FLUID N ELECTROLYTES

8/22/2019 FLUID N ELECTROLYTES

1/46

FLUID & ELECTROLYTES

ACID BASE IMBALANCES

CHAPTER 17

Megan McClintock

Winter 2012


2/46

HOMEOSTASIS

Maintained by the intake and output of waterand electrolytes and regulation by the renal andpulmonary systems

Acid-base balance is necessary for manyphysiologic processes (respiration, metabolism,function of the CNS)

Many disease and treatmentsaffect this balance


3/46

WATER

More important to life than any other nutrient

60% of an adults body weight, more in a

child, less in the elderly

Found in foods (but not in alcohol)

Daily need is about 2000 mL

1 liter of water weighs 1 kg


4/46

URINE SPECIFIC GRAVITY

Measures the kidneys ability to concentrate

or dilute urine 1.002 1.028

High is dehydrated

Low is overhydrated (or unable to concentrate)Kidney failure often causes a fixed specific

gravity


5/46

ELECTROLYTES

Cations (positively charged)

K+, Na+, Ca+, Mg+

Transmit nerve impulses to muscles and contract

skeletal and smooth musclesAnions (negatively charged)

Attached to cations

Cl-, HCO3-, PO4-, SO4-Are always kept in

balance


6/46

DISTRIBUTION OF BODY FLUIDS &

ELECTROLYTES

Intracellular (2/3) K+, PO4-

Extracellular (1/3) Na+, Cl-

Interstitial (lymph)

Intravascular (blood plasma)

Transcellular (cerebrospinal, pleural, peritoneal,

synovial fluids)


7/46

REGULATION OF FLUID & ELECTROLYTE

MOVEMENT


8/46

OSMOLALITY

Indicates the water balance of the body

Serum osmolality (275 - 295)

High is water deficit

Low is water excess

Urine osmolality (100-1300)

High is concentrated

Low is dilute


9/46

FLUID SPACING

First spacing

Normal

Second spacing

Edema

Third spacing

Ascites

Burn edema


10/46

REGULATION OF WATER BALANCE

Hypothalmic Regulation Thirst is stimulated

ADH (vasopressin) release is stimulated

Pituitary RegulationADH (vasopressin) is released

Adrenal Cortical Regulation Glucocorticoids & mineralocorticoids are released

Renal RegulationAdjust urine volume and electrolyte excretion

Normal is 1.5 Liters of urine/day


11/46

REGULATION OF WATER BALANCE (CONT.)

Cardiac Regulation

ANP & BNP will stop the action of the adrenalcortex and the kidney

GI Regulation Intake and output are reabsorbed here

Diarrhea and vomiting can lead to significantlosses

Insensible Water Loss

600-900 mL/day from the lungs and skin

Increases with fever, exercise


12/46

GERONTOLOGIC CONSIDERATIONS

Structural changes in the kidney and decreased renalblood flow

Decreased GFR

Decreased creatinine clearance

Loss of ability to concentrate urine and thus conservewater

Decrease in renin and aldosterone

Increase in ADH and ANP

Loss of subcutaneous tissue

Decrease in thirst mechanism

Musculoskeletal changes

Mental status changes


13/46

FLUID VOLUME DEFICIT

What causes

it?

What can

you do?


14/46

FLUID VOLUME EXCESS

What causes

it?

What can

you do?


15/46

NURSING INTERVENTIONS

Strict I/O Intake oral, IV, tube feedings, retained irrigants

Output urine, excess sweating, wound/tubedrainage, vomitus, diarrhea

Urine specific gravityAssessment of CV, Resp, Neuro, Skin status

Daily weight under standardized conditions

Dont catch up IV fluids No water with NG suction, use isotonic saline

Keep fluids accessible and within reach

Give warm or cold fluids (not room temperature)


16/46

SERUM ELECTROLYTES Sodium (Na) 135 - 145

Primarily responsible for maintaining osmotic pressure(intracellular and extracellular fluids)

