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Fluid and Electrolyte Balance

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Jessica Dwork

on 29 September 2016

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Transcript of Fluid and Electrolyte Balance

Fluid Balance & Electrolytes
Functions of Water in the Body
Transporting nutrients to cells and wastes from cells
Transporting hormones, enzymes, blood platelets, and red and white blood cells
Facilitating cellular metabolism and proper cellular chemical functioning
Acting as a solvent for electrolytes and nonelectrolytes
Helping maintain normal body temperature
Facilitating digestion and promoting elimination
Acting as a tissue lubricant
Two Compartments of Fluid in the Body
Intracellular fluid (ICF)—fluid within cells (70%)
Extracellular fluid (ECF)—fluid outside cells (30%)
Includes intravascular and interstitial fluids
Variations in Fluid Content
Healthy person—total body water is 50% to 60% of body weight
Electrolytes
Ions- substance capable of breaking into electrically charged ions when dissolved in a solution is called electrolytes
Cations—positive charge
Anions—negative charge
Homeostasis—total cations equal to total anions
Fluid Balance
Solvents—liquids that hold a substance in solution (water)
Solutes—substances dissolved in a solution (electrolytes and non-electrolytes)
Major Electrolytes/Chief Function
Sodium
Potassium
Calcium

Magnesium
Chloride
Bicarbonate
Phosphate
Transporting Body Fluids
Osmosis—- water passes from area of lesser solute concentration to greater concentration until equilibrium is established

Diffusion- —tendency of solutes to move freely throughout a solvent

A
ctive transport- —requires energy for movement of substances through cell membrane from lesser solute concentration to higher solute concentration

Passive transport- no energy required

Filtration- —passage of fluid through permeable membrane from area of higher to lower pressure
Osmolality of a Solution
(measure of solute concentration)
Isotonic-—same concentration of particles as plasma
Hypertonic-—greater concentration of particles than plasma
Hypotonic-—lesser concentration of particles than plasma
Source of Fluids for the Body
Ingested liquids
Food
Metabolism
Fluid Losses
Kidneys — urine
Intestinal tract — feces
Skin — perspiration
Insensible water loss
Primary Organs of Homeostasis
Kidneys normally filter 170 L plasma, excrete 15 L urine
Cardiovascular system pumps and carries nutrients and water in body
Lungs regulate oxygen and carbon dioxide levels of blood
Adrenal glands help body conserve sodium, save chloride and water, and excrete potassium
Thyroid gland increases blood flow in body and increases renal circulation
Parathyroid glands regulate the level of calcium in ECF
GI tract absorbs water and nutrients that enter body though this route
Nervous system is a switchboard to inhibit and stimulate fluid balance (thirst center and ADH storage)
A hypertonic solution has a greater osmolality, causing water to move out of the cells and to be drawn into the intravascular compartment, causing the cell to shrink.
A. True
B. False
A. True
Acid–Base Balance (pH)
Acid— substance containing hydrogen ions that can be liberated or released
Example: HCL acid
Base— substance that can accept hydrogen ions
Homeostatsis...
Buffer systems
Carbonic acid–sodium bicarbonate
Phosphate
Protein
Respiratory mechanisms (2nd line of defense)
Renal mechanisms (3rd line of defense)
Buffers: act chemically to neutralize acids or change strong acids to weak acids, help to prevent wide swings in pH
Primary regulators
React immediately
Cannot maintain pH without adequate respiratory and renal function
Which one of the following chemical buffer systems is the most important buffer system of the body in that it buffers as much as 90% of the hydrogen of ECF?
A. Phosphate buffer system
B. Protein buffer system
C. Carbonic acid-sodium bicarbonate buffer system
D. Hydrogen buffer system
C. Carbonic acid-sodium bicarbonate buffer system
Fluid Volume Excess
Hypovolemia- proportional loss of fluid and electrolytes from the ECF

