FLUIDS AND ELECTROLYTES IMBALANCE

Fluid, electrolyte and acid-base balance is fundamental to the process of life. In the presence of a severe imbalance, the most perfectly conditioned heart can not beat, neurons either can not transmit or fire uncontrollably, digestion cannot take place, and skeletal muscle cannot contract. At the cellular level operations and exchanges that are essential to the life of the cell cannot take place.

Although medical therapy to prevent and treat fluid, electrolyte or acid-base disturbance in the responsibility of physician, nurses play a major role in all aspects of patient care for those at risk for developing a disturbance or those with a disturbance.

Nursing responsibilities includes:-

·        Recognizing situations likely to cause imbalances.

·        Intervening to prevent imbalances.

·        Carrying out preventive and therapeutic measures prescribed by the physician and monitoring patient’s responses to the measures.

·        Recognizing sings and symptoms of fluid, electrolytes or acid-base disturbances.

·        Monitoring patients to prevent and or identify onset of imbalances related to their specific conditions or treatments.

·        Alleviating the effects of disturbances on the comfort and safety of patients.

·        Educating patients, where appropriate, to manage their underlying condition in order to prevent an acid-base imbalance.

ETIOLOGY

Fluid and electrolyte imbalance are common problems of patients in all clinical settings. Physiologic homeostasis is closely related to fluid and electrolyte balances usually are accompanied by electrolyte abnormalities. Any disease process can potentially affect the fluid and electrolyte balance. The causes of deficits are excesses are varied and are discussed separately in each section.

AMOUNT & COMPOSITION OF FLUIDS & ELECTROLYTES

BODY FLUIDS

Approximately 60% of a typical adult’s weight consists of fluid (water and electrolytes). Factors that influence the amount of body fluid are age, gender and body fat. In general, younger people have a higher percentage of body fluid than women. Obese people have less fluid than thin people because fat cell contains little water.

Body fluid is located in two fluid compartments: the intra-cellular space (fluid in the cells) and the extra cellular space (fluid outside the cells). Approximate two thirds of body fluid is in the intracellular fluid (ICF) compartment is located primarily in the skeletal muscle mass.

The extra cellular fluid compartment is further divided into the intravascular, interstitial, and transcellular fluid spaces. The intravascular space (the fluid within the blood vessels) contains plasma. Approximately 3L of the average 6L of blood volume is made up of plasma. The remaining 3L is made up of erythrocytes, leukocytes, and thrombocytes. The interstitial space contains the fluid that surrounds the cell and totals about 11 to 12L in an adult. Lymph is an example of interstitial fluid. The transcellular space is the smallest division of the ECF compartment and contains approximately 1L of fluid at any given time. Examples of transcellular fluid are cerebrospinal, pericardial, synovial, intraocular, and pleural fluids; sweat; and digestive secretions.

Body fluids normally shift between the two major compartments or spaces in an effort to maintain equilibrium between the spaces. Loss of fluid from the body can disrupt this equilibrium. Sometimes fluid is not lost from the body but is unavailable for use by either the ICF or ECF. Loss of ECF into a space that does not contribute to equilibrium between the ICF and the ECF is referred to as a third-space fluid shift, or “third spacing” for short.

An early clue of a third-space fluid shift is a decrease in urine output despite adequate fluid intake. Urine output decrease because fluid shifts out of the intravascular space; the kidneys than receive less blood and attempt to compensate by decreasing urine output. Other signs and symptoms of third spacing that indicate an intravascular fluid volume deficit include increased heart rate, decreased blood pressure, decrease central venous pressure, edema, increased blood weight, and imbalance in fluid intake and output(I&O). Third-space shift occur in ascites, burns, peritonitis, bowel obstruction, and massive bleeding into a joint or body cavity.

ELECTROLYTES

Electrolytes in body are active chemicals (cations, which carry positive charges, and anions, which carry negative charges).the major cations in body fluid are sodium, potassium, calcium magnesium and hydrogen ions.

These chemicals unite in varying combinations. Therefore electrolyte concentration in the body is expressed in terms of milliequivalents (mEq) per liter, a measure of chemical activities rather than in terms of milligrams (mg), a unit of weight. Most specifically, a milliequivalent is defined as being equivalent to the electrochemical activities of 1mg of hydrogen. In a solution cations and anions are equal in mEq\L.