Increased with fluid deficitDecreased with fluid excess

Potassium (K) 3.5 5.0

Major component of cardiac function Increased with poor kidney function Decreased with excessive urination, diarrhea or vomiting

Chloride (Cl) 96 106 Works with Na to maintain osmotic pressure Increased with poor kidney function

Decreased with excessive vomiting or diarrhea Calcium (Ca) 8.6 10.2

Transmission of nerve impulses, heart and muscle contractions,blood clotting, formation of teeth and bone

Phosphate (PO4) 2.4 4.4 Function of muscle, RBCs, and the nervous system


17/46

THE MAGIC FOURS

Electrolyte Range Magic 4

Potassium 3.5 - 5.0 4

Chloride 96 - 106 104Sodium 135 - 145 140

pH 7.35 - 7.45 7.4

CO2 35 - 45 40HCO3 22 - 26

24


18/46

SODIUM (135 - 145)

Major cation of ECF

Primary determinant of osmolality

GI tract absorbs sodium from foodRegulated by kidneys, ADH, aldosterone

Sodium level reflects the ratio of sodium to

water Imbalances are typically associated with fluid

volume problems


19/46

HYPERNATREMIA (HIGH SODIUM)

What can you

do?

What causes

it?


20/46

HYPONATREMIA (LOW SODIUM)

What causes

it?

What can

you do?


21/46

POTASSIUM (3.5 - 5.0)

Major cation of ICF

Sodium-potassium pump requires

magnesium

Moves into cells during formation of new

tissues and leaves the cell during tissue

breakdown

Diet is the source of potassium

Kidneys are primary route of loss


22/46

HYPERKALEMIA (HIGH POTASSIUM)

What can

you do?

What causes

it?


23/46

HYPOKALEMIA (LOW POTASSIUM)

What causes

it?

What can

you do?


24/46

CALCIUM (8.6 10.2)

Primary source is bones

Regulated by parathyroid hormone,

calcitonin, and vitamin D

Affects transmission of nerve impulses, heart

and muscle contractions, blood clotting, and

forming of teeth and bone


25/46

HYPERCALCEMIA (HIGH CALCIUM)

What can

you do?

What causes

it?What are the

symptoms?


26/46

HYP0CALCEMIA (LOW CALCIUM)


27/46

PHOSPHATE IMBALANCES

Hyperphosphatemia Cause - renal failure

S/S calcium deposits in joints, skin, kidneys, eyes;hypocalcemia, tetany, neuromuscular irritability

Tx decrease intake of dairy products, good hydration,fix hypocalcemia

Hypophosphatemia Cause malnutrition, malabsorption syndrome, alcohol

withdrawal

S/S CNS depression, confusion, muscle weakness,dysrhythmias

Tx oral supplements (Neutra-Phos), lots of dairyproducts, IV phosphate (but this can cause suddenhypocalcemia)


28/46

MAGNESIUM IMBALANCES

Hypermagnesemia Cause increased intake (ie. MOM, Maalox) with chronic

kidney disease

S/S lethargy, n/v, loss of DTRs, can have respiratory andcardiac arrest

Tx avoid magnesium-containing drugs, IV calcium,increased fluid intake, may need dialysis

Hypomagnesemia Cause prolonged fasting or starvation, chronic alcoholism,

diuretics

S/S confusion, hyperactive DTRs, tremors, seizures, cardiacdysrhythmias

Tx oral supplements, increase green veggies, nuts,bananas, oranges, peanut butter, chocolate; IV or IMmagnesium (if given too rapidly can cause cardiac orrespiratory arrest)


29/46

MEDICATIONS

Loop diuretics

Thiazide diuretics

Potassium sparing diuretics

Electrolytes

Kayexolate


30/46

ACID BASE BALANCE


31/46

REGULATION OF ACID-BASE BALANCE

Buffer system (immediate)

Primary regulator

Wont work without good functioning respiratory

and renal symptoms

Respiratory system (minutes, max in hours)

