Project: Ghana Emergency Medicine Collaborative

Document Title: Assessing Fluid and Volume Status

Author(s): Michelle Munro (University of Michigan), MS 2012

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Assessing Fluid & Volume Status

Ghana Emergency Nurses Collaborative

Michelle Munro, MS, CNM, FNP-BC

February 13, 2013

3

Introductions

Name Role at KATH Favorite thing to do in Kumasi Questions you want answered over the next

two weeks?

4

Critical Outcomes

Assesses, identifies and manages patients with fluid and electrolyte abnormalities.

5

Specific Outcomes

Discuss the basic management principles of fluid and electrolyte abnormalities.

Apply the medico-legal aspects pertaining to fluid and electrolyte abnormalities with regard to the emergency nurse.

Apply the above-mentioned knowledge when analyzing a case scenario (paper based and real life scenarios).

List the drugs used in your unit to manage fluid and electrolyte abnormalities.

Delineate the nursing process in the management of a patient with fluid and electrolyte abnormalities.

6

What are some fluids in the body?

Blood Lymph Cerebrospinal Fluid Amniotic Fluid Aqueous Humor Fluid Saliva Gastric Acid Pericardial Fluid Peritoneal Fluid Semen

Mucous Breast milk Pleural Fluid Sweat Synovial Fluid Urine Tears Sebum (skin oil) Vomit Vaginal Secretions

7

The Role of Fluids

Function to transport nutrients and wastes to and from cells

Maintain body temperature

Facilitate digestion & elimination

Lubricate joints & other body tissues 8

A body in balance

Fluid is in a state of balance when:

Its water & electrolyte components are present in the proper proportions

Fluids are distributed normally between compartments

Lost body water and electrolytes are replaced

Excess water and electrolytes are eliminated9

Fluid Compartments

Intracellular Fluid in the cells

Provides the cells with the internal aqueous medium necessary for their chemical functions

Extracellular Intravascular – refers to the space within the arteries, veins, &

capillaries Interstitial – between the cells and vascular compartments

Found outside the body cells and serve as the body’s transport system

Carry water, electrolytes, nutrients, and oxygen to the cells and remove waste of cellular metabolism 10

Underlying Concepts

11

Video

Fluid & Electrolyte Imbalance: An Overview (30 minutes)

12

What else do we need to consider with fluid balance?

Electrolytes A electrolyte is any compound that, when dissolved in water,

separates into electrically charged particles, which are call ions. Cations – positively charged ions

Potassium (K+) Sodium (Na+) Hydrogen (H+) Calcium (Ca2+) Magnesium (Mg2+)

Anions – negatively charged ions Chloride (Cl-) Phosphate (HPO4

-)

Non-electrolytes A substance that does not ionize and do not carry an electrical

charge Glucose 13

Review of electrolytes: Sodium (Na+)

Normal plasma levels: 135-145 mEq/L

Functions Maintains blood volume Controls water shifting between compartments Major cation involved in sodium-potassium pump necessary for

nerve impulses Interacts with calcium to maintain muscle contraction Major cation in bicarbonate & phosphate acid-base buffer system

Regulation Renin-angiotensin-aldosterone system 14

Review of electrolytes: Potassium (K+)

Normal plasma levels: 3.5-5.0 mEq/L

Functions Affects osmolality Major cation involved in sodium-potassium pump necessary for

transmission of nerve impulses Promotes nerve impulses, especially in heart & skeletal muscles Assists in conversion of carbohydrates to energy & amino acids

into proteins Promotes glycogen storage in liver Assists maintenance of acid-base balance through cellular

exchange with hydrogen

Regulation Renin-aniotensin-aldosterone system 15

Video

Hyperkalemia & Hypokalemia Video (9 minutes & 45 seconds) – skip between 5

minutes & 30 seconds to 8 minutes

16

Review of electrolytes: Calcium (Ca2+)

Normal plasma levels: 4.5-5.5 mEq/L

Functions Nonionized form promotes strong bones & teeth Promotes blood coagulation Promotes nerve impulse conduction, decreases neuromuscular irritability Strengthens & thickens cell membrane Assists in absorption & utilization of vitamin B12 Activates enzymes for many chemical reactions Inhibits cell membrane permeability to sodium Activates actin-myosin muscle contraction