Electrolytes concentrations in the ICF differ from those in ECF, as reflected in the table. Because special techniques are required to measure electrolyte concentrations in the ICF, it is customary to measure the electrolytes in the most accessible portion of the ECF, namely the plasma.

Sodium ions which are positively charged, far out number the other cations in the ECF. Because sodium concentrations affects the overall all concentration of the ECF, sodium is important in regulating the volume of body fluid. Retention of sodium is associated with fluid retention, and excessive loss of sodium is usually associated with decreased volume of body fluid.

The major electrolytes in the ICF are potassium and phosphate. The ECF has a low concentration of potassium and can tolerate only small changes in potassium concentrations. Therefore, release of large stores of intracellular potassium, typically caused by trauma to the cells and tissues, can be extremely dangerous.

The body expands a great deal of energy maintaining the high extracellular concentration of sodium and the high intracellular concentration of potassium. It does so by means of cell membrane pumps that exchange sodium and potassium ions. Normal movement of fluids through the capillary wall into the tissues depends on hydrostatic pressure(the pressure exerted by the fluid on the walls of the blood vessel) at both the arterial and the venous ends of the vessel and the osmotic pressure exerted by the protein of plasma. The direction of fluid movement depends on the differences in these two opposing forces (hydrostatic versus osmotic pressure).

In addition to electrolytes, the ECF transports other substances, such as enzymes and hormones. It also carries blood components, such as red and white blood cells, throughout the body.

REGULATION OF BODY FLUID COMPARTMENTS

OSMOSIS AND OSMOLALITY

When two different solutions are separated by a membrane that is impermeable to the dissolved substances, fluid shift through the membrane from the region of low solute concentration to the region of high solute concentration until the solutions are of equal concentration; this diffusion of water causes by a fluid concentration gradient is known as osmosis. The magnitude of this force depends on the number of particles dissolved in the solution, not on the weight. The number of dissolved particles contained in a unit of solution, influences the movement of fluid between the fluid compartments.

Tonicity is the ability of all solutes to cause an osmotic driving force that promotes water movement from one compartment to another. The control of tonicity determines the normal state of cellular hydration and cell size. Sodium, mannitol, glucose, and sorbitol are effective osmoles (capable of affecting water movement). Three other terms are associated with osmosis: osmotic pressure, oncotic pressure, and osmotic diuresis.

·        Osmotic pressure is the amount of hydrostatic pressure needed to stop the flow of water by osmosis. It is primarily determine by the concentration of solutes.

·        Oncortic pressure is osmotic pressure exerted by the proteins (e.g. albumin).

·        Osmotic diuresis occurs when the urine output increases due to the excretion of substances such as glucose, mannitol, or contrast agents in the urine.

DIFFUSION

Diffusion is the natural tendency of a substance to move from an area of higher concentration to one of lower concentration. It occurs through the random movement of ions and molecules. Examples of diffusion are the exchange of oxygen and carbon dioxide between the pulmonary capillaries and alveoli and the tendency of sodium to move from the ECF compartment, where the sodium concentration is high, to the ICF, where its concentration is low.

FILTRATION

Hydrostatic pressure in the capillaries tends to filter fluid out of the vascular compartment into the interstitial fluid. Movement of water and solutes occurs from an area of high hydrostatic pressure to an area of low hydrostatic pressure. Filtration allows the kidneys to filter 180L of plasma per day. Another example of filtration is the passage of water and electrolytes from the arterial capillary bed to the interstitial fluid; in this instance, the hydrostatic pressure is furnished by the pumping action of the heart.

SODIUM-POTASSIUM PUMP

As stated earlier, the sodium concentration is greater in the ECF than in the ICF, and because of this, tendency is offset by the sodium-potassium pump, which is located in the cell membrane and actively moves sodium from the cell into the ECF. Conversely, the high intra cellular potassium concentration is maintained by pumping potassium into the cell. By definition, active transport implies that energy must be expended for the movement to occur against a concentration gradient.

ROUTES OF GAINS AND LOSS

Water and electrolytes are gained in various ways. A health person gains fluid by drinking and eating. In patients with some disorders, fluids may be provided by the parenteral route (intravenously or subcutaneously) or by means of an enteral feeding tube in the stomach or intestine.

