1. FLUID AND ELECTROLYTE BALANCES

2. WHY IS IT IMPORTANT FOR NURSES TO KNOW ABOUT FLUID & ELECTROLYTE BALANCE

3. INTRODUCTION Water is found everywhere on earth including human body Water is found everywhere on earth including human body In an adult 60% of the weight is water In an adult 60% of the weight is water Two third of the body’s water is found in the cell Two third of the body’s water is found in the cell

4. DISTRIBUTION OF BODY FLUIDS Body fluids are distributed in two distinct compartments: 1.Extracellular fluids[ECF] Which includes interstitial fliud & intravascular fluid 2.Intracellular fluids[ICF]

5. COMPOSITION OF BODY FLUIDS The fluids circulating throughout the body in extracellular and intracellular fluid spaces contain 1.Electrolytes2.Minerals3.Cells

6. MOVEMENT OF BODY FLUIDS Diffusion Diffusion Osmosis Osmosis Filtration Filtration Active transport Active transport

7. REGULATION OF BODY FLUIDS Fluid intake Fluid intake Fluid output Fluid output Hormonal influence Hormonal influence Lymphatic influences Lymphatic influences Neurologic influences Neurologic influences Renal influences Renal influences

8. ACID-BASE BALANCE Chemical regulation Chemical regulation Biologic regulation Biologic regulation Physiological regulation Physiological regulation 1.Lungs 1.Lungs 2.Kidneys 2.Kidneys

9. FLUID,ELCTROLYTE AND ACID-BASE IMBALANCES

10. FLIUD IMBALANCES The five types of fluid imbalances that may occur are: Extracellular fluid imbalances(EVFVD) Extracellular fluid imbalances(EVFVD) Extracellular fluid volume excess(ECFVE) Extracellular fluid volume excess(ECFVE) Extracellular fluid volume shift Extracellular fluid volume shift Intracellular fluid vloume excess(ICFVE) Intracellular fluid vloume excess(ICFVE) Intrcellular fluid volume deficit(ICFVD) Intrcellular fluid volume deficit(ICFVD)

11. EXTRACELULLAR FLUID VOLUME DEFICIT An ECFVD, commonly called as dehydration, is a decrease in intravascular and interstitial fluids An ECFVD, commonly called as dehydration, is a decrease in intravascular and interstitial fluids An ECFVD can result in cellular fluid loss if it is sudden or severe An ECFVD can result in cellular fluid loss if it is sudden or severe

12. THREE TYPES OF ECFVD Hyperosmolar fluid volume deficit- water loss is greater than the electrolyte loss Hyperosmolar fluid volume deficit- water loss is greater than the electrolyte loss Isosmolar fluid volume deficit – equal proportion of fluid and electrolyte loss Isosmolar fluid volume deficit – equal proportion of fluid and electrolyte loss Hypotonic fluid volume deficit – electrolyte loss is greater than fluid loss Hypotonic fluid volume deficit – electrolyte loss is greater than fluid loss

13. ETIOLOGY AND RISK FACTORS Severe vomiting Severe vomiting Diaphoresis Diaphoresis Traumatic injuries Traumatic injuries Third space fluid shifts [percardial, pleural, pertonial and joint cavities] Third space fluid shifts [percardial, pleural, pertonial and joint cavities] Fever Fever Gatrointestinal suction Gatrointestinal suction Ileostomy Ileostomy Fistulas Fistulas Burns Burns Hyperventilation Hyperventilation Decresed ADH secretions Decresed ADH secretions Diabetes insipidus Diabetes insipidus Addison’s disease or adrenal crisis Addison’s disease or adrenal crisis Diuretic phase of acute renal failure Diuretic phase of acute renal failure Use of diuretics Use of diuretics

