FLUID MANAGEMENT

FLUID
FLUIDS DISTRIBUTION MANAGEMENT
Extracellular fluid (ecf) 1/3 Intracellular Fluid (icf) 2/3
Plasma 20 % Interstitial (between the protein Inside cells
PROTEIN PLASMA
OSMO: Different
S - -MEMBRANE
--
cells) 80 % 280 Na +
ACTIVE
Concentrations Passive

- - -
-295 Mg 2+  Osmotic

K +  hydrostatic

Water
Ca2+
CL-
HCO3_

Types of iv fluids
Crystalloids colloids
 Water + electrolytes / water soluble  Large insoluble molecules
molecules (proteins)
 Blood products are colloids
 Simplicity
 Cost effectiveness  Higher osmotic pressure
 Different combinations  More expensive
 No immune response  Immune Response

CRYSTALLOIDS
crystalloids
HYPOTONIC ISOTONIC HYPERTONIC
 Less osmotic  Some osmotic  Greater osmotic
concentration (<250/L) concentration (250 – concentrate (>375/L)
375/L)

Fluids moves ECF  ICF Won’t shift ECF  ICF Fluid pulled ICF  ECF
still will see shifts between
intravascular interstitial

Balanced vs. Unbalanced

compared to the balance of
natural plasma

- 3 types based on osmolality.

 Fluid Osmo Na+ Cl- K+ Ca2+ Mg2+ HCO3- Lac
Plasma 280-290 135-145 96-106 3.5-5.2 4.4-5.2 1.8-24 22.-26 I
Normal 308 154 154 – – – – –
Saline (0.9% Unbalanced
NS)
Common fluids

Most Common Issues:

  Chloride > plasma  hyperchloremic metabolic acidosis

 Negative effects on GFR (Associated w/ AKI)
o Hypercloremia – inflammation/edema =  renal blood flow

Fluid Osmo Na+ Cl- K+ Ca2+ Mg2+ HCO3- Lac

Lactated 273 130 109 4 3 – – 28
Ringers (LR) Balanced
o Renal clearance 30 – 40% slower

Most Common Issues:

 Slight hypotonic  ICF shift (cerebral edema/ICP) Lactate metabolized to

bicarb by liver.
Fluid Osmo Na+ Cl- K+ Ca2+ Mg2+ HCO3- Lac
Lactated 273 130 109 4 3 – – 28
Ringers (LR) Balanced
PlasmaLyte 295 140 98 5 – 4 – Acet: 27
Gluc: 23
Balanced
 Hepatic hypoperfussion =  lactate metabolism

Most Common Issues:

  Risk for hypochloremic metabolic acidosis

 Can use without RBC
Less liver involvement
GLUCONATE 
BICARB?
 Fluid Osmo Na+ Cl- K+ Ca2+ Mg2+ HCO3- Lac
3% Normal 1030
Saline ()
 Draw fluid from ICF  ECF

 TREATMENT FOR CEREBRAL EDEMA

 Treat severe symptomatic hyponatremia

   Na+ Cl-

 Too fast = intravascular volume overload

Fluid Osmo Na+ Cl- K+ Ca2+ Mg2+ HCO3- Lac

() ½ 154 77 77 – – – – –
Normal Unbalanced
Saline
(0.45% NS)
ECF  ICF

 Rapid administration REMEMBER

Isotonic
o Lysis of RBCs Normal Saline (0.9% NS)
Lactated Ringers (LR)
o Deplete intravascular volume
 Don’t use w/head injuries (  ICF =  Cerebral edema/ PlasmaLyte
ICP)  Hypertonic
CARDIOVASCULAR
 Treat hypernatremia Replace Free Water Deficit
3% normal saline
Hypotonic
COLLAPSE+
Fluid Osmo Na Cl- K+ Ca2+ Mg 2+
½ normal HCO
saine -
(0.45%
3
ns) Lac
Plasma 280-290 135-145 96-106 3.5-5.2 4.4-5.2 1.8-24 22.-26 I
Normal Saline (0.9% 308 154 154 – – – – –
NS) Unbalanced
Lactated Ringers (LR) 273 130 109 4 3 – – 28
Balanced
PlasmaLyte 295 140 98 5 – 4 – Acet: 27; Gluc:
23
Balanced
3% Normal Saline () 1030
() ½ Normal Saline 154 77 77 – – – – –
(0.45% NS) Unbalanced