KIDNEYS

The usual daily urine volume in the adult is 1 to 2L. A general rule is that that the output is approximately 1mL of urine per kilo-gram of body weight per hour (1mL\kg\h) in all age groups.

SKIN

Sensible perspiration refers to visible water and electrolyte loss through the skin (sweating). The chief solutes in sweat are sodium, chloride, and potassium. Actual sweat losses can vary from 0 to 1,000mL or more every hour, depending on the environmental temperature. Continuous water loss by evaporation (approximately 600mL\day) occurs through the skin as insensible loss. Fever greatly increases insensible water loss through the lungs and skin, as does loss of the natural skin barrier (e.g. through major burns).

LUNGS

The lungs normally eliminate water vapor (insensible loss) at a rate of approximately 400mL every day. The loss is much greater with increased respiration rate or depth, or in dry climate.

G I TRACT

The usual loss through the GI tract is only 100 to 200mL daily, even through approximately 8L of fluids circulates through GI system every 24hours. Because bulk of fluid is reabsorbable in the small intestine, diarrhea and fistulas causes large losses.

LABORATORY TESTS FOR EVALUTING FLUID STATUS

AVERAGE DAILY INTAKE AND OUTPUT IN AN ADULT
INTAKE(ml)		OUTPUT(ml)
Oral liquids	1300	Urine	1500
Water in food	1000	Stool	200
Water produced by metabolism	300	Insensible Lungs	300
		Skin	600
Total gain	2600	Total Loss	2600

FACTORS AFFECTING SERUM AND URINE OSMOLALITY

FLUIDS	FACTORS INCREASING OSMOLALITY	FACTORS DECREASING OSMOLALITY
Serum(25-300 mOsm \kg water)	·        Severe dehydration ·        Free water loss ·        Diabetes insipidus ·        Hypernatremia ·        Hyperglycemia ·        Stroke or head injury ·        Renal tubular necrosis ·        Consumption of methanol or ethylene glycol(antifreeze)	·        Fluid volume excess ·        Syndrome of inappropriate anti-diuretic hormone(SIADH) ·        Renal failure ·        DIURETIC USE ·        Adrenal insufficiency ·        Hyponatremia ·        Overhydration ·        Paraneoplastic syndrome associated with lungs cancer ·        Fluid volume excess ·        Diabetes insipidus ·        Hyponatremia ·        Aldosteronism ·        Pyelonephritis.
Urine(250-900 mOsm \ kg water)	·        Fluid volume deficit ·        SIADH ·        Congestive heart failure ·        acidosis	·        Fluid volume excess ·        Diabetes insipidus ·        Hyponatremia ·        Aldosteronism ·        Pyelonephritis

HOMOSTATIC MECHANISM

The body is equipped with remarkable homeostatic mechanism to keep the composition and volume of body fluid with in narrow limits of normal. Organs involved in homeostasis include the kidneys, lungs, heart, adrenal gland, parathyroid gland, and pituitary gland.

KIDNEY FUNCTIONS

Vital to the regulation of and electrolyte balance, the kidneys normally filter 170L of plasma every day in the adult, while excreting only 1.5LL of urine. They act both autonomously and in response to blood-bone messengers, such as aldosterone and antidiuretic hormone (ADH). Major functions of the kidneys in maintaining normal fluid balance include the following:

·        Regulation of ECF volume and osmolality by selective retention and excretion of body fluids.

·        Regulation of electrolyte levels in the ECF by selective retention of needed substances and excretion of unneeded substances.

·        Regulation of pH of the ECF by retention of hydrogen ions

·        Excretion of metabolic wastes and toxic substances

Given these functions, it is readily apparent that renal failure will result in multiple fluid and electrolyte problems. Renal function declines with advanced age, as do muscle mass and daily exogenous creatnine production. Thus, high-normal and minimally elevated serum creatinine value may indicates substantially reduced renal function in the elderly.

HEART AND BLOOD VESSEL FUNCTIONS

The pumping action of the heart circulates blood through the kidneys under sufficient pressure to allow for urine formation. Failure of this pumping action interferes with renal perfusion and thus with water and electrolyte regulation.

LUNG FUNCTIONS

The lungs are also vital in maintaining homeostasis. Through exhalation, the lungs remove approximately 300mL of water daily in the normal adult. Abnormal conditions, such as hyperpnea (abnormally deep respiration) or continuous coughing increases this loss; mechanical ventilation with excessive moisture decreases it.

