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Fluid and Electrolyte Imbalances: Interpretation and Assessment

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Fluid and Electrolyte Imbalances: Interpretation and Assessment The Art and Science of Infusion Nursing Mandi D. Walker, MSN, RN-BC, CCRN Fluid and Electrolyte Imbalances: Interpretation and Assessment fluid. The other one-third is found in the extracellular ABSTRACT fluid and comprises water and sodium chloride. Maintaining the balance of fluid and electrolytes Extracellular fluid is further categorized as intravascular is crucial to the care of patients across the contin- and interstitial fluid. The body maintains a balance of uum. To do this, a practitioner must be cognizant fluid to molecules, including electrolytes, which is known 1-9 of key monitoring and assessment parameters. as homeostasis. Homeostasis is maintained through the transport of Key electrolytes, their function within the body, solutes through semipermeable membranes. This is normal values, signs and symptoms of imbalanc- accomplished using many different processes. The pro- es, key treatment modalities, and other considera- cess of diffusion occurs when the ions and molecules in tions are discussed. a solution spread out for uniform distribution. Filtration Key words: calcium, electrolyte imbalances, fluid is the process through which a liquid or gas passes balance, magnesium, phosphorus, potassium, through a filter (membrane) by forces of pressure. sodium Osmosis occurs when a solute passes through a mem- brane, leaving a solution of higher concentration to a solution of lower concentration, thereby balancing the n understanding of the normal balance of solutes on either side of the membrane. Finally, active fluid and electrolytes in the body is essen- transport is the process of solutes moving against the tial not only to understand normal func- electrochemical gradient, such as the sodium-potassium tioning of the human body but also to pump that moves the electrolytes back and forth predict problems and to intervene during depending on the need of the cell.1-10 Avarious disease processes. To do that, the practitioner For fluid in the body, normal serum osmolality— must have a thorough understanding of the balance of the concentration of solutes in intravascular fluid—is fluids, homeostasis, electrolytes, and the shifts that can 275 to 295 mOsm/kg.8,9 Therefore, any serum osmo- result when 1 element is no longer in balance. lality greater than 295 is known as hyperosmolar, while a serum osmolality less than 275 is known as THE BALANCE OF FLUID hypoosmolar. The osmolality of body fluids affects the tonicity of the fluid, the pressure or tension of solutes in the solution, and will have an impact on the concen- The human body is composed of approximately 70% tration of various solutes and normal functioning in water. Two-thirds of the water is found in the intracellular the cells.8,9 This is known as osmotic pressure, which is propor- Author Affiliation: University of Louisville Hospital, Louisville, Kentucky. tional to the osmolality of a solution. In reference to the Mandi D. Walker, MSN, RN-BC, CCRN, has more than 11 years of human body, an isotonic solution has the same osmotic critical care experience. She currently serves as the critical care pressure as the intravascular fluid.1-10 Examples of iso- advanced practice educator at University of Louisville Hospital in Louisville, Kentucky. She obtained a BSN from the University of tonic solutions include 0.9% sodium chloride, lactated Louisville and an MSN in education from Walden University, which Ringer’s (LR), and 5% dextrose in water. For this rea- is based in Minneapolis, Minnesota. She is certified in critical care son, these solutions typically are the first line used to and nursing professional development. replace fluid lost in the body.8,9 Hypertonic solutions, The author has no conflicts of interest to disclose. those with a higher osmotic pressure compared with Corresponding Author: Mandi D. Walker, MSN, RN-BC, CCRN, 530 South Jackson Street, Louisville, KY 40202 (mandiwa@ulh. intravascular fluid, include 5% dextrose in 0.9% sodi- org). um chloride or LR. Hypertonic solutions can be used to DOI:10.1097/NAN.0000000000000193 draw fluid from the intracellular and interstitium into 382 Copyright © 2016 Infusion Nurses Society Journal of Infusion Nursing Copyright © 2016 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited. the intravascular space to help reverse fluid overload.8,9 magnesium are key electrolytes that have an important Hypotonic solutions, such as sodium chloride 0.45%, effect on normal functioning in the cells. contain a lower osmotic pressure than intravascular fluid and can be used to promote fluid shifts out of the Sodium intravascular space and into the intracellular or intersti- tial spaces.8,9 Sodium (Na+) is the primary cation in the body’s extra- There are several processes at work to maintain the bal- cellular fluid. Its role is to regulate fluid volume, osmo- ance of fluid in the body. When the body senses a decrease lality, and acid-base balance, as well as to conduct in circulating volume or an increase in serum osmolality, muscle