14. ELDERLY ARE HIGH RISK OF ECFVD DUE TO Decreased thirst response Decreased thirst response Decreased renal concentration of urine Decreased renal concentration of urine Altered ADH response Altered ADH response Increased drug – drug interaction Increased drug – drug interaction Multiple chronic diseases Multiple chronic diseases Decreased access to fluids due to financial or transportation barriers Decreased access to fluids due to financial or transportation barriers Debilitation Debilitation Chemical or physical restraint Chemical or physical restraint Changes in mental status Changes in mental status

15. CLINICAL MANIFESTATION In Mild ECFVD, 1to 2 L of water or 2% of the body weight is lost In Mild ECFVD, 1to 2 L of water or 2% of the body weight is lost In Moderate ECFVD, 3 to 5L of water loss or 5%weight loss In Moderate ECFVD, 3 to 5L of water loss or 5%weight loss IN Severe ECFVD, 5 to 10 L of water loss or 8% of weight loss IN Severe ECFVD, 5 to 10 L of water loss or 8% of weight loss

16. CLINICAL MANIFESTATION Thirst Thirst Muscle weakness Muscle weakness Dry mucus membrane;dry cracked lips or furrowed tongue Dry mucus membrane;dry cracked lips or furrowed tongue Eyeballs soft and sunken (severe deficit) Eyeballs soft and sunken (severe deficit) Apprehension, restlessness, headache, confusion, coma in severe deficit Apprehension, restlessness, headache, confusion, coma in severe deficit Elevated temperature Elevated temperature Tachycardia, weak thready pulse Tachycardia, weak thready pulse Peripheral vein filling> 5 seconds Peripheral vein filling> 5 seconds Postural systolic BP falls >25mm Hg and diastolic fall > 20 mm Hg, with pulse increases > 30 Postural systolic BP falls >25mm Hg and diastolic fall > 20 mm Hg, with pulse increases > 30 Narrowed pulse pressure, decreased CVP&PCWP Narrowed pulse pressure, decreased CVP&PCWP Flattened neck veins in supine position Flattened neck veins in supine position Weight loss Weight loss Oliguria(< 30 mlper hour) Oliguria(< 30 mlper hour) Decreased number and moisture in stools Decreased number and moisture in stools

17. LABORATORY FINDINGS Increased osmolality(> 295 mOsm/ kg) Increased osmolality(> 295 mOsm/ kg) Increased or normal serum sodium level (> 145mEq/ L ) Increased or normal serum sodium level (> 145mEq/ L ) Increase BUN (>25 mg / L ) Increase BUN (>25 mg / L ) Hyperglycemia ( >120 mg /dl ) Hyperglycemia ( >120 mg /dl ) Elevated hematocrit (> 55%) Elevated hematocrit (> 55%) Increased specific gravity ( > 1.030) Increased specific gravity ( > 1.030)

18. MANAGEMENT Mild fluid volume loss can be corrected with oral fluid replacement -if client tolerates solid foods advice to take 1200 ml to 1500ml of oral fluids -if client takes only fluids, increase the total intake to 2500 ml in 24 hours

19. Management of Hyperosmolar fluid volume deficit Administration of hypotonic IV solution, such as 5% dextrose in 0.2 %saline Administration of hypotonic IV solution, such as 5% dextrose in 0.2 %saline If the deficit has existed for more than 24 hours,avoid rapid correction of fluid [sodium solution to be infused at the rate of 0.5 to 0.1m Eq/ L/ hr] If the deficit has existed for more than 24 hours,avoid rapid correction of fluid [sodium solution to be infused at the rate of 0.5 to 0.1m Eq/ L/ hr]

20. If heamorrhage is the cause for ECFVD Packed red cells followed by hypotonic IV fluids is administered Packed red cells followed by hypotonic IV fluids is administered In situations where the blood loss is less than 1 L normal saline or ringer lactate may be used In situations where the blood loss is less than 1 L normal saline or ringer lactate may be used clients with severe ECFVD accompanied by severe heart, liver, or kidney disease cannot tolerate large volumes of fluid and sodium clients with severe ECFVD accompanied by severe heart, liver, or kidney disease cannot tolerate large volumes of fluid and sodium

