Fluids and Electrolytes Hand Out

8/8/2019 Fluids and Electrolytes Hand Out

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FLUIDS AND ELECTROLYTES: BALANCE AND IMBALANCE

INTRODUCTION

DEFINITION OF TERMS1. Solvent- a liquid substance where particles can be dissolved2. Solute- a substance, either dissolved or suspended in a solution3. Fluid- a solution of solvent and solute4. Electrolytes- particles which have an electrical charge capable of

conducting electricity5. Cation- ion which is positively charged6. Anion- ion which is negatively charged7. Electrolyte balance- electrical neutrality where equal number of

cation match the number of anion8. Acids- substances that can yield or donate Hydrogen (H+)9. Alkalis- substances that can accept a hydrogen (H+); also called

bases

10. Acid-Base balance- a state where body fluids maintain a stableratio of H+ to bicarbonate

11. Acidosis- condition characterized by an excess of hydrogenions/ acids where pH falls to 7.34 and below

12. Alkalosis- condition characterized by an excess of bases orbicarbonate, where the pH rises to 7.46 and above

13. Buffer- a substance that regulates pH by maintaining a stablehydrogen ion concentration

14. Osmolality- solute concentration in milli-osmoles per liter ofsolvent

15. Osmolarity- the number of solute particles per liter of solution16.

Milliequivalent- refers to the combining power of the ion; thecapacity of cation to combine with anion

17. Crystalloid- salts that dissolve readily into true solution18. Colloid- substance such as protein that does not readily

dissolve in true solution


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Summary of the Basic Principles

FluidsA. Water constitutes over 50-60% of individuals weight. It is largestsingle component.B. Body water is divided into two MAJOR compartments

1. Intracellular: within cells2. Extracellular: outside cells, further divided into interstitial andintravascular fluid

D. The third compartment is the Transcellular fluidwhere the fluid iscontained in body cavities, not readily utilizable for the body. Includedhere are the fluids in the brain ventricles- CSF, the pleural fluid, synovialfluid and peritoneal fluid.


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Normal Physiology of the BODY FLUIDS

A. Proportions of Body Fluidsy Total Body water (TBW) in an adult equals approximately 60% of

the body weight. (Normal range is 46-60%)y In a 70-kilogram adult male, 60% x 70= 42 litersy Age, sex and body fat affect the proportion of H2Oy Infants have the HIGHEST percentage of water in the body,

approximately 70-80%y Older adults tend to lose muscle mass, thereby decreasing the

water contenty Fatty tissues contain little or no water than lean tissues

(With higher water content)

B. Distribution of Body Fluidsy Total body water is divided among compartments or spaces,

separated by biologic membranesy INTRAcellular compartment is INSIDE the celly EXTRAcellular compartment is OUTSIDE the cell1. INTRACELLULAR FLUID

y Accounts for 2/3 of TBW in adultsy Contains water, solutes, electrolytes, etc.

2.EXTRACELLULAR FLUIDy Represents 1/3 of TBW in adultsy Found outside the cellsy Contains water, electrolyte, proteins, RBC, WBC, etcy This is the transport system of the bodyy Further subdivided into 3 sub compartments- the interstitial,

intravascular and transcellular fluidsa. INTERSTITIAL COMPARTMENT OF THE ECF

y Fluid surrounding the cellsy Transports water by way of lymph and into

capillariesy Normally 2/3 of the ECF

b. INTRAVASCULAR COMPARTMENT OF THE ECFy The blood plasmay Found within the blood vesselsy Usually 1/3 of the ECF

c. TRANSCELLULAR COMPARTMENT OF THE ECF


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y This is the movement ofBOTHsolute and solvent together

across a membrane from an area of higher pressure to an areaof lower pressure

4. ACTIVE TRANSPORTy Process where substances/solutes move from an area of lower

concentration to an area of higher concentration withutilization of ENERGY

y It is called an uphill movementy Usually, a carrier is required. An enzyme is utilized also.

Types of Active Transport:a. Primarily Active Transport

y Energy is obtained directly from the breakdown of ATPy One example is the Sodium-Potassium pump

b. Secondary Active Transporty Energy is derived secondarily from stored energy in the

form of ionic concentration difference between two sides

of the membrane.THE REGULATION OF BODY FLUID BALANCE

To maintain homeostasis, many body systems interact to ensure a

balance of fluid intake and output. A balance of body fluids normallyoccurs when the fluid output is balanced by the fluid input

A. Systemic Regulators of Body Fluids1. Renal Regulation

y This system regulates sodium and water balance in the ECFy The formation of urine is the main mechanism

2. Endocrine Regulationy

The primary regulatoro

f water intake is the thirstmechanism, controlled by the thirst center in thehypothalamus (anterolateral wall of the third ventricle)

y Anti-diuretic hormone (ADH) is synthesized by thehypothalamus and acts on the collecting ducts of thenephron

y ADH increases rate of water reabsorption3. Gastro-intestinal regulation

y The GIT digests food and absorbs watery The hormonal and enzymatic activities involved in digestion,

combined with the passive and active transport of

electrolyte, water and solutions, maintain the fluid balancein the body.