PITUITARY FUNCTIONS

The hypothalamus manufacture ADH, which is stored in the posterior pituitary gland and released as needed. Functions of ADH include maintaining the osmotic pressure of the cell by controlling the retention or excretion of water by the kidney and by regulating blood volume.

ADRENAL FUNCTION

Increased secretion of aldosterone causes sodium retention and potassium loss. Conversely decreased secretion of aldosterone causes sodium and water loss and potassium retention.

Cortisol, when secreted in large quantities, however it can also produce sodium and water retention and potassium deficit.

PARATHYROID FUNCTION

It regulates the calcium and phosphate balance by means of parathyroid hormones (PTH).PTH influence bone reabsorption, calcium absorption from the intestine, and calcium reabsorption from the renal tubules.

OTHER MECHANISMS

Changes in the volume of interstitial compartment within the ECF can occur with out affecting our body functions. The ECF can occur without affecting body function. The vascular compartment, however, cannot tolerate change as readily and must be carefully maintained to ensure that that tissue receives adequate nutrients.

BARORECEPTORS

They are responsible for monitoring the circulating volume, and they regulate sympathetic and parasympathetic neural activity as well as endocrine activities.

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM

Rennin is enzyme that converts angiotensinogen, an inactive substance formed by the liver, into angiotensin I. rennin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme (ACE) converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of rennin.aldosterone is a volume regulator and is also released as serum potassium increases, serum sodium decreases, or adrenocorticotropic hormone (ACTH) increases.

ANTIDIURETIC HORMONE AND THIRST

ADH and thirst mechanism have important roles in maintaining sodium concentration and oral intake of fluids. Oral intake is controlled and oral center located in the hypothalamus.

OSMORECEPTORS

Located on the surface of the hypothalamus, osmoreceptor sense changes in sodium concentration. As osmotic pressure increases, the neurons become dehydrated and quickly release impulses to posterior pituitary, which increase the release of ADH. The ADH than travels in the blood to kidneys, where it alters permeability to water, causing increased reabsorption of water and decreased urine output.

RELEASE OF ATRIAL NATRIURETIC PEPTIDE

Atrial natriuretic peptide (ANP), also called atrial natriuretic factor, is a 28-acid peptide that is synthesized, stored, and released by muscle cell of the atria of the heart in response to several factors.

FLUID VOLURE DEFICIT

Fluid volume deficient (dehydration) result from excessive loss of water electrolytes from extracellurlar fluid.

Possible causes

·        Excessive fluid loss through secretions or excretions

·        Insufficient intake of water and electrolytes

 Both of the above can occur simultaneously. A third possible cause is third-space shifting.

PATHOPHYSIOLOGY

FVD result from loss of body fluids and occurs more rapidly when coupled with decreased fluid intake. FVD can develop from inadequate intake alone if the decreased intake is prolonged. Causes of FVD include abnormal fluid losses, such as those resulting from vomiting, diarrhea, GI suctioning, and sweating, and decreased intake, as in nausea or inability to gain access to fluids.

Additional risk factors include diabetes insipidus, adrenal insufficient, osmotic diuresis, hemorrhage, and coma. Third-space fluid shift, the movement of fluid from the vascular system to other body spaces (e.g., with edema formation in burns, ascites with liver dysfunction), also cause FVD.

CLINICAL MANIFESTATIONS

Acute weight loss, decreased skin turgor, oliguria, concentration urine, weak rapid pulse, capillary filling time prolonged, low CVP, decreased blood pressure, flattened neck veins, dizziness, weakness, thirst and confusion, increased pulse, muscle cramps, sunken eyes.

LABS INDICATE: increased hemoglobin and hematocrit, increased serum and urine osmolality and specific gravity, decreased urine sodium, increased BUN and creatinine, increased urine specific gravity and osmolality.

 ASSESSMENT FINDINGS

·        Collapsed neck and hand veins

·        Decreased CVP, pulmonary artery pressure, and cardiac output.

·        Dizziness, syncope, weakness

·        Dry skin, decreased skin turgor, dry mucous membranes

·        Hypotension

·        Increased thirst

·        Nausea, vomiting

·        Oliguria

·        Orthostatic blood pressure differences

·        tachycardia

DIAGNOSTIC EVALUATION

·        BUN: creatinine greater than 10:1

·        CBC count: increased hematocrit levels

·        Serum sodium: increased (hypertonic), decreased (hypotonic),or normal (isotonic)

·        Urine specific gravity: elevated.

