This presentation is intended to satisfy the exemplar Basic Fluid Balance and Basic Electrolyte Balance under the concept of Fluid & Electrolytes in NUR 111 for the NC CIP Concept Based curriculum. Please see the corresponding case study that may be used with it.

Basic Fluid & Electrolytes Hello, I am Dr. Sheryl Cornelius, nursing faculty of Mitchell Community College in Statesville, NC Dr. Sheryl Cornelius, EdD, MSN, RN

Objectives for the Module… Describe the function, distribution, and regulation of fluids and electrolytes in the body. Identify factors affecting normal fluid and electrolyte balance. Collect assessment data related to normal fluid and electrolyte status, across the lifespan. Determine normal laboratory data related to fluid and electrolyte balance. Apply the nursing process to provide culturally competent care, across the lifespan, to clients in maintaining fluid and electrolyte balance.

Describe the function, distribution, and regulation of fluids and electrolytes in the body. Read pages assigned Know the key terms of fluid shift and balance Know the normal lab values and assessment criteria In order for you to be successful with this unit you will need to do the following.

Function A medium for metabolic reactions within the cells Transporter for nutrients, waste products, and other substances One means of regulating and maintaining body temperature A lubricant An insulator and shock absorber What does fluid do? Why do we need it? We need fluid to have a medium for metabolic reactions within the cells. A solid bumping against a solid is not likely to cause a metabolic reaction. We need fluids to create those reactions We need fluids to be a transporter for nutrients, waste products, and other substances Fluids serve as a lubricant. For example, the lungs are in a lining of liquid. No liquid the two solids rub together causing friction and pain Fluid serves as an insulator and shock absorber, we need some cushion to allow certain things to float about. If they didn’t float about then damage could occur And finally fluid is one means of regulating and maintaining body temperature

Distribution Extracellular Intracellular Interstitial fluid Intravascular fluid Trans cellular fluid Intracellular In the cell Intracellular -inside the cell this is 40% of the body’s weight Extracellular -outside the cell, but it can be in several different places Interstitial fluid is between the cells, outside the blood vessels Intravascular fluid is intra vascular in the vessels like blood, plasma Trans cellular fluid is the cerebrospinal fluid, pleural fluid, peritoneal fluid, synovial fluid

Movement of Body Fluids Osmosis Diffusion Filtration Active Transport The body is constantly moving solutes and solvents to maintain a homeostasis or equality in the body. A solute is he solid matter and the solvent is the liquid that the solute is in. Osmosis is the movement of a pure solvent (a liquid) across a semi permeable membrane from a lesser concentration to a higher concentration. Only the water can cross not the electrolytes or other solids. If you think of 2 glasses of water with marbles in them. One glass has 4 oz of water and 4 marbles. The other glass has 2 oz of water and 4 marbles. The 2 oz is a higher concentration of marbles to water. Osmosis is when the water leaves the glass that has 4 oz to go to the glass with 2 oz so they both have 3 oz water and 4 marbles. It equaled itself out. Diffusion – is the movement of the solute (or solid) from a higher concentration to lower concentration to equalize. In this case the marbles would move to equalize between the 2 glasses not the liquid. So if one glass had 6 marbles and one glass had 2 marbles then the 6 marble glass would move marbles until they were equal with 4 in each glass. Filtration – is when the fluid and the substances move together from a higher to a lower concentration. The water and the marbles move. Active Transport- is moving from a lower concentration to a higher concentration which requires more effort or energy. It is like it is moving uphill to achieve its objective.

Regulation of Body Fluids Fluid intake (adult: 2200 to 2700 ml/day) Hormonal regulation: ADH, aldosterone, renin-angiotensin Fluid output Fluid Balance: Fluid intake should equal fluid output Intake 70% of adult body consists of water If you are 1% short= thirsty If you are 5% short= slight shortage loss of water weight and dry mucus membranes 12% short= possible death Daily: ½ of body weight in ounces B. Output Average urine output= 1500 cc’s Water is also lost from: a. Skin 1. insensible: 200-400 cc’s 2. sensible: 300-500 cc’s b. Lungs: 400cc c. Gastrointestinal tract : 100 cc’s Part of that regulation is handled by the ADH, aldosterone, and renin-angiotensin

