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FLUID AND ELECTROLYTE BALANCES KRISHA LOREN F. FERRER ICU-CCU STAFF NURSE

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Page 1: Fluid and Elctrolyte Balance.... Power Point

FLUID AND ELECTROLYTE BALANCES

KRISHA LOREN F. FERRER ICU-CCU STAFF NURSE

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WHY IS IT IMPORTANT FOR NURSES TO KNOW ABOUT FLUID & ELECTROLYTE

BALANCE

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INTRODUCTION

Water is found everywhere on earth including human body

In an adult 60% of the weight is water

Two third of the body’s water is found in the cell

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FLUID CONTENT OF THE BODY

Varies with age, sex, adipose tissue- Females 45-50% TBW- Males 50-60% TBW- Infants 77% TBW- In old age , only about 45% of body weight

is water.

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DISTRIBUTION OF BODY FLUIDS

Body fluids are distributed in two distinct compartments:

1.Extracellular fluids[ECF] Which includes interstitial fliud & intravascular fluid

2.Intracellular fluids[ICF]

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SOLUTES

Non-electrolytes

-dextrose

- urea

- creatinine

Electrolytes

-Anions - negatively charged ions (Chloride, HCO3)

-Cations – positively charged ions (Sodium, potassium, calcium)

*Electrolytes have greater osmotic pressure than non-electrolytes.

*Water moves according to osmotic gradient.

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COMPOSITION OF BODY FLUIDS

The fluids circulating throughout the body in extracellular and intracellular fluid spaces contain

1.Electrolytes

2.Minerals

3.Cells

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MOVEMENT OF BODY FLUIDS

Diffusion

Osmosis

Filtration

Active transport

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REGULATION OF BODY FLUIDS

Fluid intake

Fluid output

Hormonal influence

Lymphatic influences

Neurologic influences

Renal influences

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FLIUD IMBALANCES

The five types of fluid imbalances that may occur are:

Extracellular fluid imbalances(EVFVD)

Extracellular fluid volume excess(ECFVE)

Extracellular fluid volume shift

Intracellular fluid vloume excess(ICFVE)

Intrcellular fluid volume deficit(ICFVD)

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EXTRACELULLAR FLUID VOLUME DEFICIT

An ECFVD, commonly called as dehydration , is a decrease in intravascular and interstitial fluids

An ECFVD can result in cellular fluid loss if it is sudden or severe

* The goal of treatment is to restore fluid volume, replace electrolytes as needed, and eliminate the cause of fluid volume deficit.

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THREE TYPES OF ECFVD

Hyperosmolar fluid volume deficit- water loss is greater than the electrolyte loss

- the clinical problems that occur result from alterations in the concentrations of specific plasma electrolytes.

- fluid moves the intracellular compartment into the plasma and interstitial fluid spaces, causing cellular dehydration and shrinkage.

Isosmolar fluid volume deficit (hypovolemia) – equal proportion of fluid and electrolyte loss .

- most common type of dehydration.

- results in decreased circulating blood volume and inadequate tissue perfusion.

Hypotonic fluid volume deficit – electrolyte loss is greater than fluid loss.

- fluid moves from the plasma and interstitial fluid spaces into the cells, causing a plasma volume deficit and causing cells to swell.

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CAUSES OF FLUID VOLUME DEFICIT

1. ISOTONIC DEHYDRATION

a. Inadequate intake of fluids and solutes.

b. Fluid shifts between compartments

c. Excessive losses of isotonic body fluids

2. Hypertonic dehydration – conditions that increase fluid loss, such as excessive perspiration, hyperventilation, ketoacidosis, prolonged fevers, diarrhea, early stage renal failure and diabetes insipidus.

3. Hypotonic dehydration

a. Chronic illness

b. Excessive fluid replacement (hypotonic)

c. Renal failure

d. Chronic malnutrition

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INTERVENTIONS

1. Monitor cardiovascular, respiratory, neuromuscular, renal, integumentary, and gastrointestinal status.

2. Prevent further fluid losses and increase fluid compartment volumes to normal ranges.

3. Provide oral rehydration therapy if possible and intravenous (IV) fluid replacement if the dehydration is severe; monitor intake and output.

4. Generally, isotonic dehydration is treated with isotonic fluid solutions, hypertonic dehydration with hypotonic fluid solutions, and hypotonic dehydration with hypertonic fluid solutions.

5. Administer medications as prescribed such as antidiarrheal, antimicrobial, antiemetic, and antipyretic medications, to correct the cause and treat the symptoms.

