fluid, electrolytes, acid base balance

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  • 25.4- Fluid intake is regulated through THIRST CENTER- HYPOTHALAMUS, psychological factors dry pharyngeal mucous membranes, Angiotension I create the sensation of thirst. Major PHYSIOLOGICAL stimuli to the thirst center are increase plasma concentration decreased blood volume. osmoreceptors which detect the fluid loss continually monitor osmolality Fluid output occurs through the kidney and Gastrointestinal tract average daily fluid loss is 2600-3000 ccs LYMPHATIC SYSTEM sponges up excess fluid that ’s not reabsorbed by the capillaries – LYMPH DUCTS- return fluid and some protein to the subclavian veins and empty into the right atrium.. GASTROINTESTINAL SYSTEM –besides the fluid absorbed from the dietary intake the GI tract produced PRODUCTION OF GLANDULAR AND TISSUE SECRETIONS 7 -9 liters, all than about 100 ml of this fluid is reabsorbed. RENAL SYSTEM-THE KIDNEYS ARE THE Major regulatory organs of fluid balance Chemical buffer system in extracellular fluid Carbonic acid- bicarbonate which responds to changes in pH within seconds . We have the excretion of CO2 from the lungs and the excretion of hydrogen and bicarbonate ions which is controlled by the kidneys 2nd buffering system in plasma proteins such as albumin, fibrinogen, prothrombin which can bind or release hydrogen to correct acidosis or alkalosis.
  • Pg 563-564 Fluids exist in compartments in the body yet fluid is in a continual state of exchange between the compartments the amounts in the compartments remain relatively constant. Intracellular fluid compartment- makes up 2/3 of the body ’s fluid and provide cells with internal aqueous medium necessary for their chemical functions 70%  anything that affects fluid loss at the cellular level has significant implications for the entire body. Extracellular fluid compartment – fluid found outside cells body ’s transportation system 30% Extracellular compartment carries water, electrolytes, nutrients, and oxygen, makes up the other 1/3 of fluid it is further divided into: Intravascular fluids - fluid within arteries, veins, and capillaries 6% Interstitial fluids - fluid is everywhere in body 22% Third spacing- occurs when fluid shifts from the vascular space into a space where it is not accessible as extracellular fluid; it remains in the body, but is not available for use, causing an isotonic fluid volume deficit, example fluid may be trapped in the interstitial space as edema, or peritoneal or pleural cavities Transcellular fluids - in spaces in the cerebrospinal canals of the brain, and in lymph tissue, synovial joints and eyes. 2%
  • Figure 52-4 Diffusion: The movement of molecules through a semipermeable membrane from an area of higher concentration to an area of lower concentration.
  • Figure 52-3 Osmosis: Water molecules move from the less concentrated area to the more concentrated area in an attempt to equalize the concentration of solutions on two sides of a membrane. An example of the filtration pressure changes within a capillary bed arterial blood pressure exceeds colloid osmotic pressure resulting in movement of water and dissolved substances out of the capillary into the interstitial space, on the venous end blood pressure is less than colloid osmotic pressure resulting in movement of water and dissolved substances into the capillary Hydrostatic pressure - arterial blood enter the capillaries at a pressure greater than interstitial pressure So fluid and solutes move from the capillaries toward the cells. At the venous end of the capillary bed because the hydrostatic pressure is less than interstitial pressure, fluid and waste products move from the cells back into the capillaries. Osmotic pressure is the drawing power for water to depends on the number of molecules of solution. A solution with high solute concentration has a high osmotic pressure and draws water to itself. Osmolality - is the osmotic dissolved particles needed to produced one unit of force is expressed in Milliosmoles – or OSMOLS MSM/KG Osmolarity - measurement of milliosmoles per liter of solution
  • Figure 52-5 Schematic of filtration pressure changes within a capillary bed. On the arterial side, arterial blood pressure exceeds colloid osmotic pressure, so that water and dissolved substances move out of the capillary into the interstitial space. On the venous side, venous blood pressure is less than colloid osmotic pressure, so that water and dissolved substances move into the capillary.
  • Figure 52-6 An example of active transport. Energy (ATP) is used to move sodium molecules and potassium molecules across a semipermeable membrane against sodium ’s and potassium’s concentration gradients (i.e., from areas of lesser concentration to areas of greater concentration). 566-567 Osmosis - the movement of H2O through a semi-impermeable membrane from an area of lesser concentration of particles to an area of greater concentration of particles. Osmosis is the diffusion of water across a semi-permeable (or differentially permeable or selectively permeable) membrane. The cell membrane, along with such things as dialysis tubing and cellulose acetate sausage casing, is such a membrane. The presence of a solute decreases the water potential of a substance. Thus there is more water per unit of volume in a glass of fresh-water than there is in an equivalent volume of sea-water. In a cell, which has so many organelles and other large molecules, the water flow is generally into the cell. Diffusion - passive process by molecules move through a cell membrane from an area of higher concentration to an area of lower concentration Diffusion example is gas exchange between O2 and CO2 across the alveoli and capillaries. Active Transport - molecules move from an area of lower concentration to an area of higher concentration with an expenditure of energy adenosine triphosphate (ATP)   Active transport example is sodium potassium pump  there is active movement of sodium from inside the cell to outside the cell
  • ADH from pituitary gland to kidney, especially in crisis to shut off pee.
