Fluids and electrolytes منتدى تمريض مستشفى غزة الاوروبي
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Fluids and electrolytes منتدى تمريض مستشفى غزة الاوروبي

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منتديات تمريض مستشفى غزة الاوروبي

منتديات تمريض مستشفى غزة الاوروبي

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Fluids and electrolytes منتدى تمريض مستشفى غزة الاوروبي Presentation Transcript

  • 1. EGH-NSG.ForumPalestine.com
  • 2. Prepared by ABED SHAGORA In-service Education Department EGH 2011 - 2012 FLUIDS and ELECTROLYTES
  • 3.  
  • 4. FLUIDS and ELECTROLYTES
    • BODY FLUIDS
    • Functions of 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 joints.
      • Component in all body cavities [parietal, pleural… fluids]
    • Water is the principal body fluid & essential for life.
  • 5. BODY FLUIDS Distribution of Body Fluids – 50-70% of total body weight; infant [70-80%], elderly [45-50%] ICF ECF 40% TBW 20% TBW P IS 60-kg man TBW = 0.6 x 60 kg = 36 L ICF = 0.4 x 60 kg = 24 L ECF = 12 L 3L 9L
  • 6.
    • Factors that Dictate Body Water Requirement
      • Amount needed to give the proper osmotic concentration
      • Amount needed to replace water lost excretion
    Normal Routes of water gain and loss INTAKE OUTPUT ml /day ml /day Fluid intake 1,200 Food 1,000 Metabolic water 300 TOTAL 2,500 Insensible loss 700 Sweat 100 Feces 200 Urine 1,500 TOTAL 2,500
  • 7. FLUID EXCHANGE BETWEEN BODY FLUID COMPARTMENTS Osmotic Pressure Gradient Oncotic P (Colloid osmotic P) Capillary P (Hydrostatic P) ICF ECF P ISF
  • 8. Control 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
  • 9. DISTURBANCES IN FLUID BALANCE
    • EDEMA
      •  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 disease, nephrotic syndrome]
  • 10. DISTURBANCES IN FLUID BALANCE
    • CELL 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]
  • 11. DISTURBANCES IN FLUID BALANCE
    • CELL 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
  • 12. DISTURBANCES IN FLUID BALANCE
    • CELL 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
  • 13. DISTURBANCES IN FLUID BALANCE
    • CELL DEHYDRATION
      • 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
  • 14. DISTURBANCES IN FLUID BALANCE
    • CELL DEHYDRATION
      • 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 H 2 0 loss]
      • Management
        • Fluid replacement therapy & continued fluid maintenance
  • 15. Volume Disorders 2° Alteration in Sodium Balance Expansion Isotonic Inc N No net change Isotonic fluid ingestion Hypertonic Inc Dec ICF  ECF Sea water ingestion Hypotonic Inc Inc ECF  ICF Hypotonic IVF Contraction Isotonic Dec N No net change Diarrhea Hypertonic Dec Dec ICF  ECF Diabetes insipidus Hypotonic Dec Inc ECF  ICF Addison’s disease Volume ECF ICF Water Conditions Disorder Vol. Vol. Shift
  • 16.
    • ELECTROLYTES
      • 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
  • 17. ELECTROLYTE 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)
  • 18. ELECTROLYTES
    • Functions 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
  • 19.
    • Hyponatremia [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
    ELECTROLYTES
  • 20.
    • Hyponatremia
        • Management
          • Provide foods high in sodium
          • Administer NSS IV
          • Assess blood pressure frequently
          • [measure lying down, sitting & standing]
    ELECTROLYTES
  • 21.
    • Hypernatremia [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]
    ELECTROLYTES
  • 22.
    • Hypernatremia
        • 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
    ELECTROLYTES
  • 23.
    • Hyperkalemia [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
    ELECTROLYTES
  • 24.
    • Hyperkalemia
        • Assessment
          • Thready, slow pulse
          • Shallow breathing
          • N & V, diarrhea, intestinal colic
          • Irritability
          • Muscle weakness, flaccid paralysis
          • Numbness, tingling
          • Difficulty w/ phonation, respiration
    ELECTROLYTES
  • 25.
    • Hyperkalemia
        • 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+
    ELECTROLYTES
  • 26.
    • Hypokalemia [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 solution potassium-conserving diuretics
    ELECTROLYTES
  • 27.
    • Hypokalemia
        • 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
    ELECTROLYTES
  • 28.
    • Hypokalemia
        • 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
    ELECTROLYTES
  • 29.
    • Hypercalcemia [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
    ELECTROLYTES
  • 30.
    • Hypercalcemia
