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edgardo mendoza jr

on 29 July 2012

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Transcript of fluids

Double click anywhere & add an idea FLUIDS AND ELECTROLYTES Fluid and electrolytes involve composition and movement of body fluids Normal body function demands a relatively constant volume of water and definite concentration of electrolytes FUNCTIONS OF WATER IN THE BODY 1. Transporting nutrients to cell and waste from cells 2. Transporting hormones, enzymes, blood,
platelets and red and white blood cells 3. Facilitating cellular metabolism and
proper cellular chemical functioning 4. Facilitating digestion and promoting elimination 5. Acting as solvents for electrolytes and non-electrolytes 6. Acting as a tissue lubricant and cushion 7. Helping maintain a normal body temperature MECHANISM OF BODY FLUID MOVEMENT 1.Osmosis normal osmolality of ECF and ICF = 275 to 295 mOsm / kg 2. Diffusion 3. Filtration 4. Active Transport Homeostatic Mechanism
in Fluids and Electrolytes Lungs Heart and Blood Vessels Endocrine System Kidneys Pituitary Gland Parthyroid Gland Thyroid Gland Adrenal Gland Fluid Gains and Losses in an Adult Intake
Ingested Liquids 1200 ml
Solid Foods (water) 1000 ml
Fod Oxidation (water) 300 ml

Total Intake 2500 ml Output
Kidneys (urine) 1500 ml
Intestines (feces) 200 ml
Lungs (in air expired) 400 ml
Skin (sweat, diffusion) 400 ml
Total Output 2500 ml FLUID VOLUME DEFICIT Lost water and electrolytes out of vascular,
interstitial or intracellular spaces Causes
1. vomiting, diarrhea, fistula, suctioning
2. laxative or enema use
3. diuretics (including alcohol)
4. insufficient intake to output
5. diabetes insipidis (insufficient ADH)
6. fever Manifestation
1. weight loss
2. decreased skin and tongue turgor
3. decreased urine output (<30 ml / hour)
4. drop in blood pressure
5. weak and rapid pulse
6. decreased in body temperature
7. slow capillary refill
8. flat neck veins
9. CVP < 4 cm H2O
10. increased hematocrit Treatment

1. Mild Volume Deficit
increased dietary sodium and water intake

2. Moderate to severe volume deficit
require IV fluid therapy Accurate and frequent assessment
to determine volume overload
weight, vital signs, CVP, I and O,
level of consciousness,
breath sounds, skin color Maintenance 1500 ml/m2 BSA Moderate fluid volume deficit + maintenance 2400 ml/m2 BSA
(acute weight loss < 5 %) Severe fluid volume deficit + maintenance 3000 ml/m2 BSA
(acute weight loss > 5%) Intravenous Fluid Isotonic 240 - 340 mOsm/L Hypotonic less than 240 mOsm/L Hypertonic more than 340 mOsm/L Major purpose of Fluid Therapy 1. Providing fluids to meet daily maintenance 2. Providing fluids to replace on-going losses 3. Providing electrolytes to correct any existing disturbances D5W (Isotonic) 252 mOsm/L

provides free water to ECF and ICF
as dextrose is quickly metabolized

promotes renal elimination of solutes,
treat hypernatremia

no electrolytes; 1L = 170 cal D10 W (Hypertonic) 505 mOsm/L

Osmotic diuretic, provides free water and
340 cal / L; no eletrolytes

may irritate the vein D50 W (Hypertonic) 1700 mOsm/L

Osmotic diuretic, provides calories
no electrolytes D5 0.45 NaCl (Hypertonic) 406 mOsm/L

to promote renal function and excretion
provides 170 cal/L D5 0.3 NaCl (Hypertonic) 355 mOsm/L

used to treat hypernatremia - because
the solution contains small amount of Na+,
it dilutes plasma Na+ while not allowing
it to drop too quickly LR (Isotonic) 273 mOsm/L

closely resemble the electrolyte composition
of normal blood serum and plasma. will need
additional K+;

does not provide free calories

used to treat GI losses and burns D5 LR (Hypertonic) 524 mOsm/L

same as LR plus the calories D5 0.9 NaCl (Hypertonic) 559 mOsm/L

to treat fluid volume deficit

for daily maintenance of body fluids and nutrition

basically the same as normal saline except
it provides 170 cal/L 0.9 NaCl (Isotonic) 308 mOsm/L

Replaces NaCl deficit and restores / expands
extracellular volume

the only solution that may be administered
with blood products, does not provide free
water that can hemolyze blood Intravenous Fluids Blood Loss: Plain LRS, Plain NSS Hyponatremia: Plain NSS Pediatrics: IMB, D5 0.3 NaCl Diabetes Mellitus: Non-Dextrose containing IVF Hypertension: D5 Water ICH / CVA: Plain NSS, D5 NSS, Plain LR Renal: D5 0.3 NaCl, D5 Water Metabolic Acidosis: Plain LR, D5 LR Hypokalemia: D5 NM NPO: Dextrose containing IV fluids Fluid Volume Excess Develops when both sodium and water are
retained in roughly the same proportions