DEXTROSE CONTAINING
 As Dextrose metabolized  osmolality
 Dextrose adds cals: 5% = 50g/L = 170 cal/L

10% = 100g/L = 340 cal/L

DEXTRO
SE
 Types of Fluids OSMOLALITY Remarks
ISOTONIC
5 % Dextrose – Water (D5W) 253 D5W  Free Water (hypotonic)
HYPERTONIC
5 % Dextrose – ½ Normal Saline 406 D5½NS  ½ NS (Hypotonic)
(D5½NS)
5 % Dextrose – Normal Saline (D5NS) 560 D5NS  NS (Isotonic)
5 % Dextrose – Lactated Ringers (D5LR) 527 D5LR  LR (Isotonic)
10 % Dextrose – Water (D10W) 505 D10W  Free water (Hypotonic)

cOLLOIDS
Colloids
 Referred to as volume or Plasma expanders
 High Oncotic pressure
o Don’t pass from the vascular  interstitial = pull fluid into vascular and keep there longer.
 Potential harm with capillary leak disorders (sepsis, ARDS)

ALBUMIN (Derived from plasma) HES (Hespan) & DEXTRAN

5% – Osmo: 309  Less common potential complications
25% – Osmo: 812
 Replace low levels
 Preserve renal function horrifically ill
 Adjunct to other fluids for hypovolemia
 Crystalloids + Albumin

 Watch out for:

 Heart rate
 Respiratory Rate
 Blood Pressure
 Temperature
 Character Crystalloid Colloid
In the Vein Poor Good
Hemodynamics Transient Prolong
Infusion Volume Large Moderate
Plasma COP Reduced Maintain
Tissue Edema Obvious Insignificant
Anaphylaxis Non-exist Low-mod
Cost Inexpensive Expensive

flui
FLUIDS & ELECTROLYTE BALANCE

 Nec
essa
ds
ry
for
life,

Fluid Electrolytes
 Approximately 60% of typical adult is  Active chemicals that carry positive (cations)
fluid and negative (anions) electrical charges
o Varies with age, body size, gender o Major cations: sodium, potassium,
 Intracellular fluid calcium, magnesium, hydrogen
o 2/3 of body fluid, skeletal muscle ions
mass o Major anions: chloride,
 Extracellular Fluid bicarbonate, phosphate, sulfatem
o Intravascular: plasma, erythrocytes, proteinate ions
leukocyte, thrombocytes o Expressed in terms of millequivalents
o Interstitial: lymph (mEq)
o Transcellular: Cerebrospinal,  Electrolyte concentrations differ in fluid
pericardial, synovial compartments.

Normal Values
Potassium 3.5 – 5.3 mg/dL
Sodium 135 – 145 mg/dL
Calcium 8.5 – 10.1 mg/dL
Phosphorus 3.5 – 4.5 meq/dL
Magnesium 1.5 – 2.5 meq/L
 FLUIDS

