FLUIDS AND ELECTROLYTE S

Christian Paul S. Biluan RN,USRN,MANc

Click to edit Master subtitle style

FLUID SPACES

Intracellular Extracellular Intravascular Interstitial Transcellular does not participate in homeostasis HOMEOSTASIS balance and equilibrium of fluids and electrolytes

F/E TRANSPORT

Osmosis Diffusion Active Transport Filtration

OSMOSIS fluid movement from lower to higher concentration

DIFFUSION solute movement from higher to lower concentration

ACTIVE TRANSPORT ion movement from lower to higher concentration

FILTRATION movement of fluids and solutes by hydrostatic pressure

IV SOLUTIONS

Isotonic Solutions PNSS,D5W, PLR Hypotonic Solutions 0.45NaCl, 0.3NaCl Hypertonic Solutions D10W, D5NSS, D5LR

AVERAGE DAILY I/O

INTAKE Oral Liquids 1300ml Water in food 1000ml Water produced by metabolism 300ml Total 2600ml OUTPUT Urine 1500ml Stool 200ml Skin 600ml Lungs 300ml

Total 2600ml

HOMEOSTASIS

Kidney filters and regulates f/e retention and excretion Aldosterone causes sodium and water retention and potassium loss ADH causes reabsorption of water

FLUID IMBALANCES

FLUID VOLUME DEFICIT

Dehydration occurs when the fluid intake of the body is not sufficient to meet the fluid needs of the body Goal of treatment: restore fluid volume replace electrolytes eliminate the cause of FVD.

ASSESSMENTS INCREASED PR, RR DECREASED BP, LOC, Temp, UO, Peristalsis Increased urinary specific gravity Dry, Poor skin turgor Thirst Decreased body weight Decreased GI motility and bowel sounds.

LABORATORY FINDINGS Increased serum osmolality Increased hematocrit Increased blood urea nitrogen(BUN) level Increased serum sodium level.

INTERVENTIONS Initiate IVF Increase OFI Monitor VS NVS Input/Output Electrolyte levels Weight.

FLUID VOLUME EXCESS

Description Fluid intake or fluid retention exceeds the fluid needs of the body Fluid volume excess is also called overhydration Goal of treatment: restore fluid balance correct electrolyte imbalance eliminate or control the

ASSESSMENTS INCREASED BP, PR, RR, UO, Peristalsis Distended neck and hand veins Elevated central venous pressure Moist crackles upon auscultation Headache, LOC Changes, Visual Disturbances Skeletal muscle weakness Paresthesias Pitting edema in dependent

LABORATORY FINDINGS Decreased serum osmolality Decreased hematocrit Decreased BUN level Decreased serum sodium level Decreased urine specific gravity.

INTERVENTIONS Prevent further fluid overload, and restore normal fluid balance Administer diuretics Restrict fluid and sodium intake Monitor VS NVS Input/Output Electrolyte levels Weight

ELECTROYTE IMBALANCES

SODIUM (Na)
135-145 mEq/L

Controls ECF osmotic pressure Necessary for neuromuscular functioning Determines intracellular reactions Maintains acid base balance

HYPONATREMIA
ETIOLOGY tx with diuretics Na restriction GI loss decreased aldosterone third space loss diaphoresis

ASSESSMENT Generalized skeletal muscle weakness Diminished DTR Headache Confusion, LOC Changes Seizures Increased motility and hyperactive bowel sounds Abdominal cramping and diarrhea Decreased urinary specific gravity

MANAGEMENT IVF 0.9 NaCl/IV Replace other electrolytes as needed Salty foods in diet Safety precaution.

HYPERNATREMIA
ETIOLOGY Hyperventilation high Na intake salt tablets rapid saline infusion water deprivation diarrhea

ASSESSMENT Early: spontaneous muscle twitches, irregular muscle contractions Late: skeletal muscle weakness, deep tendon reflexes diminished or absent LOC Changes Increased urinary specific gravity Decreased urinary output Dry skin, dry sticky buccal mucosa

MANAGEMENT Restrict Na in diet Monitor I & O and behavioral changes Increase oral fluids or D5W/IV Diuretics Dialysis

POTASSIUM (K+)
3.5-5.1 mEq/L

Excitability of nerves and muscles ICF osmotic pressure Maintains acid-base balance K deficit:alkalosis K excess: acidosis

HYPOKALEMIA
ETIOLOGY

Decreases intake Increased loss Intracellular shift.

ASSESSMENT DTR, RR Thready, weak, irregular pulse Anxiety, lethargy, confusion, coma Skeletal muscle weakness, eventual flaccid paralysis N/V, constipation, abdominal distention Decreased urinary specific grav, Increased urinary output

ECG changes: ST depression, shallow, flat or inverted Twaves and prominent U wave.