Regulation Parathormone

Increases calcium resorption from bone Increases calcium reabsorption form kidney tubules Increases calcium absorption from gastrointestinal tract 17

Review of electrolytes: Magnesium (Mg2+)

Normal plasma levels: 1.5-2.5 mEq/L

Functions Promotes metabolism of carbohydrates, fats, & proteins Activates many enzymes (B12 metabolism) Promotes regulation of Ca, PO4, K Promotes transmission of nerve impulses, muscle contraction, & heart

function Powers sodium-potassium pump Promotes conversion of adenosine triphosphate (ATP) to adenosine

diphosphate (ADP) for energy release Inhibits smooth muscle contraction

Regulation Parathormone

Increases or decreases magnesium reabsorption in kidney tubules relative to body need

18

Review of electrolytes: Chloride (Cl-)

Normal plasma levels: 98-106 mEq/L

Functions Regulates extracellular volume Promotes acid-base balance through exchange with

bicarbonate in red blood cells (chloride shift) Promotes protein digestion through hydrochloric (HCl)

acid; acid pH required for activation of protease

19

Review of electrolytes: Phosphate (HPO4-)

Normal plasma levels: 1.2-3.0 mEq/L

Functions Nonionized form promotes bone & teeth rigidity Promotes acid-base balance through phosphate buffer system Necessary for ATP production

Regulation Parathormone

Increases phosphate resorption from bone Inhibits phosphate reabsorption in kidney tubules Increases phosphate absorption in gastrointestinal tract as needed20

Movement of Fluids & Electrolytes

Homeostasis – maintaining equilibrium Fluid constantly shifts between compartments,

exchanging nutrients and waste products

Factors that regular the shifting of fluids: Osmosis Diffusion Active Transport Filtration

21

Osmosis

The movement of water through a semipermeable membrane from an area containing a lesser concentration of particles to an area of greater concentration of particles.

22

Concentrated sugar solution (Water less concentrated)

Movement of water

Dilute sugar solution (water more concentrated)

sugar

Hans Hillewaert, Wikimedia Commons

Osmolality

Osmolality refers to the number of milliosmoles per kilogram of water

Whenever there is a difference in osmolality between the cell and the plasma, fluid shifting is likely to occur

23

Diffusion

Refers to the passive process by which molecules move through a cell membrane from an area of higher concentration to an area of lower concentration without an expenditure of energy.

For example: electrolytes move passively from an area of higher concentration to an area of lower concentration, such as from the small bowel at the end of digestion into the blood stream

24

Active Transport

When an electrolyte moves against a concentration gradient, from an area of lower concentration to an area of higher concentration

Energy is required

For example: The sodium-potassium pump transports sodium from inside the cell to the outside of the cell

25

Filtration

Filtration pressure – the sum of (1) the forces tending to move water and dissolved substances out of the blood vessels and (2) the opposing forces

Hydrostatic pressure – the pressure exerted by the weight of fluid within a compartment Pushes fluid out of the arterial end of the capillary into the interstitial

compartments for cellular nourishment

Colloid osmotic pressure – the osmotic pressure exerted by large molecules, such as proteins Tends to hold fluid in a compartment

Filtration – the process by which water and certain smaller particles pass through a semipermeable membrane, assisted by hydrostatic and filtration pressures 26

Filtration

27

blood flow

filtration pressure

interstitial hydrostatic pressurecapillary colloidal osmotic pressure

Trisha Paul, University of Michigan

Regulation of Fluid Balance

Thirst

Lymphatic System

Neuroendocrine System Hormones Baroreceptors

Gastrointestinal System

Renal System28

Thirst

The stimulation or inhibition of the thirst response depends on changes in local plasma osmolality

Inhibit thirst by decreased osmolality: High intake of fluids Fluid retention Low sodium intake Excessive IV infusion of hypotonic solutions

Stimulate thirst by increased osmolality: Decrease in fluid intake Excessive fluid loss Excessive sodium intake (either orally or intravenously)

29

Lymphatic System

Sponges up excess fluid that is not reabsorbed into the capillaries

When the lymphatic system is not functioning properly, fluid excess occurs in the interstitial compartments

30

Neuroendocrine System

Regulates body fluid volume by producing and secreting hormones that stimulate or inhibit osmotic receptors in the carotid arteries and aortic arch