Hypervolemia—- excessive retention of water and sodium in ECF

Dehydration- negative fluid balance, loss of water

Overhydration- —above normal amounts of water in extracellular spaces

Edema- —excessive ECF accumulates in tissue space
Electrolyte Imbalances
Which one of the following electrolyte imbalances occurs due to a sodium deficit in ECF caused by a loss of sodium or gain of water?
A. Hyponatremia
B. Hypernatremia
C. Hypokalemia
D. Hyperkalemia
I am so imbalanced!!!
A. Hyponatremia
Acid–Base Imbalances
Occur when carbonic acid or bicarbonate levels become disproportionate
Respiratory acidosis—- primary excess of carbonic acid in ECF
Respiratory alkalosis—- primary deficit of carbonic acid in ECF
Metabolic acidosis- —proportionate deficit of bicarbonate in ECF
Metabolic alkalosis- —primary excess of bicarbonate in ECF
Nursing Assessments
Identify patients at risk for imbalances
Determine a specific imbalance is present and its severity, etiology, and characteristics
Determine effectiveness of plan of care
Parameters of assessment:
Nursing history and physical assessment
Fluid intake and output
**Daily weights**
Laboratory studies- BMP, CBC, Urine pH and specific gravity, Arterial blood gases
Risk Factors for Imbalances
Pathophysiology underlying acute and chronic illnesses
Abnormal losses of body fluids:
Burns
Trauma
Therapies that disrupt fluid and electrolyte balance
Nursing Diagnoses Related to Imbalances
Excess fluid volume
Deficient fluid volume
Risk for imbalanced fluid volume
Expected Outcomes
Maintain approximate fluid intake and output balance
Maintain urine specific gravity within normal range
Practice self-care behaviors to promote balance
Implementing
Dietary modifications
Modifications of fluid intake
Medication administration
IV therapy
Blood and blood products replacement
TPN
Administering Medications
Mineral-electrolyte preparations
Diuretics
Intravenous therapy
Ms. James came to the ED via ambulance after she rolled her father’s new Porsche. She is extremely upset and anxious. She is breathing rapidly and states she feels faint. Her ABG results are:

Ph 7.49
PaCO2 30
HCO3 23
Mr. Coffing is admitted in respiratory distress. He has a long history of COPD and is now in the end stages. His cough is productive of large amounts of green sputum. You review Mr. Coffing’s blood gas results which were just handed to you.

pH 7.26
PaCO2 52
HCO3 34
Respiratory compensation involves excretion or retention of:

CO2
HCO3
H2O
K
Compensation occurs as the body attempts to reach homeostasis
No compensation- pH and one ABG result is abnormal
Partial- pH and one ABG is abnormal and the other value is starting to change and the pH is starting to normalize.
Full- pH returns to normal range and both other ABG components are abnormal
Which parameter change occurs as a result of acute respiratory acidosis?

pH increases
pH decreases
CO2 decreases
HCO3 decreases
Crystalloids
Fluids that supply water and electrolytes
Help to maintain osmotic gradient between extravascular and intravascular compartments
Plasma-volume expanders caused by sodium concentrations
Do not contain proteins (colloids)
Contain fluids and electrolytes that are normally found in the body
Better for treating dehydration rather than expanding plasma volume
Used as maintenance fluids to
Compensate for insensible fluid losses
Replace fluids
Manage specific fluid and electrolyte disturbances
Promote urinary flow
Types
Normal saline (0.9% sodium chloride)
Half normal saline (0.45% sodium chloride)
Hypertonic saline (3% sodium chloride)
Lactated Ringer’s solution
D5W
Plasma-Lyte
Others
Indications
Acute liver failure
Acute nephrosis
Burns
Shock
Renal dialysis
Many other conditions
Adverse effects
May cause edema, especially peripheral or pulmonary
May dilute plasma proteins, reducing COP
Effects may be short-lived
Many other effects
Colloids
Protein substances
Increase COP (colloid osmotic pressure- a form of osmotic pressure exerted by proteins in the blood)
Move fluid from interstitial compartment to plasma compartment (when plasma protein levels are low)

Indications
Treat a wide variety of conditions
Superior to crystalloids in PV expansion, but more expensive
Adverse effects
Usually safe
Disadvantages
May cause altered coagulation, resulting in bleeding
Have no clotting factors or oxygen-carrying capacity
Few others