6. Administer oxygen as prescribed.

7. Monitor electrolyte values and prepare to administer medication to treat an imbalance, if present.

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EXTRACELLULAR FLUID VOLUME EXCESS

ECFVE is increased fluid retention in the intravasular and interstitial spaces

Flid intake or fluid retention exceeds the fluid needs of the body.

Fluid volume excess is also called OVERHYDRATION or Fluid overload.

The goal of treatment is to restore fluid balance, correct electrolyte imbalances if present, and eliminate or control the underlying cause of the overload.

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TYPES:

1. Isotonic Overhydration

a. known as hypervolemia, isotonic overhydrationresults from excessive fluid in the ECF compartment.

b. Only the ECF compartment is expanded, and fluid does not shift between the extracellular and intracellular compartment.

c. Isotonic dehydration causes circulatory overload and interstitial edema; when severe or when it occurs in a client with poor caediac function, CHF and pulmonary edema can result.

2. Hypertonic overhydration

a. Occurence of hypertonic overhydration is rare and is caused by an excessive sodioum intake

b. Fluid is drawn from the intracellular fluid compartment; the extracellular fluid volume expands; and the intracellular fluid volume.

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3. Hypotonic overhydration

a. Hypotonic overhydration is

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ETIOLOGY AND RISK FACTORS

Heart failureRenal disordersCirrhosis of liverIncreased ingestion of high sodium foodsExcessive amount of IV fluids containing sodiumElectrolyte free IV fluidsSIADH,Sepsisdecreased colloid osmotic pressurelymphatic and venous obstruction Cushing’s syndrome & glucocorticoids

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CLINICAL MANIFESTATION

Constant irritating coughDyspnea & crackles in lungsCyanosis, pleural fffusionNeck vein obstructionBounding pulse &elevated BPS3 gallopPitting & sacral edemaWeight gainIncreased CVP& PCWPChange in level of consiousness

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LAB INVESTIGATION

serum osmolality <275mOsm/ kg

Low , normal or high sodium

Decreased hematocrit [ < 45%]

Specific gravity below 1.010

Decreased BUN [< 8mg/ dl]

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MANAGEMENT

Diuretics [combination of potassium sparing and potassium depleting diuretics]

In people with CHF, ACE inhibitors and low dose of beta blockers are used

A low sodium diet

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EXTRACELLULAR FLUID VOLUME SHIFT: THIRD SPACING

Fluid that shifts into the interstitial spaces and remain there is called as third space fluid

Common sites are abdomen , pleural cavity, peritoneal cavity and pericardial sac

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RISK FACTORS

Crushing injuries, major tissue traumaMajor surgeryExtensive burnsAcid –base imbalances and sepsisPerforated peptic ulcersIntestinal obstructionLymphatic obstruction Autoimmune disordersHypoalbunemiaGI tract malabsorption

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CLINICAL MANIFESTATION

skin pallorCold extremitiesWeak and rapid pulseHypotension Oliguria

Decreased levels of consiousness LAB INVESTIGATION

Elevated hematocrit & BUN level

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MANAGEMENT

Treat the cause

1. For burns and tissue injuries large volume of isosmolar IV fluid is administered

2. Albumin is administered for protein deficit

3. IV fluid intake is maintained after major surgery to maintain kidney perfusion

4. Pericardiocentesis if pericarditis is the result

5. Paracentesis for ascitis

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INTRACELLULAR FLUID VOULME EXCESS:WATER INTOXICATION

ICFVE is increase in amount of water inside the cells

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ETIOLOGY

Administration of excessive amount of hyposmolar IV fluids[0.45%saline or 5%dextrose in water]Consumption of excessive amount of tap water without adequate nutritional intakeSIADH Schizophrenia[compulsive water consumption]

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CLINICAL MANIFESTATIONS

HeadachesBehavioral changes ApprehensionIrritability, disorientation and confusionIncreased ICP – pupillary changes and decreased motor and sensory functionBradycardia, elevated BP, widened pulse pressure & altered respiratory patterns, Babinski’s response flaccidity, projectile vomiting, Papilledema, delirium, convulsions &coma

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LABORATORY FINDINGS

High serum sodium level- 125 mEq/L

decreased hamatocrit

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MANAGEMENT

Early administration of IV fluids containing sodium chloride cam prevent SIADHoral fluids such as juices or soft drinks can be given orally every hourPerform neurologic checks every hour to see if cranial changes are presentMonitor fluid intake , IV fluids and fluid output hourly and weight dailyAdminister antiemetics for food and fluid retention

