
- decreased urine output
- orthostatic hypotension
What is the medical management of hypernatremia?
- Limit sodium intake or replace water deficits through infusion of hypotonic fluids (0.45% NaCl or 5% dextrose in water (D5W)
- Do not rapidly correct. It may lead to fluid shifts into brain tissue resulting in cerebral edema
***In an effort to correct hypernatremia intracellular water shifts into extracellular space resulting in dehydration of brain cells. As water loss is replaced water shifts back into brain cells which can result in seizures or permanent neuro damage.
