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Fluid and Electrolytes CSON Spring 2009 PREPARED BY CARLA HILTON, MSN, RN PRESENTED AND REVISED BY REBECCA POWERS, MSN, RN 15 questions from all of powers’

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Presentation on theme: "Fluid and Electrolytes CSON Spring 2009 PREPARED BY CARLA HILTON, MSN, RN PRESENTED AND REVISED BY REBECCA POWERS, MSN, RN 15 questions from all of powers’"— Presentation transcript:

1 Fluid and Electrolytes CSON Spring 2009 PREPARED BY CARLA HILTON, MSN, RN PRESENTED AND REVISED BY REBECCA POWERS, MSN, RN 15 questions from all of powers’ stuff…

2 Water Balance = Homeostasis Water in the body is used to or for: Transporting nutrients & oxygen to cells Removing waste from cells Provides medium in which electrolyte chemical reactions can occur Regulation of body temperature Lubricates joints and membranes Provides medium for food digestion liter of water weighs 2.2 lbs The most accurate way to measure fluid status in a person is daily weights, not I&O!!!

3 Water 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!

4 Osmole: the amount of substance that dissociates in solution to form one mole of osmotically active particles Concentration of solution measured in osmoles Osmolarity / Osmolality

5 Osmolality is measured in milliOsmols/Kg (mOsm/Kg) Osmolarity is measured in milliOsmols/L (mOsm/L) Evaluates serum and urine in clinical practice Normal: serum osmolality 275 – 295 mOsm/K Lality= total volume will equal 1 L plus the amount of volume taken up by the solids! The koolaid and water equal a L Larity= volume is going to be less than 1 L. The koolaid minus the water.

6 Concentrations of Solutions Isotonic: Same osmolarity as blood plasma…no osmotic “pull” Hypotonic: Less concentration than blood plasma…lower osmotic pressure Hypertonic: More concentration than blood plasma….higher osmotic pressure

7 Movement of Water Intracellular & extracellular approximately same osmolality Solvent (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…)

8 Review of Terms Osmosis Diffusion Active transport Passive transport Filtration Hydrostatic pressure

9 Osmosis Review Movement of water only Speed of movement affected by: temperature of fluid concentration of fluid electrical charge of particles in solution The higher the solute concentration, the greater the osmotic pressure is.

10 Other Mechanisms of Movement Diffusion: Solute (or gas) moves from area of higher concentration to area of lower concentration Facilitated diffusion: Solute moves against concentration gradient (passive transport) Active transport: Solute moved against concentration gradient using ENERGY

11 Active Transport Na+/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.

12 Continued Filtration: solutes & solvent move together in response to fluid pressure; moves from area of high pressure (hydrostatic pressure) to area of low pressure Hydrostatic 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.

13 Regulation of Body Fluids Intake: osmoreceptors sense osmolality of serum, signals the hypothalamus, stimulates thirst – Impact on intake: Age (decreases desire to drink), conciousness, ability to take in fluids Output: kidneys, lungs, GI tract, skin Sensible: measurable….urine output, excessive perspiration, diarrhea, vomiting Insensible: immeasurable…normal perspiration, normal breathing Output for adults should be one mL/kg (of body weight) an hour


15 Role of the Kidneys Filter approx 180 Liters of blood per day; GFR (glomerular filtration rate) Produces urine between 1-2 Liters/day If loss of 1% to 2% of body water, will conserve water by reabsorbing more water from filtrate; urine will be more concentrated If gain of excess body water, will excrete more water from filtrate; urine will be more diluted

16 Hormonal Control Antidiuretic hormone (ADH): Prevents diuresis; “water saving” Question: Osmoreceptors sensing a/an increase in osmolality will cause the release of ADH ADH acts on kidneys via the renal tubules. Makes them more permeable to water. The water will move from the tubes back into your body.

17 Hormonal Control RAA (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)

18 Hormonal Control Aldosterone: Angiotensin II causes the adrenal gland to release aldosterone Aldosterone causes the kidneys to retain Na + and water Volume regulator….released if Na + is low and K + is high; increases reabsorption of Na+ (where salt goes, water follows) and the excretion of K +

19 ANP Atrial Natriuretic Peptide: (ANP): secreted from atrial cells of heart (in response to too much volume in the blood) acts as diuretic inhibits thirst mechanism suppresses the RAA cascade

20 Thirst Mechanism Regulated by the hypothalamus Stimulates thirst: increased osmolality of ECF decreased ECF dry mucous membranes Causes: eating salty foods, inadequate intake, excessive water loss