 Regulation of fluid #1
 Movement of fluid through capillary walls depends on:
o Hydrostatic pressure: exerted on walls of the blood vessels
o Osmotic pressure: exerted by protein in plasma
 Direction of fluid movement depends on differences of hydrostatic, osmotic pressure
 Osmosis: Area of low solute concentration to area of high solute concentration
 Diffusion: solutes move from area of higher concentration to one of lower concentration
 Filtration: movement of water, solutes occurs from area of high hydrostatic pressure to area of
low hydrostatic pressure
 Active transport: Sodium – potassium pump
o Maintains higher concentration of extracellular sodium, intracellular potassium.
 Routes of gains and losses
 Gain:
o Healthy people gain fluids by drinking and eating
o Daily I&O of water are equal
 Loss:
o Kidney: urine output of 1mL/kg/hr
o Skin Loss: sensible due to sweating and insensible due to fever, exercise and burns
o Lungs: 300 mL everyday, greater with increased RR
o GI Tract: Large losses due to diarrhea and fistulas
 Gerontologic considerations
 Clinical Manifestations of imbalance may be subtle
 Fluid deficit may cause delirium
 Decreased cardiac reserve
 Reduced renal function
 Dehydration is common
 Age – related thinning of the skin and loss of strength and elasticity.
 FLUid volume imbalances
 Fluid volume deficit (FVD): hypovolemia
 Fluid volume excess (FVE): hypervolemia
Fluid volume deficit
Fluid
volume
- May occur alone or in combination with other imbalances
deficit
- Loss of extracellular fluid exceeds intake ratio of water
o Electrolytes lost in same proportion as they exist in normal body fluids
- Dehydration
o Not the same as FVD
o Loss of water alone, with increased serum sodium levels

Causes of FVD

 Abnormal fluid losses

 Vomiting, diarrhea, sweating, GI suctioning
 Decreased intake
 Nausea, lack of access to fluids
 Third – space fluid shifts
 Due to burns, ascites
 Additional causes
 Diabetes insipidus, adrenal insufficiency, hemorrhage

Clinical manifestations

 Can develop rapidly

 Severity depends on degrees of loss

Nursing management

 I&O at least every 8 hours, sometimes hourly

 Daily weight
 Vital signs closely monitored
 Skin and tongue turgor, mucosa, urine output, mental status
 Measures to minimize fluid loss
 Administration of oral fluids
 Administration of parenteral fluids
Fluid volume excess
Fluid
volume
 Isotonic expansion of the ECF caused by the abnormal retention of water and sodium in approximately
excess
the same proportions in which they normally exist in the ECF.

Secondary to an increase in the total body sodium content.

Causes of FVe

 Due to fluid overload or diminished homeostatic mechanisms

 Heart failure, kidney injury, cirrhosis of liver
 Contributing factors: consumption of excessive amounts of table salt or other sodium salts
 Excessive administration of sodium – containing fluids

Clinical manifestations

 Edema
 Distended neck veins
 Crackles

Nursing management

 I&O and daily weights; assess lung sounds, edema and other symptoms
 Monitor responses to medication – diuretics and parenteral fluids
 Promote adherence to fluid restrictions, patient teaching related to sodium and fluid restrictions
 Monitor, avoid sources of excessive sodium, including medications
 Promote rest

electrolytes
Electrolyte imbalances

 Sodium: Hyponatremia; Hyperkalemia

 Potassium: Hypokalemia; Hyperkalemia
 Calcium: Hypocalcemia; Hypercalcelmia
 Magnesium: Hypomagnesemia; Hypermagnesemia
 Phosphorus: Hypophosphatemia; Hyperphophastemia
 Chloride: Hypochloremia; Hyperchloremia
Hyponatremia
Hyponat
remia
 Serum sodium < 135 mEq/L
 Acute: Result of fluid overload of a surgical patient
 Chronic: Seen outside of hospital setting, longer duration, less serious neurologic sequelae
 Exercise associated: More common in woman of small sature, extreme temperatures, excessive fluid
intake, prolonged exercise

