Presentation on theme: "Fluid and Electrolytes"— Presentation transcript:
1Fluid and Electrolytes CSONSpring 2009PREPARED BY CARLA HILTON, MSN, RNPRESENTED AND REVISED BY REBECCA POWERS, MSN, RN15 questions from all of powers’ stuff…
2Water Balance = Homeostasis Water in the body is used to or for:Transporting nutrients & oxygen to cellsRemoving waste from cellsProvides medium in which electrolyte chemical reactions can occurRegulation of body temperatureLubricates joints and membranesProvides medium for food digestionliter of water weighs 2.2 lbsThe most accurate way to measure fluid status in a person is daily weights, not I&O!!!
3Water Distribution ICF: Intracellular fluid ECF: Extracellular fluid (lymph system, interstitial fluid, intravascular fluid or plasma)TCF: Transcellular fluid (cerebral spinal fluid, fluid in joints, GI tract, and peritoneal fluid)Third spacing: (a condition where fluid accumulates in a pocket that isn’t really serving a purpose. Acieties (sp?)- where fluid hangs out in your abd. The fluid is coming from somewhere else.)More fluid in intracellular than anywhere else in the body!
4Osmolarity / Osmolality Osmole:the amount of substance that dissociates in solution to form one mole of osmotically active particlesConcentration of solution measured in osmoles
5Osmolarity / Osmolality Osmolality is measured in milliOsmols/Kg (mOsm/Kg)Osmolarity is measured in milliOsmols/L (mOsm/L)Evaluates serum and urine in clinical practiceNormal: serum osmolality 275 – 295 mOsm/KLality= total volume will equal 1 L plus the amount of volume taken up by the solids! The koolaid and water equal a LLarity= volume is going to be less than 1 L. The koolaid minus the water.
6Concentrations of Solutions Isotonic: Same osmolarity as blood plasma…no osmotic “pull”Hypotonic: Less concentration than blood plasma…lower osmotic pressureHypertonic: More concentration than blood plasma….higher osmotic pressure
7Movement of WaterIntracellular & extracellular approximately same osmolalitySolvent (water) and solutes (electrolytes)move across selectively permeable membranes (compartments) in the body(the bigger the particle, the slower they move, and they may need a little boost…)
8Review of Terms Osmosis Diffusion Active transport Passive transport FiltrationHydrostatic pressure
9Osmosis Review Movement of water only Speed of movement affected by: temperature of fluidconcentration of fluidelectrical charge of particles in solutionThe higher the solute concentration, the greater the osmotic pressure is.
10Other Mechanisms of Movement Diffusion: Solute (or gas) moves from area of higher concentration to area of lower concentrationFacilitated diffusion: Solute moves against concentration gradient (passive transport)Active transport: Solute moved against concentration gradient using ENERGY
11Active TransportNa+/K+ pump: Maintains the higher concentrations of extracellular Na+ and intracellular K+In the cell, K is King. i.e. K is the major cation of the cell, Na is outside the cell.
12ContinuedFiltration: solutes & solvent move together in response to fluid pressure; moves from area of high pressure (hydrostatic pressure) to area of low pressureHydrostatic pressure: The force within a fluid compartment (as in the vascular system) The pressure that forces the fluid out of your capillaries.Colloidal Osmotic Pressure – pulls it back into the capillaries.
13Regulation of Body Fluids Intake: osmoreceptors sense osmolality of serum, signals the hypothalamus, stimulates thirstImpact on intake: Age (decreases desire to drink), conciousness, ability to take in fluidsOutput: kidneys, lungs, GI tract, skinSensible: measurable….urine output, excessive perspiration, diarrhea, vomitingInsensible: immeasurable…normal perspiration, normal breathingOutput for adults should be one mL/kg (of body weight) an hour
14Potter & Perry 7th edition, table 41-2 Potter & Perry 7th edition, table JUST FOR AN IDEA, NOT FOR ANY KIND OF MEMORIZATION OR ANYTHING!!! DON’T LEARN THIS!
