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Fluids and electrolytes (1)

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  • 1. FLUIDS and ELECTROLYTESBODY FLUIDSFunctions of Fluids  Body fluids:  Facilitate in the transport [nutrients, hormones, proteins, & others…]  Aid in removal of cellular metabolic wastes  Provide medium for cellular metabolism  Regulate body temperature  Provide lubrication of musculoskeletal jts.  Component in all body cavities [parietal, pleural… fluids] Water is the principal body fluid & essential for life.
  • 2. FLUIDS and ELECTROLYTESBODY FLUIDSDistribution of Body Fluids – 50-70% of total body weight; infant [70-80%], elderly [45-50%] ICF ECF 60-kg man TBW = 0.6 x 60 kg = 3.6 L ICF = 0.4 x 60 kg ECF P IS = 24 L = 12 L 3L 9L 40% TBW 20% TBW
  • 3. FLUIDS and ELECTROLYTESBODY FLUIDSFactors that Dictate Body Water Requirement 1) Amount needed to give the proper osmotic concentration 2) Amount needed to replace water lost excretion Normal Routes of water gain and loss INTAKE ml/day OUTPUT ml/day Fluid intake 1,200 Insensible loss 700 Food 1,000 Sweat 100 Metabolic water 300 Feces 200 Urine 1,500 TOTAL 2,500 TOTAL 2,500
  • 4. FLUIDS and ELECTROLYTES FLUID EXCHANGE BETWEEN BODY FLUID COMPARTMENTS ICF ECF Osmotic Pressure Gradient Oncotic P (Colloid osmotic P) Capillary P (Hydrostatic P) P ISF
  • 5. FLUIDS and ELECTROLYTESControl of Osmotic Pressure, Volume & Electrolyte Concentration OBLIGATORY Reabsorption  occurs in the proximal tubules  178 L/day of glomerular filtrate (80% reabsorbed)  2° to solute reabsorption  independent of the water requirement FACULTATIVE Reabsorption  occurs in the distal & collecting tubules  independent of the active solute transport  dependent of body’s need of water  under the control of ADH
  • 6. FLUIDS and ELECTROLYTESDISTURBANCES IN FLUID BALANCEEDEMA (Dropsy)  ↑ in the interstitial fluid volume of about 2 L or more due to increase transudation of fluid from capillaries 2° to:  Increased HP [pregnancy, CHF]  Decreased OP [malnutrition, end-stage liver dse, nephrotic syndrome]
  • 7. FLUIDS and ELECTROLYTESDISTURBANCES IN FLUID BALANCECELL OVERHYDRATION  excess of water in the ECC w/ a normal amount of solute or a deficient amount of solute  occurs in prolonged and excessive diuresis, forcing hypotonic fluids to produce diuresis in the presence of renal impairment  fluid overload from ↑ production of adrenal corticoid hormones [Cushing’s syndrome]
  • 8. FLUIDS and ELECTROLYTESDISTURBANCES IN FLUID BALANCECELL OVERHYDRATION  Symptoms  Weight gain & edema  Cough, moist rales, dyspnea [fluid congestion in lungs]  CVP, bounding pulse,neck vein engorgement [fluid excess in the vascular system]  Bulging fontanelles  ↓ Hg and Hct  Nausea & vomiting
  • 9. FLUIDS and ELECTROLYTESDISTURBANCES IN FLUID BALANCECELL OVERHYDRATION  Management  Restrict fluids to lower fluid volume  Diuretics or hypertonic saline  Continuous assessments to prevent skin breakdown  Record daily weight to assess progress of treatment
  • 10. FLUIDS and ELECTROLYTESDISTURBANCES IN FLUID BALANCECELL DEHYDRATION (DHN)  loss of body fluids, particularly from the extracellular fluid compartment  water loss > water intake  Causes  Fever  Insufficient water intake  Diarrhea, vomiting  Excess urine output [Diabetes insipidus, diuretics]  Excessive perspiration, burns  Hemorrhage, shock, metabolic acidosis
  • 11. FLUIDS and ELECTROLYTESDISTURBANCES IN FLUID BALANCECELL DEHYDRATION (DHN)  Symptoms  Thirst, dry mucus membranes, sunken eyeballs  “Doughy“ abdomen, dry skin w/ poor turgor  ↑ temp, weight loss  ↑ HR, ↑ RR, ↓ BP  Restlessness,irritability, disorientation, convulsion, coma [22-30% body H20 loss]  Management  Fluid replacement therapy & continued fluid maintenance