Causes Manifestations Management

 Imbalance of water  Poor skin turgor  Treat underlying conditions
 Losses by vomiting  Dry mucosa  Sodium replacement
 Diarrhea  Headache  Water restriction
 Sweating  Decreased salivation  Medication
 Diuretics  Decreased blood pressure  Assessment: I&O, daily weight,
 Adrenal insufficiency  Nausea lab values, CNS Changes
 Certain medications  Abdominal cramping  Encourage dietary sodium
 SIADH  Neurologic changes  Monitor fluid intake
 Effects of medication (diuretics,
lithium)

hypernat
Hypernatremia
remia
 Serum sodium > 145 mEq/L
 Occurs in patients with normal fluid volume, FVD, FVE
 Most affected are very old, very young and cognitively impaired

Causes Manifestations Management

 Fluid deprivation  Thirst  Gradual lowering of serum
 Excess sodium administration  Elevated Temperature sodium level via infusion of
 Diabetes Insipidus hypotonic electrolyte solution

 Heat Stroke  Diuretics

 Hypertonic IV Solutions  Assessment for abnormal loss of

water and low water intake
 Assess for over – the – counter
sources of sodium
 Monitor for CNS Changes
Hypokalemia
hypokal
emia
 Below normal serum potassium <3.5 mEq/L

Causes Manifestations Management

 GI losses  ECG Changes  Potassium replacement: Increased dietary
 Medications  Dysrhytmias potassium or IV for severe deficit
 Prolonged intestinal suctioning  Dilute urine  Monitor ECG for changes
 Recent ileostomy  Excessive thirst  Monitor ABGs Ph Level low or high Ph
 Tumor of the intestine  Fatigue Level

 Alterations of acid – base  Anorexia  Monitor patients receiving digitalis for

balance  Muscle weakness toxicity

 Poor dietary intake  Decreased bowel motility  Monitor for early signs and symptoms

 Hyperaldosteronism  Paresthesias  Administer IV potassium only after

adequate urine output has been
established.
 May occur with normal potassium levels: when alkalosis is present a temporary shift of serum
potassium into cells occurs

Hyperkalemia
hyperkal
emia
 Serum potassium >5.0 mEq/L
 Seldom occurs in patients with normal renal function
 Increased risk in older adults
 Cardiac arrest is frequently associated

Causes Manifestations Management

 Impaired renal function
 Rapid administration of
potassium
 Hypoaldosteronism
 Medications
 Tissue trauma
 Cardiac changes and
dysrhythmias
 Muscle weakness
 Paresthesias
 Anxiety
 GI manifestations
 Monitor ECG, assess labs (Chemistry Lab K+
Level), monitor I&O, obtain apical pulse
 Limitation of dietary potassium and dietary
teaching
 Administration of cation exchange resins
(KAYEXALATE)

 Acidosis (Ph <7.35)  Emergent care: IV Calcium Gluconate, IV

Sodium bicarbonate, IV regular insulin and
hypertonic dextrose IV, beta-2 agonists,
dialysis
 Administer IV slowly and with an infusion
pump
 Never administer K+ IV push should be IV drip
Hypocalcemia
hypocal
cemia
 Serum level <8.6 mg/dL, must be considered in conjunction with serum albumin level
 Serum calcium level controlled by parathyroid hormone and calcitonin

Causes Manifestations Management

 Hypoparathyroidism  Tetany  IV of calcium gluconate for
 Malabsorption  Circumoral numbness emergent situations
 Osteoporosis  Paresthesias  Seizure precautions
 Pancreatitis  Hyperactive DTRs  Oral calcium and Vitamin D
 Alkalosis  Trousseau sign supplements

 Transfusion of citrated blood  Chvostek sign  Exercises to decrease bone

(whole blood)  Seizures calcium loss

 Kidney injury  Respiratory symptoms of  Patient teaching related to diet

 Medication dyspnea and laryngospasm and medications.

