Fluids & Electrolytes
Nio Cruzada Noveno, RN, MAN, MSN
FLUIDS and ELECTROLYTES BODY FLUIDS Functions of Fluids o
Body fluids: o Facilitate in the transport [nutrients, hormones proteins, & others…] o Aid in removal of cellular metabolic wastes o Provide medium for cellular metabolism o Regulate body temperature o Provide lubrication of musculoskeletal joints o Component in all body cavities [parietal, pleural fluids]
Water is the principal body fluid & essential for life. 2
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Renal Disorders
FLUIDS and ELECTROLYTES BODY FLUIDS Distribution of Body Fluids: 50-70% of total body weight; infant [70-80%], elderly [45-50%] ICF
ECF 60-kg man TBW = 0.6 x 60 kg = 3.6 L
P
IS
ICF = 0.4 x 60 kg = 24 L
ECF =12 L
3L 9L 3
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40% TBW
20% TBW
Renal Disorders
FLUIDS and ELECTROLYTES BODY FLUIDS Factors that Dictate Body Water Requirement 1) Amount needed to give the proper osmotic concentration 2) Amount needed to replace water lost excretion Normal Routes of water gain and loss INTAKE
ml/day
Fluid intake 1,500 Food 800 Metabolic water 300 4
TOTAL
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2,600
OUTPUT
ml/day
Insensible loss 400 Sweat 600 Feces 100 Urine 1,500 TOTAL 2,600 Renal Disorders
FLUIDS and ELECTROLYTES FLUID EXCHANGE BETWEEN BODY FLUID COMPARTMENTS ICF
ECF
Osmotic Pressure Gradient
Oncotic P (Colloid osmotic P) Capillary P (Hydrostatic P)
5
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P
ISF
Renal Disorders
FLUIDS and ELECTROLYTES Control of Osmotic Pressure, Volume & Electrolyte Concentration OBLIGATORY Reabsorption o occurs in the proximal tubules o 178 L/day of glomerular filtrate (80% reabsorbed) o 2° to solute reabsorption o independent of the water requirement
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FACULTATIVE Reabsorption o occurs in the distal & collecting tubules o independent of the active solute transport o dependent of body’s need of water o under the control of ADH
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FLUIDS and ELECTROLYTES DISTURBANCES IN FLUID BALANCE EDEMA (Dropsy) ο
7
↑ in the interstitial fluid volume of about 2 L or more due to increase transudation of fluid from capillaries 2° to: o
Increased HP [pregnancy, CHF]
o
Decreased OP [malnutrition, end-stage liver disease, nephrotic syndrome]
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Renal Disorders
FLUIDS and ELECTROLYTES DISTURBANCES IN FLUID BALANCE CELL OVERHYDRATION
8
o
excess of water in the ECC w/ a normal amount of solute or a deficient amount of solute
o
occurs in prolonged and excessive diuresis, forcing hypotonic fluids to produce diuresis in the presence of renal impairment
o
fluid overload from ↑ production of adrenal corticoid hormones [Cushing’s syndrome]
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Renal Disorders
FLUIDS and ELECTROLYTES DISTURBANCES IN FLUID BALANCE CELL OVERHYDRATION o
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Symptoms o Weight gain & edema o Cough, moist rales, dyspnea [fluid congestion in lungs] o CVP, bounding pulse, neck vein engorgement [fluid excess in the vascular system] o Bulging fontanelles ο ↓ Hg and Hct o Nausea & vomiting
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Renal Disorders
FLUIDS and ELECTROLYTES DISTURBANCES IN FLUID BALANCE CELL OVERHYDRATION o
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Management o Restrict fluids to lower fluid volume o Diuretics or hypertonic saline o Continuous assessments to prevent skin breakdown o Record daily weight to assess progress of treatment
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Renal Disorders
FLUIDS and ELECTROLYTES DISTURBANCES IN FLUID BALANCE CELL DEHYDRATION (DHN) o o o
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loss of body fluids, particularly from the extracellular fluid compartment water loss > water intake Causes o Fever o Insufficient water intake o Diarrhea, vomiting o Excess urine output [Diabetes insipidus, diuretics] o Excessive perspiration, burns o Hemorrhage, shock, metabolic acidosis
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Renal Disorders
FLUIDS and ELECTROLYTES DISTURBANCES IN FLUID BALANCE CELL DEHYDRATION (DHN) o
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Symptoms o Thirst, dry mucus membranes, sunken eyeballs o “Doughy“ abdomen, dry skin w/ poor turgor ο ↑ temp, weight loss ο ↑ HR, ↑ RR, ↓ BP o Restlessness,irritability, disorientation, convulsion, coma [22-30% body H20 loss] o Management o Fluid replacement therapy & continued fluid maintenance
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FLUIDS and ELECTROLYTES Volume Disorders 2° Alteration in Sodium Balance Volume Disorder
ECF Vol.