21 Pressure Sensors Baroreceptors: 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)

22 Pressure Sensors Osmorecptors: Sense Na + concentration Positioned on surface of hypothalamus Increase in Na+ concentration: stimulates release of ADH Decrease in Na+ concentration: inhibits release of ADH


24 Electrolytes Minerals and salts: electrolytes Cations: Positively charged; sodium, potassium, calcium, magnesium Major cation in ECF is sodium Anions: Negatively charged; chloride, bicarbonate, sulfate Major cation in ICF is potassium


26 Hyponatremia Usually loss of Na w/o loss of fluid Causes – Salt wasting fr. Kidney – Adrenal insufficiency – GI losses – Profuse sweating – Diuretics – SIADH Syndrome of inappropriate Anti-Diruetic Hormone – Inadequate Na intake Physical Exam – Apprehension – Personality change – Postural hypotension – Tachycardia – Convulsions/coma – NV&D – Anorexia

27 Hyponatremia cont’d Labs – Serum Na + below 135 mEq/L – Serum Osmolality below 280 mOsm/kg – Urine specific gravity below Treatment Restrict water Sodium replacement

28 Hypernatremia Causes –  ingestion of salt – Iatrogenic (we caused it) –  aldosterone – Water deprivation Signs & Sxms – Thirst, sticky tongue – Dry, flushed skin – Fever – Convulsions, irritability

29 Hypernatremia cont’d Labs – Serum Na + above 145 mEq/L – Serum Osmolality above 295 mOsm/kg – Urine specific gravity above Treatment Hypotonic IV solution or D 5 W

30 Urine Na + Studies Urine Na + – Assesses volume status – Aids in diagnosing hyponatremia & acute renal failure Random normal range = mEq/L 24 hour = mEq/L

31 Hypokalemia Causes – Diuretics that “waste” potassium – D, V, & gastric suction –  aldosterone – Polyuria, sweating – Iatrogenic – K + poor solutions Signs & Sxms – Weakness, fatigue –  muscle tone – Hypoactive bowel sounds and distention – Weak, irregular pulse – Paresthesias – SOMETHING ABOUT CARDIAC FUNCTION

32 Hypokalemia cont’d Labs – K + below 3.5 mEq/L – ECG abnormalities Treatment Oral K + or IV solution w/K + Increased dietary K +

33 Hyperkalemia Causes – Renal failure – Fluid vol. deficit – Massive cellular injury (trauma/burns) – Iatrogenic – Potassium “sparing” diuretics – Addison’s disease Signs & Sxms – Anxiety – Dysrrhythmias – Paresthesia (numbness, pins & needles feeling) – Weakness – Diarrhea

34 Hyperkalemia cont’d Labs – Serum K + above 5.0 mEq/L. – ECG abnormalities – can lead to arrest (if too high or too low) Treatment Kayexalate IV Na+ bicarb IV Ca+ gluconate Regular insulin and hypertonic dextrose IV Limit via diet Possible dialysis

35 Hypocalcemia Causes – Rapid admin of blood w citrate – Hypoalbuminemia – Hypoparathyroidism – Vit. D deficiency – Pancreatitis – Stuff that relates back to preexisting conditions Signs & Sxms – Numbness, tingling of fingers & mouth – Hyperactive reflexes – Tetany- a muscle contraction that stays contracted – Muscle cramps – Pathological fractures

36 Hypocalcemia cont’d Labs – Serum Ca ++ below 4.5 mEq/L – ECG abnormalities Treatment Increase dietary intake IV calcium gluconate Ca + & vit D supplements

37 Hypercalcemia Causes – Hyperparathyroidism – Osteometastasis – Paget’s disease – Osteoporosis – Prolonged immobilization Signs & Sxms – Anorexia, N & V – Weakness, lethargy – Low back pain (stones) – Decreased LOC – Personality changes – Cardiac arrest

38 Hypercalcemia cont’d Labs – Serum Ca ++ above 5.5 mEq/L – X-rays showing osteoporosis – Stones &  BUN / creatinine fr. FVD or renal damage Treatment Lasix (diuretic) Increased fluids

39 Hypomagnesemia Causes – Inadequate intake Alcohol, Malnutrition – Inadequate absorption V&D, Gastric aspirate Fistulas, Sm. Bowel – Loss fr. Diuretics – Polyuria Signs & Sxms – Tremors – Hyperactive deep tendon reflexes – Confusion – Dysrhythmias

40 Hypomagnesemia cont’d Labs – Serum Mg ++ below 1.5 mEq/L Treatment Mag sulfate IV Oral replacement Increase dietary intake

41 Hypermagnesemia Causes – Renal failure – Excess intake of magnesium Signs & Sxms – Most frequently seen in acute – Hypoactive deep tendon reflexes & drowsiness – Decreased depth and rate of resp. – Hypotension – flushing