 Abnormal clotting
 Anxiety

Hypercalcemia
hypercal
cemia
 Serum level > 10.2 mg/dL
 Hypercalcemia crisis has high mortality

Causes Manifestations Management

 Malignancy and  Polyuria  Treat underlying cause
hyperparathyroidism  Thirst  Administer IV Fluids,
 Bone loss related to immobililty  Muscle weakness furosemide, phosphates,
 Diuretics  Intractable nausea calcitonin, bisphosphonates

 Abdominal cramps  Increase mobility

 Severe constipation  Encourage fluids

 Diarrhea  Dietary teaching, fiber for

 Peptic ulcer constipation

 Bone pain  Ensure safety

 ECG changes
 dysrhytmias
Hypomagnesemia
hypoma
gnesemi
 Serum level <1.3 mg/dL
 Associated with hypokalemia and hypocalcemia

Causes Manifestations Management

 Alcoholism  Chvostek and Trousseau signs  Magnesium sulphate IV is
 GI losses  Apathy administered with an infusion
 Enteral or parenteral feeding  Depressed mood pump, monitor vital signs and
deficient in magnesium  Psychosis urine ouput

 Medications  Neuromuscular irritability  Oral magnesium

 Rapid administration of  Muscle weakness  Monitor for dysphagia

citrated blood  Tremors  Seizure precautions

 ECH changes and dyrsthymias  Dietary teaching

Hypermagnesemia
hyperma
gnesemi
 Serum level >3.0 mg/dL
 Rare electrolyte abnormality, because the kidneys efficiently excrete magnesium

Causes Manifestations Management

 Kidney injury
 Diabetic ketoacidosis
 Excessive administration of
magnesium
 Extensive soft tissue injury
 Hypoactive reflexes
 Drowsiness
 Muscle weakness
 Depressed respirations
 ECG changes
 Dysrhythmias
 IV calcium gluconate
 Hemodialysis
 Administration of loop diuretics,
sodium chloride and LR
 Avoid medications containing
magnesium

 Cardiac arrest  Patient teaching regarding

magnesium – containing over –
the – counter medications
 Observe for DTRs and changes
in LOC
Hypophosphatemia
hypopho
sphatem
Causes Manifestations Management
 Alcoholism  Neurologic symptoms  Medical
 Refeeding of patients after  Confusion o Oral or IV phosphorus
starvation  Muscles weakness replacement
 Pain  Tissue hypoxia  Nursing
 Heat stroke  Muscle and bone pain o Assessment
 Respiratory alkalosis  Increased susceptibility to o Encouragement foods high in
 Hyperventilation infection phosphorus
 Diabetic o Gradually introduce calories for

 Ketoacidosis malnourished patients receiving

 Hepatic encephalopathy parenteral nutrition

 Major burns
 Hyperparathyroidism
 Low magnesium
 Low potassium
 Diarrhea
 Vitamin D deficiency
 Use of diuretics and antacids
 Serum level <2.5 mg/dL

Hyperphosphatemia
hyperph
osphate
Causes Manifestations Management
 Kidney injury  Few symptoms  Medical
 Excess phosphorus  Soft tissue calcifications o Treat underlying disorder
 Excess vitamin D  Symptoms occur due to o Vitamin D preparations
o Calcium – binding antacids
 Acidosis associated hypocalcemia
o Phosphate-binding gels or antacids
 Hypoparathyroidism o Loop diuretics
 Chemotherapy o NS IV
o Dialysis
 Nursing
o Assessment
o Avoid high – phosphorus foods
o Patient teaching related to diet
o Phosphate – containing substances
o Signs of hypocalcemia
 Serum level > 4.5 mg/d
Hypochloremia
hypochl
oremia
 Serum level < 97 mEq/L
 Loss of chloride occurs with loss of other electrolytes, potassium and sodium

Causes Manifestations Management

 Addison disease  Agitation  Medical:
 Reduced chloride intake  Irritability o Replace chloride – IV NS or
 GI loss  Weakness 0.45% NS
 Diabetic ketoacidosis  Hyperexcitability of muscle  Nursing:
 Excessive sweating  Dysrhythmias o Assessment