  • 12. FLUIDS and ELECTROLYTESVolume Disorders 2° Alteration in Sodium BalanceVolume ECF ICF Water ConditionsDisorder Vol. Vol. ShiftExpansionIsotonic Inc N No net change Isotonic fluid ingestion Hypertonic Inc Dec ICF → ECF Sea water ingestion Hypotonic Inc Inc ECF → ICF Hypotonic IVFContraction Isotonic Dec N No net change Diarrhea Hypertonic Dec Dec ICF → ECF Diabetes insipidus Hypotonic Dec Inc ECF → ICF Addison’s dse
  • 13. FLUIDS and ELECTROLYTESELECTROLYTES  salts or minerals in extracellular or intracellular body fluids  Sodium – major cation of ECF  Potassium – major cation of ICF  Chloride - major anion of ICF  Protein – in ICF > ISF
  • 14. FLUIDS and ELECTROLYTESELECTROLYTE Composition Electrolyte Conc Plasma (mEq/L) ISF ICF Sodium, Na+ 142 141 10 Potassium, K+ 5 4.1 150 Calcium, Ca++ 5 4.1 - Magnesium, Mg++ 3 3 40 (155) Chloride, Cl- 103 115 15 Bicarbonate, HCO3- 27 29 10 Biphosphate, HPO4- 2 2 100 Sulfate, SO4-2 1 1 20 Protein 16 1 60 Organic foods 6 3.4 - (155)
  • 15. FLUIDS and ELECTROLYTESELECTROLYTESFunctions of Electrolytes  Contribute most of the osmotically active particles in body fluids  Provide buffer systems for pH regulation  Provide the proper ionic environment for normal neuromuscular irritability & tissue function
  • 16. FLUIDS and ELECTROLYTESELECTROLYTESHyponatremia [Na+ < 135 mEq/L; Normal = 135-145 mEq/L]  Causes  ↓ Na+ intake  ↑ Na+ excretion [diaphoresis, GI suctioning]  Adrenal insufficiency  Assessment  N & V, abdominal cramps, weight loss  Cold, clammy skin, ↓ skin turgor  Apprehension, HA, convulsions, focal neurologic deficit, coma [cerebral edema]  Fatigue, postural hypotension  Rapid thready pulse
  • 17. FLUIDS and ELECTROLYTESELECTROLYTESHyponatremia [Na+ < 135 mEq/L; Normal = 135-145 mEq/L]  Management  Provide foods high in sodium  Administer NSS IV  Assess blood pressure frequently [measure lying down, sitting & standing]
  • 18. FLUIDS and ELECTROLYTESELECTROLYTESHypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L]  Causes  Excessive, rapid IV adm’n of NSS  Inadequate water intake  Kidney disease  Assessment  Dry, sticky mucus membranes  Flushed skin  Rough dry tongue, firm skin turgor  Intense thirst  Edema, oliguria to anuria  Restlessness, irritability [cerebral DHN]
  • 19. FLUIDS and ELECTROLYTESELECTROLYTESHypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L]  Nursing Intervention  Weigh daily  Assess degree of edema frequently  Measure I & O  Assess skin frequently & institute nursing measures to prevent breakdown  Encourage sodium-restricted diet
  • 20. FLUIDS and ELECTROLYTESELECTROLYTESHyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L]  Causes  Renal insufficiency  Adrenocortical insufficiency  Cellulose damage [burns]  Infection  Acidotic states  Rapid infusion of IV sol’n w/ potassium- conserving diuretics
  • 21. FLUIDS and ELECTROLYTESELECTROLYTESHyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L]  Assessment  Thready, slow pulse  Shallow breathing  N & V, diarrhea, intestinal colic  Irritability  Muscle weakness, flaccid paralysis  Numbness, tingling  Difficulty w/ phonation, respiration
  • 22. FLUIDS and ELECTROLYTESELECTROLYTESHyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L]  Nursing Interventions  Administer kayexalate as ordered  Administer/monitor IV infusion of glucose & insulin  Control infection  Provide adequate calories & carbohydrates  Discontinue IV or oral sources of K+
  • 23. FLUIDS and ELECTROLYTESELECTROLYTESHypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L]  Causes  Renal insufficiency  Adrenocortical insufficiency  Cellulose damage [burns]  Infection  Acidotic states  Rapid infusion of IV sol’n w/ potassium- conserving diuretics