        • Nursing Interventions
          • Encourage mobilization
          • Limit vitamin D intake
          • Limit calcium intake
          • Normal saline
          • Administer diuretics
          • Calcitonin
    ELECTROLYTES
  • 31.
    • Hypocalcemia [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
    ELECTROLYTES
  • 32.
    • Hypocalcemia
        • Nursing Interventions
          • Administer oral Ca lactate or IV CaCl 2 or gluconate
          • Providing safety by padding side rails
          • Administer dietary sources of calcium
          • Vitamin D
          • Provide quiet environment
    ELECTROLYTES
  • 33.
    • Hyermagnesemia [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
    ELECTROLYTES
  • 34.
    • Hypomagnesemia [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
    ELECTROLYTES
  • 35. IV FLUID REPLACEMENT THERAPY
    • Indications
        • 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
  • 36.
    • Types of Solutions
        • Isotonic
          • 0.9% sodium chloride (NSS)
          • Lactated Ringer’s solution
        • Hypotonic
          • 5% dextrose and water (D5W)
          • 0.45% sodium chloride
          • 0.33% sodium chloride
        • Hypertonic
          • 3% NaCl
          • Protein solution
        • Colloids
          • Salt pour albumin Plasmanate, Dextran
  • 37.
    • 4/2/1 Rule 4 ml/kg/hr for first 10 kg (=40ml/hr) then 2 ml/kg/hr for next 10 kg (=20ml/hr) then 1 ml/kg/hr for any kgs over that This always gives 60ml/hr for first 20 kg then you add 1 ml/kg/hr for each kg over 20 kg
    • This boils down to: Weight in kg + 40 = Maintenance IV rate/hour . For any person weighing more than 20kg
  • 38. BURNS
      • 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]
    B U R N S
  • 39.
    • CLASSIFICATION OF BURNS
        • Superficial Partial thickness (1 st degree)
          • Outer layer of dermis
          • Erythema, pain up to 48 hrs
          • Healing 1-2 wks [sunburn]
        • Deep Partial thickness (2 nd degree)
          • Epidermis & dermis
          • Blisters & edema, frequently quite painful
          • Healing 14-21 days
        • Full thickness (3 rd degree)
          • Epidermis, dermis, subcutaneous fat
          • Dry, pearly white or charred in appearance
          • Not painful
          • Eschar must be removed; may need grafting
    B U R N S
  • 40.
    • STAGES OF BURNS
    • 1 st : Shock/Fluid Accumulation Phase
        • 1 st 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
    B U R N S
  • 41.
    • STAGES OF BURNS
    • 2 nd : 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
    B U R N S
  • 42.
    • STAGES OF BURNS
    • 3 rd : Recovery Phase
        • 5 th 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
    B U R N S
  • 43.
    • ASSESSMENT
      • Assess extent of body surface burned
        • Greater morbidity & mortality for burns affecting face, hands & perineum
        • Assess for dyspnea, stridor, hoarseness
      • 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
    B U R N S
  • 44. ASSESSMENT Burn Evaluation Chart B U R N S 9% 9% 9% Front=18% Back=18% 18% 18% 1%
  • 45.
    • ASSESSMENT
      • 3. Assess depth of burn
        • Major burns – 2 nd 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
    B U R N S
  • 46.
    • EMERGENCY 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
    B U R N S
  • 47.
    • MANAGEMENT
        • Maintenance of adequate airway
        • Promoting comfort: relieve pain
        • Promoting fluid-electrolyte, acid-base balance
        • Preventing infection
        • Maintaining adequate nutrition
        • Wound care
    B U R N S
  • 48.
    • METHODS 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)
    B U R N S
  • 49.
    • BIOLOGIC 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]
    B U R N S
  • 50.
    • FLUID REPLACEMENT
    • Types of fluids:
        • Colloids
          • Blood
          • Plasma & plasma expanders
        • Electrolytes
          • Lactated Ringers
        • Non-electrolyte
          • D5W
    B U R N S
  • 51.
    • FLUID REPLACEMENT
    • EVAN’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 1 st 24 hrs – ½ [1 st 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
    B U R N S
  • 52.
    • FLUID REPLACEMENT
    • MOORES BURN BUDGET:
        • 75 ml of plasma, 75 ml of electrolyte-cont’g fluid for q 1%TBSA plus 2000 D5W
    • HYPERTONIC RESUSCITATION Formula:
        • Hypertonic salt containing 300mEq of Na+, 100mEq of Cl-, 200mEq lactate
        • Administered to maintain urinary output of 30-40 ml/hr
    B U R N S