42 Hypermagnesemia cont’d Labs – Serum Mg ++ levels above 2.5 mEq/L Treatment IV calcium gluconate Loop diuretics NS or LR IV solutions Dialysis

43 Additional Lab Data Hematocrit – Measures the volume % of RBC’s in whole blood Normal: M = 40-50%; F = 37-47% – Increases with dehydration (hemoconcentration) – Decreases with overhydration (hemodilution)

44 Hematocrit & Fluid Volume Status From “Fluids & Electrolytes Made Incredibly Easy” 4 th ed. Fluids & Electrolytes Made Incredibly Easy

45 Lab Data (cont’d) Blood urea nitrogen (BUN) – Measures kidney function – Normal range: 7-20mg/dL – Varies with protein intake, fever, dehydration, GI bleeding, liver failure, etc.

46 Lab Data (cont’d) Creatinine – End product of muscle metabolism – Better indicator of renal function than BUN Doesn’t vary w protein intake or metabolic state – Normal range: mg/dL in 24 hr urine collection – Serum: adult female: 0.5 to 1.1mg/dL adult male: 0.6 to 1.2mg/dL

47 Lab Data (cont’d) Urine Specific Gravity – Measures ability of kidney to excrete or conserve water Normal range = – Increased S.G.= concentrated urine – Decreased S.G.= dilute urine

48 Lab Data (cont’d) Serum Osmolarity – Most accurate for kidney function Remember norm? – mOsm/L – Measured directly through blood – Indirectly using Serum Osmolarity Formula

49 Maintaining Fluid Balance

50 Fluid Imbalances Isotonic – Deficit – water, electrolytes and solutes lost in equal proportions to body solutions – Excess – water, electrolytes and solutes gained in equal proportions to body solution – FVD - fluid volume deficit- HYPOVOLEMIA – FVE - fluid volume excess- HYPERVOLEMIA

51 Fluid Disturbances Osmolar Imbalances – Hyperosmolar – Dehydration – Hypoosmolar – Water excess – Loss or excesses of water only – Leads to alteration in concentration of serum


53 Fluid Volume Deficit (FVD) Water AND solutes lost in equal proportion. – Diarrhea, vomiting, fistulas, drains – Bleeding, burns – Fever, excessive perspiration – Inadequate fluid intake – Diuretics – GI suctioning

54 FVD: Signs & Symptoms Mild – Dry mouth, furrowed tongue – Orthostatic or postural hypotension – Restlessness & anxiety – Tachycardia – Less than 5% weight loss Moderate – Confusion, irritability, thirst, cool & clammy – Urine output 30cc/hr or less – Rapid weight loss – Slowed vein filling

55 FVD: Signs & Symptoms (cont’d) Severe – Pale – Flattened neck veins, delayed capillary refill – Urine output less than 10cc/hr – Marked hypotension, tachycardia, weak or absent pulses (shock) – Can lead to unconsciousness

56 FVD: Labs Lab findings vary depending on the cause – Decreased H/H with hemorrhage – Increased Hct – Elevated BUN – Urine specific gravity greater than 1.030

57 FVD: 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

58 FVD: Goal Statement Client will achieve fluid balance AEB – urine output equal to or greater than 30 mL/hr – Elastic skin turgor and moist mucous membranes

59 FVD: Medical Interventions Treat cause Replacing fluids intravenously isotonic if hypotensive (expand plasma volume) hypotonic if normotensive (provides electrolytes and water) Encourage fluids Ensure adequate O 2 and perfusion Increase blood counts, BP, & albumin levels Teaching

60 FVD: Nursing Interventions Ensure patent airway, adjust O 2 levels as ordered Lower HOB if tolerated or not contraindicated Direct pressure to bleeding, if present Administer meds, blood, albumin, & IV fluids

61 FVD: Nursing Interventions (cont’d) Weigh patients daily Provide skin care Maintain strict I&O Monitor vital signs Monitor lab work

62 FVD: Teaching Nature of condition & causes Warning S/S Treatments & importance of compliance Change positions slowly Monitor BP & pulse rate Give prescribed medications

63 Fluid Volume Excess (FVE) Water AND solutes gained in excess of normal body levels Causes: – Isotonic fluid overload – Excess sodium intake – CHF, renal failure, cirrhosis – Increase in steroids or serum aldosterone

64 FVE: Signs & Symptoms Generalized – Acute weight gain Mild-mod 5-10% Severe > 10% – Edema dependent, sacral, pulmonary Cardiovascular – Tachycardia, bounding pulse, distended neck veins, increased BP Respiratory – Dyspnea, tachypnea, crackles, frothy cough


