Fluid And Electrolytes Burns G.u. 2

FLUID AND ELECTROLYTE BALANCE

Irene M. Magbanua, RN Clinical Instructor St. Paul University Manila

DEFINITIONS OF TERMS: • • • • •

Intracellular - within cells Extracellular – outside cells Interstitial – within/between cells Intravascular- in the plasma Osmoreceptors – specialized neurons that sense the concentration of substances in blood

• Baroreceptors – stretch receptors in the aortic arch and carotid sinus that signals the brain to release ADH when blood volume decreases, systolic BP falls or the right atrium is underfilled • Renin-Angiotensin-Aldosterone-System (RAAS) – a chain of chemicals released to increase both BP and blood volume. • Osmosis – movement of water through a semi-permeable membrane from a dilute area to a more concentrated area

• Osmotic pressure – the power to draw water from an area of greater concentration • Colloids – large-sized substances such as plasma proteins. • Colloidal osmotic pressure – subtance that contributes to fluid concentration and acts as force to attract water. • Filtration – promotes the movement of fluid and some dissolved substances through a semi-permeable membrane according to pressure differences

• Passive diffusion – physiologic process by which dissolved substances (ex. electrolyte) move from an area of high concentration to an area of lower concentration thru a semipermeable membrane • Active transport – requires an energy source, called adenosine triphosphate (ATP) to drive dissolved chemicals from an area of low concentration to an area of higher concentration

• Fluid imbalance – general term describing any of severalconditions in which the body’s water in not in the proper volume or location • Skin tenting – skin that remains elevated and slow to return to underlying tissues (dehydration) • Pitting edema – indentations in the skin after compression (3L excess in the IVC volume)

• Third spacing- translocation of fluid from the IVC or intercellular space to tissue compatrment where it becomes trapped and useless. • Brawny edema – generalized edema in all the interstitial spaces • Circumoral paresthesia – tingling around the area of the mouth • tetany- - muscle twitching

Fluid compartments • Intracellular fluid (ICF) – 70% • Extracellular fluid (ECF) – 30% a. Interstitial fluid – 25% b. Intravascular fluid – 5% c. Transcellular fluid – digestive juices, water and solutes in the renal tubules and bladder, pleural fluid, CSF

Body Fluids – primary source are food and liquids • Infants – 80% of BW (body wt.) • Male – 60% • Female – 50% Functions of body water/fluids • ECF – maintains blood volume transport system to and from the cell

• ICF – maintainance of normal body temp. elimination of waste products Concepts on Body Fluids: • Fliud move between the ICF & ECF to maintain fluid balance • Fliud in the cell is the most stable since cells are resistant to major fluid shifts • Fluid in the bloodstream is the most changeable, quickly lost or gained by intake of fluids or loss of fluids thru sweat, urine, diarrhea and tears

Fluid Transport Between Vascular and Interstitial Spaces • Fluids move between compartments to maintain homeostasis. Change in pressure promote fluid movement and this takes place across the capillary walls. • Forces that move fluids are constantly at work and allow the fluid to be taken in orally to maintain BP and hydrate cells and eventually excreted as urine

• Blood moves thru the vascular system from an area of higher pressure (arteries) to areas of lower pressure (capillaries and veins) via hydrostatic pressure Electrolytes – chemical compounds in solution that have the ability to conduct electric current • Acids – substances that release hydrogen into fluid • Bases – substances that binds with hydrogen

• Break into charged particles called ions 1. cations – (+)positively charged Ca, Mg, Na, K 2. anions – negatively charged (-) Cl, HCO3, Phosphate • ECF – major cation Na (sodium) major anion Cl (Chloride) • ICF – major cation K (Potassium) major anion HPO4 (Phosphate)

• 2. 3. 4. 5.

