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fluid and electrolytes and acidosis and alkalosis

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discuss about normal fluid and electrolytes and types of IV fluids, acidosis and alkalosi

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fluid and electrolytes and acidosis and alkalosis

  1. 1. Aashish Parihar Nursing Tutor College of Nursing AIIMS, Jodhpur
  2. 2. Fluid, electrolyte and acid base balances Content-  Distribution and composition of body fluids.  Movements and regulation of body fluid and electrolytes  Regulation of acid-base balance & type of acid-base imbalance  Type of intravenous fluid  Measuring fluid intake and output and maintaining intake-output charts.  Initiating intravenous therapy.  Regulating intravenous flow rate  Maintenance of intravenous system  Changing a peripheral intravenous dressing.  Blood transfusion.  Conditions need fluid restriction.
  3. 3. distribution and composition oF body Fluids
  4. 4. distribution and composition oF body Fluids  2/3 (65%) of TBW is intracellular (ICF)  1/3 extracellular water 25 % interstitial fluid (ISF)  5- 8 % in plasma (IVF intravascular fluid) 1- 2 % in transcellular fluids – CSF, intraocular fluids, serous membranes.
  5. 5. distribution and composition oF body Fluids  Body fluids are:  Electrically neutral  Osmotically maintained  Osmolality-It is a measure of the number of particles per kilogram of water. ( m osmoles/kg)  Osmotic pressure is the amount of hydrostatic pressure needed to stop the flow of water by osmosis. It is primarily determined by the concentration of solutes.
  6. 6. distribution and composition oF body Fluids Fluid in the body compartments contains mineral salts known as electrolytes. An electrolyte is a compound that separates into ions (charged particles) when it dissolves in water. Ions that are positively charged are called cations; ions that are negatively charged are called anions.
  7. 7. distribution and composition oF body Fluids Solutes and dissolved particles-  Electrolytes –Are compounds having charged particles Cations – positively charged ions ○ Na+, K+ , Ca++, H+ Anions – negatively charged ions ○ Cl-, HCO3 - , PO4 3-  Non-electrolytes – Uncharged compounds. ○ Proteins, urea, glucose, O2, CO2
  8. 8. distribution and composition oF body Fluids
  9. 9. movements and regulation oF body Fluid and electrolytes  Active transport, diffusion, osmosis, and filtration are processes that move water and electrolytes between body compartments.  Active transport –Active transport is the movement of all types of molecules across a cell membrane against its concentration gradient (from low to high concentration).  Eg concentration of Na is high in ECF as compared to ICF. This is done by active transport- sodium potassium pump, keeping ICF lower in Na and higher in ECF, otherwise sodium can easily enter ICF through diffusion.  It requires energy in the form of ATP
  10. 10. movements and regulation oF body Fluid and electrolytes  Diffusion –passive movement of particles down a concentration gradient (i.e from an area of higher concentration to lower concentration.  Osmosis – Osmosis is the spontaneous net movement of water molecules through a partially permeable membrane into a region of higher solute concentration, in the direction that tends to equalize the solute concentrations on the two sides.
  11. 11. movements and regulation oF body Fluid and electrolytes  Fluid compartments are separated by membranes that are freely permeable to water.  Movement of fluids due to:  hydrostatic pressure  osmotic pressure  Capillary filtration (hydrostatic) pressure  Capillary colloid osmotic pressure  Interstitial hydrostatic pressure  Tissue colloid osmotic pressure
  12. 12. movements and regulation oF body Fluid and electrolytes
  13. 13. regulation oF acid-base balance  For normal function of body and normal enzyme activity a normal hydrogen ion concentration is essential.  pH is the negative log of hydrogen ion concentration.  A hydrogen ion is the single free proton release from hydrogen atom.  Normal Hydrogen ion of arterial blood is = 0.00004meq/l which is equal to pH 7.4.
  14. 14. regulation oF acid-base balance  pH of arterial blood is 7.4  pH of venous blood 7.35  Intracellular pH is slightly lower than plasma pH  pH of urine is 4.5-8.0  Acidosis is the pH of body fluid is less than normal pH  Alkalosis is the pH of the body fluid more than the normal.
