Fluids & Electrolytes

Body FluidsFluid surrounds all cells in the body and is also inside cellsFluid, electrolyte and acid-base balances within the body maintain the health and function of all body system

Body FluidsFluid amount (volume), concentration (osmolality) and composition (electrolyte concentration) and degree of acidity (pH) effects the function of the cells

Water & Cellular FunctionMedium for metabolic reactionsTransport of nutrients, waste productsLubricationInsulationRegulation & maintenance body temperature

Fluids and Electrolytes: Body FluidsBody fluids are located in two distinct compartments: extracellular fluids (ECF) outside the cells and intracellular (ICF) inside the cells

Fluids and Electrolytes: Body FluidsIntracellular Fluids (ICF)

Extracellular fluids (ECF) INTRAVASCULAR - plasma TRANSCELLULAR cerebrospinal, synovial, biliary, lymph, pleural INTERSTITIAL beteween the cells and outside vessels.

Fluids and Electrolytes: Body Fluids In adults: ICF is approximately two thirds of total body water

ECF is approximately one thirds of total body water

Fluids and Electrolytes: Composition

Electrolytes - elements or compounds able to carry an electric charge when dissolved or melted.

These electrical charges are called ions

Fluids and Electrolytes: CompositionCationsPositively charged ions AnionsNegatively charged ions Milliequivalents Unit of measure for electrolytes

Fluids and Electrolytes: CompositionMajor cations within the body fluids include:Sodium - Na+Potassium - K+Calcium - Ca++Magnesium - Mg++

Fluids and Electrolytes: CompositionMajor anions within the body fluids include:ChlorideBicarbonatePhosphorus/Phosphate

Movement of Water and ElectrolytesFluids in different body compartments have different concentrations of electrolytes that are necessary for normal function

Cells maintain their high intracellular electrolyte concentration by active transport

Movement of Water and ElectrolytesActive transport requires energy in the form of adenosine triphosphate (ATP) to move electrolyte across the cell membrane against a concentration gradient, from an area of low concentration to an area of higher concentration

Movement of Body Fluids: Osmosis

Balance of Body Fluids: Diffusion

Movement of Body Fluids: Filtration

Movement of Body Fluids: Active Transport

Fluids and Electrolytes: Movement of Body FluidsHydrostatic pressure exerted by fluidsOsmotic pressure stop osmotic flowOncotic Pressure by colloidsOsmolarity /Osmolality measurement concentrationTonicity balanced tension/concentration

Fluids and Electrolytes: Concentration of Body Fluids TONICITYIsotonic solution 0.9% NaCl, D5W

Hypotonic solution 0.45% NaCl

Hypertonic solution 3% NaCl, D5NS

ISOTONIC SOLUTIONS

Isotonic = same osmolality as blood (0.9% NaCl / NS, D5W, LR)

Hypertonic = osmolality (less H2O) than blood, H2O from cells & interstitial spaces plasma (50% glucose, 3% NaCI)

HYPOTONIC SOLUTIONSHypotonic = osmolality (more H2O) than blood, H2O moves from plasma cells (.45% NaCl, 1/2 NS)

Regulation of Extracellular FluidDecreased ECF Osmolality (hypotonicity) cells swell (hemolysed)

Increased ECF Osmolality (hypertonicity) cells shrivel (crenated)

Lab Assessment of Fluid, Electrolyte & Acid Base BalanceSerum osmolality 280-300 mOsm/kg Serum concentration the number of dissolved particles per unit of fluid.

Decreases in hydrated conditions, increases in dehydration.

Hematocrit: Males 40-54% Females 38-47%

Percentage of RBCs to blood volume in relation to plasma. Increase with dehydration Decrease with overhydration

Regulation of Fluid BalanceKidneysEndocrine systemCardiovascular systemLungsGI system

Body HomeostasisLungs - exhalationKidneys -Regulation of ECF by retention & excretion of fluids & electrolytes (Na+ & K+)Regulation of pH of ECF by retention & excretion of H+ ions Excretion of waste

Heart & Blood vessels - pumping action

Fluid Gains:Metabolism 250-300 mL

Oral fluids 1100 1400 mL

Solid food 800 1000 mL

Fluid therapy

Fluid Losses:Kidneys 1500 mLSkin 500-600 mL: Insensible/Sensible fluid lossLungs 400 mLGI Tract 100-200 mL (3-6L re-absorbed)Additional: Wounds, external bleeding, third space loss

Disorders of Fluid Balance:Hypovolemia depletion of ECF volume, abnormally low circulating blood volume.Causes: abnormal skin, GI, renal losses, bleeding, decreased intake, movement of fluid to third spaceS&S: weakness, fatigue, syncope, confusion, oliguria, low B/P, weight loss, tachycardia, sunken eyeballs.

Disorders of Fluid Balance:Hypervolemia expansion of ECF volume, increase amount intravascular fluid.Causes: chronic stimulus kidney or abnormal kidney function to conserve Na & water, excessive IV fluids, interstitial to plasma fluid shiftS&S: Edema, weight gain, increased B/P, bounding pulses, SOB, rales, tachypnea, distended neck veins, ascites.