66 FVE: Lab Values Decreased hematocrit Decreased BUN Low O 2 levels

67 FVE: 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.

68 FVE: Related Nursing Diagnoses Ineffective breathing pattern r/t increased fluids Impaired skin integrity r/t excess fluids Confusion

69 FVE: Client Goals & Outcomes Aimed at cause Decrease circulating fluid volume Lower BP and pulse Improve breathing status Maintain skin integrity Teaching

70 FVE: Goal Statement Client will achieve fluid balance manifest in following outcomes – Clear breath sounds – Denies dyspnea and affirms the ability to breathe adequately

71 FVE: Nursing Interventions Restrict Na + & fluid intake Watch for edema - dependent & respiratory Provide measures to facilitate breathing Provide skin care for weeping & edema

72 FVE: Nursing Interventions (cont’d) Monitor response to medications Accurate I/O, Consistent daily weight, VS, monitor labs Advise HCP if poor response to therapy – Hemodialysis may be needed

73 FVE: Teaching Nature of condition and causes Signs and symptoms Treatments and importance of compliance Need to monitor BP, P, O 2 Sat, & weight Rationale for Na + and fluid restrictions Medications

74 Osmolar Imbalances

75 Hyperosmolar: Dehydration Loss of water = increased serum osmolality increased 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!!


77 Causes of Dehydration Causes: – Diabetes insipidus, prolonged fever, watery diarrhea, hyperglycemia, failed thirst drive – Iatrogenic: hypertonic solutions (IV & tube feeding) – Diuresis of water alone

78 Dehydration: Signs & Symptoms Irritability, confusion, weakness, dizziness Decreased urine output, darkened urine Dry, sticky mucous membranes, sunken eyeballs, poor turgor, extreme thirst !!! Fever (insensible – continuous) Coma Tachycardia, weak, thready pulse, hypotension


80 Dehydration: Labs Elevated hematocrit Elevated serum osmolarity > 295 mOsm/kg Elevated serum sodium > 145 mEq/L Urine specific gravity > 1.030

81 Dehydration: Nursing Diagnoses Fluid volume deficit r/t fluid loss Deficient fluid volume r/t excessive fluid loss from GI tract Risk for impaired skin integrity r/t altered metabolic state If you’ve lost 20% of you initial weight from dehydration, you’re probably dead

82 Dehydration: Potential Nursing Diagnoses Deficient knowledge: unfamiliarity of disease process Disturbed thought processes r/t neurologic changes / decreased cardiac output Decreased cardiac output r/t excessive fluid loss

83 Dehydration: Client Goals & Outcomes Aimed at correcting cause Replace fluids – hypotonic, slowly re-hydrate over 48 hrs (if you go too quickly, you die) Maintain skin integrity Teaching

84 Dehydration: Nursing Interventions Replace fluids by PO route first SLOW admin. of salt-free IV solutions Monitor S/S cerebral & pulmonary edema Monitor accurate I/O, VS, daily weights Monitor labs Provide skin and mouth care

85 Dehydration: Teaching Disease process of dehydration Treatments Warning signs and symptoms Medications / IV (Vasopressin – D 5 W) Importance of compliance with therapy – Fluid intake not based on thirst alone

86 Hypoosmolar Water excess Causes – SIADH or excess water intake Signs & Sxms – Decreased LOC, convulsions, coma Labs – Serum Na + below 135 mEq/L and Serum osmolality below 280 mOsm/kg

87 Nsg Dx – Goals - Interventions Similar to FVE Make relevant to underlying cause Is very acute illness

88 Physical Assessment

89 History Medical – Acute Illness, surgery, burns Environment – exercise, hot/cold/dry areas Diet – proteins, lytes, fluids Lifestyle – smoking/alcohol Medication history


91 Areas of Concern in PA Mental status BP and pulse Skin I & O’s & WEIGHT Lungs

92 Geriatric Focus Body-water content (mass related) Kidney function Cardiac & respiratory function Hormonal regulatory function Thirst sensation Medication Use Skin & subcutaneous fat

93 Assessment of Geriatric Clients Skin turgor – Assessment is performed where? Cognition Physical being Continence

94 Laboratory Data BMP / CMP Serum osmolarity Urine specific gravity Urine sodium Hematocrit Blood urea nitrogen (BUN) Creatinine

95 Clients at Risk for F&E Imbalances Age – Very young – Very old Chronic Diseases – Cancer – Cardiovascular disease, such as congestive heart failure – Endocrine disease, such as Cushing's disease and diabetes – Malnutrition – Chronic obstructive pulmonary disease – Renal disease, such as progressive renal failure – Changes in level of consciousness