  15. 15. regulation oF acid-base balance  Acids are molecules that release hydrogen ion in solution.  Strong acids dissociates rapidly and release large amount of hydrogen ion .  Weak acids have less tendency to dissociate and release less amount of hydrogen ion
  16. 16. regulation oF acid-base balance Defence against change in pH  Buffer system of our body  Respiratory system of our body  Renal control of our body
  17. 17. regulation oF acid-base balance Defence against change in pH  Buffer system of our body Buffers are pairs of chemicals that work together to maintain normal pH of body fluids Important buffers include bicarbonate buffer, hemoglobin, protein buffer, phosphate buffer, cellular and bone buffer. Buffer normally keep the blood from becoming too acid when acids that are produced by cells circulate to the lungs and kidneys for excretion
  18. 18. regulation oF acid-base balance Defence against change in pH  Respiratory system of our body Act with in few min (3-12 min.) Control pH by altering co2 elimination from body by lungs Increased blood PCO2 and hydrogen ion stimulates respiratory center so increase the rate and depth of respiration
  19. 19. regulation oF acid-base balance Defence against change in pH  Renal control of our body By excreting acidic and basic urine Relatively slow to response Most powerful acid/base regulation system
  20. 20. type oF intravenous Fluid  Following are the criteria for categorizing the IV Fluids- 1. Molecular size and weight 2. Tonicity
  21. 21. Type of inTravenous fluid  Tonicity-Tonicity is the effective osmolality and is equal to the sum of the concentrations of the solutes which have the capacity to exert an osmotic force across the membrane.  The particles which does not move across the cell membranes easily determines the tonicity of a fluid.
  22. 22. Type of inTravenous fluid  On the basis of tonicity there are three types of IV fluids-  Isotonic- A fluid with same concentration of particles as normal blood is called isotonic.  Hypertonic – more concentrated than blood  Hypotonic- less concentrated than blood.
  23. 23. Type of inTravenous fluid Isotonic fluid  Solution has the same solute concentration (or osmolality) as normal blood plasma (290mOsm) and other body fluids  Solution stays where it is infused, inside the blood vessel  Expands the intravascular compartment  Does not affect the size of the cells  Solution maintains body fluid balance
  24. 24. Type of inTravenous fluid Isotonic fluid
  25. 25. Type of inTravenous fluid Isotonic fluid
  26. 26. Type of inTravenous fluid Isotonic fluid  These fluids remain intravascular momentarily, thus expanding the volume.  Helpful with patients who are hypotensive or hypovolemic.  Risk of fluid overloading exists.  Therefore, be careful in patients with left ventricular dysfunction, history of CHF or hypertension.
  27. 27. Type of inTravenous fluid Hypotonic fluid  Less osmolarity than serum (meaning: less sodium ion concentration than serum)  These fluids DILUTE serum thus decreasing osmolarity.  Water moves from the vascular compartment into the interstitial fluid compartment  interstitial fluid becomes diluted osmolarity decreases  water is drawn into adjacent cells.  Less than 10% remain intravascular, inadequate for fluid resuscitation  Caution with use because sudden fluid shifts from the intravascular space to cells can cause cardiovascular collapse and increased ICP in certain patients.
  28. 28. Type of inTravenous fluid Hypotonic fluid
  29. 29. Type of inTravenous fluid Hypotonic fluid  Solution has a lower osmolarity than serum (less than 240 mOsm/L)  Solution causes a fluid shift out of the blood vessels into the cells and interstitial spaces Solution hydrates cells while reducing fluid in the circulatory system  Ex.: ½ NSS (0.45% NaCl)
  30. 30. Type of inTravenous fluid Hypotonic fluid  Administer cautiously  Solution can lower blood pressure  Do not give if these solutions if the patient is at risk for:  ICP from cerebro-vascular accident  Head trauma  Neurosurgery
  31. 31. Type of inTravenous fluid Hypertonic fluid  Solution has an osmolarity higher than serum(>340mOsm/L)  Causes the solute concentration of the serum to increase pulling fluid from the cells and the interstitial compartment into the blood vessels  Reduces the risk of edema, stabilizes blood pressure, and regulates urine output
  32. 32. Type of inTravenous fluid Hypertonic fluid
  33. 33. Type of inTravenous fluid Hypertonic fluid  Monitor patient for circulatory overload  Solution can be irritating to the vein  Useful for stabilizing blood pressure, increasing urine output, correcting hypotonic hyponatremia and decreasing edema.  These can be dangerous in the setting of cell dehydration.