  • 568 figure 25.4- NEURO ENDOCRINE SYSTEM it regulates body fluid volume by producing and secreting hormones that stimulate or inhibit osmotic receptors in the carotid arteries and aortic arch –HORMONES & BAROCEPTORS- Anti diuretic Hormone which released by the posterior pituitary gland, reduces the production of urine by causing the kidney tubules to reabsorb water. When fluid volume deficit occurs ( as in vomiting, diarrhea, or hemorrhage) the amount of ADH in the blood increases and the water reabsorbed by the kidney tubules is returned to the circulating blood volume. In response to decreased blood flow or pressure in the kidney specialized receptors in the nephrons, release renin. Renin causes the conversion of angiotensin I to angiotensin II which acts directly on the nephron to cause Na+ and H2O retention. Angiontension II also stimulates the adrenal cortex to release aldosterone which causes kidneys tubules to excrete K+ and retain Na+; as a result the kidneys reabsorb water and return it to the blood volume. RENAL SYSTEM-THE KIDNEYS ARE THE Major regulatory organs of fluid balance. It can take from a few hours to several days to regulate acid base abnormalites. precise control of body water and solute concentrations is a function of several hormones acting on both the kidneys and vascular system, but there is no doubt that antidiuretic hormone is a key player in this process. Antidiuretic hormone, also known commonly as arginine vasopressin, is a nine amino acid peptide secreted from the posterior pituitary. Within hypothalamic neurons, the hormone is packaged in secretory vesicles with a carrier protein called neurophysin, and both are released upon hormone secretion. Physiologic Effects of Antidiuretic Hormone Effects on the Kidney The single most important effect of antidiuretic hormone is to conserve body water by reducing the loss of water in urine. A diuretic is an agent that increases the rate of urine formation. Injection of small amounts of antidiuretic hormone into a person or animal results in antidiuresis or decreased formation of urine, and the hormone was named for this effect.
  • Fluid volume excess- . The defining characteristics are a direct or indirect result of an increase in fluid intake or decrease in excretion of fluid without compensation by intercompartmental fluid shifts or other regulatory mechanisms It can occur because of A. Excessive intake Na Cl B. rapid administration of sodium rich infusions, C. disease that impair regulatory mechanisms, like renal failure, congestive heart failure Deficient fluid volume or low blood volume The defining characteristics are a direct or an indirect result of a rapid change in fluid output or a lack of intake without compensation by fluid shifts or other homeostatic mechanisms. It occurs when water is lost from the body but there is no loss of electrolytes, as a result serum sodium concentrations increases in the vascular fluid water is drawn into the blood from the interstitial space and cells resulting in cell dehydration. Dehydration can be caused by: Hyperventilation Prolonged fever Diabetic ketoacidosis Enteral feedings without water intake
  • Fluid volume excess-. The defining characteristics are a direct or indirect result of an increase in fluid intake or decrease in excretion of fluid without compensation by intercompartmental fluid shifts or other regulatory mechanisms It can occur because of A. Excessive intake Na Cl B. rapid administration of sodium rich infusions, C. disease that impair regulatory mechanisms, like renal failure, congestive heart failure Deficient fluid volume or low blood volume The defining characteristics are a direct or an indirect result of a rapid change in fluid output or a lack of intake without compensation by fluid shifts or other homeostatic mechanisms. It occurs when water is lost from the body but there is no loss of electrolytes, as a result serum sodium concentrations increases in the vascular fluid water is drawn into the blood from the interstitial space and cells resulting in cell dehydration. Dehydration can be caused by: Hyperventilation Prolonged fever Diabetic ketoacidosis Enteral feedings without water intake Water intoxication is overhydration and occurs when more water is gained that electrolytes the result is low serum osmolality and low serum Na+ levels. Water is drawn into the cells causing them to swell. Water intoxication occurs in conditions which both fluid and electrolytes are lost through heavy exercise, or heavy sweating and only water is replaced,
  • An example of the filtration pressure changes within a capillary bed arterial blood pressure exceeds colloid osmotic pressure resulting in movement of water and dissolved substances out of the capillary into the interstitial space, on the venous end blood pressure is less than colloid osmotic pressure resulting in movement of water and dissolved substances into the capillary Hydrostatic pressure - arterial blood enter the capillaries at a pressure greater than interstitial pressure So fluid and solutes move from the capillaries toward the cells. At the venous end of the capillary bed because the hydrostatic pressure is less than interstitial pressure, fluid and waste products move from the cells back into the capillaries. Osmotic pressure is the drawing power for water to depends on the number of molecules of solution. A solution with high solute concentration has a high osmotic pressure and draws water to itself. Osmolality - is the osmoticdissolved particles needed to produced one unit of force is expressed in Milliosmoles – or OSMOLS MSM/KG Osmolarity - measurement of milliosmoles per liter of solution
  • Hypertonic have greater concentration of solutes than plasma will move water out of cells. Solutions have lower water potential Hypotonic as lesser concentration of solutes that plasma don will move water into cells . (higher water potential). Isotonic has the same osmolality as blood plamsa . This type prevents shifting of fluid and electrolytes from intracellular fluid. solutions have equal (iso-) concentrations of substances. Water potentials are thus equal, although there will still be equal amounts of water movement in and out of the cell, the net flow is zero.