21. EXTRACELLULAR FLUID VOLUME EXCESS ECFVE is increased fluid retention in the intravasular and interstitial spaces ECFVE is increased fluid retention in the intravasular and interstitial spaces

22. ETIOLOGY AND RISK FACTORS Heart failure Heart failure Renal disorders Renal disorders Cirrhosis of liver Cirrhosis of liver Increased ingestion of high sodium foods Increased ingestion of high sodium foods Excessive amount of IV fluids containing sodium Excessive amount of IV fluids containing sodium Electrolyte free IV fluids Electrolyte free IV fluids SIADH,Sepsis SIADH,Sepsis decreased colloid osmotic pressure decreased colloid osmotic pressure lymphatic and venous obstruction lymphatic and venous obstruction Cushing’s syndrome & glucocorticoids Cushing’s syndrome & glucocorticoids

23. CLINICAL MANIFESTATION Constant irritating cough Constant irritating cough Dyspnea & crackles in lungs Dyspnea & crackles in lungs Cyanosis, pleural fffusion Cyanosis, pleural fffusion Neck vein obstruction Neck vein obstruction Bounding pulse &elevated BP Bounding pulse &elevated BP S3 gallop S3 gallop Pitting & sacral edema Pitting & sacral edema Weight gain Weight gain Increased CVP& PCWP Increased CVP& PCWP Change in level of consiousness Change in level of consiousness

24. LAB INVESTIGATION serum osmolality <275mOsm/ kg serum osmolality <275mOsm/ kg Low, normal or high sodium Low, normal or high sodium Decreased hematocrit [ < 45%] Decreased hematocrit [ < 45%] Specific gravity below 1.010 Specific gravity below 1.010 Decreased BUN [< 8mg/ dl] Decreased BUN [< 8mg/ dl]

25. MANAGEMENT Diuretics [combination of potassium sparing and potassium depleting diuretics] Diuretics [combination of potassium sparing and potassium depleting diuretics] In people with CHF, ACE inhibitors and low dose of beta blockers are used In people with CHF, ACE inhibitors and low dose of beta blockers are used A low sodium diet A low sodium diet

26. EXTRACELLULAR FLUID VOLUME SHIFT: THIRD SPACING Fluid that shifts into the interstitial spaces and remain there is called as third space fluid Fluid that shifts into the interstitial spaces and remain there is called as third space fluid Common sites are abdomen, pleural cavity, peritoneal cavity and pericardial sac Common sites are abdomen, pleural cavity, peritoneal cavity and pericardial sac

27. RISK FACTORS Crushing injuries, major tissue trauma Crushing injuries, major tissue trauma Major surgery Major surgery Extensive burns Extensive burns Acid –base imbalances and sepsis Acid –base imbalances and sepsis Perforated peptic ulcers Perforated peptic ulcers Intestinal obstruction Intestinal obstruction Lymphatic obstruction Lymphatic obstruction Autoimmune disorders Autoimmune disorders Hypoalbunemia Hypoalbunemia GI tract malabsorption GI tract malabsorption

28. CLINICAL MANIFESTATION skin pallor skin pallor Cold extremities Cold extremities Weak and rapid pulse Weak and rapid pulse Hypotension Hypotension Oliguria Oliguria Decreased levels of consiousness Decreased levels of consiousness LAB INVESTIGATION LAB INVESTIGATION Elevated hematocrit & BUN level Elevated hematocrit & BUN level

29. MANAGEMENT Treat the cause 1. For burns and tissue injuries large volume of isosmolar IV fluid is administered 2. Albumin is administered for protein deficit 3. IV fluid intake is maintained after major surgery to maintain kidney perfusion 4. Pericardiocentesis if pericarditis is the result 5. Paracentesis for ascitis

30. INTRACELLULAR FLUID VOULME EXCESS:WATER INTOXICATION ICFVE is increase in amount of water inside the cells ICFVE is increase in amount of water inside the cells

