Fluid And Electrolytes


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Last year by end of the lecture Dr Medinna gave cases to solve for Fluid and electrolytes....

He had a seperate slide for the cases..

Lecture slides are taken from Schwartz Textbook of surgery....

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  • Homeostasis means keeping everything normal Is necessary for organs to perform work Functions of body water transport nutrients, e-lytes, and O2 to the cells excretion of wastes regulates body temp lubricates joints and membranes medium for food digestion Daily body fluid intake and losses liquid 1000-1200ml urine 100-1400ml food 800-1000ml feces 100 ml oxidation 200-300ml lungs 400-500ml skin 300-500ml Total – 2000-2500ml 1800-2500ml
  • ECF shifts between the intravascular space (blood vessels) and the interstitial space (tissue) to maintain the fluid balance within the ECF compartment
  • Osmolality is determined by the number of dissolved particles, mainly Na, urea and glucose per kilogram of H2O Na is the largest contributor of particles To maintain balance between ICF and ECF, the body continues to shift Na and H2O between them ICF is maintained by K+ ECF is maintained by Na+ Regulation of F/E balance requires a constant adjustment Fluid volume, distribution, and composition is accomplished by the -kidneys and the circulatory system which are influenced by the CNS, hormones, (ADH, Aldosterone, Renin) and the thirst center in the brain. Active transport – moves from lesser to higher {} and is aided by energy from ATP Na and K use ATP to move in and out of the cell – called the Na- K pump H ydrogen and glucose also need help Osmosis is passive and occurs like dilution
  • Solutes = dissolved substances Solvent = a liquid with a substance in solution Membrane = a layer of tissue covering a surface or organ or separating spaces Permeability = the capability of a substance, molecule, or ion to diffuse through a membrane Semi-permeable membrane = artificial membrane such as a cellophane membrane Osmosis = passage of a solvent through a membrane from a solution of higher concentration in a solution of lower concentration Diffusion = movement of molecules such as gas from higher to lesser concentration Ion = a particle carrying a positive or negative charge anion = - cation = +
  • Osmosis is the movement of H2O only
  • Isotonic – equally concentrated Hypotonic – less concentrated Hypertonic more concentrated
  • As long as the hydrostatic pressure exceeds plasma colloid oncotic pressure, H2O and solutes leave the capillaries and enter the interstitial spaces If the hydrostatic pressure falls below plasma colloid oncotic pressure, water and solutes return to the capillaries As long as these pressures remain constant, there are no problem with balance WITHOUT THE COLLOID OSMOTIC PRESSURE, FLUID REMAINS IN THE TISSUES CAUSING EDEMA AND SWELLING
  • Hypothalamus senses low blood volume > Pituitary secretes ADH > ADH causes kidneys to retain water
  • pH – acid or base determines how kidneys are responding to metabolic acid bas imbalances Specific gravity indicator of fluid balance reflects renal function – if able to concentrate urine Osmolality - # of dissolved particles in solution determines renal excretion or conservation of water Creatinine clearance – determines glomerular damage to kidney instruct patient to void and discard, then collect for the next 24 hours keep refrigerated usually need a serum creatinine need height, weight, and age Na – reflects Na intake and fluid volume K+ - measures renal tubular function need 24 hour specimen