  • Deficit: abnormal losses through skin, anorexia third spacing, nausea, Excessive sweating, inability to access fluids, polyuria, impaired swallowing, Fever, confusion, NG suction, depression, bleeding, prolonged rapid respiration, Vomiting, diarrhea symptomatology: decreased BP, pulse, urine output <30 ml/ hour, decreased skin turgor, dry mucus membranes, sunken eyeballs, hemoconcentration, elevated temperature, concentrated urine weakness, confusion. Excess:, It can occur because of A. Excessive intake Na Cl B. rapid administration of sodium rich infusions, C. disease that impair regulatory mechanisms, like renal failure, congestive heart failure Symptomatology: weight gain > 2lbs in 24 hours, elevated BP, full bounding pulses, moist, labored respirations, large volume of pale urine, pitting edema, crackles, Auscultate in lungs, dyspnea, distended jugular veins
  • Electrolyte imbalance: An electrolyte disorder is an imbalance of certain ionized salts (i.e., bicarbonate, calcium, chloride, magnesium, phosphate, potassium, and sodium) in the blood. Description Electrolytes are ionized molecules found throughout the blood, tissues, and cells of the body. These molecules, which are either positive (cations) or negative (anions), conduct an electric current and help to balance pH and acid-base levels in the body. Electrolytes also facilitate the passage of fluid between and within cells through a process known as osmosis and play a part in regulating the function of the neuromuscular, endocrine, and excretory systems.
  • Respiratory acidosis is high paco2 due to alveolar hypoventilation which causes co2 to be retained. c arbonic acid levels increase and the pH falls below 7.35. the kidneys attempt to compensate by retaining HCO3, however, they are slow to respond, so compensation may require several days time. Related factors, acute lung conditions that impaired alveolar gas impair, aspiration of an foreign object ,pulmonary edema. Or chronic lung disease, narcotic or sedative overdose that depresses the respiratory center in the brain, cardiac arrest, pneumonia or Hemothorax, obesity. S&S: acute conditions: increased pulse and resp rate, headache, dizziness, confusion, decreased level of consciousness, palpitations, warm flushed skin, ventricular fib Treatment focuses on improving ventilation, bronchodilators to reduce spasm and ANTIBIOTICS, assessing respiratory status and lung sounds frequently, O2 as needed Respiratory Alkalosis: is a low PaCO2 due hyperventilation. An increase resp rate or depth cause CO2 to be excreted faster than normal. When CO2 level is high the respiratory center is stimulated; however, when CO2 level is low as in respiratory alkalosis , the respiratory center depresses or even ceases respirations. The kidneys try to compensate by excreting more bicarbonate and retaining more hydrogen. Related factors hyperventilation, hypoxemia, high fever, CNS lesions, pulmonary emboli, bacteremia, anxiety Interventions: look at cause  anxiety? Focus interventions on decreasing anxiety, Instruct client to breath more slowly or to breathe into a paper bag or apply a rebreather mask to inhale CO2, monitor ABG ’s and vital signs Metabolic Acidosis Is a low HCO3 level in relation to the amount of carbonic acid levels in the body this may be from renal failure and the inability of the kidneys to excrete hydrogen ions and produce HCO3. the resp center attempt to compensate by increasing rate and depth of respirations excreting CO2 and causing carbonic acid levels to fall. Related factors conditions that increase non volatile acids in the blood, like DM, impaired renal function Conditions that cause a loss of bicarbonate like prolonged diarrhea, acidify drugs like ammonium chloride used alkalosis or to acidify the urine. Nursing Interventions:treatment focuses on correcting the metabolic defect, IV sodium bicarbonate, IF ORDERED, monitor ABG ’s, Monitor LOC, Monitor I&O Metabolic Alkalosis Is a high HCO3 level because of excessive acid losses or due to increased ingestion or retention of bases; like when someone ingests bicarbonate of soda as an antacid. When metabolic alkalosis depresses the respiratory center the lungs attempt to compensate  respirations become slow and shallow, CO2 is retained and HCO3 levels increase. The kidneys also try to compensate by excreting K+ and NA+ with the excess bicarbonate and by retaining hydrogen related factors include excessive acid loss from vomiting or gastric suctioning, excessive use of K+ losing diuretics, ingestion of bicarbonate like antacids, abrupt relief of chronic respiratory acidosis, hypokalemia, Hyperaldosteronism, Cushings syndrome Nursing Interventions: Causative interventions.