ICF Vol.
Inc
N
Hypertonic
Inc
Dec
ICF → ECF
Hypotonic
Inc
Inc
ECF → ICF
Contraction Isotonic Hypertonic Hypotonic
Dec Dec Dec
N Dec Inc
Expansion Isotonic
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Water Shift No net change
Conditions
Isotonic fluid ingestion Sea water ingestion Hypotonic IVF
No net change Diarrhea ICF → ECF Diabetes insipidus ECF → ICF Addison’s dse Renal Disorders
FLUIDS and ELECTROLYTES ELECTROLYTES o salts or minerals in extracellular or intracellular body fluids o Sodium – major cation of ECF o Potassium – major cation of ICF o Chloride - major anion of ICF o Protein – in ICF > ISF
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Renal Disorders
FLUIDS and ELECTROLYTES ELECTROLYTE Composition Electrolyte Conc
Plasma (mEq/L)
Sodium, Na+ Potassium, K+ Calcium, Ca++ Magnesium, Mg++
142 5 5 3 (155) 103 27 2 1 16 6 (155)
Chloride, ClBicarbonate, HCO3Biphosphate, HPO4Sulfate, SO4Protein Organic foods 15
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ISF
ICF
141 4.1 4.1 3
10 150 40
115 29 2 1 1 3.4
15 10 100 20 60 Renal Disorders
FLUIDS and ELECTROLYTES ELECTROLYTES Functions of Electrolytes
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o
Contribute most of the osmotically active particles in body fluids
o
Provide buffer systems for pH regulation
o
Provide the proper ionic environment for normal neuromuscular irritability & tissue function
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Renal Disorders
FLUIDS and ELECTROLYTES ELECTROLYTES Hyponatremia [Na+ < 135 mEq/L; Normal = 135-145 mEq/L] o
o
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Causes ο ↓ Na+ intake ο ↑ Na+ excretion [diaphoresis, GI suctioning] o Adrenal insufficiency
Assessment o N & V, abdominal cramps, weight loss o Cold, clammy skin, ↓ skin turgor o Apprehension, HA, convulsions, focal neurologic deficit, coma [cerebral edema] o Fatigue, postural hypotension o Rapid thready pulse
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Hyponatremia Drugs that cause decreased sodium Anti-convulsant: Carbamazepine Antidiabetics: Chlorpropramide Tolbutamide Antipsychotics: Fluphenazine Thiozoridazine Thiothixene 18
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Antineoplastics: Cyclophosphamide Vincristine Diuretics: Bumetanide Ethacrynic acid Furosemide Thiazides Sedatives: Barbiturates Morphine Renal Disorders
FLUIDS and ELECTROLYTES ELECTROLYTES Hyponatremia [Na+ < 135 mEq/L; Normal = 135-145 mEq/L]
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Management o Provide foods high in sodium o Administer NSS IV o Assess blood pressure frequently [measure lying down, sitting & standing] o High sodium foods o Celery o Cheeses o Condiments o Processed foods o Smoked meats
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Treatment Interventions Mild Water restriction if water retention
problem Increase Na in foods if loss of Na Moderate IV 0.9% NS, 0.45% NS, LR Severe 3% NS – short-term therapy in ICU setting 20
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Renal Disorders
FLUIDS and ELECTROLYTES ELECTROLYTES Hypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L] o
o
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Causes o Excessive, rapid IV adm’n of NSS o Inadequate water intake o Kidney disease
Assessment o Dry, sticky mucus membranes o Flushed skin o Rough dry tongue, firm skin turgor o Intense thirst o Edema, oliguria to anuria o Restlessness, irritability [cerebral DHN]
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Hypernatremia
Skin flushed Agitation Low-grade fever Thirst 22
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Renal Disorders
FLUIDS and ELECTROLYTES ELECTROLYTES Hypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L] o
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Nursing Intervention o Weigh daily o Assess degree of edema frequently o Measure I & O o Assess skin frequently & institute nursing measures to prevent breakdown o Encourage sodium-restricted diet