Fluid Volume Alterations

Fluid Volume Deficits FVD:

Fluid & Electrolytes lost in = proportion Ratio of H2O/electrolytes remains the same

Not DEHYDRATION - Causes: FistulasGI suctionThird space shiftsAnorexia, intake (nausea) Inability to obtain fluids

DehydrationExcessive, rapid loss of H2O from body tissues, disturbance in the balance of Na, K+, Cl

Causes: Prolonged fever, diarrhea, vomiting

Acid Base Balance: RegulationArterial pH an indirect measurement hydrogen ion (H+) concentration

Values: normal range 7.35-7.45 acid - below 7.35 alkalosis - above 7.45

Acid-Base Balance: Function

Why a normal pH?Maintain cell membrane integritySpeeds enzymatic reactions

Acid-Base Balance

pH is maintained by the utilization of a buffer.Buffer - a substance that can absorb or release H+ to correct an acid-base imbalance: HCO-3, Phosphate, Ammonium, Protein, CO2.

Acid Base BalanceAcid base balance is based on the Hydrogen ion (H+) concentration.

Increased H+ leads to decreased pH (acidosis)Decreased H+ leads to increased pH (alkalosis)

Buffer Systems: Renal/Respiratory Lungs eliminate or retain CO2 in direct relation to arterial pH.

Kidneys increase or decrease HCO-3 concentration in body fluids.

Acid Base Imbalances:ABGs pH 7.35-7.45 PaCO2 35-45mm PaO2 80-95 O2 saturation 95-99% Base excess +- 2 HCO3 22-26 mEq/L

Alterations: Laboratory Values - Arterial Blood GasIf pH is outside of the parameter 7.35 - 7.45, ABG is labeled uncompensated

If pH is within the parameter 7.35 - 7.45, ABG is labeled compensated

If all parameters are within their specified limits, the ABG is labeled normal.

ABG: InterpretationpH 7.24UncompensatedAcidosispH 7.47UncompensatedAlkalosispH 7.49UncompensatedAlkalosis

pH 7.51UncompensatedAlkalosispH 6.88Uncompensated AcidosispH 7.42Compensated

Acid Base Imbalance: Types1. Respiratory acidosis Increased PaCO2 Decreased pH = increased H+ Respiratory depression leads to hypoxemia (COPD).

Acid Base Imbalance: Types

2. Respiratory Alkalosis Decreased PaCO2 Increased pH = Decreased H+ Seen in anxiety with hyperventilation, Initial phase of asthma attack.

Acid Base Imbalance: Types

3. Metabolic Acidosis High acid blood content leading to loss of NaHCO3 (alkaline buffer) Seen in Diabetic ketoacidosis, diarrhea.

Acid Base Imbalance: Types4. Metabolic Alkalosis

Heavy loss of acid from body or from increased levels of bicarbonate.

Most common cause: Vomiting, NG suctioning.

ABG: InterpretationBaby AndypH 7.22PaCO2 80PaO2 76HCO3 27BE -4 SaO2 93%

Uncompensated Uncompensated AcidosisUncompensated Respiratory Acidosis

ABG: InterpretationBaby BettypH 7.49PaCO2 21PaO2 145HCO3 21BE -2SaO2 93%Uncompensated Uncompensated AlkalosisUncompensated Respiratory Alkalosis

ABG: InterpretationBaby ChuckpH 7.31PaCO2 49PaO2 90HCO3 26BE -1.4SaO2 97%Uncompensated Uncompensated AcidosisUncompensated Respiratory Acidosis

ABG: InterpretationBaby DaisypH 7.18PaCO2 36PaO2 146HCO3 8BE -17SaO2 98%Uncompensated Uncompensated AcidosisUncompensated Metabolic Acidosis

ABG: InterpretationBaby JoanpH 7.37PaCO2 36PaO2 85HCO3 17BE 3 SaO2 98%Compensated Compensated AcidosisCompensated Metabolic Acidosis

ABG: InterpretationBaby IsispH 7.36PaCO2 38PaO2 86HCO3 28BE 3.6 SaO2 96%Compensated Compensated AlkalosisCompensated Metabolic Alkalosis

Alterations: AssessmentInspection General appearance Labored respiration (Kussmaul)Chest movement symmetrical?Overall skin color, turgor, and appearance Facial expressionAbility to speak complete words or complete sentencesTracheal position

Alterations: Laboratory Values - Electrolytes Na+HyponatremiaSerum level

Alterations: Laboratory Values - Electrolytes K+HypokalemiaSerum level 5.0 mEq/LEKG changesVague muscle weakness (Usually the 1st sign)

Alterations: Laboratory Values - Electrolytes Ca+ HypocalcemiaSerum level < 8.5 mg/dlChvosteks sign & Trousseaus signConfusionAltered mood or memoryAbdominal spasmsHypercalcemiaSerum level > 10.5mg/dlMuscle weaknessTendernessAnorexiaConstipationCardiac Arrest