  • pH measures the relative acidity or alkalinity of the blood Normal pH is 7.35 – 7.45 cellular function is seriously affected at <7.20 or >7.50 , 6.8O or 7.80 are incompatible with life Pa O2 is an indirect measure of blood oxygen content it is the pressure exerted by O2 dissolved in the plasma of the arterial blood Pa Co2 reflects the respiratory component of acid-base status. It is the partial pressure of CO2 in the arterial blood. HCO3 measures the metabolic component of acid base status Base Excess also reflects the metabolic component of acid base status. Sa O2 is the percentage of hemoglobin that is saturated with oxygen
  • Sodium helps the kidneys to regulate the amount of water the body retains or excretes. Consequently, individuals with elevated serum sodium levels also suffer from a loss of fluids, or dehydration. Hypernatremia can be caused by inadequate water intake, excessive fluid loss (i.e., diabetes insipidus, kidney disease, severe burns, and prolonged vomiting or diarrhea), or sodium retention (caused by excessive sodium intake or aldosteronism). In addition, certain drugs, including loop diuretics, corticosteroids, and antihypertensive medications may cause elevated sodium levels. Symptoms of hypernatremia include: thirst, orthostatic hypotension, dry mouth and mucous membranes, dark, concentrated urine, loss of elasticity in the skin, irregular heartbeat (tachycardia), irritability, fatigue, lethargy, heavy, labored breathing, muscle twitching and/or seizures. – interventions  dietary sodium restriction, give water with feedings to keep Na+ and BUN levels WNL, monitor I &O
  • Up to 1% of all hospitalized patients develop hyponatremia, making it one of the most common electrolyte disorders. Diuretics, certain psychoactive drugs (i.e., fluoxetine, sertraline, haloperidol), specific antipsychotics (lithium), vasopressin, chlorpropamide, the illicit drug "ecstasy," and other pharmaceuticals can cause decreased sodium levels, or hyponatremia. Low sodium levels may also be triggered by inadequate dietary intake of sodium, excessive perspiration, water intoxication, and impairment of adrenal gland or kidney function. Symptoms of hyponatremia include: nausea, abdominal cramping, and/or vomiting, headache, edema (swelling), muscle weakness and/or tremor, paralysis, disorientation, slowed breathing, seizures, coma. risk factors loss of GI fluids, adrenal insufficiency, sweating, diuretics, , gain of hypotonic tube feedings, oral ingestion of water, excess of administration on D5W, AIDS, malignancy tumors, head injury Nursing interventions: monitoring I&O, checking specific gravity of urine, encourage diet high in sodium
  • HYPERKALEMIA Increased oral or IV intake especially in renal disease, stored blood Decreased output as from taking angiotensin converting enzyme inhibitor with potassium rich salt substitutes or potassium sparing diuretics, renal failure, post op oliguria addinsons disease Hyperkalemia may be caused by ketoacidosis (diabetic coma), myocardial infarction (heart attack), severe burns, kidney failure, fasting, bulimia nervosa, gastrointestinal bleeding, adrenal insufficiency, or Addison's disease. Diuretic drugs, cyclosporin, lithium, heparin, ACE inhibitors, beta blockers, and trimethoprim can increase serum potassium levels, as can heavy exercise. The condition may also be secondary to hypernatremia (low serum concentrations of sodium). Symptoms may include: weakness, nausea and/or abdominal pain, irregular heartbeat (arrhythmia), diarrhea, muscle pain Nursing inteventions: monitor cardiac status, adm diuretics, Hold K+ supplements, and K+ sparing diuretics, Monitor K+ levels closely, teach at risk clients to avoid K+ laden foods and drinks, such as coffee, tea, cocoa, dried fruits, dried beans, whole grain breads.