15Role of the KidneysFilter approx 180 Liters of blood per day; GFR (glomerular filtration rate)Produces urine between 1-2 Liters/dayIf loss of 1% to 2% of body water, will conserve water by reabsorbing more water from filtrate; urine will be more concentratedIf gain of excess body water, will excrete more water from filtrate; urine will be more dilutedFrom Fluids & Electrolytes Made Incredibly Easy, 4th edition.
16Hormonal ControlAntidiuretic hormone (ADH): Prevents diuresis; “water saving”Question: Osmoreceptors sensing a/an increase in osmolality will cause the release of ADHADH acts on kidneys via the renal tubules. Makes them more permeable to water. The water will move from the tubes back into your body.
17Hormonal ControlRAA (Renin-angiotensin-aldosterone): cascade initiated by decrease in renal perfusion or low Na+If extracellular volume is decreased renal perfusion decreases renin secreted by kidneys renin acts to produce angiotensin I which then converts to angiotensin II results in massive vasoconstriction increases renal arterial perfusion and causes increased thirst, a release of aldosterone (causes the retention of Na and Water)
18Hormonal Control Aldosterone: Angiotensin II causes the adrenal gland to release aldosteroneAldosterone causes the kidneys to retain Na+ and waterVolume regulator….released if Na+ is low and K+ is high; increases reabsorption of Na+ (where salt goes, water follows) and the excretion of K+
19ANPAtrial Natriuretic Peptide: (ANP): secreted from atrial cells of heart (in response to too much volume in the blood)acts as diureticinhibits thirst mechanismsuppresses the RAA cascade
20Thirst Mechanism Regulated by the hypothalamus Stimulates thirst: increased osmolality of ECFdecreased ECFdry mucous membranesCauses: eating salty foods, inadequate intake, excessive water loss
21Pressure SensorsBaroreceptors: Nerve receptors that sense pressure in blood vessels (think barometer measures pressure in the atmosphere, this measures pressure in the blood vessels)Low pressure: sensors in the cardiac atria; stimulate SNS (sympathetic nervous system) & inhibits PSNS (parasympathetic nervous system) (sns will increase heart rate and BP)High pressure: sensors in the aortic arch, carotid sinus, and the juxtaglomerular apparatus in the kidney; stimulates PSNS and inhibits the SNS (psns will decrease your heart rate and lower BP)
22Pressure Sensors Osmorecptors: Sense Na+ concentration Positioned on surface of hypothalamusIncrease in Na+ concentration: stimulates release of ADHDecrease in Na+ concentration: inhibits release of ADH
23ELECTROLYTES and OTHER LABS RELATED TO FLUID VOLUME STATUS
24Electrolytes Minerals and salts: electrolytes Cations: Positively charged; sodium, potassium, calcium, magnesiumMajor cation in ECF is sodiumAnions: Negatively charged; chloride, bicarbonate, sulfateMajor cation in ICF is potassium
26Hyponatremia Usually loss of Na w/o loss of fluid CausesSalt wasting fr. KidneyAdrenal insufficiencyGI lossesProfuse sweatingDiureticsSIADHSyndrome of inappropriate Anti-Diruetic HormoneInadequate Na intakePhysical ExamApprehensionPersonality changePostural hypotensionTachycardiaConvulsions/comaNV&DAnorexiaADH causes retention of waterRatio of water to Na changesEffect is LOW sodium compared to amount of water
34Hyperkalemia cont’d Labs Treatment Serum K+ above 5.0 mEq/L. ECG abnormalities – can lead to arrest (if too high or too low)TreatmentKayexalateIV Na+ bicarbIV Ca+ gluconateRegular insulin and hypertonic dextrose IVLimit via dietPossible dialysis
35Hypocalcemia Causes Signs & Sxms Rapid admin of blood w citrate HypoalbuminemiaHypoparathyroidismVit. D deficiencyPancreatitisStuff that relates back to preexisting conditionsSigns & SxmsNumbness, tingling of fingers & mouthHyperactive reflexesTetany- a muscle contraction that stays contractedMuscle crampsPathological fractures
36Hypocalcemia cont’d Labs Treatment Serum Ca++ below 4.5 mEq/L ECG abnormalitiesTreatmentIncrease dietary intakeIV calcium gluconateCa+ & vit D supplements
