FLUID & ELECTROLYTES

FLUIDS and ELECTROLYTES
PRESENTED BY –
Dr.ANKITA RAJ (MDS Reader)
Oral & Maxillofacial Surgery
Department
Rama Dental College, Kanpur

BODY FLUIDS
Functions 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.

BODY FLUIDS
ICF ECF
40% TBW 20% TBW
P IS
Distribution of Body Fluids – 50-70% of total body weight;
infant [70-80%], elderly [45-50%]
60-kg man
TBW = 0.6 x 60 kg = 3.6 L
ICF = 0.4 x 60 kg
= 24 L
ECF
= 12 L
3L 9L

BODY FLUIDS
Factors 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 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

FLUID EXCHANGE BETWEEN BODY FLUID
COMPARTMENTS
Osmotic Pressure Gradient
Oncotic P (Colloid osmotic P)
Capillary P (Hydrostatic P)
ICF ECF
P ISF

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

DISTURBANCES IN FLUID BALANCE
EDEMA (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]

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]

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

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

CELL 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

CELL 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

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 dse
Volume ECF ICF Water Conditions
Disorder Vol. Vol. Shift

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

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)

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

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

Hyponatremia [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]
ELECTROLYTES

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

Hypernatremia [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
ELECTROLYTES

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

 Assessment
 Thready, slow pulse
 Shallow breathing
 N & V, diarrhea, intestinal colic
 Irritability
 Muscle weakness, flaccid paralysis
 Numbness, tingling
 Difficulty w/ phonation, respiration
ELECTROLYTES

 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

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 sol’n w/ potassium-
conserving diuretics
ELECTROLYTES

 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

 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

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

Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L]
 Encourage mobilization
 Limit vitamin D intake
 Limit calcium intake
 Normal saline
 Administer diuretics
 Calcitonin
ELECTROLYTES

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
 (+) Trousseau’s and Chvostek’s signs
ELECTROLYTES

Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L]
 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
ELECTROLYTES

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
 Withhold Mg-cont’g drugs/foods; Ca adm’n
  fluid intake, unless CI
ELECTROLYTES

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
 Provide good dietary sources of Mg
ELECTROLYTES

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

IV FLUID REPLACEMENT THERAPY
Types 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

B U R N S
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]

CLASSIFICATION 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
B U R N S

STAGES 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
B U R N S

STAGES 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
B U R N S

STAGES 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
B U R N S

ASSESSMENT
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
B U R N S

ASSESSMENT
B U R N S
9%
9% 9%
Front=18%
Back=18%
18% 18%
1%
Burn Evaluation
Chart

ASSESSMENT
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
B U R N S

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

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

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

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

FLUID REPLACEMENT
Types of fluids:
 Colloids
 Blood
 Plasma & plasma expanders
 Electrolytes
 Lactated Ringers
 Non-electrolyte
 D5W
B U R N S

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 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
B U R N S

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

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