31. ETIOLOGY Administration of excessive amount of hyposmolar IV fluids[0.45%saline or 5%dextrose in water] Administration of excessive amount of hyposmolar IV fluids[0.45%saline or 5%dextrose in water] Consumption of excessive amount of tap water without adequate nutritional intake Consumption of excessive amount of tap water without adequate nutritional intake SIADH SIADH Schizophrenia[compulsive water consumption] Schizophrenia[compulsive water consumption]

32. CLINICAL MANIFESTATIONS Headaches Headaches Behavioral changes Behavioral changes Apprehension Apprehension Irritability, disorientation and confusion Irritability, disorientation and confusion Increased ICP – pupillary changes and decreased motor and sensory function Increased ICP – pupillary changes and decreased motor and sensory function Bradycardia, elevated BP, widened pulse pressure & altered respiratory patterns, Babinski’s response flaccidity, projectile vomiting, Papilledema, delirium, convulsions &coma Bradycardia, elevated BP, widened pulse pressure & altered respiratory patterns, Babinski’s response flaccidity, projectile vomiting, Papilledema, delirium, convulsions &coma

33. LABORATORY FINDINGS High serum sodium level- 125 mEq/L High serum sodium level- 125 mEq/L decreased hamatocrit decreased hamatocrit

34. MANAGEMENT Early administration of IV fluids containing sodium chloride cam prevent SIADH Early administration of IV fluids containing sodium chloride cam prevent SIADH oral fluids such as juices or soft drinks can be given orally every hour oral fluids such as juices or soft drinks can be given orally every hour Perform neurologic checks every hour to see if cranial changes are present Perform neurologic checks every hour to see if cranial changes are present Monitor fluid intake, IV fluids and fluid output hourly and weight daily Monitor fluid intake, IV fluids and fluid output hourly and weight daily Administer antiemetics for food and fluid retention Administer antiemetics for food and fluid retention

35. INTRACELLULAR FLUID VOLUME DEFICIT Severe hypernatremia and dehydration can cause ICFVD Severe hypernatremia and dehydration can cause ICFVD Relatively rare in healthy adults Relatively rare in healthy adults common in elderly people and in those conditions that result in acute water loss common in elderly people and in those conditions that result in acute water loss Symptoms include confusion, coma, and cerebral hemorrhage Symptoms include confusion, coma, and cerebral hemorrhage

36. Sodium imbalances Definiti on Risk factors/ etiologyClinical manifestation Laboratory findings management Hyponatr -aemia It is defined as a plasma sodium level below 135 mEq/ L Kidney diseases Adrenal insufficiency Gastrointestinal losses Use of diuretics (especially with along with low sodium diet) Metabolic acidosis Weak rapid pulse Hypotension Dizziness Apprehension and anxiety Abdominal cramps Nausea and vomiting Diarrhea Coma and convulsion Cold clammy skin Finger print impression on the sternum after palpation Personality change Serum sodium less than 135mEq/ L serum osmolality less than 280mOsm/kg urine specific gravity less than 1.010 Identify the cause and treat *Administration of sodium orally, by NG tube or parenterally *For patients who are able to eat & drink, sodium is easily accomplished through normal diet *For those unable to eat,Ringer’s lactate solution or isotonic saline [0.9%Nacl]is given *For very low sodium 0.3%Nacl may be indicated *water restriction in case of hypervolaemia

37. Sodium imbalan -ce Definit ion causesClinical manifestation Lab findings management Hypernat -remia It is defined as plasma sodium level greater than 145mE q/L *Ingestion of large amount of concentrated salts *Iatrogenic administration of hypertonic saline IV *Excess alderosterone secretion  Low grade fever  Postural hypertension  Dry tongue & mucous membrane  Agitation  Convulsions  Restlessness  Excitability  Oliguria or anuria  Thirst  Dry &flushed skin *high serum sodium 135mEq/L *high serum osmolality295m O sm/kg *high urine specificity 1.030 *Administration of hypotonic sodium solution [0.3 or 0.45%] *Rapid lowering of sodium can cause cerebral edema *Slow administration of IV fluids with the goal of reducing sodium not more than 2 mEq/L for the first 48 hrs decreases this risk *Diuretics are given in case of sodium excess *In case of Diabetes insipidus desmopressin acetate nasal spray is used *Dietary restriction of sodium in high risk clients