NURSING DIAGNOSES

·        Deficient fluid volume.

TREATMENT

·        Depends on the cause; may vary from shock treatment to replacing fluids by oral supplementation and I.V. therapy.

DRUG THERAPY OPTIONS

·        Albumin

·        Blood transfusion

·        Dextrose 5% in normal saline solution

·        Vasopressors

PLANNING AND GOALS

The client will achieve and maintain adequate hydration.

Implementation

@ Monitor intake and output to assess fluid balance. Normally, the body maintains a balance of about 2,300mL of output as sensible or insensible fluid loss.

@ Weight the client daily at the same time and on the same scale with the same amount of linens or clothes to ensure accurate measurements. Each 2lb weight loss reflects a 1-L fluid loss.

@ Measures urine specific gravity as needed to evaluate the client’s fluid status and response to therapy.

@ Assess hemodynamic parameters, such as CVP, pulmonary artery pressure, and cardiac output, to monitor the client’s fluid status and response to therapy.

@ Review key teaching topics with the client and family members to ensure adequate knowledge about the condition and treatment, including:

1)     Diet instruction regarding sodium-containing foods

2)     Signs of fluid volume deficit.

EVALUATION

@ The client void at least 30ml\L

FLUID VOLUME OVERLOAD

Fluid volume overload (excess) reflects an increased accumulation of water and electrolytes in the extracellurar fluid; it usually results from an increase in total sodium concentration, causing more water to be drawn into the extracellular fluid to reestablish the proper sodium-water ratio.

PATHOPHYSIOLOGY

FVE may be related to simple fluid overload or diminished function of the homeostatic mechanisms responsible for regulating fluid balance. Contributing factors can include heart failure, renal failure, and cirrhosis of the liver. Another contributing factor is consumption of excessive amounts of table or other sodium salts. Excessive administration of sodium-containing fluids in a patient with impaired regulatory mechanisms may predispose him or her to a serious FVE as well.

POSSIBLE CAUSES

·        Diminished homeostatic mechanisms, such as those occurring in heart failure, cirrhosis, or excessive corticosteroid therapy

·        Fluid overload

·        Sodium overload

SIGNS \ SYMPTOMS

Acute weight gain, peripheral edema and ascites, distended jugular veins, crackles, and elevated CVP, shortness of breath, increased blood pressure, bounding pulse and cough, increased respiratory rate

LABS INDICATE:

Decreased hemoglobin and hematocrit, decreased serum and urine osmolality, decreased urine sodium and specific gravity.

ASSESSMENT FINDINGS

·        Bounding pulses

·        Crackles on auscultation

·        Dependent edema (such as pedal, sacral, or scrotal edema)

·        Dyspnea

·        Elevated central venous pressure, pulmonary artery pressure

·        Hypertension

·        Neck vein distention

DIAGNOSTIC EVALUATION

·        BUN: decreased

·        Decreased hematocrit

·        Serum sodium level normal or decreased

·        Serum and urine osmolality: decreased in client with normal renal function

NURSING DIAGNOSES

·        Excessive fluid volume.

TREATMENT

Drug Therapy Options

Diuretics act to increase the excretion of water and sodium and other electrolytes through the kidneys, such as:

1)     loop diuretic: bumetanide (Bumex), furosemide (lasix)

2)     osmotic: mannitol (osmitrol)

3)     potassium-sparing : spironolactone(Aldactone)

4)     Thiazide: chlorothiazide (diuril), hydrochlorothiazide (hydroDIURIL).

Implementation

·        Administer diuretics, as ordered, to decrease fluid volume.

·        Maintain fluid restrictions to promote fluid balance.

·        Monitor intake and output hourly to assess for changes in fluid status.

·        Measure urine specific gravity as needed to evaluate the client’s fluid status and response to therapy.

·        Weight the client daily at the same time and on the same scale with the client wearing the same amount of clothing to evaluate fluid balance. Significant weight gain reflects fluid volume overload.

·        Assess the client for engorged neck and hand veins, which indicate fluid volume overload.

·        Monitor the client for engorged neck and hand veins, which indicate fluid volume overload.