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INTRACELLULAR FLUID VOLUME DEFICIT

Severe hypernatremia and dehydration can cause ICFVDRelatively rare in healthy adults common in elderly people and in those conditions that result in acute water lossSymptoms include confusion, coma, and cerebral hemorrhage

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Sodium imbalances

Definition

Risk factors/ etiology Clinical manifestation

Laboratory findings

management

 Hyponatr-aemia

  It is defined as a plasma sodium level below 135 mEq/ L

Kidney diseases

Adrenal insufficiency

Gastrointestinal losses

Use of diuretics (especially with along with low sodium diet)

Metabolic acidosis

•Weak rapid pulse•Hypotension•Dizziness•Apprehension and anxiety •Abdominal cramps •Nausea and vomiting•Diarrhea•Coma and convulsion•Cold clammy skin•Finger print impression on the sternum after palpation •Personality change

•Serum sodium less than 135mEq/ L

• serum osmolality less than 280mOsm/kg

•urine specific gravity less than 1.010

•Identify the cause and treat

*Administration of sodium orally, by NG tube or parenterally

*For patients who are able to eat & drink, sodium is easily accomplished through normal diet

*For those unable to eat,Ringer’s lactate solution or isotonic saline [0.9%Nacl]is given

*For very low sodium 0.3%Nacl may be indicated *water restriction in case of hypervolaemia

 

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Sodium imbalan-ce

Definition

causes Clinical

manifestation

  Lab findings

 management

Hypernat-remia

It is defined as plasma sodium level greater than 145mEq/L

*Ingestion of large amount of concentrated salts*Iatrogenic administration of hypertonic saline IV *Excess alderosterone secretion

        Low grade fever        Postural hypertension        Dry tongue & mucous membrane        Agitation        Convulsions        Restlessness        Excitability        Oliguria or anuria        Thirst         Dry &flushed skin

*high serum sodium 135mEq/L  *high serum osmolality295mO sm/kg *high urine specificity 1.030

*Administration of hypotonic sodium solution [0.3 or 0.45%] *Rapid lowering of sodium can cause cerebral edema  *Slow administration of IV fluids with the goal of reducing sodium not more than 2 mEq/L for the first 48 hrs decreases this risk *Diuretics are given in case of sodium excess *In case of Diabetes insipidus desmopressin acetate nasal spray is used *Dietary restriction of sodium in high risk clients

 

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Potassium imbalances

Definition

Causes Clinical manifestation

Lab findings Management

Hypokalemia                 

It is defined as plasma potassium level of less than 3.0 mEq/L

*Use of potassium wasting diuretic

*diarrhea, vomiting or other GI losses

*Alkalosis

*Cushing’s syndrome

*Polyuria

*Extreme sweating

*excessive use of potassium free Ivs

*weak irregular pulse

*shallow respiration

*hypotesion

*weakness, decreased bowel sounds,

heart blocks , paresthesia, fatigue,

decreased muscle tone

intestinal obstruction

* K – less than 3mEq/L results in ST depression , flat T wave, taller U wave

* K – less than 2mEq/L cause widened QRS, depressed ST, inverted T wave

Mild hypokalemia[3.3to 3.5] can be managed by oral potassium replacement

Moderate hypokalemia*K-3.0to 3.4mEq/L need 100to 200mEq/L of IV potassium for the level to rise to 1mEq/

Severe hypokalemia K- less than 3.0mEq/L need 200to 400 mEq/L for the level to rise to l mEq/L *Dietary replacement of potassium helps in correcting the problem[1875 to 5625 mg/day]

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  Definition Causes Clinicalmanifestation

Lab findings Management

 Hyperkalemia

It is defined as the elevation of potassium level above 5.0mEq/L

Renal failure ,  Hypertonic dehydration,  Burns& trauma Large amount of IV administration of potassium, Adrenal insufficiency Use of potassium retaining diuretics & rapid infusion of stored blood

Irregular slow pulse,  hypotension,  anxiety,  irritability,  paresthesia,  weakness

*High serum potassium 5.3mEq/L results in peaked T wave HR 60 to 110 *serum potassium of 7mEq/L results in low broad P- wave *serum potassium levels of 8mEq/L results in no arterial activity[no p-wave]

*Dietary restriction of potassium for potassium less than 5.5 mEq/L  *Mild hyperkalemia can be corrected by improving output by forcing fluids, giving IV saline or potassium wasting diuretics *Severe hyperkalemia is managed by 1.infusion of calcium gluconate to decrease the antagonistic effect of potassium excess on myocardium2.infusion of insulin and glucose or sodium bicarbonate to promote potassium uptake3.sodium polystyrene sulfonate [Kayexalate] given orally or rectally as retention enema

