Fluid And Elctrolyte Balance.... Power Point

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

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

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

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.

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]

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.

COMPOSITION OF BODY FLUIDS The fluids circulating throughout the body in extracellular and intracellular fluid spaces contain 1.Electrolytes 2.Minerals 3.Cells

MOVEMENT OF BODY FLUIDS Diffusion Osmosis Filtration Active transport

REGULATION OF BODY FLUIDS Fluid intake Fluid output Hormonal influence Lymphatic influences Neurologic influences Renal influences

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)

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.

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.

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

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.

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.

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.

3. Hypotonic overhydration a. Hypotonic overhydration is

ETIOLOGY AND RISK FACTORS Heart failure Renal disorders Cirrhosis of liver Increased ingestion of high sodium foods Excessive amount of IV fluids containing sodium Electrolyte free IV fluids SIADH,Sepsis decreased colloid osmotic pressure lymphatic and venous obstruction Cushing’s syndrome & glucocorticoids

CLINICAL MANIFESTATION Constant irritating cough Dyspnea & crackles in lungs Cyanosis, pleural fffusion Neck vein obstruction Bounding pulse &elevated BP S3 gallop Pitting & sacral edema Weight gain Increased CVP& PCWP Change in level of consiousness

LAB INVESTIGATION serum osmolality <275mOsm/ kg Low , normal or high sodium Decreased hematocrit [ < 45%] Specific gravity below 1.010 Decreased BUN [< 8mg/ dl]

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

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

RISK FACTORS Crushing injuries, major tissue trauma Major surgery Extensive burns Acid –base imbalances and sepsis Perforated peptic ulcers Intestinal obstruction Lymphatic obstruction Autoimmune disorders Hypoalbunemia GI tract malabsorption

CLINICAL MANIFESTATION skin pallor Cold extremities Weak and rapid pulse Hypotension Oliguria Decreased levels of consiousness

LAB INVESTIGATION Elevated hematocrit & BUN level

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

VOULME EXCESS:WATER INTOXICATION ICFVE is increase in amount of water inside the cells

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 intake SIADH Schizophrenia[compulsive water consumption]

CLINICAL MANIFESTATIONS Headaches Behavioral changes Apprehension Irritability, disorientation and confusion Increased ICP – pupillary changes and decreased motor and sensory function Bradycardia, elevated BP, widened pulse pressure & altered respiratory patterns, Babinski’s response flaccidity, projectile vomiting, Papilledema, delirium, convulsions &coma

LABORATORY FINDINGS High serum sodium level- 125 mEq/L decreased hamatocrit

MANAGEMENT Early administration of IV fluids containing sodium chloride cam prevent SIADH oral fluids such as juices or soft drinks can be given orally every hour Perform neurologic checks every hour to see if cranial changes are present Monitor fluid intake , IV fluids and fluid output hourly and weight daily Administer antiemetics for food and fluid retention

INTRACELLULAR FLUID VOLUME DEFICIT Severe hypernatremia and dehydration can cause ICFVD Relatively rare in healthy adults common in elderly people and in those conditions that result in acute water loss Symptoms include confusion, coma, and cerebral hemorrhage

Sodium imbalances

Hyponatr -aemia

Definiti on

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

Risk factors/ etiology

Clinical manifestation

Laboratory findings

management

Kidney diseases

•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

•Identify the cause and treat

Adrenal insufficiency Gastrointestinal losses Use of diuretics (especially with along with low sodium diet) Metabolic acidosis

• serum osmolality less than 280mOsm/kg •urine specific gravity less than 1.010

*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

Sodium imbalan -ce

Definit ion

causes

Hypernat -remia

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

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

Clinical manifestation

Low grade

Lab findings

management

*high serum sodium 135mEq/L

*Administration of hypotonic sodium solution [0.3 or 0.45%]

*high serum osmolality295m O sm/kg

*Rapid lowering of sodium can cause cerebral edema

*high urine specificity 1.030

*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

fever Postural hypertension Dry tongue & mucous membrane Agitation Convulsions Restlessness Excitability Oliguria or anuria