As excessive isotonic fluid accumulates in the
ECF, fluid shifts into the interstitial compartment
causing edema Factors Affecting Edema Formation Increased Capillary hydrostatic pressure Decreased plasma oncotic pressure Increased capillary permeability Increased interstitial oncotic pressure
-lymphatic obstruction Cause
1. As excessive isotonic fluid accumulates in the
ECF, fluid shifts into the interstitial compartment
causing edema
2. Inadequate functioning heart, kidneys:
CHF, CRF, excessive steroids, cirrhosis
3. Overzealous administration of sodium containing
IV fluids
4. Excessive ingestion of sodium containing
substances in diet and medication Manifestation
1. weight gain
2. peripheral edema
3. distended neck vein
4. slow emptying peripheral vein
5. CVP > 12 cm H2O
6. polyuria
7. rales in lungs, Ascites, Pleural effusion
8. bounding full pulses
9. decreased hematocrit; low specific gravity
10. pulmonary edema in severe Treatment
1. Diuretics
2. Sodium Restriction
3. Restrict fluid
4. Dialysis Monitor I and O, weigh patient
assess breath sounds and degree of edema

monitor parenteral therapy and administer
appropriate medications Sodium Imbalances Sodium = 135 -145 mEq / L

Abundant in the ECF
Controls water distribution and ECF Volume Hyponatremia Hypernatremia Serum sodium is lower than 135 mEq / L
Indicates that body fluids are diluted by
an excess of water relative to the
total solute Cause
1. Water shifts to ECF, change in osmolality
2. loss of sodium (without water) - diuretics, GI
3. diseases - heart or renal failure; SIADH
4. excessive hypotonic IV fluids Manifestation
1. Muscle cramps, weakness, fatigue
2. GI: anorexia, nausea, vomiting, diarrhea
abdominal cramping
3. Cerebral edema symptoms (brain cell swells)
lethargy, confusion, headache, muscle twitching,
tremors, convulsion Treatment

The goal of treatment is to elevate serum sodium toward normal and to treat underlying cause

1. restricting water
2. administering sodium

Isotonic solution (ringer's, 0.9% NaCl)
Hypertonic solution IV Na Soln (3% NaCl) - severe

3. Loop Diuretics - promote isotonic diuresis Increase foods high in sodium
Restrict fluid
Assess for signs of hyponatremia
- mental status assessment
Seizure precautions
Strict intake and output, monitor weight
Reassess serum sodium Serum sodium is higher than 145 mEq/L
Hyperosmolality of ECF may occur with fluid deficit or excess Cause
1. sodium gained in excess of water
excessive salt intake or hypertonic soln
heat stroke, near drowning in sea water
2. water lost in excess of sodium
patients unable to respond to thirst,
diabetis insipidus Mannifestation
1. thirst
2. dry, sticky mucous membrane
3. altered neurologic function-
letahrgy, irritability, seizure, coma Treatment
The primary goal of treatment is to gradually lower serum sodium to normal range and restore normal serum osmolality. And this is done slowly to avoid development of cerebral edema. Treatment

Free water can be given orally or as IV D5W to patient who is normovolemic but hypernatremic

When patient is hypovolemic and hypernatremic, isotonic solution can be given IV followed by hypotonic solution

If patient is both hypervolemic and hypernatremic, concurrent administration of diuretics and D5W can be done

Dialysis if renal function is impaired Assess for abdominal losses of water, low water intake, or large sodium gains

Monitor vital signs including mental status

Check serum sodium level Potassium Imbalances Potassium (3.5 - 5.0 mEq/L)

major intracellular electrolyte
vital role in cellular metabolism, heart function and neuromuscular function Hypokalemia Serum potassium is lower than 3.5 mEq/L Cause
1. Excessive loss of potassium

kidneys - secondary to drugs, hyperaldosteronism, DM
GIT - severe vomiting, gastric suction, diarrhea, or ileostomy

2. Inadequate intake
3. Shift from extracellular to intracellular space Manifestation
1. Abnormal heart rhythm
2. Muscle weakness, including leg cramps
3. Slowed abdominal peristalsis
4. ECG changes - flattened or inverted T wave, presence of U waves Treatment
1. Potassium supplements - oral or parenteral


2. Dietary management
Potassium rich foods - fruits and vegetables

3. Regular monitoring of serum potassium levels Monitor serum potassium, complications of IV therapy

Assess for cardiac and neuromuscular changes

Instruct the patient to choose and consume foods rich in potassium, such as fruits, fruit juices, vegetables, nuts, meat and milk

Assess for phlebitis and infiltration into the subcutaneous tissues, which can cause sloughing or tissue necrosis Hyperkalemia Serum potassium is higher than 5.0 mEq/L Cause
1. Inadequate excretion of potassium
- impaired renal excretion of K
(renal failure, adrenal insufficiency)
- medications that impair K excretion