·        Monitor the client for signs of heart failure or pulmonary edema to identify changes in physical condition.

·        Assess hemodynamic parameters, such as CVP or pulmonary artery pressure, to evaluate for changes in fluid status.

·        Review key teaching topics with the patient and family members to ensure adequate knowledge about the condition and treatment, including:

1)     Diet instruction regarding sodium-containing foods

2)     Signs of fluid volume excess, including eight gain, shortness of breath, and swelling of the feet or ankles.

EVALUATION

·        The client maintains a stable body weight.

·        The client displays no overt sings of edema or dehydration.

SODIUM IMBALANCE

Sodium is the major cation in extracellular fluid. Its functions includes maintaining tonicity and concentration of extracellular fluid, acid base balance (reabsorption of sodium  ions and excretion of hydrogen ions ), nerve conduction and neuromuscular function, glandular secretion, and water balance.

A sodium-potassium pump is constantly t work in every body cell. Potassium is the major cation in intracellular fluid. According to the lows of diffusion, a substance move from an area of high concentration to an area of lower concentration. Sodium ions normally most abundant outside the cells want to diffuse outward the sodium-potassium pump work to combat this ionic diffusion and maintain normal sodium pump works to combat this ionic diffusion and maintain normal sodium-potassium balance.

During repolarization, into the cells ad potassium out of the cells; during depolarization, it does the reverse.

The body requires only 2 to 4g of sodium daily. However, most Americans consume 6 to 10g daily, excreting excess sodium through the kidney and skin.

A low sodium diet and or excessive use of diuretics may induce hyponatremia decreased serum sodium concentration; dehydration may induce hypernatremia (increased serum sodium concentration).

HYPONATREMIA

Hyponatremia refers to serum sodium level that is below normal (less than 135 mEq \L)

POSSIBLE CAUSE

Diarrhea, excessive perspiration or fever, excessive water intake. Low – sodium diet. Malnutrition potent diuretics. Starvation suctioning. Trauma, wound drainage, or burns. Vomiting.

SIGNS AND SYMPTOMS

Anorexia, nausea and vomiting, headache, lethargy, dizziness, confusion, muscle cramps and weakness, muscular twitching, seizures, papilledema, dry skin, increased pulse, decrease BP, weight gain, edema.

LABS INDICATE

Decreased serum and urine sodium, increased urine specific gravity and osmolality.

ASSESSMENT FINDINGS

·        abdominal cramps

·        anxiety

·        cold clammy skin

·        cyanosis

·        headaches

·        hypotension

·        Muscle twitching and weakness.

·        Nausea and vomiting

·        Oliguria and anuria.

·        Renal dysfunction

·        Seizures

·        Tachycardia

DIAGNOSTIC EVALUATION

·        Serum sodium level less than 135mEq\L indicates hyponatremia.

NURSING DIAGNOSES

·        Deficient fluid volume.

·        Risk for injury.

TREATMENT

·        Antibiotic: Demeclocyclin (Declomycin).

·        Saline solution I.V infusion.

·        Potassium supplement

·        Potassium chloride

IMPLEMENTATION

·        Watch for extremely low serum sodium and accompanying serum chloride levels. Monitor urine specific gravity and other laboratory result. Record fluid intake and output accurately and weight the client daily to guide the treatment plan.

·        During administration of isosmolar or hyperosmolar saline solution, watch closely for sings of hypervolemia (dyspnea, crackles, engorged neck and hand veins) to prevent respiratory distress.

·        Note conditions that may cause excessive sodium loss – diaphoresis, prolonged diarrhea or vomiting, or severe buns – to prevent hyponatremia.

·        Refer the client receiving a maintenance dosage of diuretics to a dietitian for instruction about dietary sodium intake to increase sodium intake and decrease the risk for hyponatremia.

·        Note: - salty foods instruct the client to avoid these high sodium foods

o   Baking soda and baking powder.

o   Bottled soft drinks, especially those with sodium or sodium saccharin.

o   Canned soup, broth, or vegetables.

o   Condiments, such as salted butter and margarine, ketchup, mustard, and salad dressing.

o   Fast foods

o   Foods that contain monosodium glutamate

o   Instant foods such as cereal.

o   Lunch meats and cheeses.

o   Over-the-counter medications such as antacids

o   Pickles and pickled foods.

o   Potato chips, pretzels and other snack foods

·        Review key teaching topics with client and family members with hyponatremia to ensure adequate knowledge about the condition and treatment including:

1)     The rationale for fluid restriction if necessary.