  • HYPORKALEMIA POTASSIUM certain medications such as diuretics and laxatives, excess vomiting, diarrhea, GI suctioning, diet low in potassium, renal failure Severe dehydration, aldosteronism, Cushing's syndrome, kidney disease, long-term diuretic therapy, certain penicillins, laxative abuse, congestive heart failure, and adrenal gland impairments can all cause depletion of potassium levels in the bloodstream. A substance known as glycyrrhetinic acid, which is found in licorice and chewing tobacco, can also deplete potassium serum levels. Symptoms of hypokalemia include: weakness, paralysis, increased urination, irregular heartbeat (arrhythmia), orthostatic hypotension muscle pain, tetany. Assess clients on digitalis medications Digitalis Medicines Commonly Used Brand Names in the United States: Lanoxicaps (digoxin), Lanoxin (digoxin), commonly used to treat CHF for digitalis toxicity Hypokalemia potentiates these type of drugs. Administer potassium. Educate client on potassium laden foods.
  • HYPORKALEMIA POTASSIUM certain medications such as diuretics and laxatives, excess vomiting, diarrhea, GI suctioning, diet low in potassium, renal failure Severe dehydration, aldosteronism, Cushing's syndrome, kidney disease, long-term diuretic therapy, certain penicillins, laxative abuse, congestive heart failure, and adrenal gland impairments can all cause depletion of potassium levels in the bloodstream. A substance known as glycyrrhetinic acid, which is found in licorice and chewing tobacco, can also deplete potassium serum levels. Symptoms of hypokalemia include: weakness, paralysis, increased urination, irregular heartbeat (arrhythmia), orthostatic hypotension muscle pain, tetany. Assess clients on digitalis medications Digitalis Medicines Commonly Used Brand Names in the United States: Lanoxicaps (digoxin), Lanoxin (digoxin), commonly used to treat CHF for digitalis toxicity Hypokalemia potentiates these type of drugs. Administer potassium. Educate client on potassium laden foods.
  • HYPOCALCEMIA): meds diuretics, laxatives, hypoparthyroidism, renal failure Thyroid disorders, kidney failure, severe burns, sepsis, vitamin D deficiency, and medications such as heparin and glucogan can deplete blood calcium levels. Lowered levels cause: muscle cramps and spasms tetany and/or convulsions, mood changes (depression, irritability), dry skin, brittle nails, facial twitching. Chvosteks sign= When the facial nerve is tapped at the angle of the jaw, the facial muscles on the same side of the face will contract momentarily (typically a twitch of the nose or lips) because of hypocalcaemia and hyperexcitability of nerves Trousseau ’s sign = carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally Nursing interventions: seizure precautions for severe cases, monitor airway, safety precautions for confusion, education for perimenopausal women regarding the need of CA+ supplements.
  • Help to Characterize the Nature and Severity of Fluid/Electrolyte Imbalance Highly recommended: sodium, potassium, chloride, bicarbonate (electrolytes), blood urea nitrogen (BUN), creatinine Recommended: calcium, glucose, hemoglobin, hematocrit, serum osmolality Optional: urinalysis, urine sodium, urine osmolality Urinalysis test includes, urine ph, acidity, and protein and specific gravity Specific gravity (which is directly proportional to urine osmolality which measures solute concentration) measures urine density, or the ability of the kidney to concentrate or dilute the urine over that of plasma. Dipsticks are available that also measure specific gravity in approximations. Most laboratories measure specific gravity with a refractometer. Specific gravity between 1.002 and 1.035 on a random sample should be considered normal if kidney function is normal. Since the sp gr of the glomerular filtrate in Bowman's space ranges from 1.007 to 1.010, any measurement below this range indicates hydration and any measurement above it indicates relative dehydration.
  • Generalized symptomatology weakness, fatigue, body edema (anasarca) pitting and non pitting edema in dependent areas such as legs, sacrum, and scrotum. Ascites Sudden weight gain > 2lbs/week ( 1 liter =2.2lbs or 1 kg ) daily wgt Peripheral venous distention Bulging fontanels in an infant Pulmonary progressive worsening of dyspnea, from dyspnea on exertion to orthopnea, and finally to dyspnea at rest. Increased respiratory rate Respiratory rhythm rate may become irregular or apneic Crackles present from fluid congestion in alveol Possible pulmonary edema from severe fluid congestion in alveoli 2ndary to left ventricular failure. Possible pleural effusion with audible pleural rub from congestion in pleural spaces. Cardiac tachycardia, bounding pulse, HTN systolic BP>140mm Hg or diastolic BP >90mm Hg, possible pericardial effusion with audible rub from pericardial rub for fluid congestion in pericardium GI anorexia, Nausea and vomiting Renal increased output if kidney can compensate, decreased output if kidney damage is part of etiology
  • used to tx. edema & 3rd spacing;solutions are used to replace electrolytes and shift fluids from the ICF to ECF; cell decreases in size because salt sucks; D10,D5NS,D51/2NS,D5RL(55dextros in ringers lactated)  
  • fluid, electrolytes, acid base balance

    1. 1. Fluid, Electrolyte, and Acid- Base Balance Focus 7 Nursing 53A Judy Ontiveros, RN, PHN, MSN
    2. 2. Objectives• Describe how fluid volume and electrolytes are regulated to maintain homeostasis.• Describe fluid and electrolyte balance. – Examine fluid volume imbalance and preventative interventions. – Define and discuss the major electrolytes in the maintenance of homeostasis – Explain the proper distribution of fluid in each body fluid compartment and the effect of mal-distribution• Define and discuss the major electrolytes essential in the maintenance of homeostasis
    3. 3. Objectives• Define populations particularly vulnerable to fluid and electrolyte imbalance.• Discuss preventative measures to electrolyte imbalance.• List common diagnostic tests related to fluid and electrolyte status.• Discuss the nursing purpose responsibilities of each procedure.• Examine altered means of fluid intake and the related nursing responsibilities/technical skills.