Blood Products
Oxygen-carrying resuscitation fluids
Only class of fluids that are able to carry oxygen
Increase tissue oxygenation
Increase plasma volume
Most expensive and least available fluid because they require human donors

Increase COP (colloid osmotic pressure) and PV
Pull fluid from extravascular space into intravascular space (plasma expanders)
RBC products also carry oxygen
Increase body’s supply of various products (such as clotting factors, hemoglobin)
Indications
Cryoprecipitate and plasma protein factors (PPF)
Management of acute bleeding (greater than 50% slow blood loss or 20% acutely)
Fresh frozen plasma (FFP)
Increase clotting factor levels in patients with demonstrated deficiency
PRBCs and whole blood
To increase oxygen-carrying capacity in patients with anemia, substantial hemoglobin deficits
PRBCs: for blood loss up to 25% of total blood volume
Whole blood: for blood loss over 25% of total blood volume
Adverse effects
Incompatibility with recipient’s immune system
Transfusion reaction
Anaphylaxis
Transmission of pathogens to recipient (hepatitis, HIV)
Monitor closely for signs of transfusion reactions
Principal ECF electrolytes
Sodium cations (NA+)
Chloride cations (Cl+)
Bicarbonate (HCO3)
Principal ICF electrolyte
Potassium (K+)
Magnesium (Mg)
K+
Treatment or prevention of potassium depletion when dietary means are inadequate
Adverse effects
Diarrhea, nausea, vomiting, GI bleeding, ulceration
Excessive administration
Hyperkalemia
Toxic effects
NA+
Treatment or prevention of sodium depletion when dietary measures are inadequate
Mild
Treated with oral sodium chloride and/or fluid restriction
Severe
Treated with intravenous normal saline or lactated Ringer’s solution

Adverse effects
Nausea, vomiting, cramps
Nursing Implications
Assess baseline fluid volume and electrolyte status
Assess baseline vital signs
Assess skin, mucous membranes, daily weights, I&O
Before giving potassium, assess ECG
Assess for contraindications to therapy
Assess transfusion history
Establish venous access as needed
Monitor serum electrolyte levels during therapy
Monitor infusion rate, appearance of fluid or solution, infusion site
Observe for infiltration, other complications of IV therapy
Monitor for therapeutic response
Normal lab values
RBCs, WBC, H&H, electrolyte levels
Improved fluid volume status
Increased tolerance to activities
Monitor for adverse effects

Parenteral infusions of potassium must be monitored closely
Rate should not exceed 20 mEq/hour
NEVER give as an IV bolus or undiluted
Oral forms of potassium
Must be diluted in water or fruit juice to minimize GI distress or irritation
Monitor for complaints of nausea, vomiting, GI pain, or GI bleeding
Implications
Administer colloids slowly
Monitor for fluid overload and possible heart failure
Norms....
pH 7.35 - 7.45
< 7.35 is acidosis
> 7.45 is alkalosis
Eliminates CO2
Respiratory center in medulla
controls breathing
Responds within minutes/hours to changes in acid/base
Increased respirations lead to increased CO2 elimination and decreased CO2 in blood
Respiratory system
eliminate H+ and reabsorb HCO3-
Reabsorption and secretion of electrolytes (e.g., Na+, Cl-)
Responds within hours to days
Renal system
Hypoventilation
Respiratory failure
Respiratory acidosis
Carbonic acid excess caused by:
Compensation
Kidneys conserve HCO3- and secrete H+ into urine
Respiratory Alkalosis
Carbonic acid deficit caused by
Hyperventilation
Hypoxemia from acute pulmonary disorders
Compensation rarely occurs due to aggressive treatment of causes of hypoxemia
Metabolic Acidosis
Base bicarbonate deficit caused by
Ketoacidosis
Lactic acid accumulation (shock)
Severe diarrhea
Kidney disease
Compensatory mechanisms
Increased CO2 excretion by lungs
Kussmaul respiration (deep and rapid)
Kidneys excrete acid
Metabolic Alkalosis
Base bicarbonate excess caused by
Prolonged vomiting
Gain of HCO3-
Compensatory mechanisms
Decreased respiratory rate to increase plasma CO2
Renal excretion of HCO3-
Arterial blood gas (ABG) values provide information about
Acid-base status
Underlying cause of imbalance
Body’s ability to regulate pH
Overall oxygen status
Diagnosis in 5 steps
Evaluate pH
Analyze PCO2
Analyze HCO3-
Determine if CO2 or HCO3- matches the alteration
Decide if the body is attempting to compensate
Hyponatremia and hypernatremia
Hypokalemia and hyperkalemia
Hypophosphatemia and hyperphosphatemia
Hypocalcemia and hypercalcemia
Hypomagnesemia and hypermagnesemia
Albumin 5% and 25% (from human donors)
Dextran 40, 70, or 75 (a glucose solution)
Hetastarch (synthetic, derived from cornstarch)