2)     Increasing dietary intake of sodium

3)     The medication regimen and possible adverse reactions.

EVALUATION

·        The client has serum sodium level above 138 mEq \ L.

HYPERNATREMIA

POSSIBLE CAUSE

·        Decreased water intake

·        Diabetes insipidus

·        Excess adrenocortical hormonal ,as in cushing’s syndrome

·        Severe vomiting and diarrhea with water loss that exceeds sodium loss

SIGNS AND SYMPTOMS

thirst, elevated body temperature, swollen dry tongue and sticky mucous membranes, hallucinations, lethargy, restlessness, irritability, focal or grand mal seizures, pulmonary edema, hyper-reflexia, twitching, nausea, vomiting, anorexia, increased pulse, increased BP, weight gain, edema

LABS INDICATE

Decreased serum and urine sodium, decreased urine specific gravity and osmolality ASSESSMENT FINDINGS

·        Agitation and restless

·        Circulatory disorder.

·        Decrease level of consciousness

·        Dry sticky mucous membrane

·        Dyspnea

·        Excessive weight gain

·        Fever.

·        Flushed skin

·        Hypertension

·        Intense thirst

·        Oliguria

·        Pitting

·        Edema

·        Rough

·        Dry tongue

·        seizures

·        Tachycardia.

Diagnostic evaluation

Serum sodium level greater than 145 mEq \ L indicates hypernatremia.

NURSING DIAGNOSES

·        Excessive fluid volume

·        Disturbed thought processes

TREATMENT

·        Diet: sodium restriction, Salt-free solution (such as dextrose in water), followed by infusion of half normal saline solution to prevent hyponatremia.

IMPLEMENTATION

·        Measure serum sodium levels every 6 hours or at least daily. Monitor vital sings for changes, especially for rising pulse rate. Watch for sings of hypervolemia, especially in the client receiving I.V. fluids, to guide the treatment regimen.

·        Record fluid intake and output accurately, checking for body fluid loss to prevent dehydration and accompanying hypernatremia. Weight the client daily to monitor fluid volume status.

·        Obtain a drug history to check for drugs that promote sodium retention.

·        Review key teaching topics with the client and family members with hypernatremia to ensure adequate knowledge about the condition and treatment, including the importance of sodium restriction and how to plan a low-sodium diet.

EVALUATION

·        The client has serum sodium level below 143 mEq \ L.

POTASSIUM IMBALANCE

Potassium is the major cation of the intracellular fluid. Because of the high concentration of potassium inside the cells, potassium exerts some control over the intracellular osmolarity and volume. Maintaining the difference in the potassium concentration between the intracellular fluid and the extracellular fluid is critical for enabling excitable tissues to generate action potentials and to transmit impulses. Because extracellular fluid potassium levels are extremely low, any alteration in the concentration is poorly tolerated by the body and profoundly affects physiologic activities.

Potassium intake averages about 2 to 20 g\day for most people. Almost all foods contain some amount of potassium. Some foods are higher in potassium than others. The healthy body keeps plasma potassium levels within the narrow range of normal value required by physiologic function.

The sodium-potassium pump within every body cell membrane is the primary controller of extracellular potassium concentration. Some potassium regulation also takes place through renal function. The kidney excretes 80% of potassium from the body. There’s no identified hormone that directly controls renal reabsorption of potassium, so the kidney doesn’t conserve potassium directly.

 HYPOKALEMIA

POSSIBLE CAUSES

·        Alkalosis                                 

·        Corticosteroids

·        Diarrhea

·        Digoxin

·        Diuretics

·        Inappropriate or excessive use of drugs

·        No oral intake for an extended period

·        Prolonged NG suctioning

·        Total parenteral nutrition

·        Vomiting

SIGN AND SYMPTOMS

Fatigue, anorexia, nausea and vomiting, muscle weakness, polyuria, decreased bowel mortality, ventricular asystole or fibrillation, paresthesias, leg cramps, decreased BP, ileus, abdominal distention, hypoactive reflexes. ECG: flattened T waves, prominent U waves, ST depression, prolonged pr interval.

