Fluid And Electrolytes1

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Fluid And Electrolytes1

  1. 1. Fluid, Electrolyte and Acid-Base Balance
  2. 2. Total Fluid Volumes by Age and Sex
  3. 3. Normal Water Balance <ul><ul><ul><ul><li>Intake: </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Fluid ingestion 60% </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Foods 30% </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Metabolism 10% </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Output: </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Urine 60% </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sweat 8% </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Feces 4% </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>&quot;Insensible&quot; loss 28% </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>(skin, lungs) </li></ul></ul></ul></ul></ul>
  4. 4. Fluid Compartments Extracellular Interstitial Intracellular Intravascular Intracellular
  5. 5. Fluid is in both compartments 50-60% of body weight ¾ of ECF ¼ of ECF
  6. 6. Intravascular Fluid or Plasma (1/4 of ECF) <ul><li>Volume </li></ul><ul><ul><li>Necessary for BP Maintenance </li></ul></ul><ul><li>Maintenance of Proportional Distribution </li></ul><ul><ul><li>Protein content of blood (Serum proteins- globulin and albumin </li></ul></ul><ul><ul><li>Integrity of blood vessels linings </li></ul></ul><ul><ul><li>Hydrostatic pressure inside blood vessels </li></ul></ul><ul><li>Osmolarity </li></ul><ul><ul><li>Concentration of dissolved substances expressed in mOsm/L (Normal 280-300) </li></ul></ul>
  7. 7. Movement of Body Fluids <ul><li>Filtration </li></ul><ul><ul><li>Hydrostatic pressure </li></ul></ul><ul><li>Osmosis </li></ul><ul><ul><li>Concentration- solvent moves to make concentrations even although volume is not. </li></ul></ul><ul><li>Diffusion </li></ul><ul><ul><li>Redistributing - high to low to make even </li></ul></ul><ul><li>Active Transport </li></ul><ul><ul><li>Energy requirement for selective admission </li></ul></ul>
  8. 8. Filtration
  9. 9. Osmosis <ul><ul><li>Movement of fluid through semipermeable membrane </li></ul></ul><ul><ul><li>Concentration controls- solvent moves to make concentrations even although volume is not </li></ul></ul>
  10. 10. Filtration Pressures in a Capillary
  11. 11. Problem Examples: Edema Congestive heart failure
  12. 12. Diffusion - movement of solutes against a concentration gradient; tries to to balance cations + with anions -
  13. 13. Active Transport <ul><li>Requires energy from metabolism to move larger or uneven substances across cell membranes </li></ul><ul><ul><li>Glucose needs insulin to enter cell </li></ul></ul><ul><ul><li>Na/K pump </li></ul></ul>
  14. 14. Active Transportation of Glucose
  15. 15. 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
  16. 16. Factors Affecting Fluid & Electrolyte Movement <ul><ul><li>Osmotic Pressure and Tonicity </li></ul></ul><ul><ul><li>Hydrostatic Pressure </li></ul></ul><ul><ul><li>Filtration Pressure </li></ul></ul>
  17. 17. Osmolality and Tonicity <ul><li>Osmolality (Kg) and osmolarity (L) are determined by the solutes (mainly Na) in the ECF </li></ul><ul><ul><li>Abnormalities tell us that there are problems with water regulation in the ECF. </li></ul></ul><ul><li>Tonicity is the force that the ECF solutes (mainly Na) have to pull water into the ECF. </li></ul><ul><ul><li>(Na, glucose, mannitol, sorbitol are effective osmoles.) </li></ul></ul>
  18. 18. Osmosis and Tonicity Na is the main determinant of plasma tonicity . Thirst and ADH release Swelling of cells
  19. 19. Problem Examples: Edema Congestive heart failure