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Renal Disorders
FLUIDS and ELECTROLYTES ELECTROLYTES Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L] o
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Causes o Renal insufficiency o Adrenocortical insufficiency o Cellulose damage [burns] o Infection o Acidotic states o Rapid infusion of IV sol’n w/ potassiumconserving diuretics
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Renal Disorders
Hyperkalemia Drugs that increase potassium
ACE inhibitors Antibiotics Beta blockers
25
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NSAIDs Spironolactone Chemotherapeutics
Renal Disorders
FLUIDS and ELECTROLYTES ELECTROLYTES
Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L] o Assessment o Thready, slow pulse o Shallow breathing o N & V, diarrhea, intestinal colic o Irritability o Muscle weakness, flaccid paralysis o Numbness, tingling o Difficulty w/ phonation, respiration 26
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Renal Disorders
FLUIDS and ELECTROLYTES ELECTROLYTES Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L] o
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Nursing Interventions o Administer kayexalate as ordered o Administer/monitor IV infusion of glucose & insulin o Control infection o Provide adequate calories & carbohydrates o Discontinue IV or oral sources of K+
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Renal Disorders
FLUIDS and ELECTROLYTES ELECTROLYTES Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L] o
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Causes o Renal tubule defects o Prolonged diuretic therapy o Prolonged vomiting, diarrhea, laxative use, NG suctioning, severe diaphoresis o Anorexia o Acute alcoholism o Hyperaldosteronism, excessive steroids o Metabolic alkalosis o Administration of potassium-deficient hyperalimentation sol’n, hypertonic glucose o Excessive amounts of insulin
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Renal Disorders
FLUIDS and ELECTROLYTES ELECTROLYTES Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L] o
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Assessment o Thready, rapid, weak pulse o Faint heart sounds ο ↓ BP o Skeletal muscle weakness ο ↓ or absent reflexes o Shallow respirations o Malaise, apathy, lethargy o Loss of orientation o Anorexia, vomiting, weight loss o Gaseous intestinal distention
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Renal Disorders
Hypokalemia Skeletal muscle weakness U-wave Constipation; ileus Toxic effects of digoxin Irregular, weak pulse Orthostatic hypotension Numbness [paresthesia] 30
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Renal Disorders
Hypokalemia Drugs that decrease potassium Adrenergics: Albuterol Epinephrine Antibiotics: Amphotericin B Carbenicillin Gentamicin Insulin 31
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Cisplatin Costicosteroids Diuretics: Furosemide Thiazides Laxatives [excess use]
Renal Disorders
FLUIDS and ELECTROLYTES ELECTROLYTES Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L] o
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Nursing Interventions o Administer K+ supplements to replace losses o Be cautious in administering drugs that are not potassium-sparing o Monitor acid-base balance o Monitor pulse, BP and ECG o High potassium foods o Avocados o Bananas o Dates o Oranges o Potatoes
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FLUIDS and ELECTROLYTES ELECTROLYTES Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L] o
Causes o Hyperparathyroidism o Immobility o Increased vitamin D intake o Osteoporosis & osteomalacia [early stages]
o
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Assessment o N & V, anorexia, constipation o Headache, confusion o Lethargy, stupor o Decreased muscle tone
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Renal Disorders
