Rsq solutions fluid and electrolyte balance 2014

Fluid and Electrolyte Review
Shelley Flasch

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Objectives
 At the end of this course the learner will be able to:
 Describe signs, symptoms and nursing implications in
the treatment of hypovolemic and hypervolemic
presentations.
 Differentiate signs, symptoms, nursing care and
implications for patients presenting with the following
electrolyte imbalances:
 Hypo/Hypernatremia
 Hypo/Hyperkalemia
 Hypo/Hyperchloremia
 Hypo/Hypercalcemia
 Hypo/Hypermagnesemia

Section 1- Basic review of
fluid homeostasis

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Put yourself in this situation!
 Case study on hypervolemia, hypovolemia
 I still need to come up with this, but according to
Gagne’s instructions, I want to do a thought
provoking intro.

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Body Fluid Homeostasis
 Maintenance of body fluid homeostasis is crucial
for normal functions of every system in our bodies
 Some important functions of body fluids:
 Serves as a solvent for the chemicals of metabolism
 Transports oxygen, nutrients, chemical messengers
and waste products to their appropriate destination
 Major role in temperature regulation
 Serves as a lubricant for joints

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2 Compartments of fluids
 Extracellular compartment: “Outside” the cells
 1/3 of all body fluid is extracellular
 Locations:
 Interstitial spaces between the cells
 Intravascular- within the blood vessels
 In dense connective tissue and bone
 Synovial fluid, cerebrospinal fluid, and gastrointestinal fluids
 Intracellular Compartment- Inside the cells
 2/3 of all body fluid is intracellular

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Composition of fluids
 All fluids have the same concentration of particles,
even though the compositions are different
 Extracellular fluids are rich in sodium, chloride and
bicarbonate ions
 Intracellular fluids are rich in potassium and
magnesium ions, inorganic and organic phosphates
and proteins
 The vascular portion of extracellular fluid contains
many proteins whereas the interstitial compartment
has very few proteins.

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Fluid homeostasis as a Dynamic process
 Homeostasis- A dynamic steady state, representing
the net effect of all the turnover reactions.
 Relies on the following sub-processes:
 Fluid intake/absorption
 Fluid excretion
 Fluid distribution
 Alterations in these can cause a hypovolemic state
or hypervolemic state.

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Fluid Intake/Absorption
 Normal ingestion of fluid by eating and drinking
 Additional routes of fluid intake (often times
controlled by the health care provider):
 IV fluids
 G tubes/Feeding tubes
 Subcutaneous tissue
 Bone Marrow
 Rectal Intake
 Lungs (near drowning)

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Fluid Excretion/Fluid loss
 Normal mechanisms of fluid loss:
 Largest volume of loss is from urinary output
 Urine output is dependent on adequate blood pressure
 The hormones ADH, ANH and aldosterone also affect
adequate urine output
 Insensible losses through sweat, lungs as a person
exhales.
 The bowel excretes fluid in the stool. If diarrhea occurs
dramatic fluid loss can occur.

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Fluid Distribution-Very important in
homeostasis of volume
 Distribution between the vascular compartment and
interstitial compartments is the result of Filtration
across permeable capillaries
 Distribution between interstitial compartments and
intracellular compartments occurs by Osmosis

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The forces of filtration work between the
capillary bed and the interstitium
 Primary mechanism that fluid moves from the
capillary to the interstitium:
 *Capillary Hydrostatic pressure*-outward push of fluid
against the capillary wall-
 Conversely, fluid moves from the interstitium into
the capillary
 *Capillary osmotic pressure*- the inward pulling force
of particles in the vascular fluid. This is often called
“plasma oncotic pressure” Fluid will follow the highest
concentration of large particles. In this case, large
protein molecules (primarily albumin) in the vascular
compartment attract the fluid from the interstitial space.

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Hydrostatic Pressure
 The most basic definition: The blood pressure of
the capillary
 The strength of the hydrostatic pressure actually
depends on 2 things:
 Blood pressure- net effect of arterial systems
 Resistance of the arterial and venous systems

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Capillary osmotic pressure AKA, Plasma
colloid oncotic pressure
 Plasma proteins are the key factor in influencing
capillary osmotic pressure.
 Albumin is the primary protein in the vascular
compartment. These protein molecules are so large
they normally cannot move through the semi permeable
capillary membrane.
 Fluid will follow the highest concentration of these
large protein molecules.
 Normally plasma has 4 times the concentration of
protein over the interstitial space. This keeps fluid in
the vascular compartment.

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Capillary osmotic pressure AKA, Plasma
colloid oncotic pressure (contd)
 If the capillary membrane becomes more permeable than it
should be due to injury: burns, allergic reaction, ARDS etc.
the large protein molecules can leak through causing more
fluid to follow into the interstitial spaces. This causes
edema in the interstitial space which can be in the lungs,
brain, skeletal tissue, GI spaces, etc.
 These changes also contribute to generalized hypo and
hypervolemic states.

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Fluid distribution between the vascular
and interstitial compartments
 Would like to put a pictorial explanation here from
my pathophysiology text.

