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Fluid Homeostasis & Imbalances

NRS 232 - Pathophysiology I
by

Katrina Dielman

on 14 February 2016

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Transcript of Fluid Homeostasis & Imbalances

Fluid Homeostasis & Imbalances
Principles
of

Fluid Homeostasis
Fluid
&
Electrolyte Balance
ECV
Imbalances
Osmolality
Imbalances
Clinical Dehydration
Filtration
&
Osmosis
Body Water by
Age
2/3 Intracellular
1/3 Extracellular
-
but more for infants
Also termed
saline imbalances

Because they are disorders of
isotonic salt water

Too much or too little
volume
of ECF
In the
same concentration
as the
normal plasma concentration
ECV Deficit/
Saline Deficit
ECV Excess/
Saline Excess
Hyponatremia
Hypernatremia
Also called
water imbalances
Because they are disorders of
concentration of extracellular fluid
Recognized by
abnormal serum sodium concentrations
(< 135-145 mEq/L >)
And by
abnormal serum osmolality
(< 280-300 mosmol/kg >)
A blend of
ECV deficit
and
hypernatremia
IV Fluid Distribution
by

Osmolality
Isotonic
Fluids
- Expand
ECF
Normal Saline
- 308 mosmol/kg
Lactated Ringers
- 270 mosmol/kg
Hypotonic
Fluids
- Expand both
ECF
+
ICF
D5W
- 250 mosmol/kg
0.45% NS
- 154 mosmol/kg
0.225% NS
- 77 mosmol/kg
Hypertonic
Fluids
- Stay mostly in the
Vascular Space
D5NS
- 560

mosmol/kg
D5 1/2NS
- 404 mosmol/kg
D5LR
- 525 mosmol/kg
3% NaCl
- 1032 mosmol/kg
Causes/
Risk Factors
Excessive or too rapid intake
Isotonic IVF, blood administration
Sodium-rich foods/medications
Plus water
Decreased output
Oliguria
Renal retention of saline
Hyperaldosteronism
Black licorice
Glucocorticoid excess (Cushing sydrome)
CHF
Cirrhosis
Third spacing with ECV excess
Ascites that develops gradually
Clinical Assessment -
Prioritize!
Apply

Maslow
Crackles/Rales
Dyspnea/Orthopnea
Pulmonary edema
Sudden weight gain
Dependent edema
Bounding pulse, vascular overload
Distended neck veins when upright/partially upright
Not appropriate measure for infants
Infants:
Bulging fontanel
Aldosterone
effect
Causes/
Risk Factors
Deficient intake or aborption
Lack of access to Na+ and water
Increased output of saline
Vomiting
Diarrhea/laxative abuse
Loss of GI fluids/fistula
Hemorrhage or burns
Overuse of diuretics
Hypoaldosteronism/Adrenal insufficiency
Rapid shift to third space
Ascites that develops rapidly
Lack of
aldosterone
Clinical Assessment -
Prioritize!
Teaching
About
sodium restriction
Include avoidance of non-food sources of sodium, too
Inform that salt taste changes in a few weeks
If treat with
diuretics
Monitor for adverse effects of therapy -

symptoms of ECV deficit!
Teaching
Replace body fluid losses with
both salt
and
water
Teach carefully about the need for both salt and water with
vomiting
or
diarrhea
Sudden weight loss
Dry mucous membranes
Skin tenting, poor skin turgor
Not effective for infants, elderly, obese
Rapid thready pulse, vascular underload
Postural drop in BP
Not reliable in infants or small children
Lightheadedness
Flat neck veins when supine
Not effective for infants
Longitudinal furrows in tongue
Sunken eyeballs
Impaired perfusion:
Oliguria
Syncope
Shock
Infants:
Depressed fontanel
Teach/Treat
Replace with
isotonic saline
and
extra water
Causes/
Risk Factors
Loss of more water than salt
Diabetes insipidus -
lack of ADH
Vomiting or diarrhea with replacement of Na+ but inadequate water
Urine excretion due to particulates - tube feedings
Excess sweating without fluid replacement
Gain of more salt than water
Decreased thirst, or lack of response to thirst
Difficulty swallowing
Limited access to water
Intake of high solute fluids without adequate supplementary water - tube feedings, inappropriate infant formula
Excessive infusion of hypertonic saline
Antidiuretic hormone - ADH
Clinical Assessment -
Prioritize!
Impaired cerebral function
Decreased LOC
Seizures if severe
Coma
Thirst
- not reliable in the older adult
Oliguria
Serum Na+ > 145 mEq/L
Cell shriveling!
Teaching
Need for
daily fluid intake
For older adults - teach to drink fluids regularly,
even when not thirsty
Causes/Risk Factors
Clinical Assessment -
Prioritize!
Teaching
Cell Swelling!
Antidiuretic hormone - ADH
Gain of more water than salt
Excessive ADH
- Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Irrigating GI tract with distilled water
Excessive infusion of D5W
Excessive ingestion of water
Nonselective NSAIDs - ibuprofen
Impair normal renal prostaglandin (important in urine dilution) impact upon medullary blood flow, active chloride transport, and ADH
Loss of more salt than water
Diuretic therapy
Sweating, vomiting, or diarrhea with water replacement without electrolytes
Impaired cerebral function
Decreased LOC
Seizures
Coma
Nausea
Serum Na+ < 130 mEq/L
Fluid restriction
Frequent oral care, lubricate lips
Swish fluids around mouth before swallowing
Provide in thermal containers
Keep fluids out of sight
Replace fluid losses with fruit juice or bouillon rather than tap water
Need for salt during distance running, as well as water
Irrigate GI tract with saline rather than distilled water
References
Copstead, L. & Banasik, J. (2013).
Pathophysiology
(5th ed.). St. Louis, MO: Elsevier.