  • 24. FLUIDS and ELECTROLYTESELECTROLYTESHypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L]  Assessment  Thready, rapid, weak pulse  Faint heart sounds  ↓ BP  Skeletal muscle weakness  ↓ or absent reflexes  Shallow respirations  Malaise, apathy, lethargy  Loss of orientation  Anorexia, vomiting, weight loss  Gaseous intestinal distention
  • 25. FLUIDS and ELECTROLYTESELECTROLYTESHypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L]  Nursing Interventions  Administer K+ supplements to replace losses  Be cautious in administering drugs that are not potassium-sparing  Monitor acid-base balance  Monitor pulse, BP and ECG
  • 26. FLUIDS and ELECTROLYTESELECTROLYTESHypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L]  Causes  Hyperparathyroidism  Immobility  Increased vitamin D intake  Osteoporosis & osteomalacia [early stages]  Assessment  N & V, anorexia, constipation  Headache, confusion  Lethargy, stupor  Decreased muscle tone  Deep bone/flank pain
  • 27. FLUIDS and ELECTROLYTESELECTROLYTESHypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L]  Nursing Interventions  Encourage mobilization  Limit vitamin D intake  Limit calcium intake  Normal saline  Administer diuretics  Calcitonin
  • 28. FLUIDS and ELECTROLYTESELECTROLYTESHypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L]  Causes  Acute pancreatitis  Diarrhea  Hypoparathyroidism  Lack of vitamin D I the diet  Long-term steroid therapy  Assessment  Painful tonic muscle & facial spasms  Fatigue, dyspnea  Laryngospasm, convulsions  (+) Trousseau’s and Chvostek’s signs
  • 29. FLUIDS and ELECTROLYTESELECTROLYTESHypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L]  Nursing Interventions  Administer oral Ca lactate or IV CaCl2 or gluconate  Providing safety by padding side rails  Administer dietary sources of calcium  Vitamin D  Provide quiet environment
  • 30. FLUIDS and ELECTROLYTESELECTROLYTESHyermagnesemia [Mg > 3.0 mEq/L; Normal = 1.5-3.0 mEq/L]  Causes  Renal insufficiency, dehydration  Excessive use of Mg-containing antacids or laxatives  Assessment  Lethargy, somnolence, confusion  N&V  Muscle weakness, depressed reflexes  ↓ pulse and respirations  Nursing Intervention  Withhold Mg-cont’g drugs/foods; Ca adm’n  ↑ fluid intake, unless CI
  • 31. FLUIDS and ELECTROLYTESELECTROLYTESHypomagnesemia [Mg < 1.50 mEq/L; Normal = 1.5-3.0 mEq/L]  Causes  Low intake of Mg in the diet  Prolonged diarrhea  Massive diuresis  Hypoparathyroidism  Assessment  Paresthesias, muscle spasm  Confusion, hallucination, convulsions  Ataxia, tremors, hyperactive deep reflexes  Flushing of the face, diaphoresis  Nursing Intervention  Provide good dietary sources of Mg
  • 32. FLUIDS and ELECTROLYTESIV FLUID REPLACEMENT THERAPYIndications  Replacement of abnormal fluid & electrolyte losses [surgery, trauma, burns, GI bleeding]  Maintenance of daily fluid & electrolyte needs  Correction of fluid disorders  Correction of electrolyte disorders
  • 33. FLUIDS and ELECTROLYTESIV FLUID REPLACEMENT THERAPYTypes of Solutions  Isotonic  0.9% sodium chloride (NSS)  Lactated Ringer’s sol’n  Hypotonic  5% dextrose and water (D5W)  0.45% sodium chloride  0.33% sodium chloride  Hypertonic  3% NaCl  Protein sol’ns  Colloids  Salt pour albumin Plasmanate, Dextran
  • 34. BURNSBURNS  wounds caused by excessive exposure to the following agents or causes: Causes of Burns:  Thermal [moist or dry heat]  Electrical  Chemical [strong acids and strong alkali  Radiation [UV, x-rays, radium, sunburns]
  • 35. BURNSCLASSIFICATION OF BURNS  Superficial Partial thickness (1st degree)  Outer layer of dermis  Erythema, pain up to 48 hrs  Healing 1-2 wks [sunburn]  Deep Partial thickness (2nd degree)  Epidermis & dermis  Blisters & edema, frequently quite painful  Healing 14-21 days  Full thickness (3rd degree)  Epidermis, dermis, subcutaneous fat  Dry, pearly white or charred in appearance  Not painful  Eschar must be removed; may need grafting