MANAGEMENT Potassium rich foods

Banana dried fruits (raisins,prunes) orange raw carrot raw tomato baked potato Melon Watermelon

Potassium supplement Oral: K+ durule tab 1-3 tabs daily KCl IV incorporation slow drip K sparing diuretics

HYPERKALEMIA
ETIOLOGY Excess intake Retention of K Extracellular shift.

ASSESSMENT Early: Muscle twitches, cramps, paresthesia Late: profound weakness, ascending flaccid paralysis in the arms and legs BP, PR, RR Increased motility, hyperactive bowel sounds, Diarrhea ECG changes: Tall peak waves, flat P waves, widened QRS complexes and prolonged PR intervals

MANAGEMENT Avoid K-rich foods Diuretic 10% glucose with regular insulin/IV Ca Gluconate Dialysis.

CALCIUM (K+)
4.5 5.8 mEq/L or 8.6 -10 mg/dL 2 types of Ca Ionized Plasma protein bound Free Ionized Ca is needed for Blood coagulation Muscle contraction Nerve function Bone and teeth formation Vit D and PTH increases GI Ca absorption

HYPOCALCEMIA
ETIOLOGY Decreased ionized Ca Inadequate intake Excess loss Decreased bone and GI tract absorption.

ASSESSMENT Irritable skeletal muscles: twitches, cramps, tetany, seizures Irritability, Paresthesias, numbness Positive Trosseaus and Chvosteks sign Hyperactive DTR Decreased heart rate, Hypotension Increased gastric motility, Hyperactive bowel sounds Abdominal cramping, diarrhea ECG changes: Prolonged ST interval, prolonged QT interval

MANAGEMENT High Ca diet Ca gluconate, oral Ca salts Phosphate binder (AL-OH) Monitor breathing (laryngeal stridor) Seizure precaution

HYPERCALCEMIA
ETIOLOGY Loss from bones immobilization Excess intake Mobilization from bones steroid.

ASSESSMENT Increased heart rate in the early phase Bradycardia in late phases Increased blood pressure Bounding, full peripheral pulses Profound muscle weakness DTR, RR, Peristalsis Disorientation, lethargy or coma Decreased motility and hypoactive bowel sounds Increased urinary ooutput leading to dehydration Formation of renal calculi ECG changes: Shortened ST

MANAGEMENT Increase fluid intake (3-4 L/day), prevent urolithiasis Acid-ash fruit juices (prune, cranberry), ascorbic acid NSS/IV and diuretic Mithramycin reduces serum Ca level Protect from injury to avoid fracture

HYPOMAGNESEMIA
1.5 2.5 mEq/L ETIOLOGY Decreased intake Impaired GI absorption Excessive excretion

ASSESSMENT Tachycardia, hypertension Shallow respirations DTR, Twitches, paresthesias Positive Trousseaus and Chvosteks signs Tetany, seizures Decreased motility, decreased bowel sounds Irritability, Confusion ECG changes: Tall T waves, depressed ST segments

MANAGEMENT Diet supplements: fruits, green leafy vegetable, whole grain cereals, meats, nuts, seafoods Mg salts oral/parenteral Promote safety, prevention of injury Monitor for laryngeal stridor.

HYPERMAGNESEMIA
ETIOLOGY Renal failure Diabetic ketoacidosis Frequent use of magnesium-containing antacids, cathartics

ASSESSMENT Bradycardia, dysrhythmias, Hypotension Respiratory insufficiency Diminished or absent deep tendon reflexes Skeletal muscle weakness Drowsiness and lethargy that progresses to coma

ECG changes: Prolonged PR interval, widened QRS complexes

MANAGEMENT Ca gluconate/IV Dialysis if with renal failure Correct primary cause

HYPOPHOSPHATEMI A
2.5 4.5 mg/dL ETIOLOGY Hyperparathyroidism Hypercalcemia

HYPERPHOSPHATEMI A
ETIOLOGY Hypoparathyroidism Hypocalcemia ASSESSMENT Signs of hypocalcemia

ACID-BASE IMBALANCES

ARTERIAL BLOOD GASES

Ph 7.35-7.45 PCO2 35 45 mmHg HCO3 22-26 mEq/L PaO2 80-100 mmHg SaO2 95-100%

To determine A/B imbalance

1.

1.

2.

Check pH To determine acidity/alkalinity Determine if Respiratory or Metabolic Use ROME technique Respi CO2 Meta HCO3 Check for compensation FC if pH normalizes UC if no change in the other indicator PC if the other indicator fluctuates

Exercise
Ph 7.34 PCO2 49 HCO3 26

Exercise
Ph 7.50 PCO2 35 HCO3 30

Exercise
Ph 7.36 PCO2 34 HCO3 15

Exercise
Ph 7.38 PCO2 49 HCO3 22

Exercise
Ph 7.48 PCO2 25 HCO3 28