  34. 34. Type of inTravenous fluid
  35. 35. Type of inTravenous fluid Types of IV fluid on the basis of molecular size and weight-  Crystalloid  colloid
  36. 36. Type of inTravenous fluid Crystalloid fluid  Clear solutions –fluids- made up of water & electrolyte solutions; small molecules.  These fluids are good for volume expansion.  However, both water & electrolytes will cross a semi-permeable membrane into the interstitial space and achieve equilibrium in 2-3 hours.  Remember: 3mL of isotonic crystalloid solution are needed to replace 1mL of patient blood.  This is because approximately 2/3rds of the solution will leave the vascular space in approx. 1 hour.
  37. 37. Type of inTravenous fluid Crystalloid fluid  Advantages: Inexpensive Easy to store with long shelf life Readily available with a very low incidence of adverse reactions Variety of formulations available that are effective for use as replacement fluids or maintenance fluids  A major disadvantage is that it takes approximately 2-3 x volume of a crystalloid to cause the same intravascular expansion as a single volume of colloid.
  38. 38. Type of inTravenous fluid Colloid fluid  Colloids are large molecular weight solutions (nominally MW > 30,000 Daltons)  Macromolecular substances made of gelatinous solutions which have particles suspended in solution and do NOT readily cross semi-permeable membranes or form sediments.  Their high osmolarity, are important in capillary fluid dynamics because they are the only constituents which are effective at exerting an osmotic force across the wall of the capillaries.  These work well in reducing edema  draw fluid from the interstitial and intracellular compartments into the vascular compartments.  Initially these fluids stay almost entirely in the intravascular space for a prolonged period of time compared to crystalloids.
  39. 39. Type of inTravenous fluid Colloid fluid The general problems with colloid solutions are:  Much higher cost than crystalloid solutions  Small but significant incidence of adverse reactions  Gelatinous properties  cause platelet dysfunction and interfere with fibrinolysis and coagulation factors thus possibly causing Coagulopathy in large volumes.  These fluids can cause dramatic fluid shifts which can be dangerous if they are not administered in a controlled setting.
  40. 40. Type of inTravenous fluid Colloid fluid The general problems with colloid solutions are:  Much higher cost than crystalloid solutions  Small but significant incidence of adverse reactions  Gelatinous properties  cause platelet dysfunction and interfere with fibrinolysis and coagulation factors thus possibly causing Coagulopathy in large volumes.  These fluids can cause dramatic fluid shifts which can be dangerous if they are not administered in a controlled setting.
  41. 41. Type of inTravenous fluid Colloid fluid  Dextran -Polysaccharide fluid  Albumin -Natural plasma protein from donor plasma  Mannitol -Sugar alcohol substance  Hetastarch -Synthetic colloid made from starch
  42. 42. CCoommmmoonn ppaarreenntteerraall fflluuiidd tthheerraappyy SSoolluuttiioonnss VVoolluummeess NNaa++ KK++ CCaa22++ MMgg22++ CCll-- HHCCOO33 -- DDeexxttrroossee mmOOssmm//LL EECCFF 142 4 5 103 27 280-310 LLaaccttaatteedd RRiinnggeerr’’ss 130 4 3 109 28 273 00..99%% NNaaCCll 154 154 308 00..4455%% NNaaCCll 77 77 154 DD55WW 50 DD55//00..4455%% NNaaCCll 77 77 50 406 33%% NNaaCCll 513 513 1026 66%% HHeettaassttaarrcchh 500 154 154 310 55%% AAllbbuummiinn 250,500 130- 160 <2.5 130- 160 330 2255%% AAllbbuummiinn 20,50,100 130- 160 <2.5 130- 160 330
  43. 43. Measuring fluid inTake and ouTpuT  Fluid and electrolyte homeostasis is maintained in the body  Neutral balance: input = output  Positive balance: input > output  Negative balance: input < output
  44. 44. Measuring fluid inTake and ouTpuT
  45. 45. Measuring fluid inTake and ouTpuT Intake and Output  Defines as the measurement and recording of all fluid intake and output during a 24 – hour period provides important data about the client's fluid and electrolyte balance.  Unit of measurement of intake and output is mL (milliliter).  To measure fluid intake, nurses convert household measures such as glass, cup, or soup bowl to metric units.  Gauge fluid balance and give valuable information about your patient's condition.