Can you drink too much water? Have students do an online search for Jennifer Strange or show the news report on Jennifer Strange, a 28 year old who died of water intoxication after participating in a contest at a radio station to win a Wii. “Hold your wee for a wii” was the name of the contest. You were to see how much water you could drink without going to the bathroom. Even after healthcare professionals called in to tell the radio station how dangerous this practice was, they did not stop and she died of water intoxication. Have them look this up and find out what exactly happened to them. Have students discuss: How much water do we need a day? How much water is too much? Which organs help to regulate water balance in the body? www.news10/net/display _story.aspx?storyid=23350

Identify factors affecting normal fluid and electrolyte balance. Intake & output Age/gender/body size Temperature/weather Metabolic rate Temperature/Vital Signs Physical activity level Chronic disease Physical state Mental state Are you hydrated? As humans there are triggers that tell us we are thirsty and if we are thirsty we drink. I have often watched comedians talk about how different child hood is today. We are ready on the side lines of a peewee soccer game to hydrate our children with gatorade and juice boxes when most of us as children played outside and then got a drink from the garden hose when we were thirsty. Basically what he was saying is that we do not listen to our bodies anymore. Some things to look at that effect our fluid status are one your screen here. We worry most about the very old and the very young for fluid balance issues. Children have the small body size, elderly have less subcutaneous tissue to insulate. Fat cells contain little to no water, lean muscle is mostly water so an obese person is more likely to be dehydrated than a lean muscled person. Weather activity level obviously make us burn calories quicker, use fluid more freely, sweat, expiration is more with activity. The increased metabolism that comes with fever or other chronic disease processes also make us expend more energy and thusly more fluid. If we could speculate on what is going on with this child in the picture. I am seeing a possible fever – the increased metabolic rate due to the fever. I am seeing a smaller person so the body size and age is an issue. She looks as though she doesn’t feel good so she is probably not eating or drinking as she should. All of these are factors that will contribute to a shift in fluid status to the negative.

Collect assessment data related to normal fluid and electrolyte status, across the lifespan. Here is a look at our little ones. The newborn and infant have a high percentage of body weight comprised of water, especially extracellular fluid, which is lost from the body easily. Note the small stomach size, which limits ability to rehydrate quickly. (NC Concept-Based Learning Editorial Board, 2011)

Assessment Skin Mucus membranes Eyes Fontanels Respiratory system Cardio vascular system Neurologic So tell me about the skin. What will we assess on the skin? Color, temperature, moisture. Are they flushed, warm to touch, very dry, diaphoretic, cool and pale? What is the skin turgor like? Do you know how to assess skin turgor? Pinch up a fold of skin over sternum or back of hand for adults to geriatrics. Over forehead or medial thigh for children. Is there presence of edema? Any visible swelling around eyes, fingers, lower extremities. Compress the skin over the top of the foot, ankle area, over tibia, sacral area if bed bound. Mucus membranes are the moist, pink? Are they dry, cracked? Tongue dry and cracked? How do we assess the eyes? Have the patient close their eyes and gently palpate the eyeball with the lid closed. It should be firm. Soft would be abnormal. Respiratory rate and rhythm. We discussed what the obligatory losses were. Increase or decrease of rate can make significant differences in fluid balance. Cardivascualr system- what are we looking at? Heart rate, peripheral pulses, blood pressure, capillary refil, venous filling. So we are checking pulses all the way to extremities – make sure you know anatomically where the dorsalis pedis and posterior tibial pulses are. Make sure you are comparing right to left in all extremities. Cap refill, remember where we pinch the finger to check how fast the blood flows back into the nailbed? Venous filling where we are checking jugular veins of neck and venous status in hands and legs. We check blood pressure lying, sitting, and standing. Fluid can make a substantial difference in the readings here. Neurologic we are looking at level of consciousness, orientation, cognition, that we are testing mostly by questioning and observation. Reflexes, strength testing with specific exercises.