  • 36. BURNSSTAGES OF BURNS 1st: Shock/Fluid Accumulation Phase  1st 48 hrs  IVC → ISC  Generalized DHN [fluid shifting]  Hypovolemia [plasma loss], ↓ BP, ↓ C.O.  Hemoconcentration, ↑ Hct [liquid blood component → ISC]  Oliguria [↓ renal perfusion], ADH release & aldosterone  HyperK, hypoNa  Metabolic acidosis
  • 37. BURNSSTAGES OF BURNS 2nd: Diuretic/Fluid Remobilization Phase  After 48 hrs  ISC → IVC  Hypervolemia,  Hemodilution, ↓ Hct  Diuresis [↑ renal perfusion], ↓ ADH & aldosterone secretion  HypoK, hypoNa [K moves back into the cells, Na+ still trapped in the edema fluids  Metabolic acidosis
  • 38. BURNSSTAGES OF BURNS 3rd: Recovery Phase  5th day onwards  Hypocalcemia  Ca is lost on the exudates  Ca is utilized in the granulation tissue formation  Negative nitrogen balance  Due to stress response  ↑ protein catabolism  Protein intake is lesser than the demand  HypoK
  • 39. BURNSASSESSMENT 1. Assess extent of body surface burned  Greater morbidity & mortality for burns affecting face, hands & perineum  Assess for dyspnea, stridor, hoarseness 2. Assess extent of burn injury  Rule of nine – immediate appraisal  Lund-Browder chart – more accurate  Berkow’s method – based on client’s age & changes that occur in proportion of head & legs to the rest of the body as one grows
  • 40. BURNSASSESSMENT 9% Front=18% 9% Back=18% 9% 1% Burn Evaluation 18% 18% Chart
  • 41. BURNSASSESSMENT 3. Assess depth of burn  Major burns – 2nd degree over 30% of body  Hospitalization - eyes, face, neck, hands, perineum, genitalia 4. Assess unique contributing factors  Age of client  Health history  Diabetes, preexisting ulcers  Tetanus immunization
  • 42. BURNSEMERGENCY MANAGEMENT Stop the burning process  Remove patient from source of injury  Advise client to roll on the ground if clothing is in flame [STOP-DROP-ROLL]  Throw a blanket over the client to smother the flame  Remove clothing only if hot or for scald burn  Immerse affected part in cold water [10 min]  Irrigate copiuosly w/ large amount of running water w/ chemical burns [except w/ phosphorus]  Interrupt power source w/ electrical burn
  • 43. BURNSMANAGEMENT  Maintenance of adequate airway  Promoting comfort: relieve pain  Promoting fluid-electrolyte, acid-base balance  Preventing infection  Maintaining adequate nutrition  Wound care
  • 44. BURNSMETHODS OF TREATING BURNS  Open method or Exposure method  Face, neck, perineum, trunk  Allowing exudate to dry in 3 days  Occlusive  Less pain, absorption of secretion, comfort, transportability, accelerated debridement  Aesthetic considerations  Semi-open method  Covering of wound w/ topical antimicrobials:  Silver sulfadiazine 1% (Flamazine)  Silver nitrate 0.5% sol’n  Mafenide acetate (sulfamylon acetate)
  • 45. BURNSBIOLOGIC DRESSING (Skin Graft)  Allograft  Skin taken from other person [cadaver]  Autograft  Same person  Heterograft  Different species  Xenograft [segment of skin from animal such as pig or dog]
  • 46. BURNSFLUID REPLACEMENT Types of fluids:  Colloids  Blood  Plasma & plasma expanders  Electrolytes  Lactated Ringers  Non-electrolyte  D5W
  • 47. BURNSFLUID REPLACEMENTEVAN’S Formula:  C – 1ml x % burns x kgBW  E - 1ml x % burns x kgBW  Glucose 5% for insensible loss – 2,000ml D5W  Administer sol’n 1st 24 hrs – ½ [1st 8hrs], ½ [16hrs]BROOKE Formula: [Administer as in Evan’s]  C – 0.5ml x % burn x kgBW  E - 1.5ml x % burns x kgBW  Water – 1000ml D5W
  • 48. BURNSFLUID REPLACEMENTMOORES BURN BUDGET:  75 ml of plasma, 75 ml of electrolyte-cont’g fluid for q 1%TBSA plus 2000 D5WHYPERTONIC RESUSCITATION Formula:  Hypertonic salt containing 300mEq of Na+, 100mEq of Cl-, 200mEq lactate  Administered to maintain urinary output of 30-40 ml/hr