  46. 46. Measuring fluid inTake and ouTpuT Need –  It helps us determine the patient’s fluid status:  1. Are they Hydrated?  2. Are they Dehydrated?  3. Are they in Fluid Overload?  4. Is there an obstruction?
  47. 47. Measuring fluid inTake and ouTpuT Intake 1. Oral Fluids: Water, Ice, Beverages 2. Semi-Liquid Foods: Pudding, Jell-O, Custards, Yogurt 3. Parenteral Fluids: IV Fluid, Medications, Blood Products 4. Any Food Liquid at Room Temperature: Popsicles, ice cream, and frozen yogurt 8. Tube feedings 9. Catheter or tube irrigants
  48. 48. Measuring fluid inTake and ouTpuT Output  Urine  Vomitus and liquid feces  Tube drainage  Wound drainage and draining fistulas
  49. 49. Measuring fluid inTake and ouTpuT Measurement of Volume  1 tablespoon (tbsp) = 15 milliliters(ml)  3 teaspoons(tsp) = 15 milliliters(ml)  1 cup(C) = 240 milliliters(ml)  8 ounces(oz) = 240 milliliters(ml)  1 teaspoon(tsp) = 5 milliliters(ml)  1 cup(C) = 8 ounces(oz)  16 ounces(oz) = 1 pound(lb)  1 ounce (oz) = 30milliliters(ml)
  50. 50. Measuring fluid inTake and ouTpuT DOs  Identify whether your patient has undergone surgery or if he has a medical condition or takes medication that can affect fluid intake or loss.  Measure and record all intake and output. If you delegate this task, make sure you know the totals and the fluid sources.  At least every 8 hours, record the type and amount of all fluids he's received and describe the route as oral, parenteral, rectal, or by enteric tube.
  51. 51. Measuring fluid inTake and ouTpuT DOs  Record ice chips as fluid at approximately half their volume.  Record the type and amount of all fluids the patient has lost and the route.  Describe them as urine, liquid stool, vomitus, tube drainage and any fluid aspirated from a body cavity.  If irrigating a nasogastric or another tube or the bladder, measure the amount instilled and subtract it from total output.
  52. 52. Measuring fluid inTake and ouTpuT DOs  For an accurate measurement, keep toilet paper out of your patient's urine.  Measure drainage in a calibrated container.  Observe it eye level and take the reading at the bottom of the meniscus.  Evaluate patterns and values outside the normal range, keeping in mind the typical 24 – hour intake and output.
  53. 53. Measuring fluid inTake and ouTpuT DOs  When looking at 8 – hour urine output, ask how many times the patient voided, to identify problems.  Regard intake and output holistically because age, diagnosis, medical problem, and type of surgical procedure can affect the amounts. Evaluate trends over 24 to 48 hours.
  54. 54. Measuring fluid inTake and ouTpuT DONTs  Don't delegate the task of recording intake and output until you're sure the person who's going to do it understands its importance.  Don't assess output by amount only. Consider color, color changes, and odor too.  Don't use the same graduated container for more than one patient.
  55. 55. MainTaining inTake-ouTpuT charTs
  56. 56. MainTaining inTake-ouTpuT charTs
  57. 57. inTravenous Therapy (inTravenous infusion) Definition Introduction of large amount of fluid into body via veins is termed as intravenous infusion.