  • HCT - % of blood volume which is RBC’s ^ in dehydration, fluid volume deficit low indicates fluid excess Serum Creat = metabolic waste product better indicator then BUN for renal function BUN = high is fluid deficit low is fluid volume excess Osmolality = measures blood concentration ^ is fluid volume deficit low is fluid volume excess Albumin = protein in blood that maintains volume by colloid osmotic pressure low and water shifts into the interstitial compartment Electrolytes =
  • Risks – vomiting/diarrhea, kidney disease, CHF, diabetes, burns, diuretics, NG tubes Patient complaints – fatigue, weakness, edema, dyspnea, confusion Vital signs – shows changes in volume pulse - ^ with volume excess, Na excess and Mg deficit weak, irregular, rapid may indicate severe K+ excess or Na deficit bounding – volume excess respirations – fluid volume excess acid base changes – slow shallow in metabolic alkalosis deep, rapid in metabolic acidosis temperature – fever increases metabolic rate with fluid loss subnormal with volume excess B/P – orthostatic with fluid volume deficit ^ with fluid volume overload I/O Keep accurate record problems may be prevented if found early measure all fluids in and out Weight indicator of fluid loss or gain Skin color, moisture, turgor, temperature indicate fluid balance edema reflects Na retention Mucus membranes furrow on the tongue oral cavity Veins jugular hand veins- time it takes for veins to empty and fill
  • Fluid And Electrolytes

    2. 2. FLUIDS <ul><li>50-60% of the human body is water (decreases with age) </li></ul><ul><li>Body fluids are classified according to their location with most of the body’s fluids found within the cell </li></ul><ul><ul><li>Intracellular </li></ul></ul><ul><ul><li>Extracellular (mainly responsible for transport of nutrients and wastes) </li></ul></ul><ul><li>Fluid compartments are separated by selectively permeable membranes that control movement of water and solutes </li></ul><ul><li>The process of homeostasis involves delivery of oxygen and nutrients to the cells and removal of waste </li></ul>
    3. 6. Transport of Water and Fluids <ul><li>Osmolality : concentration of a solution determined by the number of dissolved particles per kilogram of water. Osmolality controls water movement and distribution in body fluid compartments </li></ul><ul><li>Diffusion : the random movement of particles in all directions through a solution </li></ul><ul><li>Active transport : movement of solutes across membranes; requires expenditure of energy </li></ul><ul><li>Filtration : transfer of water and solutes through a membrane from a region of high pressure to a region of low pressure </li></ul><ul><li>Osmosis : movement of water across a membrane from a less concentrated solution to a more concentrated solution </li></ul>
    4. 9. Fluid Pressures (Starling’s Law) <ul><li>ECF and ICF fluid shifts occur related to changes in pressure within the compartments </li></ul><ul><li>Fluid flows only when there is a difference in pressure </li></ul><ul><li>3 types of body fluids </li></ul><ul><ul><li>Isotonic </li></ul></ul><ul><ul><li>Hypotonic </li></ul></ul><ul><ul><li>Hypertonic </li></ul></ul>
    5. 10. Hydrostatic Pressure and Colloid Osmotic Pressure <ul><li>Tissue fluids and plasma in the capillaries have hydrostatic and colloid osmotic pressure </li></ul><ul><li>Hydrostatic pressure forces fluid and solutes through the capillary walls </li></ul><ul><li>When the hydrostatic pressure inside the capillary is greater than the pressure in the surrounding interstitial space, fluids and solutes inside the capillary they are forced out into the interstitial space </li></ul><ul><li>This also happens in the reverse </li></ul>
