Fluid And Electrolytes1
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Fluid And Electrolytes1 Fluid And Electrolytes1 Presentation Transcript

  • Fluid, Electrolyte and Acid-Base Balance
  • Total Fluid Volumes by Age and Sex
  • Normal Water Balance
          • Intake:
            • Fluid ingestion 60%
            • Foods 30%
            • Metabolism 10%
          • Output:
            • Urine 60%
            • Sweat 8%
            • Feces 4%
            • "Insensible" loss 28%
            • (skin, lungs)
  • Fluid Compartments Extracellular Interstitial Intracellular Intravascular Intracellular
  • Fluid is in both compartments 50-60% of body weight ¾ of ECF ¼ of ECF
  • Intravascular Fluid or Plasma (1/4 of ECF)
    • Volume
      • Necessary for BP Maintenance
    • Maintenance of Proportional Distribution
      • Protein content of blood (Serum proteins- globulin and albumin
      • Integrity of blood vessels linings
      • Hydrostatic pressure inside blood vessels
    • Osmolarity
      • Concentration of dissolved substances expressed in mOsm/L (Normal 280-300)
  • Movement of Body Fluids
    • Filtration
      • Hydrostatic pressure
    • Osmosis
      • Concentration- solvent moves to make concentrations even although volume is not.
    • Diffusion
      • Redistributing - high to low to make even
    • Active Transport
      • Energy requirement for selective admission
  • Filtration
  • Osmosis
      • Movement of fluid through semipermeable membrane
      • Concentration controls- solvent moves to make concentrations even although volume is not
  • Filtration Pressures in a Capillary
  • Problem Examples: Edema Congestive heart failure
  • Diffusion - movement of solutes against a concentration gradient; tries to to balance cations + with anions -
  • Active Transport
    • Requires energy from metabolism to move larger or uneven substances across cell membranes
      • Glucose needs insulin to enter cell
      • Na/K pump
  • Active Transportation of Glucose
  • Na-K Pump: For every molecule of ATP, 3 molecules of Na move to outside of cell and 3 molecules of K move inside the cell
  • Factors Affecting Fluid & Electrolyte Movement
      • Osmotic Pressure and Tonicity
      • Hydrostatic Pressure
      • Filtration Pressure
  • Osmolality and Tonicity
    • Osmolality (Kg) and osmolarity (L) are determined by the solutes (mainly Na) in the ECF
      • Abnormalities tell us that there are problems with water regulation in the ECF.
    • Tonicity is the force that the ECF solutes (mainly Na) have to pull water into the ECF.
      • (Na, glucose, mannitol, sorbitol are effective osmoles.)
  • Osmosis and Tonicity Na is the main determinant of plasma tonicity . Thirst and ADH release Swelling of cells
  • Problem Examples: Edema Congestive heart failure
  • Tonicity HYPO 0.45% saline (1/2 normal) Moves fluid into cells
  • Tonicity ISO Same osmolarity as plasma 0.9 % saline (Normal saline) – no fluid shift
  • Tonicity HYPER 3% saline Pulls fluid from cells
  • Tonicity
  • Electrolytes + - - - - - + + + +
  •  
  • ECF Electrolytes
      • Sodium - Na 135-145mEq/L
      • Potassium - K 3.5-5.0 mEq.L
      • Calcium - Ca 4.5-5.5 mEq/L
      • Magnesium - Mg 1.5 - 2.5 mEq/L
      • Chloride - Cl 90-110 mEq/L
      • Bicarbonate – HCO 3
          • Arterial 22-26 mEq/L
          • Venous 24-30 mEq/L
  • Sodium and ECFV
    • The total amount of Sodium in ECF is the major determinant of the size of the ECF Volume
      • Na increases = ECFV increases until ECF ‘volume overload’ results (edematous states)
        • CHF, Cirrhosis of the liver, nephrotic syndrome
        • Pleural effusions, pulmonary edema, ascites
      • Na decreases = ECFV decreases eventually leading to ‘volume depletion’ manifested by poor skin turgor, tachycardia, orthostatic hypotension
  • Sodium Regulation
    • Kidney receptors sense changes in renal perfusion causing renin-angiotensin system to retain sodium in kidney.