Determine normal laboratory data related to fluid and electrolyte balance. There should be normal values in your book. This is from the Pearson Concept based book. All may be a little different depending on facility. Follow the facility norms when in clinical. We also need to notice the unit of measure. Notice the difference in calcium. It depends on whether your facility uses mEq/L or mg/dL. We also should be looking at urine – specific gravity – color, clarity, consistency. The patient should have at least 30 mL urine/hr. This bare minimum is called oliguria. Anuria is no urine. Remember your medical terminology – a means without. A CBC – complete blood count will give us some clues as well. Increased levels sometimes mean more concentrated due to loss of fluid. And the reverse if you are over hydrated things could be low due to diluted sample. (NC Concept-Based Learning Editorial Board, 2011)

Let’s get into groups and we will make a care plan! Apply the nursing process to provide culturally competent care, across the lifespan, to clients in maintaining fluid and electrolyte balance. An elderly gentleman comes to the emergency department driven by a neighbor that picked him up off the front lawn. He has been mowing for 2+ hours, 96 degrees F outside, he presents slightly confused, normally healthy for age. Skin red, warm to touch, mucus membranes dry, eyes sunken, skin turgor inelastic, no reported urine output in last 6-8 hours. Let’s get into groups and we will make a care plan! So let’s see what we learned and put it into a care plan.

The 154-pound adult client has had vomiting and diarrhea for 4 days secondary to a viral infection. The nurse has been monitoring intravenous fluids and urine output. What hourly urine measurement would indicate to the nurse that efforts to rehydrate this client have not yet been successful and should continue? A) 35 mL per hour B) 80 mL per hour C) 50 mL per hour D) 25 mL per hour Think about what we spoke about with hourly urine output. The question asks which one is an indicator that the rehydration is NOT successful. So they want the one that is negative, right? Q1

The 154-pound adult client has had vomiting and diarrhea for 4 days secondary to a viral infection. The nurse has been monitoring intravenous fluids and urine output. What hourly urine measurement would indicate to the nurse that efforts to rehydrate this client have not yet been successful and should continue? A) 35 mL per hour B) 80 mL per hour C) 50 mL per hour D) 25 mL per hour The answer is D 25mL per hour. This is below the oliguric level. We should see at least 30 mL per hour of urine output so in this question the IV fluids are not replacing at a level that is rehydrating the patient at 25mL/hour. A1

Which assessment finding obtained while taking the history of an older individual should alert the nurse to the possibility of fluid and electrolyte imbalance? A) I am often cold and need to wear a sweater, even when others are warm. B) I seem to urinate more when I drink coffee. C) In the summer, I feel thirsty more often. D) My rings are tighter this month. Q2

Which assessment finding obtained while taking the history of an older individual should alert the nurse to the possibility of fluid and electrolyte imbalance? A) I am often cold and need to wear a sweater, even when others are warm. B) I seem to urinate more when I drink coffee. C) In the summer, I feel thirsty more often. D) My rings are tighter this month. D is the answer. Rings becoming tighter is a direct indicator that the fluid is increased. A is not correct because it is normal for an older person to feel cooler than others in some circumstances, as we age we do not retain the subcutaneous tissue. B is not correct because everyone urinates more with coffee. It is a liquid and the caffeine is a bladder irritant. C is not correct because we naturally are sweating more in the summer and need to replace what we are sweating out. A2

What is the nurse's best action for the individual whose serum sodium level is 138 mEq/L? A) Document the findings as the only action. B) Assess the individual's deep tendon reflexes. C) Urge the individual to increase water intake. D) Notify the physician. Need to know your normal values here. Q3

What is the nurse's best action for the individual whose serum sodium level is 138 mEq/L? A) Document the findings as the only action. B) Assess the individual's deep tendon reflexes. C) Urge the individual to increase water intake. D) Notify the physician. Yes we would document the findings because 138 mEq/L is normal. The general normal for sodium is 135-145mEq/L. A3

What is the single best indicator of fluid status in the nurse's assessment? A) Lungs B) Intake and output C) Serum electrolyte levels D) Daily body weight This is a simple yet very important one. Q4

What is the single best indicator of fluid status in the nurse's assessment? A) Lungs B) Intake and output C) Serum electrolyte levels D) Daily body weight Daily weight is definitely the answer. All other answers will give you some insight into the patients fluid status, but the one we are most likely to see most accurately and will base changes in treatment from is the daily weight. A change in body weight of 2 pounds in a 24 hour period will make a difference in a Lasix dose or the bolus of fluids in a patient with chronic illness. A4

In reviewing the results of the individual's blood work, the nurse recognizes which value that should be reported to the physician? A) Calcium 3.9 mEq/L B) Sodium 140 mEq/L C) Potassium 3.8 mEq/L D) Magnesium 2.1 mEq/L Q5

