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Determinants of Assessment of Fluid and Electrolyte Balance

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Danny Torregrossa

on 29 October 2013

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Transcript of Determinants of Assessment of Fluid and Electrolyte Balance

Determinants of Assessment of Fluid and Electrolyte Balance
Danny Torregrossa
Body Fluid Composition and Distribution
Fluid Compartments
Intracellular Compartments
contains potassium, phosphate, protein, magnesium, and sulfate
Na/K Pump
requires ATP to actively move sodium and potassium
hypoxia interferes with the pump
when the pump fails water and Na is retained
Extracellular Compartment
Transcellular Fluid
Intravascular Fluid
Interstitial Fluid
Movement of Fluids
Osmosis
Osmolality
net diffusion or movement of water across the cell membrane
water moves from an area of lesser concentration to an area of greater concentration
concentration of solute in body water
reflects hydration status
Regulation of Fluid Balance
Hypothalamus Regulation
Osmoreceptors
Baroreceptors
stimulated under certain conditions
triggers thirst response
senses a decrease in arterial blood pressure
responds with vasoconstriction
reduces urine output
Endocrine Regulation
Adrenocortiocotropic Hormone
Renin-Angiotensin-Aldosterone System
Antidiuretic Hormone
decrease in sodium -> release ACTH -> release aldosterone
sodium is reabsorbed; potassium is excreted
ADH promotes water resorption
renin is released -> angiotensin I is released -> converted into angiotensin II -> aldosterone is released
Waterloss
fluids are lost through the lungs, sweat glands, gastrointestinal fluids, and kidneys
Older adult patients are predisposed to develop fluid volume deficit for which reasons? (Select all that apply)
A. Decreased muscle mass

B. Increased fat stores

C. Decrease in proportion of body fluids

D. Alterations in thirst
Which statement is correct regarding low serum osmolality?
A. It reflects fluid volume deficit

B. It reflects fluid volume excess

C. It is associated with dehydration

D. It is associated with hypernatremia
What is the primary regulator of water intake?
A. Nervous System

B. Endocrine System

C. Renal System

D. Hypothalamus
Assessment of Fluid Balance
History
Does the patient have an injury or disease process that can alter fluid and electrolyte balance?
How does the total intake of fluids compare with the total output of fluids?
Does the patient have dietary restrictions that can alter fluid and electrolyte balance?
Is the patient receiving any medication that can alter fluid and electrolyte balance?
Vital Signs
Temperature
Arterial Blood Pressure
Respirations
Pulse
Physical Assessment
Inspection
Fluid Volume Deficit: sunken eyes, dry oral tissue, flat jugular vein
Fluid Volume Overload: edematous face, jugular vein distention
Palpation
Skin turgor is assessed by pinching the skin on the forehead or sternum
Decreased capillary refill may be present in patients with hypovolemia
Useful for evaluating edema
Not a good diagnostic tool for the level of hydration in older adults
Abnormal Extravascular Accumulation of Fluids
Second-Spacing of Fluids
Pitting
Edema
excess accumulation of fluid in interstitial spaces
Clinical Manifestations
Third-Spacing of Fluids
shift of fluid from the intravascular compartment into a "third" space
important to measure abdominal girth
cavities are deep structures
Body Weight
1 kg = 1 L
10 L of excess fluid results in pitting edema
5 L of excess fluid results in peripheral edema
Auscultation
Heart
Lungs
3rd or 4th heart sound w/ FVE
crackles may indicate fluid volume overload
pericardial friction rub is a sign of pericardial effussion
tachycardia may indicate FVD
Percussion
flank pain may indicate kidney infection
percussion of abdomen may offer volume status of ascites
Hemodynamic Monitoring
Central Venous Pressure: 2-6 mmHg

Cardiac Output: 4-5 L/min

Cardiac Index: 2.4-4 L/min/m2

Mean Arterial Pressure: 70-90 mm Hg

Pulmonary Artery Wedge Pressure: 4-12 mm Hg
Urine
Assessment
Urine Volume
provides important information about fluid volume status
high urine volume suggests FVE
low urine volume suggests FVD
Urine Concentration
Urine Specific Gravity
Urine Osmolality
< 1.005: FVE
> 1.030: FVD
more accurate than urine specific gravity
200-800 mOsm/kg
Laboratory Assessment
Serum Labs
Blood Urea Nitrogen
Serum Albumin
BUN-to-Creatinine Ratio
Creatinine
Urine Lab
Creatinine Clearance
Urinalysis
During a physical assessment it is noted that the patient has pitting edema around the ankles, with a 4 mm indentation. How should this be documented?
A. +1 pitting edema
B. +2 pitting edema
C. +3 pitting edema
D. +4 pitting edema
Elevated temperature can cause FVD through which process? (Select all that apply)
A. Diaphoresis

B. Tachypnea

C. Vasoconstriction

D. Diarrhea
Electrolytes
Sodium
135-145 mEq/L
may precipitate heart failure and pulmonary edema
supply is abundant in many foods
responsible for water balance, transmission of impulses, and maintaining acid-base balance
Chloride
Calcium
Potassium
Magnesium
Phosphate
95-105 mEq/L
8.5-10.2 mg/dL
3.5-5.3 mEq/L
1.5-2.5 mEq/L
1.7-2.6 mEq/L
Total Calcium vs Ionized Calcium
required for blood coagulation, neuromuscular contraction, and bone integrity
located almost entirely within bone
follows sodium levels
assists in maintaining the resting membrane potential and maintains osmolality of the ECF space
abnormal levels can produce potentially lethal dysrhythmias or cardiac arrest
vital in maintaining cardiac and neuromuscular function
kidneys have a remarkable ability to conserve magnesium
transmits CNS messages and maintains neuromuscular activity
vital for normal neuromuscular function
combines with calcium BUT has an inverse relationship with calcium
What is one cause of hyperkalemia
A. Renal failure

B. Diuretics

C. Metabolic acidosis

D. Severe Diarrhea
Chloride levels closely follow the levels of which electrolyte
A. K

B. Na

C. Ca

D. Mg
Assessment of Electrolyte Balance
Physical Assessment
Vital Signs & Cardiovascular Assessment

Neurologic Assessment

Neuromuscular & Musculoskeletal Assessment

GI Assessment
Laboratory Testing
Serum Electrolytes


Urine Electrolytes
The nurse is evaluating the most recent serum electrolytes on a patient. Which should be the most concerning?
A. Na: 142 mEq/L

B. K: 4.1 mEq/L

C. Mg: 2.5 mEq/L

D. Cl: 80 mEq/L
Hypokalemia and hyponatremia have which neurologic effect?
A. Confusion and lethargy

B. Irritability and coma

C. Disorientation and seizures

D. Hallucinations and tetany
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