  58. 58. inTravenous Therapy (inTravenous infusion) Purposes  To restore the fluid volume that is lost from the body due to hemorrhage, vomiting, diarrhea, drainage etc.  To meet the patient’s basic requirement for calories, minerals, water and vitamins.  To prevent and treat shock and collapse.  To administer medicines.  To supply adequate amount of fluid, electrolytes and nutrients when patient is unable to take orally or when contraindicated orally.
  59. 59. inTravenous Therapy (inTravenous infusion) Indications  Hemorrhage, shock, extensive burns etc.  Prolonged nausea, vomiting, peritonitis, paralytic ileus, fistulas etc.  Toxemias and septicemias  When intestinal tract is not intact  To administer medications which can be destroyed by the gastric juices.
  60. 60. inTravenous Therapy (inTravenous infusion) Solutions used  Nutrient solutions  Electrolyte solutions  Plasma expanders  Acidifying or alkalinizing solutions
  61. 61. intravenous therapy (intravenous infusion) General instructions for IV infusion  Follow strict aseptic technique  Fluid should be administered only with clearly written order. The order should include type of solution, concentration, amount to be administered and total time of infusion.  Maintain the specified rate of flow to prevent the circulatory overload.  During infusion observe the patient for any unfavorable symptoms and if found report immediately.
  62. 62. intravenous therapy (intravenous infusion) General instructions for IV infusion  Following observations should be made throughout the infusion-  Flow rate, dislodgment of needle  Signs of circulatory overload  Urine out put  Infusion site for infiltration and thrombophlebitis  Fluid level in the bottle  Patency of the IV tubing  Intake and output chart  Regular estimation of electrolytes in blood.
  63. 63. intravenous therapy (intravenous infusion) General instructions for IV infusion  When electrolytes are used, flow rate should be slow.  Always check the expiry date before opening the IV bottle  Any suspended articles in IV bottles, discolored or cloudy fluid should not be used for infusion.  Make sure that drip set is sterile and in good working condition  Select a proper site for IV infusion  Never allow the bottle to get empty completely to prevent the entry of the air into tissues.  Fluid should always be administered at body temperature.  Monitor the vital sign at regular intervals
  64. 64. intravenous therapy (intravenous infusion) Complication of IV infusion  Circulatory overload  Infiltration  Damage to the walls of blood vessels and extravasation of blood (hematoma)  Thrombophlebitis  Pyrogenic reactions  Air embolism  Infection at the needle site  Allergic reaction  Serum hepatitis  Osmotic diuresis  Nerve damage
  65. 65. intravenous therapy (intravenous infusion) Complication of IV infusion  Circulatory overload  Circulatory overload means that the intravascular fluid compartment contains more fluid than the normal.  It occurs due to rapid administration of fluid or the fluid administered is more than requirement.  Circulatory overload results in cardiac failure and pulmonary edema  Signs of pulmonary edema include dyspnoea, cough, red frothy sputum, gurgling sounds on respiration etc.  Puffiness of the face, generalized edema and engorged neck veins indicate the cardiac failure.