  20. 20. Tonicity HYPO 0.45% saline (1/2 normal) Moves fluid into cells
  21. 21. Tonicity ISO Same osmolarity as plasma 0.9 % saline (Normal saline) – no fluid shift
  22. 22. Tonicity HYPER 3% saline Pulls fluid from cells
  23. 23. Tonicity
  24. 24. Electrolytes + - - - - - + + + +
  25. 26. ECF Electrolytes <ul><ul><li>Sodium - Na 135-145mEq/L </li></ul></ul><ul><ul><li>Potassium - K 3.5-5.0 mEq.L </li></ul></ul><ul><ul><li>Calcium - Ca 4.5-5.5 mEq/L </li></ul></ul><ul><ul><li>Magnesium - Mg 1.5 - 2.5 mEq/L </li></ul></ul><ul><ul><li>Chloride - Cl 90-110 mEq/L </li></ul></ul><ul><ul><li>Bicarbonate – HCO 3 </li></ul></ul><ul><ul><ul><ul><li>Arterial 22-26 mEq/L </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Venous 24-30 mEq/L </li></ul></ul></ul></ul>
  26. 27. Sodium and ECFV <ul><li>The total amount of Sodium in ECF is the major determinant of the size of the ECF Volume </li></ul><ul><ul><li>Na increases = ECFV increases until ECF ‘volume overload’ results (edematous states) </li></ul></ul><ul><ul><ul><li>CHF, Cirrhosis of the liver, nephrotic syndrome </li></ul></ul></ul><ul><ul><ul><li>Pleural effusions, pulmonary edema, ascites </li></ul></ul></ul><ul><ul><li>Na decreases = ECFV decreases eventually leading to ‘volume depletion’ manifested by poor skin turgor, tachycardia, orthostatic hypotension </li></ul></ul>
  27. 28. Sodium Regulation <ul><li>Kidney receptors sense changes in renal perfusion causing renin-angiotensin system to retain sodium in kidney. </li></ul><ul><li>Volume receptors in great veins sense filling and release atrial natriuretic factor that promotes Na excretion. </li></ul><ul><li>Pressure receptors in aorta and carotid sinus activate sympathetic NS to retain Na . </li></ul><ul><li>Water ALWAYS follows Na </li></ul><ul><li>Therefore when ECFV increases, these mechanisms are activated to increase Na excretion; and conversely, if ECFV decreases, the same means promotes Na retention. </li></ul>
  28. 29. Water Regulation ( Hypo- and Hyper-Natremia are always a problem with water, not Sodium) <ul><li>Osmolality increase in ECF -> Thirst </li></ul><ul><li>Renal responsiveness to tonicity </li></ul><ul><li>Adequate delivery of water and solutes to glomerulus of kidney ( Problem: Early reabsorption of water due to volume depletion or edematous states ) </li></ul><ul><li>Water conservation mechanisms in kidney (Can be overridden by diuretics either in loop or in distal tubule. </li></ul><ul><li>ADH in response to tonicity changes, i.e., Na, or in response to volume changes (Problems: SIADH and DI) </li></ul>
  29. 30. Diuretics <ul><li>Both Thiazides and Loop diuretics block Na reabsorption and cause decrease in ECF, too. </li></ul><ul><li>Loop cause greater loss of Na but equal water, but thiazides lose less water than Na and can cause hyponatremia . </li></ul>
  30. 31. Manifestations of Fluid, and Electrolyte Imbalances <ul><li>Imbalances of Intake and Output and Body Weight </li></ul><ul><li>Changes in Mental Status </li></ul><ul><li>Changes in Vital Signs </li></ul><ul><li>Abnormal Tissue Hydration </li></ul><ul><li>Abnormal Muscle Tone </li></ul>
  31. 32. 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. <ul><li>Difficulty swallowing </li></ul><ul><li>Clumsiness </li></ul><ul><li>Shriveled skin </li></ul><ul><li>Sunken eyes </li></ul><ul><li>Visual disturbances </li></ul><ul><li>Painful urination </li></ul><ul><li>Numb skin </li></ul><ul><li>Muscle spasm </li></ul><ul><li>Delirium </li></ul><ul><li>Headache </li></ul><ul><li>Fatigue </li></ul><ul><li>Loss of appetite </li></ul><ul><li>Flushed skin </li></ul><ul><li>Heat intolerance </li></ul><ul><li>Light-headedness </li></ul><ul><li>Dry mouth or eyes </li></ul><ul><li>Burning sensation in stomach </li></ul><ul><li>Dark urine with strong odor </li></ul>Advanced Dehydration Early Dehydration