B. Fluid Intakey Healthy adult ingests fluid as part of the dietary intake.y 90% of intake is from the ingested food and water


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y 10% of intake results from the products of cellular metabolismy Usual intake of adult is about 2, 500 ml per dayy The other sources of fluid intake are: IVF, TPN, Blood products,

and colloids

C. Fluid Outputy The average fluid losses amounts to 2, 500 ml per day,

counterbalancing the input.y The routes of fluid output are the following:y A. SENSIBLE LOSS- Urine, feces or GI losses, sweaty B. INSENSIBLE LOSS- though the skin and lungs as water vapory URINE- is an ultra-filtrate of blood. The normal output is 1,500

ml/day or 30-50 ml per houry FECAL loss- usually amounts to about 200 ml in the stool

Normal Physiology of the ELECTROLYTES

Electrolytes are charged ions capable of conducting electricity and

are solutes found in all body compartments.1. Sources of electrolytes

y Foods and ingested fluids, medications; IVF and TPN solutions2. Functions of Electrolytes

y Maintains fluid balancey Regulates acid-base balancey Needed for enzymatic secretion and activationy Needed for proper metabolism and effective processes of muscular

contraction, nerve transmission

3. Types of Electrolytesy CATIONS- positively charged ions; examples are sodium, potassium,

calciumy ANIONS- negatively charged ions; examples are chloride and

phosphates]y The major ICF cation is potassium (K+); the major ICF anion is

Phosphatesy The major ECF cation is Sodium (Na+); the major ECF anion is

Chloride (Cl-)

THE CATIONS

SODIUMy The most abundant cation in the ECFy Normal range in the blood is 135-145 mEq/Ly Major contributor of the plasma Osmolalityy Sources: Diet, medications, IVF. The minimum daily requirement is 2

gramsy Functions:

1. Participates in the Na-K pump


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y Functions:

1. Intracellular production and use of ATP2. Protein and DNA synthesis3. Neuromuscular irritability

y Regulations: GIT absorption and excretiony Imbalances: Hypomagnesemia= 2.1 mEq/L

THE ANIONS

CHLORIDEy The major Anion of the ECFy Normal range is 95-108 mEq/Ly Sources: Diet, especially high salt foods, IVF (like NSS), HCl (in the

stomach)y Functions:

1. Major component of gastric juice

2. Regulates serum Osmolality and blood volume3. Participates in the chloride shift4. Acts as chemical buffer

y Regulations: Renal regulation by absorption and excretion; GITabsorption

y Imbalances: Hypochloremia= < 95 mEq/L; Hyperchloremia= >108mEq/L

BICARBONATESy Present in both ICF and ECFy

Regulates acid-base balance together with hydrogeny Normal range is 22-26 mEq/Ly Sources: Diet; medications and metabolic by-products of the cells.y Function: Component of the bicarbonate-carbonic acid buffer systemy Regulation: Kidney production, absorption and secretiony Imbalances: Metabolic acidosis= 26 mEq/

Normal Physiology ACID BASE BALANCE

FACTORS AFFECTING BODY FLUIDS, ELECTROLYTES AND ACID-BASEBALANCE

1. AGEy Infants have higher proportion of body water than adultsy Water content of the body decreases with age


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Generally speaking, the imbalances in the body are classified into

two-

EXCESS- hyper DEFICIT- hypo

FLUID IMBALANCES FLUIDDEFICIT

FLUID VOLUME DEFICIT or HYPOVOLEMIAy Definition: This is the loss of extra cellular fluid volume that exceeds

the intake of fluid. The loss of water and electrolyte is in equalproportion. It can be called in various terms- vascular, cellular orintracellular dehydration. But the preferred term is hypovolemia.

y Dehydration refers to loss of WATER alone, with increased solutesconcentration and sodium concentration

Risk Factors:Hemorrahage, comaASSESSMENT:

y Physical examinationy Weight loss, tented skin turgor, dry mucus membraney Hypotensiony Tachycardiay Cool skin, acute weight lossy Flat neck veinsy Decreased CVP

y Subjective cueso Thirsto Nausea, anorexiao Muscle weakness and crampso Change in mental state