Hypercalcemia Drugs that increase calcium Calcium-containing antacids Calcium preparations Lithium Thiazide diuretics Vitamin A Vitamin D 34
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Renal Disorders
FLUIDS and ELECTROLYTES ELECTROLYTES Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L] o
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Nursing Interventions o Encourage mobilization o Limit vitamin D intake o Limit calcium intake o Normal saline o Administer diuretics o Calcitonin
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Renal Disorders
FLUIDS and ELECTROLYTES ELECTROLYTES Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L] o
o
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Causes o Acute pancreatitis o Diarrhea o Hypoparathyroidism o Lack of vitamin D in the diet o Long-term steroid therapy
Assessment o Painful tonic muscle & facial spasms o Fatigue, dyspnea o Laryngospasm, convulsions
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FLUIDS and ELECTROLYTES ELECTROLYTES Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L] o
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Nursing Interventions o Administer oral Ca lactate or IV CaCl2 or gluconate o Providing safety by padding side rails o Administer dietary sources of calcium o Vitamin D o Provide quiet environment o High calcium foods o Milk o Dairy products
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Renal Disorders
FLUIDS and ELECTROLYTES ELECTROLYTES Hyermagnesemia [Mg > 3.0 mEq/L; Normal = 1.5-3.0 mEq/L] o
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Causes o Renal insufficiency, dehydration o Excessive use of Mg-containing antacids or laxatives o Assessment o Lethargy, somnolence, confusion o N&V o Muscle weakness, depressed reflexes ο ↓ pulse and respirations o Nursing Intervention o Withhold Mg-cont’g drugs/foods; Ca adm’n
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FLUIDS and ELECTROLYTES ELECTROLYTES Hypomagnesemia [Mg < 1.50 mEq/L; Normal = 1.5-3.0 mEq/L] o
39
Causes o Low intake of Mg in the diet o Prolonged diarrhea o Massive diuresis o Hypoparathyroidism o Assessment o Paresthesias, muscle spasm o Confusion, hallucination, convulsions o Ataxia, tremors, hyperactive deep reflexes o Flushing of the face, diaphoresis o Nursing Intervention
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Hypomagnesemia Drugs that decrease magnesium Aminoglycoside: Amikacin, gentamicin, streptomycin, tobramycin
Amphotericin B Cisplatin Cyclosporine 40
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Insulin Laxative Loop diuretics Pentamidine isethionate
Renal Disorders
Hypomagnesemia Seizures Tetany Anorexia & arrhythmias Rapid heart rate Vomiting Emotional lability Deep tendon reflexes increased [tremors, twitching, tetany] 41
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Renal Disorders
Dietary sources Chocolates Dry beans and peas Green, leafy vegetables Meats Nuts Seafood Whole grains 42
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Renal Disorders
FLUIDS and ELECTROLYTES IV FLUID REPLACEMENT THERAPY
Indications o Replacement of abnormal fluid & electrolyte losses [surgery, trauma, burns, GI bleeding] o Maintenance of daily fluid & electrolyte needs o Correction of fluid disorders 43
o Correction of electrolyte disorders
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Renal Disorders
FLUIDS and ELECTROLYTES IV FLUID REPLACEMENT THERAPY Types of Solutions o
44
Isotonic o 0.9% sodium chloride (NSS) o Lactated Ringer’s sol’n o Hypotonic o 5% dextrose and water (D5W) o 0.45% sodium chloride o 0.33% sodium chloride o Hypertonic o 3% NaCl o Protein sol’ns o Colloids
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BURNS BURNS
wounds caused by excessive exposure to the following agents or causes: Causes of Burns: o o o o 45
Thermal [moist or dry heat] Electrical Chemical [strong acids and strong alkali] Radiation [UV, x-rays, radium, sunburns]