96 Clients at Risk for F&E Imbalances Trauma – Crush injuries – Head injuries – Burns – Major surgery Therapies – Diuretics – Steroids – Intravenous (IV) therapy – Total parenteral nutrition (TPN) Gastrointestinal losses – Gastroenteritis – Nasogastric suctioning – Fistulas

97 Fluid & Electrolytes Nursing DXs Risk for imbalanced Body temperature Ineffective Breathing pattern Decreased Cardiac output Deficient Fluid volume Risk for deficient Fluid volume Excess Fluid volume Impaired Gas exchange Knowledge deficient regarding disease management Impaired Mobility Impaired Oral mucous membrane Impaired Skin integrity Risk for impaired Skin integrity Ineffective Therapeutic regimen management Impaired Tissue integrity Ineffective Tissue perfusion


99 Intravenous Fluid Therapy in Fluid Balance Disorders

100 ISOtonic solutions Same osmolarity as body fluids – mOsm/kg Expands the IVC without pulling fluids from other compartments Examples – Normal saline (NS) – Lactated Ringers (LR)

101 IVs: Normal Saline (NS) Isotonic 0.9% Sodium Chloride Different amounts Sample order – 75cc/hr

102 IVs: Lactated Ringer’s (LR) Isotonic Solution Contents – Na +, Cl -, K +, Ca ++, Lactate in sterile water One strength, two common amounts Sample orders – 100cc/hr – 75cc/hr

103 HypOtonic solutions Osmolarity less than serum Pulls fluid from the IVC into the ICC causing cells to expand – Over hydration – Rehydration Example – ½ NS – D 5 W - after absorbed into body RISKRISK

104 IVs: Dextrose Solutions Concentrations – 5% in water (hypotonic after enters body) – 10% in water (hypertonic) – 50% in water (rescue solution – small volume) – As additive to NS or LR D5NS or D5LR

105 HypERtonic solutions Osmolarity of solution is higher than serum osmolarity – >300 mOsm/kg Pulls fluid from ICC into IVC causing cells to shrink – dehydrate Examples – D 5 1/2 NS - D5NS - D5LR – 3% NS (CRITICAL Strength)


107 IVs: Common Additives Potassium (never add to a bag!) Multivitamins Additives makes the solution hypertonic to some extent – depends on amount

108 IV Additives: Potassium Available as KCl (potassium chloride) NEVER add K + to a bag of fluid – Added by pharmacy or premixed Different strengths Sample orders – NS c 20 mEq 75 cc/hr – LR c 40 mEq 75 cc/hr

109 Medications Used in Fluid & Electrolyte Imbalance Disorders

110 Meds: Antidiarrheals Assess I /O & electrolytes Provide oral care Monitor for constipation Teaching – Take as directed – Avoid overdose Examples: Lomotil & Immodium

111 Meds: Antiemetics Assess VS & emesis status before and after Monitor for extrapyriamidal side effects – involuntary movement of eyes, face or limbs, flat affect, shuffled gait, drooling Provide fluid replacements – Oral electrolyte solutions – Water Sample Meds: Zofran, Phenergan & Vistaril

112 Meds: Diuretics Assess – Weight, edema, skin turgor, & mucus membranes, lung sounds Monitor – weight, I /O, electrolytes Teaching – diet, weigh daily, & dosing times Examples: – Thiazides (HCTZ) – HTN – Potassium sparing (spironolactone) – Osmotic (mannitol) – decrease ICP – Loop (lasix) – pull fluids

113 Meds: Potassium Forms: tablets (SR), effervescent, EC, IV Administration considerations – PO: Give on a full stomach at mealtime am/pm – IV: NEVER give as bolus, follow protocol, dilute for IV administration, can burn & lead to infiltration Monitor: K + levels – monitor EKG if elevated

114 Meds: Kayexelate Removes K + from system Available as enema or by PO route – Retain enema for ½ to 1 hr – Follow resin w 100 mL water – After expulsion, rinse colon w 1 liter of water and drain out immediately

115 Other Meds r/t F/E status Glucocorticosteroids Digoxin Electrolyte supplements

116 Stuff To Add for the Test A L of fluid weighs 2.2 lbs – 1 lb of fluid is 454 mL – If a L of fluid weighs 2.2 lbs you need to be able to figure out how many mL a ½ lb is 10% fluid loss is serious, but 20% loss is mostly death If you have someone who begins to have a transfusion reaction (hemolytic) watch for – Fever, low back pain, itching, hypotension, N/V, drop in urine output, chest pain, dyspnea – If 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!

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