MANAGEMENT1. Assess the ongoing status of the patient by doing an accurateinput and output monitoring

2. Monitor daily weights. Approximate weight loss 1 kilogram =1liter!3. Monitor Vital signs, skin and tongue turgor, urinary concentration,mental function and peripheral circulation4. Prevent Fluid Volume Deficit from occurring by identifying riskpatients and implement fluid replacement therapy as neededpromptly


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MAGNESIUM DEFICIT: HYPOMAGNESEMIA

y Serum magnesium below 1.5 mEq/LPathophysiologyy Etiologic factors1. Poor Nutrition2. Alcoholism3. GI and renal losses

Subjective Cues1. Insomnia2. Depression3. Irritability and mood changes

NURSING MANAGEMENT1)Observe patient for complications. Monitor for signs of toxicity

such as hot, flushed skin, diaphoresis, anxiety or lethargy,

Hypotension and laryngeal stridor2)Institute seizure precaution3)Monitor ECG and pulses for abnormalities4)Assess the clients ability to swallow before administering oral

medications or feeding client5)Instruct the patient about the importance of Mg rich foods like

nuts, whole grains, cornmeal, spinach, bananas, oranges6)Monitor patients receiving digitalis closely because a deficit of

magnesium predisposes to toxicity.7)Discuss the misuse of diuretics and laxatives if necessary

MAGNESIUM EXCESS: HYPERMAGNESEMIA

y Serum Magnesium greater than 2.5 meq/LPathophysiology

Etiologic factors1. Untreated diabetes mellitus2. Renal failure is the most common3. Overuse of Mg containing antacids and laxatives/enemas4. Excessive magnesium administration5. Severe dehydration as occurs in diabetic ketoacidosis

ASSESSMENTPhysical Examination

1. Hot flushed face2. Hypoactive reflexes3. Hypotension4. Bradycardia5. Depressed respiration6. Cardiac arrhythmias


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NURSING MANAGEMENT1. Discontinue all parenteral Mg medication2. Monitor vital signs carefully- RR, BP, reflexes, HR and LOC3. Administer medications prescribed4. Monitor the cardiac status5. Prepare the patient for hemodialysis6. During respiratory or cardiac emergencies, collaborate with the

physician and respiratory therapist providing ventilatory support.7. Institute safety precautions including side-rails up, brakes locked,

and client repositioning8. Teach the client about the adverse effects of overuse of laxatives,

enemas and Mg-antacids9. Instruct the client to read all labels for mg content

PHOSPHORUS DEFICIT: HYPOPHOSPHATEMIAy Serum phosphate level less than 2.5 mg/dL

Pathophysiologyy Etiologic factors

1. Overzealous Administration of calories or carbohydrates to

patients with severe PCMy 2. Chronic alcoholism, alcohol withdrawal and intense

hyperventilationy 3. Diabetic ketoacidosisy 4. Thermal burnsy 5. Hyperparathyroidismy 6. Excess intake of phosphate-binding drugsy

7. Total parenteral nutritional administrationy 8. Severe dehydration

Physical Examination1. Irritability2. Muscle Weakness and pain (if severe, rhabdomyolysis)3. Seizures and coma4. Hypoxic signs leading to increased respiration5. Respiratory alkalosis related to HYPERVENTILATION6. Bruising and bleeding (due to platelet dysfunction if deficiency is

chronic)7. Increased susceptibility to infectionNURSING MANAGEMENT

1. Continuously monitor patients in the hospital2. Monitor the serum Phosphate level3. Monitor for possible complications of IV phosphorus4. Ensure adequate nutrition5. Prevent infection6. Administer medications as ordered with close monitoring7. Prevent injury by instituting safety precaution


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8. Provide client teaching. Instruct the importance of preventing

infection because hypophosphatemia may produce changes in thegranulocytes.

PHOSPHATE EXCESS: HYPERPHOSPHATEMIAy Serum phosphate levels above 4.5 mg/dLy

Pathophysiologyy Etiologic factors1. Renal failure is the most common2. Chemotherapy for neoplastic disease3. Hypoparathyroidism4. High phosphate intake5. Profound muscle necrosis6. Increased phosphate absorption

Physical Examination1. Tetany due to a high PO4 leading to LOW Ca++2. Muscle weakness3. Hyperreflexia4. Tachycardia5. Soft tissue calcification

Subjective cues1. Tingling sensation2. Anorexia, nausea, vomitingNURSING MANAGEMENT1. Avoid giving phosphate rich foods such as hard cheese, nuts, grains

and dried foods.

2.Avoid phosphate containing drugs or medications such as laxativesand enemas

3. Instruct patient to avoid foods high in phosphorus such as hardcheese, cream, nuts, whole grain products, dried fruits and driedvegetables.