    4. 4. Body Fluid Distribution
    5. 5. Fluid and Electrolyte Balance• Homeostasis – Balance of fluids, electrolytes, acids and bases • Physiologic processes that control intake and output – Body composed of 46 – 60% of adult weight – Every illness has potential to upset the balance
    6. 6. Maintaining Fluid Balance• Intake should equal fluid output – Intake at 2000 mL – Output at 1500 mL – Difference within 200 – 300 mL
    7. 7. Movement of Fluids• Osmosis• Diffusion• Filtration• Active transport
    8. 8. Diffusion
    9. 9. Osmosis
    10. 10. Filtration
    11. 11. Active Transport
    12. 12. Regulating Body Fluids• Fluid intake • Maintaining – Thirst homeostasis• Fluid output – Kidneys – Urine – ADH – Insensible loss – Renin-angiotensin- aldosterone system – Feces – Atrial natriuretic system
    13. 13. Fluid and Electrolyte Balance• Volume imbalance: • Net volume gain – hypervolemia • Net volume loss - hypovolemia • Water intoxication – overhydration
    14. 14. Fluid Volume Excess (FVE) Intake Exceeds Output• Weight gain • Cardiac palpitations – Surgery • Decreased urinary• Pitting edema output• Cough • Mental status changes• Dyspnea
    15. 15. Fluid Volume Deficit (FVD) Output exceeds intake• Diarrhea • Fever• Diuretics • Excess urine output• Vomiting • Change in mental• Gastric suction status• Anorexia • Traumatic injury• Increasing fatigue (burn) and weakness • Blood loss• Weight loss
    16. 16. Factors Affecting Distribution• Filtration• Hydrostatic Pressure• Osmotic Pressure
    17. 17. • Hypertonic• Isotonic• Hypotonic
    18. 18. Regulating Electrolytes• Sodium• Potassium• Calcium• Magnesium• Chloride• Phosphate• Bicarbonate
    19. 19. Composition of Body Fluids
    20. 20. Regulating Acid-Base Balance
    21. 21. Regulating Acid-Base Balance• Low pH = acidic• High pH = alkalinic• Body fluids maintained between pH of 7.35 and 7.45 by• Buffers• Respiratory system• Renal system
    22. 22. Figure 52-10 Carbonic acid–bicarbonate ratio and pH. • Prevent excessive changes in pH • Major buffer in ECF is HCO3 and H2CO3 • Other buffers include: – Plasma proteins – Hemoglobin – Phosphates
    23. 23. Acid-Base Imbalances• Respiratory acidosis• Respiratory alkalosis• Metabolic acidosis• Metabolic alkalosis
    24. 24. Lungs• Regulate acid-base balance by eliminating or retaining carbon dioxide• Does this by altering rate/depth of respirations• Faster rate/more depth = get rid of more CO2 and pH rises• Slower rate/less depth = retain CO2 and pH lowers
    25. 25. Kidneys• Regulate by selectively excreting or conserving bicarbonate and hydrogen ions• Slower to respond to change
    26. 26. Arterial Blood Gas• pH 7.35-7.45• PaO2 80-100 mm Hg• PaCO2 35-45 mm Hg• HCO3 22-26 mEq/L• Base Excess -2 - +2 mEq/L• SaO2 95-98%
    27. 27. Factors Affecting Body Fluid, Electrolyte, and Acid-Base Balance• Age• Gender• Body size• Environmental temperature• Lifestyle
    28. 28. Risk Factors for Fluid, Electrolyte, and Acid-Base Imbalances• Chronic diseases• Acute conditions• Medications• Treatments• Extremes of age• Inability to access food and fluids
    29. 29. Specific Illnesses• COPD, Asthma, • Malnutrition, anorexia Cystic Fibrosis nervosa, bulimia• CHF • Ileostomy• Kidney disease • Gastroenteritis• Diabetes Mellitus • Bowel obstruction• Cushing’s or • Head injury Addison’s disease • Fever, draining• Cancer wounds, fistulas • Surgery
    30. 30. Medications to Monitor• Diuretics – Water depletion – Electrolyte depletion• Corticosteroids – Water retention• NSAIDS/Opoiods – Constipation