Functions of the electrolytes: Promote neuromuscular irritability Maintain body fluid volume and osmolarity Distribute body water between fluid compartments Regulate acid-base balance

Normal Fluid Intake and Loss in Adults • Intake: water in food 1,000 mls water from oxidation 300 mls water as liquid 1,200 mls Total 2,500 mls

• Output: skin lungs feces kidneys

500 mls 300 mls 150 mls 1,500mls Total 2,500mls

Fluid and Elecrolyte Distribution 1. 2. 3. 4. •

Osmosis Diffusion Filtration Active transport Internal Regulation of body water and electrolytes: Thirst – major control of actual fluid intake

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Kidney – major organ controlling output ADH (anti diuretic hormone) – causes increased water reabsorption in the distal convulated tubules and collecting ducts RAAS – Renin-AngiotensinAldosterone System

Electrolyte Imbalances • Sodium - Normal value is 135-145 mEq/L - essential for maintaining normal nerve and muscle activity - regulating osmotic pressure - preserving acid-base balance - if Na is reabsorbed, water is also reabsorbed in equal proportions

Hyponatremia – plasma Na level below 135 mEq/L • 2. 3. 4. 5. 6. 7.

Etiology Vomiting, diarrhea and fistula Diaphoresis Chronis use of diuretics and laxative Low-salt diet Addison’s disease SIADH

7. excessive ingestion of plain water or administration of non-elecrolyte IV fluids Clinical Manifestations: • Poor skin turgor • Dryness of mucous membrane • Decrease BP • Nausea and vomiting • Abdominal cramping • Altered mental status • Elevated temp, tachycardia

Diagnostic Findings: 2. Serum sodium level below 135 mFq/L 3. Urinalysis reveals urine Na and specific gravity is low Management: 5. Increase intake of high Na rich foods 6. Preventing injury by observing seizure precautions 7. For severe deficits, administration of IV solutions containing NaCl as ordered

Hypernatremia – Na level above 145 mEq/L. Excess Na in the blood • 2. 3. 4. 5. 6.

Etiology Profuse watery diarrhea Excessive salt intake without suffidient water intake High fever Decreased water intake DM, DI, Cushing Syndrome

Clinical Manifestations: 1. Thirst, dry, sticky mucous membrane 2. Decreased urine output 3. Fever, rough dry tounge 4. Lethargy and restlessness Diagnostic Findings: 6. Serum Na level exceeds 145 mEq/L 7. Urine specific gravity is increased

Management: 1. Infusion of hypotonic solution, such as 0.45% NaCl 2. Maintain normal fluid balance 3. Protect client from injury 4. I and O monitoring 5. Limit dietary intake of Na untila lab tests results are normal

Nursing Management for Sodium Imbalances 1. Early detection especially those at risk 2. Apportion oral fluids according to target volumes 3. Maintain accurate I and O 4. Close monitoring of vital signs

Potassium - Normal value is 3.4 – 5.0 mEq/L - very important in the production of nerve impulses and promotion of proper, skeletal, smooth, and cardiac muscle activity - promotes enzyme action for cellular metabolism and glycogen storage in the liver - an increase Na intake promotes K loss - major excretion is in the kidney

Types of Solution 1. Hypertonic- exerts greater concentration of particles outside than inside the cell; cells shrink e.g. D51/2NS, D5 NS, D5 LR, 3%NS, 5%NS 2. Hypotonic- exerts lesser concentration of particles outside than inside the cells; cells swell eg. 1/2 NS, 1/4 NS, 1/3 NS, 2.5% Dextrose, D5W 3. Isotonic- same concentration of particles inside and outside the cell; no change on size and shape of cells eg. Normal Saline, Lactated Ringer’s

Types of Solution 1. Hypertonic- exerts greater concentration of particles outside than inside the cell; cells shrink e.g. D51/2NS, D5 NS, D5 LR, 3%NS, 5%NS 2. Hypotonic- exerts lesser concentration of particles outside than inside the cells; cells swell eg. 1/2 NS, 1/4 NS, 1/3 NS, 2.5% Dextrose, D5W 3. Isotonic- same concentration of particles inside and outside the cell; no change on size and shape of cells eg. Normal Saline, Lactated Ringer’s