ASSESSMENT FINDINGS

·        Nausea, vomiting

·        ECG abnormalities, including ST depression, inverted T wave, prominent U wave, heart block.

·        Leg cramps

·        General skeletal muscle weakness.

·        Orthostatic hypotension

·        Constipation.

·        Abdominal distension

·        Anxiety, lethargy, confusion, coma

·        Hypoactive or absent bowel sounds

·        Decreased breath sounds

·        Polyuria

·        Low specific gravity

DIAGNOSTIC EVALUATION

·        Serum potassium less than 3.5 mEq \L

·        ECG changes

NURSING DIAGNOSES

·        Imbalanced nutrition: less than body requirements

·        Risk for deficient fluid volume

·        Impaired physical mobility

TREATMENT

·        Potassium supplements (oral or I.V.)

·        Potassium-sparing diuretics

·        Increased potassium in diet

PLANNING AND GOALS

·        The client’s serum potassium level will return to normal.

·        The client will be aware of the appropriate foods to include in his daily diet.

·        The client won’t have cardiac complications, such as ventricular tachycardia.

·        The client will have normal muscle function when potassium levels return to normal.

IMPLEMENTATION

·        Monitor potassium levels frequently to guide the treatment plan.

·        Monitor for arrhythmias to for cardiac involvement.

·        Administer potassium supplements as needed. Oral supplements must be diluted in at least 4 ounces of fluid to prevent stomach irritations. I.V. supplements shouldn’t be infused faster than 20mEq \ hour because this can cause life-threatening arrhythmias.

·        Review key teaching topics with the client and family members to ensure adequate knowledge about the condition and treatment, including:

1)     The importance of having potassium levels drawn at regular intervals when client is taking diuretics.

2)     diet and foods high in potassium

3)     awareness of problems with weakness and leg cramps

4)     The importance of follow-up care..

EVALUATION

·        The client’s potassium level is within normal limits(between 3.5 and 5.0 mEq \ L)

·        The client has no cardiovascular complications.

·        The client knows what foods are high in potassium and what diet should be followed.

·        The client demonstrates normal neuromuscular function.

Hyperkalemia

POSSIBLE CAUSES

·        Acidosis

·        Dehydration

·        Overeating of potassium-containing I.V. solutions

·        Renal failure.

SIGN AND SYMPTOMS

Vague muscular weakness, tachycardia      bradycardia, dysrhythmia, flaccid paralysis, paresthesias, intestinal colic, cramps, irritability, anxiety. ECG: tall tented T waves, prolonged PR interval and QRS duration, absent p waves, ST segment depression.  ASSESSMENT FINDINGS

·        ECG abnormalities, such as widened QRS complex, prolonged PR interval, ectopic beats

·        Muscle twitches, cramps, paresthesia(early hyperkalemia)

·        Low blood pressure

·        Hyperactive bowel sounds

·        Diarrhea

·        Ascending flaccid paralysis: progresses distal to proximal with extremities

·        Profound weakness (late hyperkalemia)

 DIAGNOSTIC EVALUATION

·        Serum potassium greater than 5.0 mEq \ L

·        ECG changes

NURSING DIAGNOSES

·        Imbalanced nutrition : more than body requirements

·        Diarrhea

·        Activity intolerance

TREATMENT

·        Potassium-excreting diuretics(furosemide)

·        Sodium polystyrene sulfonate(kayexalate)

·        Insulin

·        Dialysis, if needed

IMPLEMENTATION

·        Monitor potassium levels frequently to guide the treatment plan.

·        Monitor for arrhythmias to assess for cardiac involvement.

·        Monitor diet to decrease foods high in potassium to prevent increase of hyperkalemia.

·        Instruct the client to avoid these high-potassium foods:

o   Apricots

o   Bananas

o   Dark, green leafy vegetables

o   Dried fruits

o   Oranges

o   Peanuts

o   Strawberries

o   Tomatoes.

·        Review key teaching topics with the client and family members to ensure adequate knowledge about the condition and treatment, including:

1)     The need to avoid salt substitutes, which usually contain potassium.

2)     Diet and foods to avoid the contain levels of potassium.

EVALUATION

·        The client’s potassium level is within normal limits(between 3.5 and 5.0 mEq \ L)

·        The client has no cardiovascular complications.

·        The client knows what foods are high in potassium and what diet should be followed.

·        The client demonstrates normal neuromuscular function