fluids n electrolyte imbalance

1. REHANA TABBASUM
BSN (POST RN)
POST BASIC SPECIALIZATION
@ IICU /CCN

2. AmountandCompositionofBody Fluids

3. Amount and Composition of Body
Fluids
 Approximately 60% of typical adult is fluid
Varies with age, body size, gender
 Intracellular fluid 40%
 Extracellular fluid 20%
Intravascular
Interstitial
Transcellular
 “Third spacing”: loss of ECF into space that
does not contribute to equilibrium

4. Electrolytes
Are active chemicals (cations that carry
and anions that carry
).
The major cations in body fluid are
sodium, potassium, calcium,
magnesium, and hydrogen ions.
The major chloride,
bicarbonate,
anions are
phosphate, sulfate, and
.

5. Regulation of Fluid
Movement of fluid through capillary walls
depends on
Hydrostatic pressure: exerted on walls of
blood vessels
Osmotic pressure: exerted by protein in
plasma
Direction of fluid movement depends o
n
differences of hydrostatic, osmotic
pressure

6. Passive
Transport
Osmosis

7. RegulationofBody Fluid
Compartments
Diffusion
Filtration:
○ Hydrostatic pressure in the capillaries tends to filter fluid out
of the intravascular compartment into the interstitial fluid.
Movement of water and solutes occurs from an area of high
hydrostatic pressuretolowhydrostatic pressure

8. RegulationofBody Fluid
Compartments
Active Transport
Sodium-Potassium Pump
○ Movement of sodium and potassium against
the concentration gradient with expenditure of
energy
○ Sodium –Extracellular cation
○ Potassium- intracellular cation

9. Osmolality
c o n c e n t r a t i o n o f s o l u t i o n
e x p r e s s e d a s t o t a l s o l u t e p a r t i c l e s i n
p e r k g .
 Electrolytes are measured
milliequivalent per l i t r e of w at e r
(mEq / L )

10. Osmolality

11. Osmolality

12. SystemicRoutesofGains andLosses
Kidneys
Output is approximately 1 mL of urine per
kilogram of body weight per hour (1 mL/kg/h)
Skin
Continuous water loss by evaporation (approximately
600 mL/day) occurs through the skin as insensible
perspiration
Lungs
The lungs normally eliminate water vapor at a rate of
approximately 300 mL every day
Gastrointestinal Tract
The usual loss through the GI tract is 100 to 200 mL
daily,

13. HomeostaticMechanisms

14. HomeostaticMechanisms
Kidney Functions
Water and electrolyte balance
Lung Functions
Decrease or increase water loss through
lungs
Pituitary Functions
ADH-water and sodium retention
Adrenal Functions
Inc. Aldosteron-water and sodium
retention

15. HomeostaticMechanisms
Baroreceptors
Renin–Angiotensin–Aldosterone
System
Osmoreceptors
Atrial Natriuretic Peptide
Decrease secretion of aldosteron
and renin

17. FluidVolumeImbalances
Fluid volume deficit (FVD): hypovolemia
Fluid volume excess (FVE )
:
hypervolemia

18. FLUIDVOLUMEDISTURBANCES
 Hypovolemia (Fluid volume deficit)
Occurs when loss
exceeds the intake
of ECF
of fluid. It
volume
occurs
when water and electrolytes are lost in the
same proportion as they exist in normal
body fluids
 Dehydration:
○ which refers to loss of water alone, with
increased serum sodium levels and other
electrolyte imbalances

19. 1 . Fluid L
oss
2 . Fluid shifts
3. Reduced Fluid Intake

20. Dehydration
Causes:
fluid loss from vomiting, diarrhea, GI
suctioning, sweating, decreased intake,
inability to gain access to fluid
Risk factors:
diabetes insipidus, adrenal insufficiency,
osmotic diuresis, hemorrhage, coma, third-
space shifts