Hormones: Antidiuretic hormone (ADH) – opposes fluid loss Aldosterone – promotes the reabsorption of sodium and the

excretion of potassium resulting in the passive reabsorption of water Thyroid hormones (T4 & T3) – influence cardiac output

Baroreceptors: Specialized nerve endings in the walls of large veins and arteries and

in the atria of the heart that respond to the slightest changes in pressure inside the blood vessels

31

Gastrointestinal System

Absorbs fluid from dietary intake

Produces about 7 to 9 liters of glandular and tissue secretions per day

Gastrointestinal fluid contains many nutrients, including electrolytes

For example: Excessive diarrhea and vomiting can result in dehydration & hypokalemia

32

Renal System

Renal system works interdependently with the neuroendocrine system to regulate the volume to extracellular fluid

The kidneys are targeted by: The renin–angiotensin system (RAS) or

the renin–angiotensin–aldosterone system (RAAS), which is a hormone system that regulates blood pressure and water (fluid) balance.

33

1. When blood volume is low, juxtaglomerular cells in the kidneys secrete renin directly into circulation.

2. Plasma renin then carries out the conversion of angiotensinogen released by the liver to angiotensin I.

3. c I is subsequently converted to angiotensin II by the enzyme angiotensin converting enzyme found in the lungs.

4. Angiotensin II is a potent vaso-active peptide that causes blood vessels to constrict, resulting in increased blood pressure.

5. Angiotensin II also stimulates the secretion of the hormone aldosterone from the adrenal cortex.

6. Aldosterone causes the tubules of the kidneys to increase the reabsorption of sodium and water into the blood. This increases the volume of fluid in the body, which also increases blood pressure.

34

Review: Regulation of fluid balance How does thirst regulate fluid balance? What does thirst mean?

Thirst center is located in hypothalmus & is stimulated by changes in plasma osmolality

Being thirsty can mean dehydration or fluid volume deficit

How does the lymphatic system regulate fluid balance? Soaks up excess fluid that is not reabsorbed into the capillaries

How does the neuroendocrine system regulate fluid balance? Produces & secretes hormones that stimulate or inhibit osmotic receptors in the

carotid arteries & aortic arch Hormones: antidiuretic hormone (ADH), aldosterone, thyroid hormones (T3 & T4) Baroreceptors: respond to changes in pressure

How does the gastrointestinal system regulate fluid balance? What could happen from excessive vomiting or diarrhea? Absorbs fluid from dietary intake & produces secretions that are reabsorbed Diarrhea and vomiting could lead to dehydration (fluid volume deficit) and an

electrolyte imbalance (hypokalemia)

Renal System Regulates the volume of extracellular fluid

35

Review Question

The majority of the body’s water is contained in which of the following fluid compartments? 

a. interstitial b. intracellular c. extracellular d. intravascular

36

Review Answer

Intracellular About 2/3 of the body’s water (70%) exists in the

intracellular spaces

37

Review Question

One of the most common electrolyte imbalances is:

38

Review Answer

Hypokalemia

39

Review Question

If the blood plasma has a higher osmolality than the fluid within a red blood cell, the mechanism involved in equalizing the fluid concentration is:

a. Osmosis

b. Diffusion

c. Active transport

d. Facilitated diffusion

40

Review Answer

Osmosis

41

Video

Fluid & Electrolyte Imbalance: Cause and Assessment (30 minutes)

42

General Strategy: Assessment

Assessment General assessment of fluid balance Health history Physical examination Diagnostic tests

43

Assessment: Health History

Factors affecting fluid balance Lifestyle Environmental Developmental

Physiological factors Body systems review

Clinical factors Recent clinical procedures and/or treatments

44

Assessment: Factors affecting fluid balance

Lifestyle Factors Nutrition

An alteration in the intake of fluids increases risk People require at least 1,500 mL of fluid daily

Recommendation for fluid intake is 8 to 10 glasses of fluid daily (2,000 – 2,400 mL)

Clinical Examples: In a healthy person – the body compensates for excess fluid, sodium, or both by

increasing excretion In a person with cardiac, renal, or liver disease – excess intake can lead to fluid

volume excess Exercise

Fluid deficit can result from exercise or activity in hot, humid environments

Stress Physical, psychological, or environmental stressors can lead to

hormone changes that increase blood volume to improve tissue perfusion (fight or flight)

45

Lifestyle Factors: Intake & Output

46Source undetermined

Assessment: Factors affecting fluid balance

Environmental Factors

Exposure to hot, humid weather At work, with exercise, etc.