  32. 34. Nursing Interventions <ul><li>Health Promotion </li></ul><ul><ul><li>Teaching depending upon setting </li></ul></ul><ul><li>Altered Function </li></ul><ul><ul><li>Oral fluid increase </li></ul></ul><ul><ul><li>Oral fluid restriction </li></ul></ul><ul><ul><li>Electrolyte replacement </li></ul></ul><ul><ul><ul><li>Diet or supplement </li></ul></ul></ul><ul><ul><ul><li>IV therapy </li></ul></ul></ul>
  33. 35. 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
  34. 36. Objective Data <ul><li>Neck Vein Distention </li></ul><ul><li>Central Venous Pressure </li></ul><ul><li>Pulmonary Artery Pressure </li></ul><ul><li>Bowel Assessment </li></ul><ul><li>Laboratory and Diagnostic Tests </li></ul><ul><ul><li>Urine Tests </li></ul></ul><ul><ul><li>Blood Tests </li></ul></ul>
  35. 37. Central Venous Pressure or Jugular Venous Distention
  36. 38. Assessment <ul><li>Subjective Data </li></ul><ul><ul><li>Normal Pattern Identification </li></ul></ul><ul><ul><li>Risk Identification </li></ul></ul><ul><ul><li>Dysfunction Identification </li></ul></ul><ul><li>Objective Data—Physical Assessment </li></ul><ul><ul><li>Intake and Output </li></ul></ul><ul><ul><li>Body Weight </li></ul></ul><ul><ul><li>Integumentary Assessment </li></ul></ul>
  37. 39. 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
  38. 40. 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
  39. 41. Factors Affecting Fluid, Electrolyte, and Acid-Base Balance <ul><li>Fluid and Food Intake </li></ul><ul><li>Fluid and Electrolyte Output </li></ul><ul><li>Stress </li></ul><ul><li>Chronic Illnesses </li></ul><ul><li>Surgery </li></ul><ul><li>Pregnancy </li></ul>
  40. 42. Acid Base Balance Two systems work to maintain correct pH. Respiratory System by adjusting respirations. Metabolic system by adjusting serum HCO3
  41. 43. Acid Base Balance
  42. 44. Acidosis pH < 7.4 Increased paCO2 Decreased HCO3
  43. 45. Acid…………………Base <ul><li>High CO2 </li></ul><ul><li>Low HCO3 </li></ul><ul><li>Low CO2 </li></ul><ul><li>High HCO3 </li></ul>pCO2 = 35-45 HCO3 = 22-28
  44. 46. Respiratory Acidosis <ul><li>Hypoventilation for any reason </li></ul><ul><li>COPD </li></ul><ul><li>Paralysis of respiratory muscles </li></ul><ul><li>Cardiac Arrest – Code </li></ul>
  45. 47. Metabolic Acidosis <ul><li>Starvation </li></ul><ul><li>DKA </li></ul><ul><li>Renal Failure </li></ul><ul><li>Lactic Acidosis from heavy exercise </li></ul><ul><li>Drugs – EtOH, ASA </li></ul><ul><li>Diarrhea </li></ul>
  46. 48. Alkalosis pH > 7.4 Decreased CO2 Increased HC03
  47. 49. Respiratory Alkalosis <ul><ul><li>Hyperventilation from any cause </li></ul></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Too high ventilator settings </li></ul></ul>
  48. 50. Metabolic Alkalosis <ul><li>Excessive vomiting </li></ul><ul><li>Gastric suctioning </li></ul><ul><li>Hypokalemia OR Hypercalcemia </li></ul><ul><li>Excess aldosterone </li></ul><ul><li>Drugs – Steroids, diuretics, NaHCO3 </li></ul>
  49. 51. Easy Read of Blood Gases <ul><li>Check pH </li></ul><ul><li><7.4 = Acidosis; > 7.4 = alkalosis </li></ul><ul><li>Which of the following parameters matches the pH? </li></ul><ul><ul><li>CO2 or HCO3? </li></ul></ul><ul><ul><ul><li>High C02 is acid; low CO2 is alkaline- respiratory </li></ul></ul></ul><ul><ul><ul><li>High HCO3 is alkaline; low HCO3 is acid - metabolic </li></ul></ul></ul>Matching parameter + pH direction is diagnosis! If both parameters match, then it is a combined _____; if opposite parameter is abnormal, compensation is occurring.

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