Care of Clients with Burns Irene M. Magbanua, RN

Burns • wounds caused by excessive exposure to thermal, electrical, chemical and radioactive materials •usually secondary to carelessness or ignorance

Nursing Assessment 1. ABC’s • Age • Burn Location • Coverage 2. Tetanus immunization

3. TBSA- Total Body Surface Area a. Berkow formula •calculated on the basis of the client’s age •changes that occur in proportion of the head and legs to the rest of the body as the individual grows •arms and trunk have a fixed proportion throughout life Eg. Head: 1yo = 19%; 1-4yo = 17%; 5-9yo =13%; 10-14yo = 11%; 15yo = 9%; adult = 7%

B. Lund and Browder Chart • thought to be more accurate •takes into account changes in % of burned surface at various stages of development C. Rule of Nine • useful for immediate appraisal of the burned area •body is divided into areas, each represents 9% of or multiples of 9; inaccurate

Classifications of Burns: 1. Major- partial thickness> 25% or full thickness > 10% 2. Moderate- partial thickness 15-25% or full thickness <10% 3. Minor- partial thickness <15% or full thickness < 2%

Categories of burn depth: 1. Partial thickness a. Superficial Partial Thickness (First degree) depth: epidermis cause: sunburn, splashes of hot liquid sensation: painful characteristic: erythema, blanching on pressure, no vesicles

B. Deep Partial Thickness (second degree) depth: epidermis and dermis cause: flash, scalding or flame burn sensation: very painful characteristic: fluid filled vesicles, red, shiny, wet after vesicle rupture

2. Full thickness (third and fourth degree) depth: all skin layers and nerve endings, may involve muscles, tendons and bones cause:flame, chemicals, scalding, electric current sensation: little or no pain characteristic:wound dry, white, leathery, or hard tissue

*eschar- leathery or hard tissue due to loss of blood supply

Nursing Management in Different Stages of Burns: 1. Emergent phase- remove person from source of burn goals: relief of pain, minimize contamination, transport a. Thermal- stop, drop and roll; flame off b. Smoke inhalation- ensure patent airway c. Chemical- remove clothing that contains chemical; lavage with copious amounts of water d. Electrical- shut off source of electricity; note entry or exit wound

Nursing Interventions: b. Ensure patent airway c. Wrap in dry, clean sheet or blanket or prevent contamination of wound d. Provide warmth e. Provide IV route if possible f. Tetanus prophylaxis g. Transport immediately

2. Shock Phase- 1st 24-48 hrs post burns •

Fluid shift from plasma to interstitial fluid= hypovolemia; fluid also moves to areas that normally have little or no fluid (third spacing)

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Dehydration, decreased BP, increased pulse, decreased urinary output, thirst

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Hyperkalemia, hyponatremia, increased hematocrit, metabolic acidosis, loss of HCO3 ions

3. Fluid remobilization or Diuretic phase (2-5 days post-burns) b. Interstitial fluid returns to vascular compartments c. Increased BP, increased urinary output d. Hypokalemia

4. Convalescent phase g. Starts when diuresis is completed and wound healing begins h. Dry, waxy-white appearance of full-thickness burn changing to dark brown; wet, shiny, serous exudate in partial thickness i. Hyponatremia

Nursing Interventions: 2. Provide relief or control pain 3. Administer analgesic or narcotics (morphine sulfate) 30 mins before wound care 4. Position burns to alignment 5. Monitor alterations in fluid-electrolyte balance 6. Monitor foley catheter output hourly (30 cc/hr) 7. Weigh daily 8. Administer water or colloids 9. Promote maximal nutritional status 10. Wound care done 1hr before meals 11. Prevent wound infection

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Biologic dressing- used to cover large denuded areas

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Grafts- autograft, allograft, xenograft or heterograft

3. Controlled sterile environment 4. Hydrotherapy not more than 30 mins to prevent electrolyte loss 5. Sulfamylon, silvadene, silver nitrate, betadine, gentamycin applied using sterile technique 6. Prevent GI complications 7. Provide client teaching and discharge plan •

