The document discusses body fluids and electrolytes. It covers the functions of fluids and electrolytes in the body, fluid compartments, factors affecting fluid balance, and disturbances in fluid and electrolyte balance like edema, dehydration, hyponatremia, hypernatremia, hypokalemia, hyperkalemia, and other electrolyte imbalances. It provides information on assessment and nursing management of various fluid and electrolyte disorders.

1. Nio Cruzada Noveno, RN, MAN, MSN Fluids & Electrolytes

2. 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 joints Component in all body cavities [parietal, pleural fluids] Water is the principal body fluid & essential for life. Renal Disorders [email_address] FLUIDS and ELECTROLYTES

3. Renal Disorders [email_address] FLUIDS and ELECTROLYTES FLUIDS and ELECTROLYTES 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

4. BODY FLUIDS Factors that Dictate Body Water Requirement Amount needed to give the proper osmotic concentration Amount needed to replace water lost excretion Normal Routes of water gain and loss Renal Disorders [email_address] FLUIDS and ELECTROLYTES INTAKE OUTPUT ml/day ml/day Fluid intake 1,500 Food 800 Metabolic water 300 TOTAL 2,600 Insensible loss 400 Sweat 600 Feces 100 Urine 1,500 TOTAL 2,600

5. FLUID EXCHANGE BETWEEN BODY FLUID COMPARTMENTS Osmotic Pressure Gradient Oncotic P (Colloid osmotic P) Capillary P (Hydrostatic P) Renal Disorders [email_address] FLUIDS and ELECTROLYTES ICF ECF P ISF

6. 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 Renal Disorders [email_address] FLUIDS and ELECTROLYTES

7. 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 disease, nephrotic syndrome] Renal Disorders [email_address] FLUIDS and ELECTROLYTES FLUIDS and ELECTROLYTES

8. DISTURBANCES IN FLUID BALANCE 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] Renal Disorders [email_address] FLUIDS and ELECTROLYTES

9. DISTURBANCES IN FLUID BALANCE 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 Renal Disorders [email_address] FLUIDS and ELECTROLYTES

10. DISTURBANCES IN FLUID BALANCE 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 Renal Disorders [email_address] FLUIDS and ELECTROLYTES

11. DISTURBANCES IN FLUID BALANCE 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 Renal Disorders [email_address] FLUIDS and ELECTROLYTES

12. DISTURBANCES IN FLUID BALANCE 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 H 2 0 loss] Management Fluid replacement therapy & continued fluid maintenance Renal Disorders [email_address] FLUIDS and ELECTROLYTES

13. Renal Disorders [email_address] FLUIDS and ELECTROLYTES 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

14. 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 Renal Disorders [email_address] FLUIDS and ELECTROLYTES

15. 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, HCO 3 - 27 29 10 Biphosphate, HPO 4 - 2 2 100 Sulfate, SO 4 - 1 1 20 Protein 16 1 60 Organic foods 6 3.4 - (155) Renal Disorders [email_address] FLUIDS and ELECTROLYTES

16. 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 Renal Disorders [email_address] FLUIDS and ELECTROLYTES

17. 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 Renal Disorders [email_address] FLUIDS and ELECTROLYTES FLUIDS and ELECTROLYTES

18. Hyponatremia Drugs that cause decreased sodium Anti-convulsant: Carbamazepine Antidiabetics: Chlorpropramide Tolbutamide Antipsychotics: Fluphenazine Thiozoridazine Thiothixene Antineoplastics: Cyclophosphamide Vincristine Diuretics: Bumetanide Ethacrynic acid Furosemide Thiazides Sedatives: Barbiturates Morphine Renal Disorders [email_address]

19. 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] High sodium foods Celery Cheeses Condiments Processed foods Smoked meats Snack foods ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

20. Treatment Interventions Mild Water restriction if water retention problem Increase Na in foods if loss of Na Moderate IV 0.9% NS, 0.45% NS, LR Severe 3% NS – short-term therapy in ICU setting Renal Disorders [email_address]

21. 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 Renal Disorders [email_address] FLUIDS and ELECTROLYTES

22. Hypernatremia S kin flushed A gitation L ow-grade fever T hirst Renal Disorders [email_address]

23. 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 Renal Disorders [email_address] FLUIDS and ELECTROLYTES

24. 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 Renal Disorders [email_address] FLUIDS and ELECTROLYTES

25. Hyperkalemia Drugs that increase potassium ACE inhibitors Antibiotics Beta blockers NSAIDs Spironolactone Chemotherapeutics Renal Disorders [email_address]

26. Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L] Assessment Thready, slow pulse Shallow breathing N & V, diarrhea, intestinal colic Irritability Muscle weakness, flaccid paralysis Numbness, tingling Difficulty w/ phonation, respiration ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

27. Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L] 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 Renal Disorders [email_address] FLUIDS and ELECTROLYTES

28. Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L] Causes Renal tubule defects Prolonged diuretic therapy Prolonged vomiting, diarrhea, laxative use, NG suctioning, severe diaphoresis Anorexia Acute alcoholism Hyperaldosteronism, excessive steroids Metabolic alkalosis Administration of potassium-deficient hyperalimentation sol’n, hypertonic glucose Excessive amounts of insulin ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

29. Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L] 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 Renal Disorders [email_address] FLUIDS and ELECTROLYTES

30. Hypokalemia S keletal muscle weakness U -wave C onstipation; ileus T oxic effects of digoxin I rregular, weak pulse O rthostatic hypotension N umbness [paresthesia] Renal Disorders [email_address]

31. Hypokalemia Drugs that decrease potassium Adrenergics: Albuterol Epinephrine Antibiotics: Amphotericin B Carbenicillin Gentamicin Insulin Cisplatin Costicosteroids Diuretics: Furosemide Thiazides Laxatives [ excess use ] Renal Disorders [email_address]

32. Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L] Nursing Interventions 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 High potassium foods Avocados Bananas Dates Oranges Potatoes Raisins ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

33. 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 Renal Disorders [email_address] FLUIDS and ELECTROLYTES

34. Hypercalcemia Drugs that increase calcium Calcium-containing antacids Calcium preparations Lithium Thiazide diuretics Vitamin A Vitamin D Renal Disorders [email_address]

35. Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L] Nursing Interventions Encourage mobilization Limit vitamin D intake Limit calcium intake Normal saline Administer diuretics Calcitonin ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

36. Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L] Causes Acute pancreatitis Diarrhea Hypoparathyroidism Lack of vitamin D in the diet Long-term steroid therapy Assessment Painful tonic muscle & facial spasms Fatigue, dyspnea Laryngospasm, convulsions (+) Trousseau’s and Chvostek’s signs ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

37. Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L] Nursing Interventions Administer oral Ca lactate or IV CaCl 2 or gluconate Providing safety by padding side rails Administer dietary sources of calcium Vitamin D Provide quiet environment High calcium foods Milk Dairy products ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

38. 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 Nursing Intervention Withhold Mg-cont’g drugs/foods; Ca adm’n  fluid intake, unless CI ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

39. 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 Nursing Intervention Provide good dietary sources of Mg ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

40. Hypomagnesemia Drugs that decrease magnesium Aminoglycoside: Amikacin, gentamicin, streptomycin, tobramycin Amphotericin B Cisplatin Cyclosporine Insulin Laxative Loop diuretics Pentamidine isethionate Renal Disorders [email_address]

41. Hypomagnesemia S eizures T etany A norexia & arrhythmias R apid heart rate V omiting E motional lability D eep tendon reflexes increased [tremors, twitching, tetany] Renal Disorders [email_address]

42. Dietary sources Chocolates Dry beans and peas Green, leafy vegetables Meats Nuts Seafood Whole grains Renal Disorders [email_address]

43. 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 Renal Disorders [email_address] FLUIDS and ELECTROLYTES

44. 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 poor albumin Plasmanate, Dextran Renal Disorders [email_address] FLUIDS and ELECTROLYTES

45. 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] Renal Disorders [email_address] B U R N S

46. CLASSIFICATION OF BURNS Superficial Partial thickness (1 st degree) Outer layer of dermis Erythema, pain up to 48 hrs Healing 1-2 wks [sunburn] Deep Partial thickness (2 nd degree) Epidermis & dermis Blisters & edema, frequently quite painful Healing 14-21 days Full thickness (3 rd degree) Epidermis, dermis, subcutaneous fat Dry, pearly white or charred in appearance Not painful Eschar must be removed; may need grafting Renal Disorders [email_address] B U R N S

47. STAGES OF BURNS 1 st : Shock/Fluid Accumulation Phase 1 st 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 Renal Disorders [email_address] B U R N S

48. STAGES OF BURNS 2 nd : 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 Renal Disorders [email_address] B U R N S

49. STAGES OF BURNS 3 rd : Recovery Phase 5 th 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 Renal Disorders [email_address] B U R N S

50. ASSESSMENT Assess extent of body surface burned Greater morbidity & mortality for burns affecting face, hands & perineum Assess for dyspnea, stridor, hoarseness 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 Renal Disorders [email_address] B U R N S

51. ASSESSMENT Burn Evaluation Chart Renal Disorders [email_address] B U R N S 9% 9% 9% Front= 18% Back= 18% 18% 18% 1%

52. ASSESSMENT 3. Assess depth of burn Major burns – 2 nd 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 Renal Disorders [email_address] B U R N S