21. • Rapid weight loss,
• Oliguria,
• Concentrated urine,
• Postural hypotension,
• Rapid weak pulse,
• Increased temperature,
due to
•Cool clammy skin
vasoconstriction,
• Lassitude,
• Nausea,
• Muscle weakness,
• Cramps

22. BUN elevated out of proportion to the
serum creatinine (ratio greater than
20:1).
Hematocrit level is greater than normal
Urine specific gravity is increased

24. I&O, daily weight, vital signs
Monitor for symptoms: skin and tongue turgor,
mucosa, urine output, mental status
Measures to minimize fluid loss
Oral care
Administration of oral fluids
Administration of parenteral fluids

25. Question
What is a major indicator of extracellular
FVD?
A. Full and bounding pulse
B. Drop in postural blood pressure
C. Elevated temperature
D. Pitting edema of lower extremities

26. Answer
B. Drop in postural blood pressure
Rationale: FVD signs and symptoms include acute weight loss;
decreased skin turgor; oliguria; concentrated urine; orthostatic
hypotension due to volume depletion; a weak, rapid heart
rate; flattened neck veins; increased temperature; thirst;
decreased or delayed capillary refill; decreased central
venous pressure; cool, clammy, pale skin related to peripheral
vasoconstriction; anorexia; nausea; lassitude; muscle
weakness; and cramps. Clinical manifestations of FVE result
from expansion of the ECF and include edema, distended
neck veins, and crackles (abnormal lung sounds).

27. Question
What is the average daily urinary output in
an adult?
A. 0.5 L
B. 1.0 L
C. 1.5 L
D. 2.5 L

28. Answer
C. 1.5 L
Rationale: Vital to the regulation of fluid
and electrolyte balance, the kidneys
normal filter 170 L of plasma every day
in the adult, while excreting only 1.5 L of
urine.

29. FluidVolumeExcess
Fluid volume excess (FVE), o
r
hypervolemia, refers to an isotonic
expansion of the ECF caused by the
abnormal retention of water and sodium in
approximately the same proportions in
which they normally exist in the ECF. It is
always secondary to an increase in the total
body sodium content, which, in turn, leads
to an increase in total body water.

30. Causes ofFVE
Risk factors: heart failure, renal failure
cirrhosis of liver
Contributing factors: excessive diatary
sodium or sodium-containing IV
solutions

31. Edema, distended neck veins, abnormal
lung sounds (crackles), tachycardia,
blood
and CVP
,
pressure,
increased
pulse
weight,
increased
pressure
increased urine output, shortness of
breath and wheezing

32. Directed at cause
Pharmacologic Therapy
Diuretics : Loop, Thiazide, may cause
electrolyte imbalance especially potassium
imbalance, then potassium sparing diuretics
may be given.
Dialysis
Nutritional Therapy
Restrictions of sodium and fluids

33. I&O and daily weights; An acute weight gain of 2.2 lb (1 kg)
is equivalent to a gain of approximately 1 L of fluid.
assess lung sounds
Edema:
Monitor responses to medications—diuretics
Promote adherence to fluid restrictions, patient teaching
related to sodium and fluid restrictions

34. Promote rest
Semi-Fowler’s position for orthopnea
Skin care, positioning/turning
Monitor, avoid sources of excessive
sodium, including medications

35. Edema can occur as a result of
increased capillary fluid pressure,
decreased capillary oncotic pressure, or
increased interstitial oncotic pressure,
causing expansion of the interstitial fluid
compartment

36. Copyright © 2017 by Tanzeel Ul Rahman
Edema can be localized (eg, in the ankle, as i
n
rheumatoid arthritis) or
generalized (as in cardiac and renal failure).
Severe generalized edema is called anasarca
Edema can be pitting and non pitting
Pitting edema is assessed by pressing a finger
into the affected part, creating a pit or
indentation that is evaluated on a scale of 1
(minimal) to 4 (severe).
Peripheral edema is monitored by measuring
the circumference of the extremity with a tape
marked in millimeters