In reviewing the results of the individual's blood work, the nurse recognizes which value that should be reported to the physician? A) Calcium 3.9 mEq/L B) Sodium 140 mEq/L C) Potassium 3.8 mEq/L D) Magnesium 2.1 mEq/L Correct Calcium is the correct answer. This level would be low or hypo calcemia. All others are within normal limits. A5

Post op abdominal surgery client is ordered a clear liquids diet Post op abdominal surgery client is ordered a clear liquids diet. Mid AM the client begins to vomit, NPO status is enacted and an NG tube is placed to Low wall suction. Calculate the fluid balance for this client for a 24 hour period: IV NS at 80 ml/hr, 600 ml urine, 30 ml drainage from Jackson Pratt drain, 8 ounces of tea, 300 mL vomit, 4 ounces of coke, 8 ounces of apple juice, 1000 ml from NG tube. A) -1830 B) -1250 C) -590 D) +590 Get out your calculators! This makes you look at what is intake and what is output. It ensures you know oz. to mL. Again, simple but very important. You need a net total which could be positive or negative. Q6

Post op abdominal surgery client is ordered a clear liquids diet Post op abdominal surgery client is ordered a clear liquids diet. Mid AM the client begins to vomit, NPO status is enacted and an NG tube is placed to Low wall suction. Calculate the fluid balance for this client for a 24 hour period: IV NS at 80 ml/hr, 600 ml urine, 30 ml drainage from Jackson Pratt drain, 8 ounces of tea, 300 mL vomit, 4 ounces of coke, 8 ounces of apple juice, 1000 ml from NG tube. A) -1830 B) -1250 C) -590 D) +590 Correct! The positive 590 is correct. 80mL/hr for 24 hours is 1920- 600 urine=1320. Subtract 30 from JP = 1290. add 8 oz tea which is 240mL = 1530. subtract 300 mL vomit which brings us to 1230. add 4 oz coke which is 120mL and brings us to 1350mL. Add 8 oz. apple juice which is 240mL and brings us to 1590mL and finally subtract the 1000mL from the NG which is a final number of 590 ml net total I&O. A6

A client is prescribed 0. 9% sodium chloride (normal saline) A client is prescribed 0.9% sodium chloride (normal saline). What is the primary goal of this intravenous therapy? A) Expand the volume of fluid in the vascular system B) Pull fluid from the cells C) Keep protein levels normal D) Move fluid into the cells Let’s think about this one. Normal saline which is what the body normally has should not pull fluids one way or the other, correct? That should narrow your answers down significantly. Q7

A) Expand the volume of fluid in the vascular system A client is prescribed 0.9% sodium chloride (normal saline). What is the primary goal of this intravenous therapy? A) Expand the volume of fluid in the vascular system B) Pull fluid from the cells C) Keep protein levels normal D) Move fluid into the cells Good answer, if it is not pulling fluid into or out of the cell then it is just expanding the expanding the amount of fluid in the system as a whole. A7

Which food will have the greatest impact on the water balance of the person consuming it? A) A pickle B) A banana C) A milkshake D) A spinach salad This is another one of those simple but a good concept to delegate. They will not be this obvious on the exam. Think about which electrolyte impacts the fluid balance the greatest and then think about which electolyte is seen in each of these foods. Q8

Which food will have the greatest impact on the water balance of the person consuming it? A) A pickle B) A banana C) A milkshake D) A spinach salad Correct, the pickle will make the greatest difference. The pickle is full of salt or sodium. The sodium is going to change the balance and potentially increase the retention of fluid in the patient. A banana is full of potassium. A milkshake is full of calcium because of the milk. Spinach is also full of potassium and magnesium among many other things. A8

References North Carolina Concept-Based Editorial Board, (2011). Nursing: A Concept Based Approach. Upper Saddle River, New Jersey: Pearson Education, Inc. Marquis, B. L. & Huston, C. J. (2009). Leadership roles and management functions in nursing: Theory and application. (6th ed.). Philadelphia : Lippincott, Williams & Wilkins. Taylor, C., Lillis, C., Lemone, P., (2011). Fundamentals of Nursing: The Art & Science of Nursing Care. (7th ed.) Philadelphia, Lippincott, Williams & Wilkins. These are the references that I have used that you may want to visit as well for further readings.