2. Excessive high intake of potassium

3. Shift from intracellular to extracellular space
- acidosis, tissue trauma Manifestation
1. Abnormal heart function
2. Skeletal muscle irritability, tremors progress to weakness and paralysis
3. GI disturbance: initially, diarrhea and colic
4. Peaked T wave, prolonged conduction PR Treatment
1. Stop all potassium supplements

2. Medications to lower serum potassium and stabilize conduction of heart

10% calcium gluconate IV
Dextrose 50% + regular insulin (10 u) IV - moves potassium intracellularly

3. Sodium polysterene sulfonate (Kayexalate)

4. Loop diuretics

5. Dialysis Dietary restriction

Monitor urine output

Potassium Wasting diuretics

Check serum potassium Consideration in the Administration of Potassium IV

1. Concentrated Potassium solutions should never be administered
without first being diluted appropriately.

2. The appropriate dilution of potassium chloride solution depends on

a. the amount of fluid the patient can tolerate
b. the site of administration
c. the patient’s tolerance for pain at the insertion site. 3. Rate of administration is dependent on the urgency for potassium replacement.

4. It is important to monitor carefully the rate of urinary output. Treatment of Severe Hyperkalemia

1. Calcium Gluconate
2. Sodium Bicarbonate
3. Insulin and Hypertonic dextrose Calcium Imbalances Calcium (8.5 – 10.5 mg/dL)

Over 99 % of the body’s calcium in the skeletal system. About 1% of skeletal calcium is rapidly exchangeable w/ blood calcium

Plays a major role in the transmission of nerve impulses & helps regulate muscle contraction & relaxation, including cardiac muscle Hypocalcemia Serum calcium level < 8.5 mg/dl Causes

1. Hypoparathyroidism
2. Acute pancreatitis
3. Electrolyte imbalances (low Mg, high phosphate)
4. Malabsorption disorders
5. Medications – loop diuretics, anticonvulsants
6. Massive transfusion of banked blood Manifestation

1. Tetany (tonic muscle spasm) and convulsion
2. Numbness and tingling around mouth,
in hands and feet, hyperactive deep tendon reflex
3. Positive Chvostek’s sign and Trousseau’s sign
4. Respiratory – laryngeal spasm
5. Cardiac – hypotension, bradycardia,
ventricular dysrrhythmias and cardiac arrest Treatment

1. Calcium Supplements
2. Severe hypocalcemia – Intravenous calcium
3. Dietary management includes Ca in diet
4. Vitamin D therapy Seizure precaution
Status of the airway is closely monitored
Instruct need for adequate dietary calcium intake Hypercalcemia Serum calcium level greater than 10.5 mg/dl Serum calcium level greater than 10.5 mg/dl Causes

1. Increased reabsorption of calcium from bones
- hyperparathyroidism, malignancies, immobility and lack of weight-bearing

2. Diminished elimination of calcium - medication Manifestation

1. Decreased neuromuscular irritability
- muscle weakness, depressed DTR, advances to
confusion, lethargy to coma
2. GI – anorexia, nausea, vomiting, constipation
3. Cardiac – heart conduction disturbances:
bradycardia, heart block
4. Polyuria and increased thirst Treatment
Goal to promote Ca elimination by kidneys; to reduce Ca reabsorption from bone

1. Administer fluids to dilute serum calcium & promote excretion by kidneys.
2. Administer loop diuretics, calcitonin

Encourage fluid intake
Restrict dietary calcium intake Treatment

Goal is to promote Calcium elimination by kidneys;
to reduce Ca reabsorption from bone

1. Administer fluids to dilute serum calcium &
promote excretion by kidneys.

2. Administer loop diuretics, calcitonin

Encourage fluid intake
Restrict dietary calcium intake Magnesium Imbalances Magnesium (1.6 – 2.6 mg/dl) Vital to cellular processes, enzyme and protein synthesis
Implicated in neuronal control, neuromuscular transmission, and cardiovascular tone

Affected by potassium and calcium levels Hypomagnesemia Magnesium level less than 1.6 mg/dl
Common in critically ill patients Cause

1. Usually occurs along with K and Ca deficiencies
2. Loss of GI fluids
3. Impaired nutrition absorption from gut – NPO
4. Chronic alcoholism
5. Medications – diuretics Treatment

1. Intravenous Magnesium Sulfate
2. Encourage balanced diet Monitor Vital signs and neuro status
Continuous cardiac monitoring
Reassess laboratory results Hypermagnesemia Magnesium level less than 2.6 mg/dl Cause

1. Renal Failure Manifestation

1. Weakness, lethargy, weak or absent DTR
2. Hypotension, flushing sweating, bradyarhythmias
3. Nausea, vomiting Treatment

1. Withold medications containing magnesium
2. Administer diuretics or saline solution
3. Dialysis for patients with renal failure
4. Calcium gluconate IV - reversal of neuro and
cardiac effects
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