Escharotomy- lengthwise incision through eschar to allow expansion of skin as edema forms

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Fasciotomy- surgical incision done on underlying tissues or muscles to explore for viability

Care of Client with Problems Related to the Genitourinary System Irene M. Magbanua, RN East West Educational Specialists

Renal functions: Homeostasis 2. Maintain constancy of internal environment by regulating water and electrolyte content and acid base balance 3. Conserve appropriate amounts of essential substances vital to normal cell function 4. Excrete waste products of metabolism, toxic substances, and drugs in urine 5. Endocrine role- production of renin, erythropoietin and prostaglandin 6. Metabolism of vitamin D

Manifestations of impaired renal function: 2. Abnormal urinary volume c. Oliguria-< 500ml/24hr d. Anuria- <250ml/ 24hr; renal shutdown, decrease filtartion secondary to renal disease, hypotension, dehydration, decreased renal blood flow e. Polyuria- volume >2000ml/24hr f. Pollakuria- abnormally frequent urination g. Nocturia- frequent urination at night h. Isosthernuria- kidneys cannot concentarte urine i. Strangury- desire to pass urine but not received by micturition j. Incontinence- true, false, paradoxical overflow; stress related

1. Abnormal urine color Abnormal constituents in urine 2. Abnormal constituents in urine c. Albuminuria- presence of albuminin the urine secondary to inflammation and damage to glomeruli d. Hematuria- presence of blood (RBC) in urine

6. Azotemia- metabolic wastes accumulated in blood, increased urea, craetinine and uric acid g. Uremia- symptomatic elevation of metabolic waste products in urine; a state or complex of symptoms reflecting failure of kidneys to excrete metabolic wastes and excess substances

1. Fluid, electrolyte and pH imbalance- edema, metabolic acidosis- failure of kidneys to excrete hydrogen ions with increased sodium, phosphate and ammonia 3. Vital signs- increased BP in renal insufficiency; pulse weak, dyspnea in pulmonary edema; kussmaul breathing in acidosis; breath- uremic or ammoniacal odor in advanced renal failure, fever 5. Gastrointestinal- anorexia, nausea or vomiting, diarrhea, hiccups in advanced renal failure 7. Headache- secondary hypertension and cerebral edema

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Visual disturbances- papilledema and retinal hemorrhages

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Neurological- irritability, lethargic and drowsy, disoriented to comatose; convulsion

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Skin changes- yellowish brown discoloration dryness or scaliness, pruritus and urea frost (uremic frost) excreted by sweat glands

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Hematological- dec erythropoeisis leading to anemia and bleeeding tendencies- petechiae, purpura

Diagnostic Assessments 2. Urine examination or analysis c. Routine- midstream first voided urine d. Sterile or catheterized e. 24 hours- collection starts at second voided urine f. Residual 7. Blood examination or chemistry h. CBC i. BUN j. Creatinine k. Uric acid l. Electrolytes

1. Radiologic b. KUB (Kidneys, Ureters, Bladder)- identifies number and size of kidney, ureters, bladder, tumors, malformation,. Calculi c. IVP (Intravenous Pyelography)- fluoroscopic visualization of kidney after dye injection via IV d. Cystography or cystoscopy Prep- NPO 6-8 hrs with premedications like nubain, valium f. PSP (phenolsuphthalein)- checks the secretory ability of the kidneys; urine expected to be red 7. Renal angiography 8. Percuatneous renal biopsy

Common Disorders: 2. Urolithiasis- presence of stones anywhere in the urinary tract; often in men 20- 55yo; more in summer Predisposing Factors: d. Diet- large amount of calcium, oxalate, uric acid e. Increased uric acid levels f. Sedentary lifestyle, immobility g. Family history of gout or calculi or hyperparathyroid h. Genetic- xanthine, cystine stone

Signs and Symptoms: b. Abdominal or flank pain c. Renal colic d. Hematuria e. Cool moist skin