41Hypermagnesemia Causes Signs & Sxms Renal failure Excess intake of magnesiumSigns & SxmsMost frequently seen in acuteHypoactive deep tendon reflexes & drowsinessDecreased depth and rate of resp.Hypotensionflushing
42Hypermagnesemia cont’d LabsSerum Mg++ levels above 2.5 mEq/LTreatmentIV calcium gluconateLoop diureticsNS or LR IV solutionsDialysis
43Additional Lab Data Hematocrit Normal: M = 40-50%; F = 37-47% Measures the volume % of RBC’s in whole bloodNormal: M = 40-50%; F = 37-47%Increases with dehydration (hemoconcentration)Decreases with overhydration (hemodilution)
44FLUID & ELECTROLYTES MADE INCREDIBLY EASY, 4TH ED. Hematocrit & Fluid Volume Status From “Fluids & Electrolytes Made Incredibly Easy” 4th ed.FLUID & ELECTROLYTES MADE INCREDIBLY EASY, 4TH ED.Fluids & Electrolytes Made Incredibly Easy
45Lab Data (cont’d) Blood urea nitrogen (BUN) Measures kidney function Normal range: 7-20mg/dLVaries with protein intake, fever, dehydration, GI bleeding, liver failure, etc.
46Lab Data (cont’d) Creatinine End product of muscle metabolism Better indicator of renal function than BUNDoesn’t vary w protein intake or metabolic stateNormal range: mg/dL in 24 hr urine collectionSerum: adult female: 0.5 to 1.1mg/dLadult male: 0.6 to 1.2mg/dL
47Lab Data (cont’d) Urine Specific Gravity Normal range = 1.010 - 1.025 Measures ability of kidney to excrete or conserve waterNormal range =Increased S.G.= concentrated urineDecreased S.G.= dilute urine
48Lab Data (cont’d) Serum Osmolarity Remember norm? Most accurate for kidney functionRemember norm?mOsm/LMeasured directly through bloodIndirectly using Serum Osmolarity Formula
50Fluid Imbalances Isotonic Deficit – water, electrolytes and solutes lost in equal proportions to body solutionsExcess – water, electrolytes and solutes gained in equal proportions to body solutionFVD - fluid volume deficit-HYPOVOLEMIAFVE - fluid volume excess-HYPERVOLEMIA
51Fluid Disturbances Osmolar Imbalances Hyperosmolar – Dehydration Hypoosmolar – Water excessLoss or excesses of water onlyLeads to alteration in concentration of serum
55FVD: Signs & Symptoms (cont’d) SeverePaleFlattened neck veins, delayed capillary refillUrine output less than 10cc/hrMarked hypotension, tachycardia, weak or absent pulses (shock)Can lead to unconsciousness
56FVD: Labs Lab findings vary depending on the cause Decreased H/H with hemorrhageIncreased HctElevated BUNUrine specific gravity greaterthan 1.030
57FVD: Nursing Diagnosis Statement Example:Fluid volume deficit r/t active fluid volume loss as evidenced by decreased blood pressure (90/50 mmHg), thirst, fever (102°), rapid heart rate (110 bpm), urine output less than or equal to 25 mL/hr, & urine specific gravity of
58FVD: Goal Statement Client will achieve fluid balance AEB urine output equal to or greater than 30 mL/hrElastic skin turgor and moist mucous membranes
59FVD: Medical Interventions Treat causeReplacing fluids intravenouslyisotonic if hypotensive (expand plasma volume)hypotonic if normotensive (provides electrolytes and water)Encourage fluidsEnsure adequate O2 and perfusionIncrease blood counts, BP, & albumin levelsTeaching
60FVD: Nursing Interventions Ensure patent airway, adjust O2 levels as orderedLower HOB if tolerated or not contraindicatedDirect pressure to bleeding, if presentAdminister meds, blood, albumin, & IV fluids
62FVD: Teaching Nature of condition & causes Warning S/S Treatments & importance of complianceChange positions slowlyMonitor BP & pulse rateGive prescribed medications
63Fluid Volume Excess (FVE) Water AND solutes gained in excess of normal body levelsCauses:Isotonic fluid overloadExcess sodium intakeCHF, renal failure, cirrhosisIncrease in steroids or serum aldosterone
67FVE: Nursing Diagnosis Statement Fluid volume excess r/t excess fluid intake aeb Hct of 23, 10# weight gain in two days, dyspnea (Pt states, “I can’t get enough air.”), and crackles on inspiration and expiration in all lobes.