Types
pH decreases
CO2
Resp. alkalosis
Partially compensated resp. acidosis
4.Metabolic alkalosis
Arterial blood gas levels are obtained for the client. If the client’s results are pH 7.48, CO2 42 mm Hg, and HCO3 32 mEq/L, the client is exhibiting which one of the following acid-base imbalances?

1.Metabolic acidosis
2.Respiratory acidosis
3.Respiratory alkalosis
4.Metabolic alkalosis
The nurse is aware that the compensating mechanism that is most likely to occur in the presence of respiratory acidosis is:

1.Hyperventilation to decrease the CO2 levels
2.Hypoventilation to increase the CO2 levels
3.Retention of HCO3 by the kidneys to increase the pH level
4.Excretion of HCO3 by the kidneys to decrease the pH level
3.Retention of HCO3 by the kidneys to increase the pH level
Of all of the following clients, the nurse recognizes that the individual who is most at risk for a fluid volume deficit is:

1.A 6-month-old learning to drink from a cup
2.A 12-year-old who is moderately active in 80° F weather
3.A 42-year-old with severe diarrhea
4.A 90-year-old with frequent headaches
3. A 42-year-old with severe diarrhea
In reviewing the results of the client’s blood work, the nurse recognizes that the unexpected value that should be reported to the health care provider is:

1.Calcium 7.2 mEq/L
2.Sodium 140 mEq/L
3.Potassium 3.5 mEq/L
4.Magnesium 2.1 mEq/L
1.Calcium 7.2 mEq/L
The nurse anticipates that the client with a fluid volume excess will manifest a(n):

1.Increased urine specific gravity
2.Decreased body weight
3.Increased blood pressure
4.Decreased pulse strength
3.Increased blood pressure
Fluid volume deficit
Insterstitial fluid is forced into the intravascular space in an effort to compensate for fluid loss in the blood vessels
Cells are left with inadequate fluid in order to function properly
Results from fluid loss
Young children, elderly, and people who are ill are especially vulnerable
Retention of water and sodium
Common causes: malfunctioning kidneys, heart failure,
increased extracellular pressure causes fluid to be pulled from cells
Dehydration—decreased volume of water and electrolyte change
Hypovolemia—deficiency in amount of water and electrolytes in ECF with near normal water/electrolyte proportions
Third-space fluid shift—distributional shift of body fluids into potential body space
Ascites
Pleural effusion
A patient is taken to the trauma unit after a motorcycle accident. He has lost a substantial amount of blood (exact amount undetermined), and he is in hypovolemic shock. As he is prepared for emergency surgery, which blood product will he most likely receive?

1. Packed red blood cells
2. Whole blood
3. Cryoprecipitate
4. Fresh frozen plasma

2. Whole blood
Electrolyte Normal Values
Sodium (Na+) 135-145 mEq/L
Potassium (K+) 3.5-5 mEq/L
Calcium (Ca +) 8.5-10 mg/dL
Magnesium (Mg2+) 1.6-2.6 mEq/L
Chloride (Cl-) 95-105 mEq/L
Phosphate (PO4-) 1.7-2.6 mEq/L
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