Nursing Interventions: b. Strain all urine with gauze or strainer c. Crush all clots d. Force fluids 3000-4000cc/ day e. Encourage ambiulation to prevent stasis f. Relieve pain by analgesics or moist heat g. I and O

Classification of Stones: b. Acid stones- uric acid, cystine. Xanthine c. Alkaline stones- phosphate, calcium, oxalate

Nursing Management: 2. Modified diet c. Alkaline ash- for acid stones; vegetables, fruits, except prunes, plums and cranberries d. Acid ash- for alkaline stones; cranberries, prunes and plums, meat fish, eggs, whole grain; limit milk *avoid oxalates- tea, chocolate, spinach *avoid purine- liver,brain, kidneys, shell fish, legumes

1. Allopurinol or zyloprim- decrease uric acid production; enhance excretion of uric acid 2. Lithotripsy- crushing of stone c. ESWL- Extracorporeal Shock Wave Lithotripsy d. Electrohydraulic Lithotripsy 5. Surgery f. Lithopalaxy g. Pyelithotomy, Nephrolithotomy, Utero-lithotomy, Cystolithotomy

1. Bladder Cancer- most common Ca in urinary tract; incidencemen 50-70 yrs Predisposing Factors: exposure to chemical especially, aniline dye, cigarette smoking and chronic bladder infection Nursing Management d. Surgery •

Cystectomy

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Uterosigmoidostomy

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Ileal conduit

h. Radiation i. Chemotherapy

1. Benign Prostatic Hypertrophy- hyperplasia and overgrowth of smooth muscles and connective tissues of the prostate glaned; most common problem of male reproductive system Incidence: 50% men over 50; 75% men over 75 Cause: hormonal mechanism Signs and Symptoms- nocturia, frequency, decrease force and amount of urinary system, hesitancy, hematuria, increased alkaline phophatase Nursing mgt: f. Antibiotics g. Proscar h. Prostacatheter

a. Surgery •

TURP Trans Urethral Resection of Prostate

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Suprapubic Prostatectomy

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Retropubic Prostatectomy

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Perineal Prostatectomy

Nursing Care in Cystolysis (CBI- Continuous Bladder Irrigation): b. Maintain patency of the catheter system c. Monitor appearance of urine; red to light pink (24hrs) to amber or tea-colored (3days) d. Monitor for signs of water intoxication; prevent water intoxication by using saline solution e. Avoid enemas and rectal temperature f. Used prescribed medications like analgesics and antispasmodics g. After catheter removal, monitor output for signs of urinary retention; monitor for continence; perineal exercise (kegal) if with dribbling; encourage frequent voiding and increased fluid intake

4. Renal Failure- state of total or nearly total loss of kidney function Acute Renal Failure- sudden inability of the kidneys to regulate fluid and electrolyte balance and remove toxic products from the body; reversible Causes: a. Pre-renal- factors interfering with perfusion and resulting in decreased blood flow and glomerular filtrate,ischemia and oliguria b. Intra-renal- conditions that cause damage to nephrons c. Postrenal- mecanical obstruction from tubules to urethra

Phases: 1. Onset- period precipitating event to development of oliguria 2. Oliguria ( to anuria)- urinary output less 400ml 3. Diuretic- gradual return of GFR and BUN level 4. Convalescent- renal function stabilizes with gradual improvement in 3-12 months

Signs and Symptoms: a. oliguria to anuria b. edema c. anorexia d. nausea or vomiting e. leukocytosis f. anemia g. bleeding tendencies h. drowsy i. Muscle twitching and coma (uremic encephalopathy)

Nursing Management a. Fluid and nutrition- limited fluids to 500ml to replace obligatory loss from lungs or skin b. Low protein diet c. Rest d. Precautions: side rails up e. Mouth or skin care f. Pharmacotherapeutics- diuretics g. Dialysis