75Hyperosmolar: Dehydration Loss of water = increased serum osmolalityincreased serum Na+Compensatory Mechanism: water shifts out of cells (ICF) into the ECF…..if not corrected, water continues to move out of cells (ICF) and into ECF causing the cells to shrink….shrunken cells don’t function properly!!
76REFERENCE: MEDICAL-SURGICAL NURSING: CRITICAL THINKING FOR COLLABORATIVE CARE, 5TH ED., IGNATAVICUS. FIGURE 15-3, P. 214.
77Causes of Dehydration Causes: Diabetes insipidus, prolonged fever, watery diarrhea, hyperglycemia, failed thirst driveIatrogenic: hypertonic solutions (IV & tube feeding)Diuresis of water alone
81Dehydration: Nursing Diagnoses Fluid volume deficit r/t fluid lossDeficient fluid volume r/t excessive fluid loss from GI tractRisk for impaired skin integrity r/t altered metabolic stateIf you’ve lost 20% of you initial weight from dehydration, you’re probably dead
82Dehydration: Potential Nursing Diagnoses Deficient knowledge: unfamiliarity of disease processDisturbed thought processes r/t neurologic changes / decreased cardiac outputDecreased cardiac output r/t excessive fluid loss
83Dehydration: Client Goals & Outcomes Aimed at correcting causeReplace fluids – hypotonic, slowly re-hydrate over 48 hrs (if you go too quickly, you die)Maintain skin integrityTeaching
84Dehydration: Nursing Interventions Replace fluids by PO route firstSLOW admin. of salt-free IV solutionsMonitor S/S cerebral & pulmonary edemaMonitor accurate I/O, VS, daily weightsMonitor labsProvide skin and mouth care
85Dehydration: Teaching Disease process of dehydrationTreatmentsWarning signs and symptomsMedications / IV (Vasopressin – D5W)Importance of compliance with therapyFluid intake not based on thirst alone
86Hypoosmolar Water excess Causes Signs & Sxms Labs SIADH or excess water intakeSigns & SxmsDecreased LOC, convulsions, comaLabsSerum Na+ below 135 mEq/L and Serum osmolality below 280 mOsm/kg
87Nsg Dx – Goals - Interventions Similar to FVEMake relevant to underlying causeIs very acute illness
93Assessment of Geriatric Clients Skin turgorAssessment is performed where?CognitionPhysical beingContinence
94Laboratory Data BMP / CMP Serum osmolarity Urine specific gravity Urine sodiumHematocritBlood urea nitrogen (BUN)Creatinine
95Clients at Risk for F&E Imbalances AgeVery youngVery oldChronic DiseasesCancerCardiovascular disease, such as congestive heart failureEndocrine disease, such as Cushing's disease and diabetesMalnutritionChronic obstructive pulmonary diseaseRenal disease, such as progressive renal failureChanges in level of consciousness
96Clients at Risk for F&E Imbalances TraumaCrush injuriesHead injuriesBurnsMajor surgeryTherapiesDiureticsSteroidsIntravenous (IV) therapyTotal parenteral nutrition (TPN)Gastrointestinal lossesGastroenteritisNasogastric suctioningFistulas
97Fluid & Electrolytes Nursing DXs Risk for imbalanced Body temperatureIneffective Breathing patternDecreased Cardiac outputDeficient Fluid volumeRisk for deficient Fluid volumeExcess Fluid volumeImpaired Gas exchangeKnowledge deficient regarding disease managementImpaired MobilityImpaired Oral mucous membraneImpaired Skin integrityRisk for impaired Skin integrityIneffective Therapeutic regimen managementImpaired Tissue integrityIneffective Tissue perfusion