    • Volume receptors in great veins sense filling and release atrial natriuretic factor that promotes Na excretion.
    • Pressure receptors in aorta and carotid sinus activate sympathetic NS to retain Na .
    • Water ALWAYS follows Na
    • Therefore when ECFV increases, these mechanisms are activated to increase Na excretion; and conversely, if ECFV decreases, the same means promotes Na retention.
  • Water Regulation ( Hypo- and Hyper-Natremia are always a problem with water, not Sodium)
    • Osmolality increase in ECF -> Thirst
    • Renal responsiveness to tonicity
    • Adequate delivery of water and solutes to glomerulus of kidney ( Problem: Early reabsorption of water due to volume depletion or edematous states )
    • Water conservation mechanisms in kidney (Can be overridden by diuretics either in loop or in distal tubule.
    • ADH in response to tonicity changes, i.e., Na, or in response to volume changes (Problems: SIADH and DI)
  • Diuretics
    • Both Thiazides and Loop diuretics block Na reabsorption and cause decrease in ECF, too.
    • Loop cause greater loss of Na but equal water, but thiazides lose less water than Na and can cause hyponatremia .
  • Manifestations of Fluid, and Electrolyte Imbalances
    • Imbalances of Intake and Output and Body Weight
    • Changes in Mental Status
    • Changes in Vital Signs
    • Abnormal Tissue Hydration
    • Abnormal Muscle Tone
  • Signs and Symptoms of Dehydration *Poor skin turgor (tenting of the skin of the back of the hand is common in normal geriatric patients b/c of age-related skin changes A recent history of poor oral intake and/or a documented weight loss are probably better warning signs of dehydration in geriatric residents.
    • Difficulty swallowing
    • Clumsiness
    • Shriveled skin
    • Sunken eyes
    • Visual disturbances
    • Painful urination
    • Numb skin
    • Muscle spasm
    • Delirium
    • Headache
    • Fatigue
    • Loss of appetite
    • Flushed skin
    • Heat intolerance
    • Light-headedness
    • Dry mouth or eyes
    • Burning sensation in stomach
    • Dark urine with strong odor
    Advanced Dehydration Early Dehydration
  •  
  • Nursing Interventions
    • Health Promotion
      • Teaching depending upon setting
    • Altered Function
      • Oral fluid increase
      • Oral fluid restriction
      • Electrolyte replacement
        • Diet or supplement
        • IV therapy
  • Renal failure, chemoTx, enemas containing Malnourished, alcohol withdrawal, phosphate- binding antacids Muscle, RBC’s, CNs, w/ Calcium in bones and teeth 1.7-4.6 Phos Phosphate Maalox and Milk of Magnesia in patients with renal failure Diarrhea, vomiting, NG Suction, hyper aldosteronism Muscle, RBC’s and CNS, metabolism 1.5-2.5 Mg Magnesium Mult. Myeloma, thiazide diuretics, malignancies, Chronic renal failure, Vit D deficiency, pancreatiti,s, loop diuretics, diarrhea hyporparathyroidism Transmission of nerve impulses, cardiac contractions, bone, blood clotting 4.5-5.5 Ca Calcium Acidosis Renal disease K containing drugs K salt substitute GI Losses – diarrhea, vomiting, duretics, diaphoresis Major ICF cation; cellular and metabolic functions including cardiac rhythms 3.5-5.0 K Potassium High fever, heatstroke due to insensible water loss, diabetes insipidus GI Losses Diuretics, burns, wound drainage Maintains concentration of ECF 135-145 Na Sodium Hyper Causes Hypo Causes Function Normal Value Symbol Name Serum Electrolytes
  • Objective Data
    • Neck Vein Distention
    • Central Venous Pressure
    • Pulmonary Artery Pressure
    • Bowel Assessment
    • Laboratory and Diagnostic Tests
      • Urine Tests
      • Blood Tests
  • Central Venous Pressure or Jugular Venous Distention