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Renal Disorders
BURNS CLASSIFICATION OF BURNS o
46
Superficial Partial thickness (1st degree) o Outer layer of dermis o Erythema, pain up to 48 hrs o Healing 1-2 wks [sunburn] o Deep Partial thickness (2nd degree) o Epidermis & dermis o Blisters & edema, frequently quite painful o Healing 14-21 days o Full thickness (3rd degree) o Epidermis, dermis, subcutaneous fat o Dry, pearly white or charred in appearance o Not painful o Eschar must be removed; may need grafting
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BURNS STAGES OF BURNS 1st : Shock/Fluid Accumulation Phase o o o o o o o o 47
1st 48 hrs IVC → ISC Generalized DHN [fluid shifting] Hypovolemia [plasma loss], ↓ BP, ↓ C.O. Hemoconcentration, ↑ Hct [liquid blood component → ISC] Oliguria [↓ renal perfusion], ADH release & aldosterone HyperK, hypoNa Metabolic acidosis
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Renal Disorders
BURNS STAGES OF BURNS 2nd : Diuretic/Fluid Remobilization Phase o o o o o o o 48
After 48 hrs ISC → IVC Hypervolemia, Hemodilution, ↓ Hct Diuresis [↑ renal perfusion], ↓ ADH & aldosterone secretion HypoK, hypoNa [K moves back into the cells, Na+ still trapped in the edema fluids Metabolic acidosis
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Renal Disorders
BURNS STAGES OF BURNS 3rd : Recovery Phase o o
o
o 49
5th day onwards Hypocalcemia o Ca is lost on the exudates o Ca is utilized in the granulation tissue formation Negative nitrogen balance o Due to stress response ο ↑ protein catabolism o Protein intake is lesser than the demand HypoK
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Renal Disorders
BURNS ASSESSMENT 1. Assess extent of body surface burned o Greater morbidity & mortality for burns affecting face, hands & perineum o Assess for dyspnea, stridor, hoarseness 1. Assess extent of burn injury o Rule of nine – immediate appraisal o Lund-Browder chart – more accurate o Berkow’s method – based on client’s age & changes that occur in proportion of head & legs to the rest of the body as one grows 50
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Renal Disorders
BURNS ASSESSMENT 9%
9%
Front=18% Back=18%
9%
1% 18% 18%
51
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Burn Evaluation Chart
Renal Disorders
BURNS ASSESSMENT 3. Assess depth of burn o Major burns – 2nd degree over 30% of body o Hospitalization - eyes, face, neck, hands, perineum, genitalia 4. Assess unique contributing factors o Age of client o Health history o Diabetes, preexisting ulcers o Tetanus immunization
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Renal Disorders
BURNS EMERGENCY MANAGEMENT Stop the burning process o Remove patient from source of injury o Advise client to roll on the ground if clothing is in flame [STOP-DROP-ROLL] o Throw a blanket over the client to smother the flame o Remove clothing only if hot or for scald burn o Immerse affected part in cold water [10 min] o Irrigate copiuosly w/ large amount of running water w/ chemical burns [except w/ phosphorus] o Interrupt power source w/ electrical burn 53
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Renal Disorders
BURNS MANAGEMENT
54
o
Maintenance of adequate airway
o
Promoting comfort: relieve pain
o
Promoting fluid-electrolyte, acid-base balance
o
Preventing infection
o
Maintaining adequate nutrition
o
Wound care
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Renal Disorders
BURNS METHODS OF TREATING BURNS
55
o
Open method or Exposure method o Face, neck, perineum, trunk o Allowing exudate to dry in 3 days
o
Occlusive o Less pain, absorption of secretion, comfort, transportability, accelerated debridement o Aesthetic considerations
o
Semi-open method o Covering of wound w/ topical antimicrobials: o Silver sulfadiazine 1% (Flamazine) o Silver nitrate 0.5% sol’n o Mafenide acetate (sulfamylon acetate)
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Renal Disorders