Exposure to environmental toxins Can lead to fluid & electrolyte loss through vomiting,

diarrhea, or both

47

Assessment: Factors affecting fluid balance

Developmental Factors

Younger children The younger the child, the greater the risk for fluid deficit Are at greater risk because of immature kidneys, increased body

surface area, and increased metabolic activity

Adolescents Are at increased risk due to hormonal activity and teenage pregnancy

Older adults Are at increased risk due to the incidence of chronic diseases (heart

problems, kidney problems, etc.) & a decreased thirst mechanism

48

Proportion of Body Water by Age

Age Percent of Body Weight

Neonate 77%

6 months 72%

2-16 years 60%

20-39 years 59% (female) to 60% (male)

40-59 years 47% (female) to 55% (male)

65 years and older 45% to 50%49

Assessment: Physiological factors

Cardiovascular problems

Respiratory problems

Gastrointestinal problems

Renal problems

Integumentary problems

Trauma50

Assessment: Cardiovascular Problems Cardiovascular

problems Fluid overload due to

heart disease

When the left ventricle cannot contract efficiently, the buildup of fluid pressure has a retrograde effect, causing an increase in left atrial pressure followed by increased pulmonary pressure, which lead to pulmonary congestion 51

Wapcaplet, Wikimedia Commons

De-oxygenated blood from body

Oxygenated blood to body

De-oxygenated blood to lungs

Oxygenated blood to heartOxygenated

blood to heart

Decreased blood flow through lungs and to body

Back-up of blood flow increases size of right ventricle

Normal Cardiopulmonary Blood Flow Blood Flow with Severe Congestion

Assessment: Respiratory Problems

Respiratory problems

Any situation or pathology that increases the respiratory rate also increases the amount of fluids lost

Patrick J. Lynch, Wikimedia Commons

52

Assessment: Gastrointestinal Problems

Gastrointestinal problems

Vomiting, diarrhea, ileostomies, & fistulas all lead to increased fluid loss

Liver disease can result in fluid overload

53

Assessment: Renal Problems

Renal problems

End-stage renal disease can first lead to fluid deficit & then fluid overload

Gray’s Anatomy

54

Assessment: Integumentary Problems

Integumentary problems

Loss of protective skin barriers can lead to fluid loss & third spacing This is where fluid is physiologically

unavailable because it is trapped in an inaccessible area Ascites – fluid in the peritoneal space Pericardial effusion – fluid in the pericardial

space Pleural effusion – fluid in the pleural space

Np0x, Wikimedia Commons

55

Assessment: Trauma

Trauma

Tissue damage can lead to fluid loss

Sepsis can lead to more fluid, electrolyte, and protein loss

Head trauma can result in either fluid deficit or fluid excess

56

Superficial (first degree) burn

Partial thickness (second degree) burn

QuinnHK,Wikimedia Commons

Snickerdo,Wikimedia Commons

Craig0927,Wikimedia Commons

Full thickness (third degree) burn

K.Aainsqatsi,Wikimedia Commons

Assessment: Clinical factors

Surgery

Medications

Gastrointestinal intubation

Intravenous therapy Can contribute to fluid volume excess or deficit

57

Assessment: Surgery

Surgery

Fluid volume deficit related to blood loss or infection

58

Assessment: Medications

Medications

Fluid volume deficit from medications such as diuretics (Lasix) & oral hypoglycemics (Metformin)

Fluid volume excess from medications such as narcotics (Morphine) & steroids

59

Assessment: Gastrointestinal Intubation

Gastrointestinal intubation

Fluid volume deficit related to nasogastric tube & diarrhea associated with tube feedings

60

NASOGASTRIC TUBE

NASOGASTRIC TUBE

Alan Hoofring, Wikimedia Commons

Assessment: Intravenous Therapy

Intravenous therapy

Can contribute to fluid volume excess or deficit

Fluid Volume Deficit - if IV replacement is not enough to meet patient’s needs

Fluid Volume Excess – if IV replacement is more than the patient needs (i.e., too fast a rate)

Michaelberry, Wikimedia Commons

61

Assessment: Physical Exam

Standard clinical measurements Temperature Blood pressure Pulse Respiration rate

Weight 2.2 kg (1 lb) = 1 L of fluid loss or gain

Measuring intake & output when necessary Intake: measure intake orally, by tube, and/or by IV Output: measure output by urine, diarrhea, vomiting, suction,

and/or would drainage

62

Assessment: Physical Exam Integumentary exam

Edema Pitting edema can be assessed over the

indentation left over a 5 second period on the tibia, foot, sacrum (there is no uniform scale for measurement – most are similar to the one described below)

1+ = 2mm depression, barely detectable. Immediate rebound.