    31. 31. Treatments that affect fluid balance• Chemotherapy• IV therapy or TPN• Nasogastric suction• Enteral Feedings• Mechanical Ventilation
    32. 32. Fluid Imbalances• Isotonic loss of water and electrolytes (fluid volume deficit)• Isotonic gain of water and electrolytes (fluid volume excess)• Hyperosmolar loss of only water (dehydration)• Hypo-osmolar gain of only water (overhydration)
    33. 33. Electrolyte Imbalances• Hyponatremia • Hypomagnesemia• Hypernatremia • Hypermagnesemia• Hypokalemia • Hypochloremia• Hyperkalemia • Hyperchloremia• Hypocalcemia • Hypophosphatemia• Hypercalcemia • Hyperphosphatemi a
    34. 34. Hypernatremia• Sodium – 145 mEq/L• Risk Factors – water deprivation, hypertonic tube feedings, with inadequate water supplements, fever, unusually high Na+ intake, profuse sweating, heatstroke, diabetes insipidus• Defining Characteristics – thirst, dry sticky mucus membranes, red, dry swollen tongue, dyspnea, fatigue, disorientation, convulsions
    35. 35. Hyponatremia• Sodium – 135 mEq/L• Risk Factors – loss of GI fluids, adrenal insufficiency, sweating, diuretics, gain of water, hypotonic tube feedings, oral ingestion of water, excess administration of Dextrose, disease states head injury, AIDS, malignant tumors• Defining Characteristics – headache, muscle twitching, seizure activity, abdominal cramps, N&V, anorexia, lethargy, confusion
    36. 36. Hyperkalemia• Potassium• 5.5 mEq/L (serum)• Risk Factors – decrease K+ excretion, renal failure, K+ conserving diuretics, hypoaldosteronism, High K+ intake during renal insufficiency, too rapid K+ infusion, too high dose of K+ PCN or KCL dose• Defining Characteristics – ECG changes, vague muscle weakness, GI hyperactivity  diarrhea, nausea, irritability, apathy, confusion, cardiac arrhythmias, arrest, absence of reflexes, flaccid muscles paralysis, numbness and paresthesias in extremities, face and tongue
    37. 37. Hypokalemia• Potassium• 3.5 mEq/L (serum)• Risk Factors – vomiting, gastric suction, diarrhea, heavy diaphoresis, use of K+ wasting drugs like lasix and thiazide diuretics, steriod adminstration, low intake of K+ from ETOHism or anorexia, hyperaldosteronism, osmotic diuresis from uncontrolled DM• Defining Characteristics – ABGs show alkalosis, ECG changes, cardiac arrhythmias, muscle weakness, paresthesias, muscle soreness, leg cramps, fatigue, lethargy, anorexia, N&V, decrease bowel sounds and motility,
    38. 38. EKG Changes with K+ Imbalance
    39. 39. Hypokalemia
    40. 40. Hypercalcemia• Calcium – 5.5 mg/dL• Risk Factors – hyperparathyroidism, prolonged immobility, megadoses of vitamin D, bone malignancy, paget’s disease, thiazide diuretics, overuse of Ca+ containing antacids and supplements• Defining Characteristics – ECG changes, lethargy, weakness, depressed deep tendon reflexes, constipation, anorexia, N&V, polyuria, polydipsia, decreased memory and attention span, confusion, renal stones, flank pain, neuroses, psychosis reversible, cardiac arrest
    41. 41. Hypocalcemia• Calcium• 4.5 mEq/L• Risk Factors – hypoparathyroidism, malabsorption, vitamin D deficiency, acute pancreatitis, thyroid CA, hypomagnesemia, alkalosis, sepsis, alcohol abuse• Defining Characteristics – numbness, tingling, hyperactive deep tendon reflexes, muscle tremors, cramps, progressing to tetany and convulsions, cardiac arrhythmias, mental changes, Chvostek’s sign, Trousseau’s sign
    42. 42. Collecting Assessment Data• Nursing history• Physical assessment• Clinical measurement• Review of laboratory test results• Evaluation of edema
    43. 43. Figure 52-11 Evaluation of edema.