BURNS BIOLOGIC DRESSING (Skin Graft)
56
o
Allograft o Skin taken from other person [cadaver]
o
Autograft o Same person
o
Heterograft o Different species o Xenograft [segment of skin from animal such as pig or dog]
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Renal Disorders
BURNS FLUID REPLACEMENT Types of fluids:
57
o
Colloids o Blood o Plasma & plasma expanders
o
Electrolytes o Lactated Ringers
o
Non-electrolyte o D5W
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Renal Disorders
BURNS FLUID REPLACEMENT EVAN’S Formula: o o o
C – 1ml x % burns x kg BW E - 1ml x % burns x kg BW Glucose 5% for insensible loss – 2,000ml D5W
Administer sol’n 1st 24 hrs – ½ [1st 8hrs], ½ [16hrs] BROOKE Formula: [Administer as in Evan’s] o o o 58
C – 0.5ml x % burn x kg BW E - 1.5ml x % burn x kg BW Water – 1000ml D5W
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Renal Disorders
BURNS FLUID REPLACEMENT MOORES BURN BUDGET: o
75 ml of plasma, 75 ml of electrolyte-cont’g fluid for q 1% TBSA plus 2000 D5W
HYPERTONIC RESUSCITATION Formula: o o
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Hypertonic salt containing 300 mEq of Na+, 100 mEq of Cl-, 200mEq lactate Administered to maintain urinary output of 30-40 ml/hr
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Renal Disorders
ACID-BASE DISORDERS Disorder
Clinical manifestation
Compensation
Respiratory acidosis
↑Paco2, ↑ or normal HCO3-, ↓ pH
Kidneys eliminate H+ and retain HCO3-
Respiratory alkalosis ↓ Paco2, ↓ or normal HCO3-, ↑ pH
Kidneys conserve H+ and eliminate HCO3-
Metabolic acidosis
↓ or normal Paco2, ↓HCO3-, ↓ pH
Lungs eliminate CO2 and conserve HCO3-
Metabolic alkalosis
↑ or normal Paco2, ↑HCO3-, ↑ pH
Lungs hypoventilate to ↑ Paco2, kidneys conserve H+ excrete HCO3-
nal Disorders60
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Causes of Acid-Base Disorders Metabolic acidosis Causes: DKA, uremia, starvation, diarrhea, severe infections Manifestations: Headache, nausea and vomiting Signs of hyperkalemia Seizures, coma, hyperventilation
nal Disorders61
Nursing management: Administer sodium bicarbonate Monitor for signs of hyperkalemia Provide alkaline mouthwash Lubricate lips to prevent dryness I & O Institute seizure precaution Monitor ABG & electrolyte losses
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Causes of Acid-Base Disorders Metabolic alkalosis Causes: Severe vomiting, NGT suctioning, diuretic therapy, excessive ingestion of NaHCO3, biliary drainage Manifestations: Nausea and vomiting Signs and symptoms of hypokalemia
nal Disorders62
Nursing management: Decreased respirations Replace fluids nad electrolytes losses I & O Assess for signs of hypokalemia Monitor ABG & electrolytes
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Causes of Acid-Base Disorders Respiratory acidosis Causes: Hypoventilation: COPD, barbiturate or sedative overdose, acute airway obstruction, neuromuscular disorders Manifestations: Headache, weakness, visual disturbances, rapid respirations, confusion, drowsiness, tachycardia, coma
nal Disorders63
Nursing management: Semi-Fowler’s Patent airway Turn, cough, deepbreath Administer fluids O2 therapy Monitor ABG
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Causes of Acid-Base Disorders
nal Disorders64
Respiratory alkalosis Causes: Hyperventilation, mechanical overventilation, encephalitis Manifestations: Numbness and tingling of mouth and extremities Inability to concentrate Rapid respirations, dry mouth, coma
Nursing management: Offer reassurance Encourage breathing into a paper bag Provide sedation as ordered Monitor mechanical ventilation and ABG
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Interpretation UC
PC
FC
pH
↓ or ↑
↓ or ↑
normal
HCO3-
↓ or ↑ normal
↓ or ↑
↓ or ↑
Paco2
↓ or ↑ normal
↓ or ↑
↓ or ↑
nal Disorders65
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Fluids & Electrolytes
Nio Cruzada Noveno, RN, MAN, MSN