Felver, L. (2013). Online Materials:
PROP- Pathophysiology online.
Retrieved from https://evolve.elsevier.com/

Giddens, J. (2013).
Concepts for nursing practice
(1st ed.). St. Louis, MO: Elsevier Mosby.
NRS 232 - Pathophysiology I
H2O
Na+
K+
Normal
human osmolality:
280-300
mosmol/kg
ECF
= Extracellular Fluid
ICF
= Intracellular Fluid
(Normal bulging fontanel from crying)
The "
salt-water
" hormone
Aldosterone!!
Antidiuretic Hormone - ADH!!
The "
tap-water
" hormone
(Actually, empathy is the professional response; however, fluid restrictions are usually a challenge for both patient and nurse)
This young man needed more free water via his gastrostomy tube following his tube feedings. This photo was taken just prior to his hospitalization for hypernatremia.
Oral Rehydration Solution - ORS
Helped this physician and her colleagues to survive Ebola
http://www.npr.org/sections/goatsandsoda/2014/10/23/358108367/ill-gag-drink-to-that-oral-rehydration-key-for-ebola-patients
Mary, a 23-year-old sales clerk with a high school education, is recovering from moderate clinical dehydration after several days of diarrhea. When you tell her that she needs to replace fluid losses from vomiting or diarrhea with salty fluids, she says, "But I heard on TV that salt is bad for you!"

Reply as if you are talking directly to Mary.
Ima Student
says, "The signs and symptoms of hypernatremia include confusion, lethargy, coma--"

"Hey, wait a moment!" interrupts
Ima Notherstudent,
"Those are the signs and symptoms of hyponatremia."

"You are both right," says
Ima Thirdstudent
.

"How is this possible?" says one of the
Imas
.

Reply as if you are speaking directly to these students.
A new graduate nurse needs to irrigate a nasogastric tube to keep it patent. "I was told to use normal saline and never to use distilled water for irrigating," the new graduate nurse says. "But I do not see why. People drink water. Why can't I irrigate with it?"

Reply as if you are speaking directly to the new graduate nurse.
Mr. Morton
has an ECV excess associated with congestive heart failure. He has bilateral ankle edema. "When I sit around all afternoon with my feet up, the swelling goes down," he observes. "So maybe I should keep my feet up and I won't have to cut down on my salt."

Respond as if you are talking directly to him.
You are a visiting nurse for a community agency. Today a nurse who is experienced in working with hospitalized adults but has not worked with infants for many years is orienting under your direction.

At the first house, where you have gone to change a dressing on the matriarch of the household, a young mother in the home asks you to look at her 2-month-old baby. "I am worried," she says. "He has had 10 diapers with watery poop already this morning. I called the doctor and she said to ask you to check him for dehydration. I am giving him fluids like the doctor said."

You ask the orienting nurse to check the baby's extracellular volume (ECV) status while you finish the dressing change. After looking at the infant, the orienting nurse says, "This is really embarrassing. I do not know what to do. The baby has such a fat little neck that I cannot see if his neck veins are flat while he is lying here! I tried to measure postural blood pressure but it's impossible to hold him upright and support his head while trying to take a BP reading. I feel like an idiot! Can you help me?"

Reply as if you are talking directly to the nurse
.
The "salt-water" hormone
Retention of Na+
Excretion of K+
The "
tap-water
" hormone
Reapsorption of H2O at collecting tubules
Full transcript