4. Instruct patients to avoid phosphate-containing substances such aslaxatives and enemas that contain phosphate.

SHOCKy An abnormal physiologic state where an imbalance exists

between the amount of circulating blood volume and the size ofthe vascular bed

Assessment FindingsA. Skin

1. Cool, pale, moist in hypovolemic and cardiogenic shock2. Warm, dry, pink in septic and neurogenic shock

B. Pulse1. Tachycardia, due to increased sympathetic stimulation2. Weak and thready

C. Blood pressure


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1. Early stages: may be normal due to compensatory mechanisms2. Later stages: systolic and diastolic blood pressure drops.

D. Respirations: rapid and shallow, due to tissue anoxia and excessiveamounts of CO (from metabolic

Acidosis)E. Level of consciousness: restlessness and apprehension, progressing tocomaF. Urinary output: decreases due to impaired renal perfusionG. Temperature: decreases in severe shock (except septic shock).

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MANAGEMENT:

Maintain patent airway and adequate ventilation.

1. Establish and maintain airway.2. Administer oxygen as ordered.3. Monitor respiratory status, blood gases.

4. Start resuscitative procedures as necessaryMinimize factors contributing to shock.

1. Patient in supine position-elevate lower extremities to 20, withknees straight, trunk horizontal and the head slightly elevated-to


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promote venous return to heart, thereby improving cardiac output(modified Trendelenburg)2. Avoid theTrendelenburgs position because this increases respiratoryimpairment.3. Promote rest by using energy-conservation measures and maintainingas quiet an environment as possible.

BURNS

Cellular destructionofthelayersoftheskinand theresultant depletionoffluidsand electrolytes.

Burns Classification as to ETIOLOGY1. Thermal: most common type; caused by flame, flash, scalding, andcontact (hot metals, grease)2. Smoke inhalation: occurs when smoke (particulate products of a fire,gases, and superheated air)

causes respiratory tissue damage3. Chemical: caused by tissue contact, ingestion or inhalation of acids,

alkalis, or vesicants4. Electrical: injury occurs from direct damage to nerves and vesselswhen an electric current passes

CURRENT CLASSIFICATION as to DEPTHTo emphasize:

Superficial Partial thickness (1st degree)

Outer layer of dermis Erythema, pain up to 48 hrs Healing 1-2 wks [sunburn]

Deep Partial thickness (2nd degree)

Epidermis & dermis Blisters & edema, frequently quite painful Healing 14-21 days

Full thickness (3rd degree)

Epidermis, dermis, subcutaneous fat Dry, pearly white or charred in appearance Not painful Eschar must be removed; may need grafting

CLASSIFICATION AS TO EXTENT of BurnsESTIMATION of BURNSy Three methods are utilized for estimating the extent of burn injury1. The Rule of Nines in adults


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y Head and Neck- 9%y Anterior trunk- 18%y Posterior trunk- 18%y Upper arms- 18% (9% each x 2)y Lower ext- 36% (18% EACH x 2)y Perineum- 1%

Implementation Step: Phases of Burn Management

1.EMERGENT PHASEy Begins at the time of injury and ends with the restoration of the

capillary permeability (with 48-72 hours)y The GOAL is to PREVENT hypovolemic shock and preserve the vital

body organ functiony Emergency and pre-hospital care or on-the-scene care

2.RESUSCITATIVE PHASE

y Begins with the initiation of fluids and ENDS when capillary integrityreturns to near-normal and large fluid shifts have decreased

y The GOAL is to prevent shock by maintaining adequate circulatingblood volume to maintain vital organ perfusion

3.ACUTE PHASEy Begins when the client is HEMODYNAMICALLY stable, capillary

permeability is restored and DIURESIS has beguny Usually begins 48-72 hours after time of injuryy Emphasis is placed on restorative therapy and the phase continues

until wound closure is achievedy

The FOCUS is on infection control, wound care, wound closure,nutritional support, pain management and physical therapy

4.REHABILITATIVE PHASEy The final phase of Burn carey Goals of this phase patient independence and restoration of

maximal function

General Medical Management

1. Supportive therapy: fluid management (lVFs), catheterization2. Wound care: hydrotherapy, debridement (enzymatic or surgical)

3. Drug therapya. Topical antibiotics: mafenide (Sulfamylon), silver sulfadiazine(Silvadene), silver nitrate, povidone-iodine (Betadine) solutionc. Tetanus toxoid or hyperimmune human tetanus globulin (burnwound good medium for anaerobic

growth)4. Surgery: excision and grafting

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Fluids and Electrolytes Hand Out