  • Assessment
    • Subjective Data
      • Normal Pattern Identification
      • Risk Identification
      • Dysfunction Identification
    • Objective Data—Physical Assessment
      • Intake and Output
      • Body Weight
      • Integumentary Assessment
  • plasma expander Isotonic (308 mOsm/L) 10% Dextran 40 in 0.9%NS closely resemble the electrolyte composition of normal blood serum and plasma; will need additional K; does not provide calories or  free water; used to treat losses from lower GI tract and burns.   Isotonic (273 mOsm/L) Lactated Ringer’s Solution provides free water (hypotonic) to the extracellular and intracellular spaces, as the dextrose is quickly metabolized; promotes renal elimination of solutes; treats hypernatremia; does not provide electrolytes; one liter is 170 calories Isotonic (252 mOsm/L) D5W - 5% Dextrose in water to treat fluid volume deficit; for daily maintenance of body fluids and nutrition; basically the same as NS, except provides 170 calories per liter Hypertonic (559 mOsm/L) D5NS - 5% Dextrose & 0.9NaCl to promote renal function and excretion; basically the same as .45NS except provides 170 calories per liter Hypertonic (406 mOsm/L) D5 1/2 NS - 5% Dextrose & 0.45NaCl assists with renal function; provides free water, Na and Cl.; replaces normal hypotonic daily fluid losses- assists with daily body fluid needs, but not with electrolyte replacement or provision of calories. Hypotonic (154 mOsm/L) 1/2 NS - 0.45%NaCl replaces NaCl deficit and restores/expands extracellular fluid volume; the only solution that may be administered with blood products --does not provide free water that causes hemolysis of red blood cells Isotonic (308mOsm/L) NS - 0.9% NaCl Usage and Limitations Osmolality Solution
  • Third Spacing: Loss of fluid into a space that cannot contribute to ICF/ECF equilibrium S&S: Urine output decreases Increased heart rate Decreased BP Decreased CVP Increased body weight Edema I & O imbalance Causes: Burns Ascites Peritonitis Bowel obstruction Massive bleeding into joint or body cavity
  • Factors Affecting Fluid, Electrolyte, and Acid-Base Balance
    • Fluid and Food Intake
    • Fluid and Electrolyte Output
    • Stress
    • Chronic Illnesses
    • Surgery
    • Pregnancy
  • Acid Base Balance Two systems work to maintain correct pH. Respiratory System by adjusting respirations. Metabolic system by adjusting serum HCO3
  • Acid Base Balance
  • Acidosis pH < 7.4 Increased paCO2 Decreased HCO3
  • Acid…………………Base
    • High CO2
    • Low HCO3
    • Low CO2
    • High HCO3
    pCO2 = 35-45 HCO3 = 22-28
  • Respiratory Acidosis
    • Hypoventilation for any reason
    • COPD
    • Paralysis of respiratory muscles
    • Cardiac Arrest – Code
  • Metabolic Acidosis
    • Starvation
    • DKA
    • Renal Failure
    • Lactic Acidosis from heavy exercise
    • Drugs – EtOH, ASA
    • Diarrhea
  • Alkalosis pH > 7.4 Decreased CO2 Increased HC03
  • Respiratory Alkalosis
      • Hyperventilation from any cause
      • Pneumonia
      • Too high ventilator settings
  • Metabolic Alkalosis
    • Excessive vomiting
    • Gastric suctioning
    • Hypokalemia OR Hypercalcemia
    • Excess aldosterone
    • Drugs – Steroids, diuretics, NaHCO3
  • Easy Read of Blood Gases
    • Check pH
    • <7.4 = Acidosis; > 7.4 = alkalosis
    • Which of the following parameters matches the pH?
      • CO2 or HCO3?
        • High C02 is acid; low CO2 is alkaline- respiratory
        • High HCO3 is alkaline; low HCO3 is acid - metabolic
    Matching parameter + pH direction is diagnosis! If both parameters match, then it is a combined _____; if opposite parameter is abnormal, compensation is occurring.
  •