2+ = 4mm deep pit. A few seconds to rebound.

3+ = 6mm deep pit.10-12 seconds to rebound.

4+ =8mm: very deep pit. >20 seconds to rebound.

James Heilman, Wikimedia Commons

63

Assessment: Physical Exam

Integumentary Exam Skin Tenting or Turgor

Can be assessed by grasping the skin on the back of the hand, lower arm, or abdomen between two fingers so that it is tented up. The skin is held for a few seconds then released.

A slow return of the skin to its normal position after being pinched is a sign of either moderate to severe dehydration, or aging, or both 64

Skin with decreased turgor remains elevated after being pulled up and released

sh6 pinch, flickr

Assessment: Diagnostic Tests

Blood tests for: Sodium* Plasma osmolality* Hematocrit* Blood urea nitrogen (BUN)* Creatinine Liver Function Tests Potassium Chloride Calcium Magnesium

Urine tests for: Urine osmolality*

Afrobrazilian, Wikimedia Commons

65

Focused Assessment: Fluid Volume Deficit

Generalized Sudden weight loss Decreased skin turgor Dry mucous membranes and tongue Weakness Depressed fontanels in infants

Cardiac Hypotension with compensatory tachycardia Weak, thready pulse

Gastrointestinal Constipation

Renal Urinary output decreased

Derek Jenson, Wikimedia Commons

66

Focused Assessment: Fluid Volume Excess

Generalized Weakness and fatigue Body edema, pitting edema Ascites Sudden weight gain of more than 1kg/week Jugular venous distension Bulging fontanels in an infant

Pulmonary Increased respiratory rate (may have an irregular rhythm) Crackles or dyspnea Possible pleural edema or pleural effusion

Cardiac Tachycardia Bounding pulse Hypertension Possible third heart sound (S3 gallop)

Gastrointestinal Anorexia, nausea, vomiting

Renal Increased output if kidney can compensate

Wang Kai-feng, Pan Hong-ming, Lou Hai-zhou, Shen Li-rong, Zhu Xi-yan, Wikimedia Commons

67

Review Question

An elderly woman is admitted to the medical unit with dehydration. A clinical indication of this problem is:

a. Weight loss

b. Full bounding pulse

c. Engorged neck veins

d. Kussmaul respiration

68

Review Answer

Weight Loss

Full bounding loss – seen in fluid overload Engorged neck veins – seen in fluid overload Kussmaul respiration – deep, labored

breathing pattern often associated with severe metabolic acidosis (particularly diabetic ketoacidosis)

69

Review Question

The lungs act as an acid-base buffer by 

a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load 

b. increasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load 

c. decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load 

d. decreasing respiratory rate and depth when CO2 levels in the blood are low, increasing acid load

70

Review Answer

Increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load

71

Review Question

Clinical assessment of dehydration would be confirmed if the nurse identified:

a. 2.2kg weight loss

b. Engorged neck vessels

c. Dry mucous membranes

d. Full bounding radial pulse

72

Review Answer

Dry mucous membranes

Dry mucous membranes are a clinical sign of dehydration.

Weight loss can be associated with dehydration but is not a confirming sign.

Engorged neck vessels and bounding pulse are signs of fluid overload.

73

Review Question

The client most at risk for fluid volume deficit is:

1. Elder adult

2. Adult

3. Child

4. Infant

74

Review Answer

Infant

75

Review Question

One reason older adults experience fluid and electrolyte imbalance and acid-base imbalances, is they: 

a. Eat poor quality foods b. Have a decreased thirst sensation c. have more stress response d. have an overly active thirst response

76

Review Answer

Have a decreased thirst sensation

77

Questions

Dkscully (flickr) 78