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Calcium imbalances

Definition

Causes Clinical manifestation

Lab findings

Management

hypocalcemia

It is a plasma calcium level below 8.5 mg/dl

•Rapid administration of blood containing citrate,

•hypoalbuminemia,

•Hypothyroidism ,  •Vitamin deficiency,

•neoplastic diseases,

•pancreatitis

•Numbness and tingling sensation of fingers,

•hyperactive reflexes,• Positve Trousseau’s sign, positive chvostek’s sign ,

•muscle cramps,

•pathological fractures,

•prolonged bleeding time

Serum calcium less than 4.3 mEq/L and ECG changes

1.Asymtomatic hypocalcemia is treated with oral calcium chloride, calcium gluconate or calcium lactate 2.Tetany from acute hypocalcemia needs IV calcium chloride or calcium gluconate to avoid hypotension bradycardia and other dysrythmias 3.Chronic or mild hypocalcemia can be treated by consumption of food high in calcium

 

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Calcium imbalance

Definition Causes Clinical manifestation

Lab findings Management

  Hypercalcemia

It is calcium plasma level over 5.5 mEq/l or 11mg/dl

•Hyperthyro•idism, •Metastatic bone tumors,  •paget’s disease,

•osteoporosis ,

•prolonged immobalisation

•Decreased muscle tone,

•anorexia,  •nausea, vomiting,

•weakness , lethargy,  •low back pain from kidney stones,

•decreased level of consciousness & cardiac arrest

•High serum calcium level 5.5mEq/L,

• x- ray showing generalized osteoporosis,

•widened bone cavitation,

•urinary stones,

•elevated BUN 25mg/100ml,

•elevated creatinine1.5mg/100ml

1.IV normal saline, given rapidly with Lasix promotes urinary excretion of calcium  2.Plicamycin an antitumor antibiotics decrease the plasma calcium level 3.Calcitonin decreases serum calcium level 4.Corticosteroid drugs compete with vitamin D and decreases intestinal absorption of calcium 5. If cause is excessive use of calcium or vitamin D supplements reduce or avoid the same 

 

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Acid-Base imbalance

Definition Causes Clinical manifestation

Lab findings Management

Respiratory acidosis Hypoventilation& excessiveCO2 production       

It is a clinical disorder in which the pH is less than 7.35 and the paCO2 is greater than 42mmHg

COPD, neuromuscular disorder, Guillian-Barre syndrome, Myssthenia gravis, Respiratory center depression, Drugs, late ARDS,

Dyspnea , disorientation, coma

PH lesser than 7.35,Paco2 greater than 45mmHg, Hyperkalemia, Hypoxemia

1.Treat underlying cause 2.Support ventilation 3.Correct electrolyte imbalance 4.Intravenous NaHCO3

Respiratory Alkalosis Hyperventilation

It is a clinical condition in which the arterial Ph is greater than7.45 and the paCO2 is less than 38mmHg

Hypoxemia, impaired lung expansion, thickened alveolar – capillary membrane, Chemical stimulation of respiratory center, traumatic stimulation of respiratory center

Tachypnea, giddiness, dizziness, syncope, convulsions, coma, weakness, paresthesia, tetany

PH greater than 7.35PaCO2 lesser than 35 mmHg, Hypokalemia,Hypocalcemia

Increase CO2 retention through CO2 rebreathing & sedation and mechanical hypoventilation

 

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  Definition causes Clinical manifestation

Lab findings Management

Metabolic Acidosis      

It is a clinical condition in which the HCO3 & pH is decreased 

Renal failure, Diabetic ketoacidosis, Lactic acidosis, ingested toxins, renal tubular acidosis

Hyperventilation confusion, drowsiness, coma, headache

PH< 7.35,HCO3< 22mEq/L

1.Treat the underlying cause

2.Intravenous NaHCO3

3.correct electrolyte imbalance

Metabolic Alkalosis

It is a clinical condition in which PH is raised

Hypokalemia, gatric fluid loss, massive correction of whole blood, Overcorrection of acidosis with NaCO3

HypoventilationDysrythmias

PH >7.45HypokalemiaHypocalcemiaPaCO2 normal or increased

1.Treat the underlying cause

2.Administer KCL

3.intravenous acidifying salts[NH4CL]

4.Administer acetazolamide

 

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CONCLUSION