*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

Potassium imbalances

Definitio n

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

*weak irregular pulse

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

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

*shallow respiration

*diarrhea, vomiting or other GI losses

*hypotesion

*Alkalosis

*weakness, decreased bowel sounds,

*Cushing’s syndrome *Polyuria

heart blocks , paresthesia, fatigue,

*Extreme sweating

decreased muscle tone

*excessive use of potassium free Ivs

intestinal obstruction

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

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]

Hyperkal emia

Definition

Causes

Clinical manifestation

Lab findings

Management

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

Renal failure ,

Irregular slow pulse,

*High serum potassium 5.3mEq/L results in peaked T wave HR 60 to 110

*Dietary restriction of potassium for potassium less than 5.5 mEq/L

Hypertonic dehydration,

hypotension,

Burns& trauma

anxiety,

Large amount of IV administration of potassium,

irritability,

Adrenal insufficiency Use of potassium retaining diuretics & rapid infusion of stored blood

paresthesia, weakness

*serum potassium of 7mEq/L results in low broad Pwave *serum potassium levels of 8mEq/L results in no arterial activity[no pwave]

*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 myocardium 2.infusion of insulin and glucose or sodium bicarbonate to promote potassium uptake 3.sodium polystyrene sulfonate [Kayexalate] given orally or rectally as retention enema

Calcium imbalan ces

Definitio n

Causes

Clinical manifestation

Lab findings

hypocalc emia

It is a plasma calcium level below 8.5 mg/dl

•Rapid administration of blood containing citrate,

•Numbness and tingling sensation of fingers,

•hypoalbuminemia,

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

Serum calcium less than 4.3 mEq/L and ECG changes

•Hypothyroidism , •Vitamin deficiency, •neoplastic diseases, •pancreatitis

•muscle cramps, •pathological fractures, •prolonged bleeding time

Management

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

Calcium imbalance

Hypercalc emia

Definition

Causes

Clinical manifestation

Lab findings

Management

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

•Hyperthyro •idism,

•Decreased muscle tone,

•High serum calcium level 5.5mEq/L,

•Metastatic bone tumors,

•anorexia,

1.IV normal saline, given rapidly with Lasix promotes urinary excretion of calcium

•paget’s disease,

•nausea, vomiting, •weakness , lethargy,

•osteoporosis , •prolonged immobalisation

•low back pain from kidney stones, •decreased level of consciousness & cardiac arrest

• x- ray showing generalized osteoporosis,

2.Plicamycin an antitumor antibiotics decrease the plasma calcium level

•widened bone cavitation,

3.Calcitonin decreases serum calcium level

•urinary stones,

4.Corticosteroid drugs compete with vitamin D and decreases intestinal absorption of calcium

•elevated BUN 25mg/100ml, •elevated creatinine1.5mg /100ml

5. If cause is excessive use of calcium or vitamin D supplements reduce or avoid the same

Acid-Base imbalance

Definition

Causes

Clinical manifestation

Lab findings

Management

Respiratory acidosis

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

COPD, neuromuscular disorder, GuillianBarre syndrome, Myssthenia gravis, Respiratory center depression, Drugs, late ARDS,

Dyspnea ,

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

1.Treat underlying cause

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

Hypoventilation & excessive CO2 production

Respiratory Alkalosis Hyperventilation

disorientation, coma

2.Support ventilation 3.Correct electrolyte imbalance 4.Intravenous NaHCO3

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

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

Increase CO2 retention through CO2 rebreathing & sedation and mechanical hypoventilation

Metabolic Acidosis

Metabolic Alkalosis

Definition

causes

Clinical manifestation

Lab findings

Management

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

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

Hypoventilation Dysrythmias

It is a clinical condition in which PH is raised

2.Intravenous NaHCO3 3.correct electrolyte imbalance

PH >7.45 Hypokalemia Hypocalcemia PaCO2 normal or increased

1.Treat the underlying cause 2.Administer KCL 3.intravenous acidifying salts[NH4CL] 4.Administer acetazolamide

CONCLUSION