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Cellular Fluid Homeostasis
 Distribution of fluid between the interstitial
and the intracellular compartments is called
Osmosis.
 Cells have semi-permeable membranes
which allow water to cross, but not
electrolytes.

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Cellular fluid homeostasis contd:
 Electrolytes are also considered particles
but require specialized transport
mechanisms to pass through the semi-
permeable cell membrane.
 Electrolytes do not travel by osmosis

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Fluid shifts in relation to cellular
structure:
Osmosis is the process where
WATER moves in and out through
a semipermeable membrane in an
attempt to equalize
CONCENTRATIONS of particles.

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Cellular Shrinkage (Crenation)
 If there is too little water in the extracellular
compartment (hypovolemia) causing a high
concentration of particles (i.e. sodium molecules),
water from within the cell will cross the cellular
membrane in an effort to balance the concentration
between the extracellular and intracellular
compartments.
 This will cause the cell to shrink, additionally the
water needed for cellular processes won’t be there
causing cell death.

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Cellular Swelling
 If there is too much water diluting the extracellular
compartment, water will enter the cell in an effort to
balance the concentrations of solutes and
depending on how big of a disparity, the swelling
may grow so large that the cell bursts and dies.

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Normal/Abnormal fluid distribution between
the capillary bed and interstitium
 Fluid distribution is an ongoing process to change
out wastes, bring in nutrients, etc. Normally only
10% of the fluid stays in the interstitial space and is
then drained into the lymphatic system to be
returned to the circulation later.
 Abnormal amount of fluid stays in the interstitial
space in the form of edema if:
 Lymphatic flow is impaired
 Capillaries become more permeable and “leak”
 Additionally, high BP and changes in the vascular
system can contribute

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Review Question #1: Which of the following
conditions will not cause an increase in the
hydrostatic pressure within the capillary bed?
a) Hemorrhage with hypotension
b) Large amounts of IV fluids
c) Heart failure with increases in venous pressure
d) Peripheral venous obstruction from a clot, emboli
or Peripheral vascular disease.
Answer: a- Hemorrhage with hypotension would
cause a decrease in arterial BP therefore a
decrease in hydrostatic pressure.
b, c and d all result in an increase in venous
pressures which increase net capillary hydrostatic
pressure.

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Review Question #2: Capillary osmotic
pressure is important in regulating
extracellular volume homeostasis. Based on
this, answer the following questions:
1. Body fluid will follow large concentrations of
proteins in the extracellular compartment.
a) True
b) False
1. Damage to capillary membranes will increase
permeability to large protein molecules.
a) True
b) False

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Review question #2 contd.
1. When protein molecules seep into the interstitial
space, fluid will follow, causing edema
a) True
b) False

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Review question #3: Edema can occur in any
interstitial space. Which of the following
factors can contribute to edema?
a) Alterations in Lymphatic flow
b) Elevated venous pressures
c) Damage to capillary membranes
d) Elevated arterial blood pressures
e) All of the above

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Review Question #3 contd
 Answer: e. All of the above
 I will add more specific rationale

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Review Question #4
 Electrolytes move in and out of the cell by osmosis.
a) True
b) False

Section 2-
Hypovolemic/Hypervolemic
presentations

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Fluid Imbalances
 3 categories of fluid imbalance:
1. Imbalances of Extracellular Volume (ECF)
 May be hypervolemic or hypovolemic as related to the
actual volume of the ECF.
 The concentrations (particles/electrolytes) are normal,
the volumes are just either too little or too much.
2. Imbalances of Body Water Concentration
1. These disorders are the result of the concentration of
the ECF rather than the amount of fluid.
2. Serum sodium concentration is normally 135-145
meq/L
3. Combination of Volume and Concentration imbalances

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Common types of abnormal
Vascular/interstitial fluid shifts (Extracellular
Volume)
 Hypervolemia:
 Edema
 Acites
 Hypovolemia:
 Loss of fluid through burns
 Hemorrhage
 Emesis
 Diarhea

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Hypovolemia- ECF Volume Deficit
 In the Vascular and interstitial compartments,
sodium-containing fluid of the body has been
depleted or displaced, also can be referred to as a
saline deficit
 Causes:
 GI Loss- Emesis, diarrhea, Gastric suction, Fistula
drainage
 Renal Loss- Adrenal insufficiency, renal disorders,
extensive diuretic use, prolonged bedrest
 Other Losses- Hemorrhage, diaphoresis, Third spacing,
paracentesis, burns.