  66. 66. intravenous therapy (intravenous infusion) Complication of IV infusion  Circulatory overload  Circulatory overload can be prevented by carefully regulating the flow rate over 24 hours.  Flow rate can be calculated with the following formula- Flow rate= total volume infused (ml)×drops/ml total time of the infusion in minutes
  67. 67. intravenous therapy (intravenous infusion) Complication of IV infusion  Infiltration  Infiltration is the escape of fluid into the subcutaneous tissues due to dislodgment of needle.  Following sign and symptoms indicate the infiltration-  Infusion rate slows or stops completely  Development of swelling, hardness, and pain around the injection site  Feeling of numbness and coolness around the injection site  Failure of blood to return to the tubing when the bottle is lowered
  68. 68. intravenous therapy (intravenous infusion) Complication of IV infusion  Infiltration  When infiltration has taken place, stop the infusion immediately and apply warm compress over the side of infusion and restart the infusion at another site
  69. 69. intravenous therapy (intravenous infusion) Complication of IV infusion  Damage to the walls of the blood vessels and extravasation of blood (hematoma)  Walls of the blood vessels may be damaged due to careless introduction of the needle into body.  The needle may puncture the blood vessels in more than one place and the blood may flow into the tissues  It causes the hematoma (swelling) formation at the site of the puncture  To treat the hematoma withdraw the needle immediately and apply pressure to the control bleeding  Apply cold compress over the injured site
  70. 70. intravenous therapy (intravenous infusion) Complication of IV infusion  Thrombophlebitis  Thrombophlebitis is caused by mechanical trauma to the vein or the chemical irritations of some substances introduced into the veins such as KCl.  With thrombophlebitis patient may complaints of burning pain along the vein  Nurse may observe the redness, swelling, and increased skin temperature over the vein  General symptoms such as fever, rapid pulse malaise etc. may occur  Treatment includes- stop IV fluid, restart at another site, apply warm moist compress, do not massage or rub the area because it may dislodge the clot and may lead to pulmonary embolism.
  71. 71. intravenous therapy (intravenous infusion) Complication of IV infusion  Pyrogenic reaction  It occurs in 30 minutes after the infusion.  Characterized by fever, chills, headache, nausea, vomiting, and circulatory collapse in severe cases.  Pyrogenic reactions usually caused by pyrogens present in the IV fluids or due to the contaminated IV tubing and needles used for infusion.  Prevention of pyrogenic reaction-  Check the IV fluids in good light before they are infused  Any solution that is cloudy or containing suspended particles or with a color change should not be used  Use sterile needle and tubing for infusion
  72. 72. intravenous therapy (intravenous infusion) Complication of IV infusion  Pyrogenic reaction  Treatment of pyrogenic reaction-  Stop the infusion immediately  Change the IV fluid and tubing  Administer anti-allergic drugs  Apply cold therapy to lower the body temperature  Restart the IV infusion
  73. 73. intravenous therapy (intravenous infusion) Complication of IV infusion  Air embolism  An air embolism is an air bubble trapped in a blood vessel.  As a result tissues will not receive adequate oxygen.  Pulmonary embolism characterized by-  Dyspnoea  Cyanosis  Low blood pressure  Shock  Tachycardia  Unconsciousness
  74. 74. intravenous therapy (intravenous infusion) Complication of IV infusion  Air embolism  Prevention of air embolism-  Expelled air completely from the tubing and the needle before introducing the needle into the vein.  Do not elevate the arm or leg receiving the infusion above the level of heart.  Never allow the IV drip to run dry  There should be a little fluid left in the tubing when the infusion is discontinued.
  75. 75. intravenous therapy (intravenous infusion) Complication of IV infusion  Air embolism  Management of air embolism-  Pulmonary embolism is a life threatening condition which should be treated intensively  Monitor the vital signs regularly  Stop the fluid
  76. 76. intravenous therapy (intravenous infusion) Complication of IV infusion  Infection at the needle site-  The needle may become contaminated during insertion or infection may occur at the needle site when it is left exposed for a long period  Prevention of infection-  Follow strict aseptic technique during procedure  Cover the needle with sterile dressing.
  77. 77. intravenous therapy (intravenous infusion) Complication of IV infusion  Allergic reaction-  This may be due certain type of medications administered with IV fluids.  Serum hepatitis-  Infectious hepatitis have been attributed to improperly disinfected syringes and needles.  inoculation of .0004 ml of infected blood may transmit the serum hepatitis.
  78. 78. intravenous therapy (intravenous infusion) Complication of IV infusion  Osmotic diuresis-  If dextrose solution is administered too rapidly the patient may develop glucose overload and as a result excessive diuresis will take place  If diuresis remains unchecked extreme dehydration followed by shock and collapse will ensure  To prevent osmotic diuresis-  Observe vital sign frequently  Monitor urine out put  Assess the body weight  Frequently monitor the urine for acetone and sugar  Nerve damage-  Nerve damage may occur from tying the arm too tight with the splint.

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