Excretes CO2 and water

Renal system (2-3 days to max respond)

Reabsorbs HCO3


32/46

ARTERIAL BLOOD GAS

pH (7.35 7.45)

CO2 (35 45)

HCO3 (22 26)

Base excess (+2 to -2) If high, metabolic alkalosis

If low, metabolic acidosis


33/46

DETERMINING

ACIDBASE BALANCE

1. Is pH acid, base or normal?

2. Is CO2 acid, base or normal?

3. Is HCO3 acid, base or normal?4. Which of the components match?

5. Is there compensation?Is non-matching reading abnormal? partial compensation

Is non-matching reading normal? no compensation


34/46


35/46


36/46

RESPIRATORY ALKALOSIS


37/46

RESPIRATORY ALKALOSIS

Causes Hyperventilation

Pulmonary disease

High altitudes

Signs/symptoms Hyperventilation

Feels light-headed

Arrhythmias

Anxiety

Treatment Breathe into paper bag

Rebreather mask

Anti-anxiety medicine

Relaxation techniques Reduce stimulation

Treat pain/fever

Assess:

Resp rate/depth HR & BP

Serum K levels

Hydration status

Check for digitalis toxicity


38/46

RESPIRATORY ACIDOSIS


39/46

RESPIRATORY ACIDOSIS

Causes CNS depression

Loss of lung surface

Neuromuscular disease

Immobility

Mechanical ventilation Signs/symptoms

Dyspnea

Hypoxia

Drowsiness

Tachycardia Seizures

Diaphoresis

Treatment Turn, cough, deep breathe

Semi-Fowlers position

Suction

Incentive spirometer

Seizure precautions Decrease use of sedatives

Bronchodilators

May need ventilator

Assess:

Resp rate/depth HR & BP

Patiency of airway


40/46

METABOLIC ALKALOSIS


41/46

METABOLIC ALKALOSIS

Causes NG suctioning

Prolonged vomiting

Diuretic use

Multiple bloodtransfusions

CPR (given bicarb)

Signs/symptoms Dizziness

Dysrhythmias Convulsions

Confusion

Muscle cramps (late sign)

Treatment Identify and treat the

cause!

IV fluids

Stop giving bicarbonate

Give antiemetics

Give Diamox

Assess: Resp rate/depth

HR & BP

Serum K levels (usuallylow)

Hydration status (tend to bedehydrated)

Check for digitalis toxicity

Parasthesias


42/46

METABOLIC ACIDOSIS


43/46

METABOLIC ACIDOSIS

Causes Diabetic ketoacidosis

Renal or liver failure

Severe diarrhea

Vomiting Starvation

Signs/symptoms Kussmaul respirations

Hypotension

Arrythmias Warm to hot ,flushed skin

Confusion

Treatment Identify and treat the

cause!

Administer insulin (if due toketoacidosis)

Give antiemetics IV fluids

IV bicarbonate

Assess: Renal function (BUN,

creatinine) Serum K levels (tends to go

up but down once insulingiven)

Hydration status


44/46

IV FLUIDS

Isotonic NS

D5W

LR Hypertonic

3% NS

D51/2NS

D10W Hypotonic

1/2NS

Plasma Expanders


45/46

CENTRAL VENOUS ACCESS DEVICES

Centrallyinsertedcatheters(CVCs)

Peripherallyinserted centralcatheters

(PICCs)

Implanted

infusion ports


46/46

NURSING CARE OF CVADS

Inspect site for redness, edema, warmth, drainage,pain

Dressing change/cleaning with sterile technique usingchlorhexidine (back and forth scrub to generate

friction) Maintain transparent dressing c/d/I

Change injection caps using sterile technique

Teach pt to turn head away from insertion site duringcleaning and cap change

Have patient Valsalva during cap change if unable toclamp

Use push-pause method to flush (creates turbulence)

Removal of non-tunneled CVCs and PICCs may be

Documents

FLUID N ELECTROLYTES