    6. 11. Albumin’s Role in F/E Balance <ul><li>Reabsorption prevents too much fluid from leaving the capillaries </li></ul><ul><li>Albumin is a large molecule and will not pass through the capillary membrane </li></ul><ul><li>When fluid filters through the capillary, the protein albumin remains behind </li></ul><ul><li>When the concentration of albumin increases, fluid begins to move back into the capillary wall by osmosis </li></ul><ul><li>The pulling force of albumin in the intravascular space is called plasma colloid oncotic pressure </li></ul>
    7. 12. Plasma Colloid Osmotic Pressure Solutes Interstitial Spacer Capillary
    8. 13. Regulation of Fluid Volume <ul><li>Kidneys </li></ul><ul><ul><li>Capillary pressure forces fluid through the walls and into the tubule </li></ul></ul><ul><ul><li>At this point H2O or electrolytes are then either retained or excreted </li></ul></ul><ul><ul><li>The urine becomes more dilute or more concentrated based on the needs of the body </li></ul></ul>
    9. 14. Regulation of Fluid Volume, cont. <ul><li>Antidiuretic hormone (ADH) </li></ul><ul><ul><li>Produced by the hypothalamus </li></ul></ul><ul><ul><li>Stored in the pituitary gland </li></ul></ul><ul><ul><li>Restores blood volume by increasing or decreasing excretion of water </li></ul></ul><ul><ul><li>Increased osmolality or decreased blood volume stimulates the release of ADH </li></ul></ul><ul><ul><li>Then the kidneys reabsorb water </li></ul></ul><ul><ul><li>Also may be released by stress, pain, surgery, and some meds </li></ul></ul>
    10. 15. Regulation of Fluid Volume, cont. <ul><li>Renin-angiotensin-aldosterone system </li></ul><ul><ul><li>Renin secreted in kidney </li></ul></ul><ul><ul><ul><li>Amount of renin produced depends on blood flow and amount of Na in the blood </li></ul></ul></ul><ul><ul><li>Produces angiotensin II (vasoconstrictor) </li></ul></ul><ul><ul><li>Angiotensin causes peripheral vasoconstriction </li></ul></ul><ul><ul><li>Angiotensin II stimulates the production of aldosterone </li></ul></ul>
    11. 16. Regulation of Fluid Volume, cont. <ul><li>Aldosterone </li></ul><ul><ul><li>Secreted by the adrenal gland response to angiotensin II </li></ul></ul><ul><ul><li>The adrenal gland may also be stimulated by the amount of Na and K + in the blood </li></ul></ul><ul><ul><li>Causes the kidneys to retain Na and H2O </li></ul></ul><ul><ul><li>Leads to increases in fluid volume and Na levels </li></ul></ul><ul><ul><li>Decreases the reabsorption of K+ </li></ul></ul><ul><ul><li>Maintains B/P and fluid balance </li></ul></ul>
    12. 17. Regulation of Fluid Volume, cont <ul><li>Atrial natriuretic peptide or factor (ANP) (ANF) </li></ul><ul><ul><li>Cardiac hormone </li></ul></ul><ul><ul><li>Released in response to increased pressure in the atria (increased blood volume) </li></ul></ul><ul><ul><li>Opposes the renin-angiotensin-aldosterone system </li></ul></ul><ul><ul><li>Stimulates excretion of Na and H2O </li></ul></ul><ul><ul><li>Suppresses renin level </li></ul></ul><ul><ul><li>Decreases the release of aldosterone </li></ul></ul><ul><ul><li>Decreases ADH release </li></ul></ul><ul><ul><li>Reduces vascular resistance by causing vasodilation </li></ul></ul>
    13. 19. Fluid shifting <ul><li>1st space shifting- normal distribution of fluid in both the ECF compartment and ICF compartment. </li></ul><ul><li>2nd space shifting- excess accumulation of interstitial fluid (edema) </li></ul><ul><li>3rd space shifting- fluid accumulation in areas that are normally have no or little amounts of fluids (ascites) </li></ul>
    15. 21. Diagnostic Tests for F/E <ul><li>Urine studies </li></ul><ul><ul><li>Urine pH Urine specific gravity </li></ul></ul><ul><ul><li>Urine osmolarity </li></ul></ul><ul><ul><li>Urine creatinine clearance </li></ul></ul><ul><ul><li>Urine sodium </li></ul></ul><ul><ul><li>Urine potassium </li></ul></ul>