Chronic Renal Failure- progressive irreversible destruction of kidneys that continues until nephrons are replaced with scar tissues Predisposing Factors: recurrent infections, exacerbations of nephritis, urinary tract obstructions, diabetes, hypertension Signs and Symptoms: a. Electrolyte imbalance b. Cardiovascular- hypertension,left ventricular hypertrophy, CHF c. Hematologic- anemia, decreased erythropoeitin, increased hematocrit and bleeding tendencies

d. Gastro-intestinal- anorexia, nausea, vomiting e. Respiratory- fluid overload, pulmonary edema: “uremic lung” f. Orthopedic- increased Ca elimination, decreased serum Ca, osteodystrophy or osteomalacia g. Dermatological- excoriation or dry skin, uremic frost h. Neurologic- peripheral neuropathy, burning feet; CNS nystagmus, twitching, seizure i.Reproductive-menstrual irregularities impotence, testicular atrophy and decreased sperm count j. Psychological- behavioral and personality changes k. impaired immunologic system- increased susceptibility to infection

Stages of CRF: 1. Renal impairment 2. Renal insufficiency 3. Renal failure 4. End stage of Renal disease

Nursing Management: 1. Conservative- assess uremia, mental function and supportive; avoid undue fatigue 2. Advanced renal failure- oliguric or uremic phase a. peritoneal dialysis b. hemodialysis c. kidney transplant 3. Dietary- early- no restriction - advanced- low protein Giordano or Giovanette diet- low protein with amino acids

Dialysis- removal by artificial means of metabolic wastes, excess electrolytes and excess fluids

Principles: -Diffusion, Osmosis, Ultrafiltration Purposes: 1. To remove excessive amounts of drugs or toxins in poisoning 2. To check serious electrolyte or acid base imbalance 3. To maintain kidney function when renal shutdown occurs 4. To temporarily replace kidney function in patients with acute renal failure and permanently replace in chronic renal failure

Peritoneal Dialysis- introduction of specially prepared dialysate solution into the abdominal cavity where the peritonem acts as a semipermeable membrane between the dialysate and blood in the abdominal vessels Nursing Interventions: a. weight, VS every 15 mins then every hour b. Patient voids c. Warm dialysate solution to body temperature d. Assist in trocar insertion e. Inflow time, Dwell time and Drain time f. Observe character of dialysate flow

Complications: • Peritonitis •Respiratory Difficulty •Protein loss

Types of Peritoneal Dialysis • CAPD- Continuous Ambulatory Peritoneal Dialysis •CCPD- Continuous Cycle Peritoneal Dialysis •IPD- Intermittent Peritoneal Dialysis

Hemodialysis- shunting of blood from client’s vascular system through an artificial dialyzing system and return of dialyzed blood to client’s circulation Dialysis coil- acts as a semipermeable mebrane Access Routes: • AV shunt or cannula • AV fistula • Femoral or subclavian cannulation

Nursing Interventions: 1. Auscultate for bruit and palpate thrill- check patency 2. Check bleeding 3. Observe arm precaution 4. Avoid restrictive clothing or dressings over site Complications: 1. Hypovolemic Shock 2. Dialysis disequilibrium syndrome

Renal transplant pre-requisites 1. Evaluation of patient’s medical immunologic, psychological and social status 2. Should be identical- ABO and HLA compatible Contraindications: 1. Acute infection 2. Malignancy 3. COPD 4. Liver disorder 5. DM 6. Atherosclerosis

Pre-op care: 1. Dialysis to make patient non-toxic 2. Treat all complications 3. Immunosuppressive drug to start 24hrs before transplant; immuran, prednisone, sandimmune 4. Transplanted kidney placed on thigh, usually iliac fossa

Post-op care: 1. Reverse isolation 2. Monitor renal functions 3. Respiratory, therapy, deep breathing and coughing exercises 4. Aseptic wound care 5. Oral hygiene 6.NGT to prevent paralytic ileus 7. Early ambulation 8. Health adjustment process 9. Lifetime-immune suppressive drugs

Complications: • Acute rejection • Chronic rejection