Fluid And Electrolytes

FLUID AND ELECTROLYTES

Anatomy and Physiology TOTAL BODY WATER (TBW) 60% Body Weight • INTRACELLULAR FLUID (ICF) 40% • EXTRACELLULAR FLUID (ECF)20% Interstitial Intravascular Trancellular • THIRD SPACE FLUID Disease; injury

Electrolytes  Na  Cl K  PO4

Extracellular CATION Extracellular ANION Intracellular CATION Intracellular ANION

Body Fluid Transport • DIFFUSION Higher to lower concentration • OSMOSIS Lower to higher concentration Semi permeable membrane • FILTRATION Particles • ACTIVE TRANSPORT Na-K Pump Requires ATP

Fluids • BODY INPUT Fluids Food Digestion Total

1500mL 500mL 500mL >2500mL

• BODY OUTPUT Urine 1500mL Feces 200-400mL Respiration200-400mL Skin 200-400mL Total >2500mL

Intravenous Fluids  ISOTONIC:

Equal in concentration • 0.9% NaCl or NSS • D5 Water, Lactated Ringer’s

Intravenous Fluids  HYPOTONIC:

↓ Salt or solute Cellular swelling • 0.45% NaCl, Distilled water  HYPERTONIC:

↑ Solute Cellular shrinkage • D5 NSS, D10 Water • D5 0.45 % NaCl, D5 LRS

FLUID VOLUME DEFICIT DEHYDRATION

Inadequate Intake Excessive Loss Types: • ISOTONIC Dehydration • HYPERTONIC Dehydration • HYPOTONIC Dehydration

FLUID VOLUME DEFICIT Assessment:

↓ BP; ↑ PR Weak and thready pulses Flat neck veins Lethargic to coma Dry skin; poor skin turgor Oliguria (↓ UO) ↑ Urine specific gravity Thirst

FLUID VOLUME DEFICIT Management:

Monitor VS; BP and PR Mild: Oral Rehydrating Solution (ORS) Severe: IV fluid Administer prescribed meds • Antibiotics • Antiemetics • Antipyretics Monitor/ correct electrolyte imbalances

FLUID VOLUME EXCESS FLUID OVERLOAD Types: • ISOTONIC • HYPOTONIC • HYPERTONIC

FLUID VOLUME EXCESS Assessment:

↑ BP and CVP Bounding pulse ↑ RR, Dyspnea Crackles Distended neck vein Altered level of consciousness Weight gain Ascites; pedal edema Polyuria

FLUID VOLUME EXCESS Management:

Monitor VS: BP and RR Monitor I and O Restrict fluid and Na intake Weight and AC OD pre-breakfast Administer prescribed diuretics Monitor/treat electrolyte imbalances

HYPOKALEMIA Normal K 3.5-5.0 meq/L K ↓ 3.5 meq/L Causes:

Diuretics, digitalis, and steroids Cushing’s syndrome Metabolic Alkalosis Diarrhea, NPO ↑ Insulin

HYPOKALEMIA Assessment:

Weak irregular pulses ECG: • U wave • Inverted T waves Altered LOC Shallow respiration Weakness; hyporeflexia Ileus; constipation

HYPOKALEMIA Management:

Monitor VS; PR Monitor serum K values Bed rest Encourage K-rich foods: • Banana, avocado, raisins, orange, potatoes Diet: High fiber foods K- sparing diuretics • Spirinolactone (Aldactone)

HYPOKALEMIA Management: • Oral Potassium Kalium Durule (PC) K-Lor • IV Potassium NEVER given by IV push, IM nor SC 5-10 meq/hr Use of cardiac monitor Assess IV site

HYPERKALEMIA K ↑ 5.5 meq/L Causes:

Excessive K intake K sparing diuretics Addison’s disease Chronic renal failure (CRF) Metabolic Acidosis Tissue damage; injury

HYPERKALEMIA Assessment:

Irregular weak pulses, ↓ BP ECG: • Tall T wave • Flat P wave Muscular weakness Paresthesia Diarrhea

HYPERKALEMIA Management:

Monitor VS Restrict K rich foods Discontinue K supplements PO/ IV If no renal disease; Diuretics Na polystyrene sulfonate (KAYEXALATE) → K excretion

Prepare for dialysis Administer NaHCO3 Glucose with insulin

HYPONATREMIA Serum Na 135-145meq/L Na ↓ 135 meq/L Causes:

Diuretics Diaphoresis Addison’s Disease SIADH NPO, ↓ Salt diet Freshwater drowning

HYPONATREMIA Assessment:

↑ Pulse rate Shallow respiration Headache; altered LOC Seizures Weakness Polyuria (↑ UO)

HYPONATREMIA Management:

Monitor VS Monitor LOC Intake of Na rich foods: →Table salt, soy sauce, cured pork, canned and processed foods Hypovolemia: IVF NSS (ISOTONIC) Fluid excess: Osmotic diuretics SIADH: Lithium and Demeclocycline → Antagonize ADH Seizure precautions

HYPERNATREMIA Na

↑145 meq/L

Causes:

Steroids ↑ Na intake ↓ Water intake Cushing’s syndrome Chronic renal failure (CRF)

HYPERNATREMIA Assessment:

↓ PR Shallow respiration Weakness Dry flaky skin Altered LOC Oliguria (↓ UO)

HYPERNATREMIA Management:

Monitor VS Restrict Na and fluid Diuretics Hypovolemia: D5W and HYPOTONIC IVF

HYPOCALCEMIA Serum Ca 8-10.5 mg/dL 4.5-5.5 meq/L Ca ↓ 8 mg/dL Causes:

↓ Intake of Ca and vitamin D Lactose intolerance Parathyroidectomy CRF Diuretics

HYPOCALCEMIA Assessment:

Irregular pulses ECG Prolonged ST interval Prolonged QT interval Paresthesia; numbness Weakness Tetany; carpopedal spasm (+) Trosseau’s sign (+) Chvostek’s sign

HYPOCALCEMIA Management:

Monitor VS; PR/ CR Monitor serum Ca and Mg Encourage Ca-rich foods: Milk and poultry, cheese, eggs Oral Ca supplement: • CaCO3 (Calci-Aid) 1-2 hrs PC or HS

HYPOCALCEMIA Management:

IV Ca: • Calcium Gluconate Given very SLOWLY Never thru IV push, IM or SQ Use of cardiac monitor Assess PR/ CR

HYPERCALCEMIA Ca ↑10.5mg/dL Causes:

Excessive intake of Ca or Vitamin D Use of Thiazides; Lithium Hyperparathyroidism Malignancy Immobility; Fracture

HYPERCALCEMIA Assessment:

Irregular CR cardiac arrest ECG: • Shortened ST interval Altered LOC Muscle weakness Colic pain → Renal stones Constipation

HYPERCALCEMIA Management:

Monitor VS; CR Restrict Ca rich foods Discontinue PO and IV Ca Give prescribed Diuretics ↑ Fluid intake • Calcitonin; Biphosphanates • ASA and NSAIDS →Inhibit Ca resorption from bones Prepare for dialysis

ACID BASE BALANCE Hydrogen ions (H)  

ACIDS BASES

→ pH

→ Hydrogen donors → Hydrogen acceptors

CARBONIC ACID/ BICARBONATE SYSTEM Maintains pH of 7.4 Bicarbonate to Carbonic Acid Ratio  

CARBONIC ACID BICARBONATE

Lungs Kidneys

20:1

ACID BASE BALANCE  ACIDOSIS

→ Hyperkalemia (↑ K)  ALKALOSIS → Hypokalemia (↓ K)

ARTERIAL BLOOD GAS PH PCO2 HCO3 PO2

7.35- 7.45 35- 45 mmHg 22- 26 meq/L 80- 100 mmHg

ARTERIAL BLOOD GAS  ROME

• Respiratory Acidosis • Respiratory Alkalosis • Metabolic Acidosis • Metabolic Alkalosis

↓pH ↑pH ↓pH ↑pH

↑pCO2 ↓pCO2 ↓HCO3 ↑HCO3

ARTERIAL BLOOD GAS Pre-op care:  ALLEN’S Test

Rest x 30 min NO SUCTION  Note O2 therapy 

Room air: → No O2 

Prepare heparinized syringe

ARTERIAL BLOOD GAS Post-op care: Container with ice Client’s temperature  O2 and respirator set up  Pressure dressing x 5-10 min

RESPIRATORY ACIDOSIS 

↓pH

↑pCO2

Causes:  Pulmonary Diseases: • PTB, Pneumonia • COPD, B. Asthma  Brain Injury  Medications: • Sedatives, Narcotics, Anesthetics

RESPIRATORY ACIDOSIS Assessment:  HYPOVENTILATION

(Rapid, shallow breathing) ↑ PR Headache Blurring of vision  Restlessness  Cyanosis 

RESPIRATORY ACIDOSIS Management:  Semi to high fowlers  Monitor VS; RR  Administer O2  Coughing and deep breathing exercises Turning from side to side Encourage hydration Suction secretion PRN Appropriate treatment as prescribed • Bronchodilators, Antibiotics • Respirator; CTT/ Thoracentesis

RESPIRATORY ALKALOSIS 

↑pH

↓pCO2

Causes:  Hysteria  Anxious; panic states  Severe pain; fever  Over- use of respirator

RESPIRATORY ALKALOSIS Assessment:  HYPERVENTILATION

(Rapid, deep breathing) Headache; dizziness Mental status changes Paresthesia  Weakness  Tetany; carpopedal spasm 

RESPIRATORY ALKALOSIS Management:  Monitor VS; RR  Emotional support and reassurance  Appropriate breathing patterns: → ↑pCO2

• Brown bag • Voluntary holding of breath Monitor electrolytes 

Cautious care with clients on respirator

Administer prescribed medication

METABOLIC ACIDOSIS 

↓pH

↓HCO3

Causes:  DM/DKA  CRF

Starvation; malnutrition Lactic acidosis ASA and ethanol intoxication  Severe diarrhea 

METABOLIC ACIDOSIS Assessment:  KUSSMAUL BREATHING

(Rapid, deep breathing) Irregular pulses Headache Altered LOC  Fruity or ketone breath  ↑ Serum K 

METABOLIC ACIDOSIS Management:  Monitor VS; RR and PR  Assess LOC

Monitor I and O 

Assess and correct serum K

Safety and seizure precaution Administer NaHCO3  Administer Kayexalate 

DM: Give prescribed insulin CRF: Prepare for dialysis

METABOLIC ALKALOSIS 

↑pH

↑HCO3

Causes:  Excessive NaHCO3 intake  Chronic use of diuretics  Excessive vomiting/GI suctioning

Several BT with FWB (Citrate)

METABOLIC ALKALOSIS Assessment: Nausea and vomiting  Irregular pulses 

Restlessness Paresthesia 

↓ Serum K

METABOLIC ALKALOSIS Management:  Monitor VS; PR

Assess and correct serum K Safety precautions Discontinue HCO3  Administer prescribed anti-emetics 