53. 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 Renal Disorders [email_address] B U R N S

54. MANAGEMENT Maintenance of adequate airway Promoting comfort: relieve pain Promoting fluid-electrolyte, acid-base balance Preventing infection Maintaining adequate nutrition Wound care Renal Disorders [email_address] B U R N S

55. 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) Renal Disorders [email_address] B U R N S

56. 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] Renal Disorders [email_address] B U R N S

57. FLUID REPLACEMENT Types of fluids: Colloids Blood Plasma & plasma expanders Electrolytes Lactated Ringers Non-electrolyte D 5 W Renal Disorders [email_address] B U R N S

58. FLUID REPLACEMENT EVAN’S Formula: C – 1ml x % burns x kg BW E - 1ml x % burns x kg BW G lucose 5% for insensible loss – 2,000ml D5W Administer sol’n 1 st 24 hrs – ½ [1 st 8hrs], ½ [16hrs] BROOKE Formula: [Administer as in Evan’s] C – 0.5ml x % burn x kg BW E - 1.5ml x % burn x kg BW Water – 1000ml D5W Renal Disorders [email_address] B U R N S

59. FLUID REPLACEMENT MOORES BURN BUDGET: 75 ml of plasma, 75 ml of electrolyte-cont’g fluid for q 1% TBSA plus 2000 D 5 W HYPERTONIC RESUSCITATION Formula: Hypertonic salt containing 300 mEq of Na + , 100 mEq of Cl - , 200mEq lactate Administered to maintain urinary output of 30-40 ml/hr Renal Disorders [email_address] B U R N S

60. ACID-BASE DISORDERS Renal Disorders [email_address] Disorder Clinical manifestation Compensation Respiratory acidosis ↑ Paco 2 , ↑ or normal HCO 3 - , ↓ pH Kidneys eliminate H + and retain HCO 3 - Respiratory alkalosis ↓ Paco 2 , ↓ or normal HCO 3 - , ↑ pH Kidneys conserve H + and eliminate HCO 3 - Metabolic acidosis ↓ or normal Paco 2 , ↓HCO 3 - , ↓ pH Lungs eliminate CO 2 and conserve HCO 3 - Metabolic alkalosis ↑ or normal Paco 2 , ↑HCO 3 - , ↑ pH Lungs hypoventilate to ↑ Paco 2 , kidneys conserve H + excrete HCO 3 -

61. Causes of Acid-Base Disorders Metabolic acidosis Causes : DKA, uremia, starvation, diarrhea, severe infections Manifestations: Headache, nausea and vomiting Signs of hyperkalemia Seizures, coma, hyperventilation Nursing management: Administer sodium bicarbonate Monitor for signs of hyperkalemia Provide alkaline mouthwash Lubricate lips to prevent dryness I & O Institute seizure precaution Monitor ABG & electrolyte losses Renal Disorders [email_address]

62. Causes of Acid-Base Disorders Metabolic alkalosis Causes: Severe vomiting, NGT suctioning, diuretic therapy, excessive ingestion of NaHCO 3 , biliary drainage Manifestations: Nausea and vomiting Signs and symptoms of hypokalemia Nursing management: Decreased respirations Replace fluids nad electrolytes losses I & O Assess for signs of hypokalemia Monitor ABG & electrolytes Renal Disorders [email_address]

63. Causes of Acid-Base Disorders Respiratory acidosis Causes: Hypoventilation: COPD, barbiturate or sedative overdose, acute airway obstruction, neuromuscular disorders Manifestations: Headache, weakness, visual disturbances, rapid respirations, confusion, drowsiness, tachycardia, coma Nursing management: Semi-Fowler’s Patent airway Turn, cough, deep-breath Administer fluids O 2 therapy Monitor ABG Renal Disorders [email_address]

64. Causes of Acid-Base Disorders Respiratory alkalosis Causes: Hyperventilation, mechanical overventilation, encephalitis Manifestations: Numbness and tingling of mouth and extremities Inability to concentrate Rapid respirations, dry mouth, coma Nursing management: Offer reassurance Encourage breathing into a paper bag Provide sedation as ordered Monitor mechanical ventilation and ABG Renal Disorders [email_address]

65. Interpretation Renal Disorders [email_address] UC PC FC pH ↓ or ↑ ↓ or ↑ normal HCO 3 - ↓ or ↑ normal ↓ or ↑ ↓ or ↑ Paco 2 ↓ or ↑ normal ↓ or ↑ ↓ or ↑

66. Nio Cruzada Noveno, RN, MAN, MSN Fluids & Electrolytes