37. 1+ (2mm depression,immediate
rebound)Mild pitting
2+ (4mm depression,few sec to
rebound)Moderate pitting
3+ (6mm depression,10-12 sec to
rebound)Deep pitting
4+ (8mm deep, >20 sec to
rebound)Very deep pitting

38. Treating the cause of the edema, other
treatments may include
Diuretic therapy
Restriction of fluids and sodium
Elevation of the extremities, application of
anti-embolism stockings,
Paracentesis
Dialysis, and
Continuous renal replacement therapy in
cases of renal failure

40. Electrolytimbalnce
Sodium: hyponatremia, hypernatremia
Potassium: hypokalemia, hyperkalemia
Calcium: hypocalcemia, hypercalcemia
Magnesium: hypomagnesemia,
hypermagnesemia
Phosphorus: hypophosphatemia,
hyperphosphatemia
Chloride: hypochloremia, hyperchloremia

41. Sodium Imbalanc
• Sodium is the most abundant electrolyte in the ECF; its
concentration ranges from 135 to 145 mEq/L (135 to 145
mmol/L) and it is the primary
ECF volume and
determinant of
osmolality.
The average intake of sodium is 4 to 5 g/day

42. Hyponatremia
Serum sodium less than 135 mEq/L
Causes: adrenal insufficiency, water intoxication, SIADH o
r
losses by vomiting, diarrhea, sweating, diuretics
Manifestations: poor skin turgor, dry mucosa, headache,
decreased salivation, decreased blood pressure, nausea,
abdominal cramping, neurologic changes
Medical management: water restriction, sodium
replacement
Nursing management: assessment and prevention, dietary
sodium and fluid intake, identify and monitor at-risk
patients, effects of medications (diuretics, lithium)

43. Hypernatremia
Serum sodium greater than 145 mEq/L
Causes: excess water loss, excess sodium administration,
diabetes insipidus, heat stroke, hypertonic IV solutions
Manifestations: thirst; elevated temperature; dry, swollen
tongue; sticky mucosa; neurologic symptoms; restlessness;
weakness
Medical management: hypotonic electrolyte solution or
D5W
Nursing management: assessment and prevention,
assess for OTC sources of sodium, offer and encourage
fluids to meet patient needs, provide sufficient water with
tube feedings

44. Potassiumimbalance

45. Hypokalemia
Below-normal serum potassium (<3.5 mEq/L),
Causes: GI losses, medications, alterations of acid–base
balance, hyperaldosterism, poor dietary intake
fatigue,
muscle
glucose
anorexia,
weakness
intolerance,
nausea,
and
decreased
vomiting,
cramps,
muscle
M a n i f e s t
a t ions:
dysrhythmias,
paresthesias,
strength, DTRs
Medical management: increased dietary potassium, potassium replacement, IV for
severe deficit
Nursing management: assessment, severe hypokalemia i
s life-threatening, monitor ECG
and ABGs, dietary potassium, nursing care related to IV potassium
administration

46. Hyperkalemia
Serum potassium greater than 5.0 mEq/L
Causes: usually treatment related, impaired
renal function, hypoaldosteronism, tissue
trauma, acidosis
Manifestations: cardiac changes and
dysrhythmias, muscle weakness with potential
respiratory impairment, paresthesias, anxiety, GI
manifestations
Medical management: monitor ECG, limitation of
dietary potassium, cation-exchange resin
(Kayexalate), IV sodium bicarbonate, IV calcium
gluconate, regular insulin and hypertonic
dextrose IV, -2 agonists, dialysis

47. Hyperkalemia (cont’d)
Nursing management: assessment of serum
potassium levels, mix IVs containing K+ well,
monitor medication affects, dietary potassium
restriction/dietary teaching for patients at risk
Hemolysis of blood specimen or drawing of
blood above IV site may result in false
laboratory result
Salt substitutes, medications may contain
potassium
Potassium-sparing diuretics may cause
elevation of potassium
Should not be used in patients with renal dysfunction