 Fever  Seizures o Avoid free water

 Burns  Coma o Encourage high – chloride

 Medications foods

 Metabolic alkalosis o Patient teaching related to

high – chloride foods

Hyperchloremia
hyperchl
oremia
 Serum level > 107 mEq/L
 Normal serum anion gap

Causes Manifestations Management

 Excess sodium chloride  Tachypnea  Medical:
infusions with water loss  Lethargy o Restore electrolyte and fluid
 Head injury  Weakness balance
 Hypernatremia  Rapid deep respirations o Lactated Ringers
 Dehydration  Hypertension o Sodium Bicarbonate
 Severe diarrhea  Cognitive changes o Diuretics
 Respiratory alkalosis  Nursing:
 Metabolic acidosis o Assessment
 Hyperparathyroidism o Patient teaching related to
 Medication diet and hydration
 Acid-base balance
Maintaining acid-base balance

 Normal plasma ph 7.35 – 7.45: hydrogen ion concentration

 Major extracellular fluid buffer system; bicarbonate – carbonic acid buffer system
 (Kidneys) Regulate bicarbonate in ECF
 Lungs, under control of medulla, regulate CO2 and thus the carbonic acid in ECF
 Other buffer systems:
 ECF: inorganic phosphates, plasma proteins
 ICF: proteins, organic, inorganic phosphates
 Hemoglobin

Metabolic Acidosis

 Low pH <7.35
 Low Bicarbonate <22 mEq/L

Manifestations Management
 Headache  Decreased cardiac output Correct underlying problem,
 Confusions  Dysrhythmias correct imbalance
 Drowsiness  Shock Bicarbonate may be
 Increased respiratory rate  If decrease is slow administered
and depth  Patient may be
 Decreased blood pressure asymptomatic until
bicarbonate is 15 mEq/L or
less
 Most commonly due to kidney injury

 With acidosis, hyperkalemia may occur as potassium shifts out of cell

 As acidosis is corrected, potassium shifts back into cell, potassium levels decrease
 Monitor potassium levels
 Serum calcium levels may be low with chronic metabolic acidosis
o Must be corrected before treating acidosis

Metabolic Alkalosis

 High pH >7.45
 High Bicarbonate >26 mEq/L
  Most commonly due to vomiting or gastric suction
o May also be due to medications, especially long – term diuretic use
 Hypokalemia will produces alkalosis

Manifestations Management
 Symptoms related to decreased calcium  Correct underlying problem
 Respiratory depression  Supply chloride to allow
 Tachycardia excretion of excess
 Symptoms of hypokalemia bicarbonate
 Restore fluid volume with
sodium chloride solutions
 With
acidosis, hyperkalemia may occur as potassium shifts out of cell
 As acidosis is corrected, potassium shifts back into cell, potassium levels decrease
 Monitor potassium levels
 Serum calcium levels may be low with chronic metabolic acidosis
o Must be corrected before treating acidosis

Respiratory Acidosis

 Low pH <7.35
 PaCO2 <22 mEq/L

Manifestations Management
 With chronic respiratory o Mental changes Treatment aimed at improving
acidosis, body may o Feeling of fullness in head ventilation
compensate, may be  Potential increased intracranial
asymptomatic pressure
 Symptoms may include:
o Increased pulse
rate, respiratory
rate and BP
 Always due to respiratory problem with inadequate excretion of CO2

Respiratory Acidosis

 High pH >7.45
 PaCO2 <35 mmHg
 Always due to hypertension

Manifestations Management
 Lightheadedness Correct cause of hyperventilation
 Inability to concentrate
 Numbness
 Tingling
 Sometime loss of consciousness
ARTERIAL BLOOD GASES

 pH 7.35 – (7.4) – 7.45

 PaCO2 35 – (40) – 45 mmHg
 HCO3 22 – (24) – 26 mEq/L
o Assumed average values for ABG interpretation
 PaO2 80 – 100 mmHg
 Oxygen Saturation >94%
 Base excess/deficit + 2 mEq/L