and nerve activity.1-10 The body regulates sodi- multiple pathways serve to correct the issue. First is the um through dietary intake, excretion by the kidneys, thirst mechanism, which is housed in the hypothalamus and hormonal responses to aldosterone and ADH.1-10 and is driven by either a decrease in intravascular volume The normal range for sodium is 135 to 145 mEq/L.11,12 or an increase in serum osmolality.1-9 When the body senses either of these states, the body interprets the prob- lem and responds by triggering the urge to drink. In addi- Critical Thinking Exercise 1 tion, antidiuretic hormone (ADH) is released by the pitui- As you read the following information regarding tary gland in response to a decrease in circulating volume sodium imbalances, consider this patient scenario: and promotes retention of fluid in the body.1-9 In the kid- You are caring for a 26-year-old autistic patient who neys, the juxtaglomerular apparatus measures renal blood was just admitted for sudden onset of seizures and a flow. When a decrease in renal flow is detected, it works to decreased level of consciousness. His mother says he regulate both sodium and fluid levels in the body through “really likes water” and “drinks at least a couple of the renin-angiotensin-aldosterone system (RAAS). The gallons a day.” What could be the cause of his symp- RAAS causes the kidneys to reabsorb sodium, which then toms, and how should you treat him? pulls water from the intracellular fluid and into the intra- vascular fluid, increasing flow.1-9 Causes of hypovolemia include decreased intake; Hypernatremia (Na > 145) can be caused either by decreased absorption, such as from a bowel resection; excessive intake—whether from dietary intake or from hemorrhage; excessive diuresis, such as with diabetes rapid infusion of isotonic or hypertonic solutions—or insipidus (DI); and prolonged vomiting and diarrhea.1-9 from excessive loss of water through, for example, DI, Clinical manifestations include thirst, dry mucous mem- an impaired thirst center, decreased intake, or an inabil- branes, tachycardia, poor skin turgor, and the later ity to concentrate urine. Clinical manifestations of signs of hypotension and oliguria.1-9 Treatment should hypernatremia include thirst and dry mucous mem- focus first on stopping the loss and then on replacing branes, disorientation and hallucinations, oliguria or the volume.1-9 anuria, and a rapid, weak pulse.1-12 When the heart senses an increase in blood volume, The key to treating hypernatremia is to identify and atrial natriuretic peptide is released, which then blocks treat the underlying cause. For example, DI should be the RAAS, resulting in the loss of both sodium and fluid treated with vasopressin to cause the kidneys to retain in an attempt to normalize blood pressure and circulat- water. Additionally, an infusion of a hypotonic solution ing volume.1-9 should be used to help replace fluid without increasing Causes of hypervolemia include inadequate sodium sodium levels. If the hypernatremia is an acute condi- and water excretion (such as with Cushing’s syndrome, tion, aggressive therapy to reduce sodium levels by heart failure, or renal failure) or excessive sodium 1 mEq/L/h should be instituted. If the hypernatremia is intake.1-9 Hallmarks of fluid overload include periph- a chronic condition (in existence for more than 48 eral and pulmonary edema, hypertension, venous dis- hours), care should be taken to reduce sodium levels tension, and acute weight gain.1-9 Treatment should be slowly. During hypernatremia, the body’s initial response focused on correcting the underlying cause and possibly is to pull water from the intracellular fluid, including restricting intake.1-9 the cells in the brain. A rapid decrease in sodium during a chronic condition will then cause a massive influx of water back into the cells and can result in cerebral THE BALANCE OF ELECTROLYTES edema. The reduction of sodium should be slow, about 0.5 mEq/L/h (or 10-12 mEq/L over 24 hours).1-12 The shift and flux of electrolytes are how the body Hyponatremia (Na < 135) can be caused by excessive relays messages and conducts normal functioning with- diuresis, adrenocorticoid insufficiency, increased fluid in the cells. Cations are positively charged electrolytes, intake, ketoacidosis, and syndrome of inappropriate anti- while anions are negatively charged. Although there are diuretic hormone (SIADH). Signs and symptoms include others, sodium, potassium, calcium, phosphorus, and muscle cramps and weakness, lethargy and/or agitation, VOLUME 39 | NUMBER 6 | NOVEMBER/DECEMBER 2016 Copyright © 2016 Infusion Nurses Society 383 Copyright © 2016 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited. orthostatic hypotension, anorexia, and in extreme cases, manifestations of hyperkalemia include muscle cramps, seizures. Sodium levels less than 115 mEq/L can cause weakness and paresthesias, hyperreflexia, and changes permanent neurological dysfunction.1-12 to the electrocardiogram (ECG), including widened Again, the key to treatment is to identify and correct QRS and tall, peaked T waves, and, in severe cases, the underlying cause.
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