99Intravenous Fluid Therapy in Fluid Balance Disorders
100ISOtonic solutions Same osmolarity as body fluids mOsm/kgExpands the IVC without pulling fluids from other compartmentsExamplesNormal saline (NS)Lactated Ringers (LR)
101IVs: Normal Saline (NS) Isotonic0.9% Sodium ChlorideDifferent amountsSample order75cc/hr
102IVs: Lactated Ringer’s (LR) Isotonic SolutionContentsNa+, Cl-, K+, Ca++, Lactate in sterile waterOne strength, two common amountsSample orders100cc/hr75cc/hr
103HypOtonic solutions RISK Osmolarity less than serum Pulls fluid from the IVC into the ICC causing cells to expandOver hydrationRehydrationExample½ NSD5W - after absorbed into bodyRISK
104IVs: Dextrose Solutions Concentrations5% in water (hypotonic after enters body)10% in water (hypertonic)50% in water (rescue solution – small volume)As additive to NS or LRD5NS or D5LR
105HypERtonic solutionsOsmolarity of solution is higher than serum osmolarity>300 mOsm/kgPulls fluid from ICC into IVC causing cells to shrinkdehydrateExamplesD51/2 NS D5NS D5LR3% NS (CRITICAL Strength)
107IVs: Common Additives Potassium (never add to a bag!) Multivitamins Additives makes the solution hypertonic to some extent – depends on amount
108IV Additives: Potassium Available as KCl (potassium chloride)NEVER add K+ to a bag of fluidAdded by pharmacy or premixedDifferent strengthsSample ordersNS c 20 mEq 75 cc/hrLR c 40 mEq 75 cc/hr
109Medications Used in Fluid & Electrolyte Imbalance Disorders
110Meds: Antidiarrheals Assess I /O & electrolytes Provide oral care Monitor for constipationTeachingTake as directedAvoid overdoseExamples: Lomotil & Immodium
111Meds: Antiemetics Assess VS & emesis status before and after Monitor for extrapyriamidal side effectsinvoluntary movement of eyes, face or limbs, flat affect, shuffled gait, droolingProvide fluid replacementsOral electrolyte solutionsWaterSample Meds: Zofran, Phenergan & Vistaril
113Meds: Potassium Forms: tablets (SR), effervescent, EC, IV Administration considerationsPO: Give on a full stomach at mealtime am/pmIV: NEVER give as bolus, follow protocol, dilute for IV administration, can burn & lead to infiltrationMonitor: K+ levels – monitor EKG if elevated
114Meds: Kayexelate Removes K+ from system Available as enema or by PO routeRetain enema for ½ to 1 hrFollow resin w 100 mL waterAfter expulsion, rinse colon w 1 liter of water and drain out immediately
115Other Meds r/t F/E status GlucocorticosteroidsDigoxinElectrolyte supplements
116Stuff To Add for the Test A L of fluid weighs 2.2 lbs1 lb of fluid is 454 mLIf a L of fluid weighs 2.2 lbs you need to be able to figure out how many mL a ½ lb is10% fluid loss is serious, but 20% loss is mostly deathIf you have someone who begins to have a transfusion reaction (hemolytic) watch forFever, low back pain, itching, hypotension, N/V, drop in urine output, chest pain, dyspneaIf you are doing VS for these people and they have these symptoms, GO FIND THE NURSE IMMEDIATELY! They don’t need any more blood whatsoever!