    16. 22. Blood Studies <ul><li>Serum Hematocrit = 40-54%/men, 38-47% for women </li></ul><ul><li>Serum Creatinine = 0.6 – 1.5 mg/dl </li></ul><ul><li>BUN = 8-20 mg/dL </li></ul><ul><li>Serum osmolality </li></ul><ul><li>Serum Albumin – 3.5-5.5 g/dL </li></ul><ul><li>Serum Electrolytes </li></ul>
    17. 23. ASSESSMENT FOR F/E BALANCE <ul><li>History of potential factors which place patient at risk </li></ul><ul><li>Vital signs </li></ul><ul><li>I/O </li></ul><ul><li>Body weight </li></ul><ul><li>Skin </li></ul><ul><li>Mucus membranes </li></ul><ul><li>Vascular system </li></ul>
    18. 24. FLUID VOLUME DEFICITE <ul><li>Hypovolemia: isotonic extracellular fluid deficit </li></ul><ul><li>Deficiency of both water & electrolytes </li></ul><ul><li>Caused by decreased intake, vomiting, diarrhea, fluid shift </li></ul><ul><li>Dehydration: hypertonic extracellular fluid deficit </li></ul><ul><li>Deficiency of water </li></ul><ul><li>Caused by water loss related to high blood glucose, inadequate ADH production, high fever, excess sweating </li></ul>
    19. 25. Assessment of Fluid Deficit <ul><li>Hypotension </li></ul><ul><li>Weak rapid pulse </li></ul><ul><li>Temperature decreased if hypovolemic, and increased in dehydration </li></ul><ul><li>Weight loss </li></ul><ul><li>Skin turgor poor in dehydration and possible edema in hypovolemic </li></ul><ul><li>Concentrated urine and blood </li></ul>
    20. 26. Treatment of Deficit <ul><li>Correct cause </li></ul><ul><li>IV fluids </li></ul><ul><li>I and O </li></ul><ul><li>Skin care </li></ul><ul><li>Assist with ADL’s </li></ul>
    21. 27. FLUID VOLUME EXCESS <ul><li>Extracellular: isotonic fluid excess </li></ul><ul><li>Excess of both water and electrolytes </li></ul><ul><li>Caused by retention of water and electrolytes related to kidney disease; overload with isotonic IV fluids </li></ul><ul><li>Intracellular: water excess </li></ul><ul><li>Excess of body water without excess electrolytes </li></ul><ul><li>Caused by over-hydration in the presence of renal failure; administration of D5W </li></ul>
    22. 28. FLUID VOLUME EXCESS/Assessment <ul><li>Isotonic </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Bounding pulse </li></ul></ul><ul><ul><li>Crackles, dyspnea </li></ul></ul><ul><ul><li>Weight gain </li></ul></ul><ul><ul><li>Edema in extremities </li></ul></ul><ul><ul><li>JVD </li></ul></ul><ul><ul><li>Irritable, confused </li></ul></ul><ul><li>Hypotonic </li></ul><ul><ul><li>Systolic B/P ^ </li></ul></ul><ul><ul><li>Decreased pulse </li></ul></ul><ul><ul><li>Increased respirations </li></ul></ul><ul><ul><li>Weight gain </li></ul></ul><ul><ul><li>Cerebral edema </li></ul></ul><ul><ul><li>Irritable, confused </li></ul></ul>
    23. 29. FLUID VOLUME EXCESS/ Treatment <ul><li>Isotonic </li></ul><ul><ul><li>Correct cause </li></ul></ul><ul><ul><li>Restrict H2O and Na </li></ul></ul><ul><ul><li>Diuretics </li></ul></ul><ul><ul><li>Digitalis </li></ul></ul><ul><ul><li>Possible dialysis </li></ul></ul><ul><li>Hypotonic </li></ul><ul><ul><li>Correct cause </li></ul></ul><ul><ul><li>Restrict H2O intake </li></ul></ul><ul><ul><li>IV fluids with E-lytes </li></ul></ul>
    24. 30. FLUID VOLUME EXCESS/Nursing Care <ul><li>Isotonic </li></ul><ul><ul><li>Monitor for excess excretion of H2O R/T diuretics </li></ul></ul><ul><ul><li>Maintain fluid restriction </li></ul></ul><ul><ul><li>Consult dietary for salt restrictions </li></ul></ul><ul><ul><li>Watch for skin problems </li></ul></ul><ul><ul><li>HOB ^ 30 degrees </li></ul></ul><ul><li>Hypotonic </li></ul><ul><ul><li>IV’s and meds as ordered </li></ul></ul><ul><ul><li>I/O </li></ul></ul><ul><ul><li>Oral care and ice chips </li></ul></ul><ul><ul><li>Safety precautions </li></ul></ul><ul><ul><li>Seizure precautions </li></ul></ul>