    44. 44. Diagram of SerumElectrolyte Results
    45. 45. Desired Outcomes• Maintain or restore normal fluid balance• Maintain or restore normal balance of electrolytes• Maintain or restore pulmonary ventilation and oxygenation• Prevent associated risks• Tissue breakdown, decreased cardiac output, confusion, other neurologic signs
    46. 46. Nursing Interventions• Monitoring• Fluid intake and output• Cardiovascular and respiratory status• Results of laboratory tests• Assessing• Client’s weight• Location and extent of edema, if present• Skin turgor and skin status• Specific gravity of urine• Level of consciousness, and mental status
    47. 47. Nursing Interventions• Fluid intake modifications• Dietary changes• Parenteral fluid, electrolyte, and blood replacement• Other appropriate measures such as:• Administering prescribed medications and oxygen• Providing skin care and oral hygiene• Positioning the client appropriately• Scheduling rest periods
    48. 48. • Monitoring daily Intake and Output (I&O)• Monitoring daily Weight -same time (am), same clothes – 1 Kg.(2.2 lbs) is equal to 1 Liter(1000 mL) of fluid loss or gain• Orthostatic Blood Pressure monitoring – L_____ S_____ St______
    49. 49. Laboratory tests-• Electrolytes- Metabolic Panel – Serum Na – Serum K – Blood Urea Nitrogen (BUN) – Creatinine – Glucose• Urine osmolality (Sp. Gravity)• H & H or CBC
    50. 50. Implementing and Documenting I&O• Evaluating Outcomes – HCT ( hematocrit ) • Range of 40 – 54% males • Range of 38 – 47% Females • Increased values = FVD • Decreased Values = FVE – Specific Gravity – 1.010-1.-25 • High = FVD • Low = FVE
    51. 51. Promoting Fluid and Electrolyte Balance• Consume 6-8 glasses water daily• Avoid foods with excess salt, sugar, caffeine• Eat well-balanced diet• Limit alcohol intake• Increase fluid intake before, during, after strenuous exercise• Replace lost electrolytes
    52. 52. Promoting Fluid and Electrolyte Balance• Maintain normal body weight• Learn about, monitor, manage side effects of medications• Recognize risk factors• Seek professional health care for notable signs of fluid imbalances
    53. 53. Practice Guidelines Facilitating Fluid Intake• Explain reason for required intake and amount needed• Establish 24 hour plan for ingesting fluids• Set short term goals• Identify fluids client likes and use those• Help clients select foods that become liquid at room temperature• Supply cups, glasses, straws• Serve fluids at proper temperature• Encourage participation in recording intake• Be alert to cultural implications
    54. 54. Planning and Implementation of I&O• Assessing each patient’s situation – Age • Infants and Children – Greater fluid turnover – high metabolic rate – Kidneys immature – lose more water – Respirations rapid – – Body surface area larger than adult – Increases insensible losses – Fluid and electrolyte losses occur very rapidly • Elderly – Thirst response diminished – Nephrons less functional to conserve water – Increase risk of dehydration – Risks of HD, CRF, multiple medications  increases risk for fluid and electrolyte imbalance
    55. 55. Practice Guidelines Restricting Fluid Intake• Explain reason and amount of restriction• Help client establish ingestion schedule• Identify preferences and obtain• Set short term goals; place fluids in small containers• Offer ice chips and mouth care• Teach avoidance of ingesting chewy, salty, sweet foods or fluids• Encourage participation in recording intake
    56. 56. Correcting Imbalances• Oral replacement – If client is not vomiting – If client has not experienced excessive fluid loss – Has intact GI tract and gag and swallow reflexes
    57. 57. Correcting Imbalances• Restricted fluids may be necessary for fluid retention• Vary from nothing by mouth to precise amount ordered• Dietary changes
    58. 58. Oral Supplements• Potassium• Calcium• Multivitamins• Sports drink
    59. 59. Correcting Imbalances • Intravenous Fluids – Hypotonic • osmotic pressure less to that of plasma. • 0.45% Na CL or half normal saline • used for dehydration and • promotes waste elimination of kidneys
    60. 60. Intravenous Fluids• Isotonic – osmotic pressure equal to that of plasma• Example #1 - 5% dextrose in H2O (D5W) – supplies free water to aid in renal excretion of solutes – expands intracellular and extracellular volumes• Example #2 - Lactated Ringers, 0.9% NaCL or normal saline (NS) – expands vascular volume – contains multiple electrolytes in physiological concentrations – used to treat hypovolemia, burns, and diarrhea – used to treat mild metabolic acidosis
    61. 61. Intravenous Fluids• Hypertonic – osmotic pressure above that of plasma• Example #1 - 5% dextrose in 0.45% NaCl (D5 ½ NS) – treats hypovolemia – maintains hydration – draws fluid out of the intracellular and interstitial spaces into the vascular space – expands volume
    62. 62. Intravenous Fluids• Hypertonic – Example #2 - 5% dextrose 0.9% NaCl (D5NS) • replaces calories and electrolytes • temporary treatment of hypovolemia
    63. 63. Evaluation• Collect data as identified in the plan of care• If desired outcomes are not achieved, explore the reasons before modifying the care plan

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