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Clinical Manifestations of Hypovolemia
 Increased Heart Rate
 Postural hypotension
 Dizzyness, syncope
 Concentrated urine/oliguria
 Dry mucous membranes, skin tenting, sunken
eyeballs, decreased capillary refill time (CRT)
 Absence of tears or sweat
 Weight loss (1 liter of saline weighs 1 kg)

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Nursing Implications in the RX of
Hypovolemia
 Ensure rapid vascular access- Ideally 16-18 G IV
placement in the upper extremities: antecubital,
forearm, hand.
 Skin prep for 30 seconds with bactericidal agent of your
hospitals choice.
 Apply occlusive dressings as outlined by your
institution.
 If IV access is difficult, do not delay treatment by
trying multiple times. Other options include:
 Intraosseous Access to humeral head or tibia
 Request your physician starts a central line- femoral or
Internal jugular are common sites

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Nursing implications for the hypovolemic
patient (contd)
 Obtain lab/blood specimens ASAP- In simple ECF
deficit the sodium level will be normal:135-
145meq/L
 If the patient is tachycardic, and you are suspecting
a volume deficit, perform orthostatic blood
pressures to confirm the findings. Remember, a
drop in BP of ≥20 mm Hg, or in diastolic BP of ≥10
mm Hg, or experiencing lightheadedness or
dizziness is considered abnormal
 Anticipate weakness and fall potential in this group-
ensure call light is available and place patient on
bed rest or “up with assist” only instructions

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Nursing implications for the hypovolemic
patient (contd)
 In the case of hemorrhage- make all attempts to
stop the hemorrhage by using direct pressure,
tourniquet or other means.
 Measure urine output as a direct measure of fluid
volume resuscitation. An adult should have at least
30mls/hour of urine output.
 Understand the differences in fluid replacements:
 Crystalloids
 Colloids
 Blood products

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Crystalloids
 Crystalloids are the most common fluid
replacement solutions
 They can be classified in 3 ways:
1. Isotonic- “same” concentration as normal body saline.
These fluids stay within the intravascular space and
increase intravascular volume.
 Normal Saline- Used for dehydration
 Lactated Ringers- general volume expander/ used when
patient is at risk for free water loss

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Crystalloids- contd
 2. Hypotonic solutions: Used to shift fluid into the
intracellular space
 NS 0.45%- Shifts water into intracellular spaces
 NS 0.2% - prevents dehydration and assess renal
status
 D5W- Use with mixing meds and when the patient is at
risk for free water loss

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Crystalloids Contd
 3. Hypertonic solutions: Used to move fluid out of
the cell and promote diuresis
 Dextrose 5% NS
 Dextrose 10% NS
 Dextrose 10% in water
 Dextrose 5% in 0.45 Normal saline
 Dextrose 20% in Water

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Colloids in Fluid Replacement
 Colloids: Pull fluid in from the interstitial space to
increase vascular volume.
 May be natural or synthetic products.
 Remember the concept of capillary osmotic
pressure/plasma oncotic pressure! Fluid follows
high concentrations of large protein molecules!

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Natural colloids
 Fresh Frozen Plasma (FFP)- contains clotting factors
and large protein molecules
 Plasma Protein Fraction (no clotting factors)
 Whole blood and Packed RBC’s (will be discussed in a
later module)
 Risks:
 Potential for Blood borne Pathogens
 Hypersensitivity reactions
 Hypocalcemia, hyperkalemia, and hypothermia
 May cause hypotension with rapid infusion

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Clinical Manifestations of Hypervolemia
 The patient has an excess of fluid, but that fluid has
normal concentrations. The Sodium level is normal.
 If the sodium level is dilute, it means too much free
water, and the sodium concentration is too low:
Hyponatremia…I need to finish this!

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Clinical dehydration- the combination of loss
of ECF and the fluids are too concentrated
 Infants and older adults are at highest risk for true
clinical dehydration…
 Cell shriveling- crenation.
 Need to add more here, obviously

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Pediatric Pearls/Geriatric pearls
 Signs of hypovolemia: sunken fontanel, neck vein
assessment is not reliable
 Also add in how much % is water in their body
 Will add just a little more…

Section 2: Review
questions…need to finish

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Alterations in fluid homeostasis of the human
body could be influenced by which of the
following:
a) Surgical removal of a portion of small bowel
b) Swimming in the ocean
c) Renal failure with oliguria
d) Running a marathon
e) IV fluids running at a high rate for hours
f) Psychological issues with eating or drinking
g) All the above
h) a, c, d, e, f only

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#1. Answer with rationale to review
question:
 Answer E- a, c, d, e, f only
 When a portion of the small bowel is removed,
absorption of fluids and nutrients is altered.
 Renal failure with oliguria (no urine output) will
decrease the ability to rid the body of waste
products, metabolites and fluids causing volume
overload and electrolyte imbalances
 Running a marathon will produce sweating,
increase insensible losses through breathing, if
fluids and electrolytes are not replaced,
hypovolemia and electrolyte imbalances occur.

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# 1. Review rationale continued:
 IV fluid can volume overload any patient, especially
those with heart failure. Infusions of IV fluids must
be regulated to ensure hypervolemia does not
occur
 Some psychological disorders such as anorexia,
bingeing, purging and drinking excessive amounts
of water can cause electrolyte and volume
disturbances.
 Simply swimming or soaking will not cause fluid
homeostasis changes. However, drowning, or near
drowning would cause changes in the distribution
of fluids, especially in the lungs.

Section 3:Electrolyte
disorders

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This is a HEADING AND CONTENT slide
 Bullet one will go here. Bullet one will go here.
Bullet one will go here. Bullet one will go here and
 Bullet two will go here.
 Bullet three will go here with a bunch of text to see
what it looks like.
 Sub bullet
 Sub bullet

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