Alterations: Laboratory Values - Electrolytes Mg+HypomagnesemiaSerum level 3 mEq/lFlushing (Due to peripheral vasodilation)HypotensionDepressed respiration

Nursing Process AssessmentNursing HistoryRisk factors that may cause or contribute to fluid, electrolyte and acid-base imbalanceAgeEnvironmentDietary IntakeLifestyle

Nursing Process AssessmentMedicationRecent SurgeryGastrointestinal OutputAcute Illness or TraumaRespiratory disordersBurnsChronic Illness

Nursing Diagnosis: Electrolyte and Acid/Base BalanceIneffective breathing patternDecreased Cardiac OutputFluid Volume Deficit (Risk)Fluid Volume ExcessAlteration in Gas Exchange

Altered Oral Mucous MembraneImpaired Skin Integrity (Risk for)

Alteration in Perfusion (Peripheral, Cardiac, generalized)

Nursing ProcessPlanningThe patients clinical condition determines the priority nursing diagnosisGoals need to be individualized and realistic with measurable outcomesConsultations with the healthcare team helps to set realistic time frames for the goals

Nursing Process ImplementationHealth PromotionPatient and caregivers education to recognize risk factors for developing imbalances and implement appropriate preventive measuresVomiting or diarrhea in infants People with chronic diseases

Nursing Process ImplementationAcute careEnteral replacement of fluidsRestriction of fluidsParenteral Replacement of fluids and electrolytesParenteral NutritionIntravenous Therapy (Crystalloids)Vascular Access Devices

Nursing ProcessEvaluationEvaluate the effectiveness of interventions using the goals and outcomes established for the patients nursing diagnosis

Modifications maybe needed if outcomes are nor achieved

Nursing Diagnosis: Plan of Care Nursing Diagnosis - Impaired gas exchange R/T excessive pulmonary secretions AEB: Obj: positive productive cough, SaO2 < 95%, tachyapnea and cyanosis. Subj: Its hard to breathe.

Nursing Diagnosis: Plan of CareLong-Term Goal Patient will maintain SaO2 > 95% throughout hospitalization.

Short-Term Goal Patients excessive pulmonary secretions will return to baseline levels within 2 days.

Nursing Diagnosis: Plan of CareNursing InterventionsSuction q2hrs and PRNMaintain O2 per DO and monitor s/s of medications effectivenessSaO2Rate, depth and pattern of respiration Instruct patient to turn q2hrsEncourage patient to C&DB q2hrs W/AIncrease fluid intake to 1500ml po qd

Nursing Diagnosis: Plan of CareNursing EvaluationAuscultate clients lungsObserve clients coughObserve color, consistency and amount of secretionsObserve clients respirations

Nursing Diagnosis: Plan of CareExpected OutcomesPatients sputum will be clear, white within 48 hours.Patients adventitious lung sounds will disappear within 48 hours.Patients respiratory rate will be between 20 and 28 within 24 hours Client will be able to clear airway by coughing in 24 hours

Medical /Nursing ManagementDietaryLow Sodium/PotassiumImpaired Renal FunctionHTNHigh SodiumSodium DeficitHead Trauma (IVF)

Low PotassiumImpaired Renal Function Elevated Serum K+High PotassiumDeficit Serum K+DiureticsLow ProteinImpaired Hepatic Function

Medical /Nursing ManagementOxygenMedicalNon-RebreatherVentimaskNCPartial Non-RebreatherIntubationETT or NTTBag Valve MaskMedications

OxygenNursingPositioningSuctioningPatient EducationEncourage C&DBIncrease po Fluid IntakeAssess VS, Mental Status, Hydration, I&O, and laboratory values

Blood Component TherapyWhole Blood Blood ComponentPacked Red Blood CellsPlateletsPlasma

Blood Component TherapyBlood Groups and TypesA, B, O and ABRh factorPositiveNegativeAutologous TransfusionCollection and transfusion of patients own blood

Transfusing BloodTwo RNs or one RN and a LPN must check the label on the blood against the medical record and against the patients identification number, blood group and complete name before the blood is administered

Transfusing BloodAdults require a large IV catheter Blood is administered in a special blood administration tubingTubing is primed with 0.9% sodium chloride to prevent hemolysis or breakdown of the RBCs

Transfusing BloodStay with the patient during the first 15 minutes to observe for a reactionA unit of blood should be infused between 2-4 hoursVital signs are monitored at the beginning of the transfusion, 15 minute. into the transfusion, at 1 hour and at the end of the transfusion

Transfusion ReactionRange from mild to severe reaction both of which are life threateningStop the transfusionReplace the IV tubing and infuse 0.9% NSNotify the MD and follow the institution protocol for transfusion reaction

***Movement of water from lower to higher concentration*Movement of molecules from higher to lower concentration*From an area of high pressure to lesser pressure*Movement against concentration gradient requiring energyPositive Chvosteks sign contraction of facial muscles when facial nerve is tapped

Positive Trousseaus sign carpal spasm with hypoxia, numbness and tingling of fingers and circumoral (around mouth) region, hyperactive reflexes, muscle twitching and cramping, tetany, seizures, laryngospasm, cardiac dysrhythmias*