38. Potassium imbalances DefinitionCausesClinical manifestation Lab findingsManagement Hypokalemia It is defined as plasma potassium level of less than 3.0 mEq/L *Use of potassium wasting diuretic *diarrhea, vomiting or other GI losses *Alkalosis *Cushing’s syndrome *Polyuria *Extreme sweating *excessive use of potassium free Ivs *weak irregular pulse *shallow respiration *hypotesion *weakness, decreased bowel sounds, heart blocks, paresthesia, fatigue, decreased muscle tone intestinal obstruction * K – less than 3mEq/L results in ST depression, flat T wave, taller U wave * K – less than 2mEq/L cause widened QRS, depressed ST, inverted T wave Mild hypokalemia[3.3to 3.5] can be managed by oral potassium replacement Moderate hypokalemia *K-3.0to 3.4mEq/L need 100to 200mEq/L of IV potassium for the level to rise to 1mEq/ Severe hypokalemia K- less than 3.0mEq/L need 200to 400 mEq/L for the level to rise to l mEq/L *Dietary replacement of potassium helps in correcting the problem[1875 to 5625 mg/day]

39. DefinitionCausesClinical manifestation Lab findingsManagement Hyperkal emia It is defined as the elevation of potassium level above 5.0mEq/L Renal failure, Hypertonic dehydration, Burns& trauma Large amount of IV administration of potassium, Adrenal insufficiency Use of potassium retaining diuretics & rapid infusion of stored blood Irregular slow pulse, hypotension, anxiety, irritability, paresthesia, weakness *High serum potassium 5.3mEq/L results in peaked T wave HR 60 to 110 *serum potassium of 7mEq/L results in low broad P- wave *serum potassium levels of 8mEq/L results in no arterial activity[no p- wave] *Dietary restriction of potassium for potassium less than 5.5 mEq/L *Mild hyperkalemia can be corrected by improving output by forcing fluids, giving IV saline or potassium wasting diuretics *Severe hyperkalemia is managed by 1.infusion of calcium gluconate to decrease the antagonistic effect of potassium excess on myocardium 2.infusion of insulin and glucose or sodium bicarbonate to promote potassium uptake 3.sodium polystyrene sulfonate [Kayexalate] given orally or rectally as retention enema

40. Calcium imbalanc es Definitio n CausesClinical manifestation Lab findings Management hypocalc emia It is a plasma calcium level below 8.5 mg/dl Rapid administration of blood containing citrate, hypoalbuminemia, Hypothyroidism, Vitamin deficiency, neoplastic diseases, pancreatitis Numbness and tingling sensation of fingers, hyperactive reflexes, Positve Trousseau’s sign, positive chvostek’s sign, muscle cramps, pathological fractures, prolonged bleeding time Serum calcium less than 4.3 mEq/L and ECG changes 1.Asymtomatic hypocalcemia is treated with oral calcium chloride, calcium gluconate or calcium lactate 2.Tetany from acute hypocalcemia needs IV calcium chloride or calcium gluconate to avoid hypotension bradycardia and other dysrythmias 3.Chronic or mild hypocalcemia can be treated by consumption of food high in calcium

41. Calcium imbalance DefinitionCausesClinical manifestation Lab findingsManagement Hypercalc emia It is calcium plasma level over 5.5 mEq/l or 11mg/dl Hyperthyro idism, Metastatic bone tumors, paget’s disease, osteoporosis, prolonged immobalisation Decreased muscle tone, anorexia, nausea, vomiting, weakness, lethargy, low back pain from kidney stones, decreased level of consciousness & cardiac arrest High serum calcium level 5.5mEq/L, x- ray showing generalized osteoporosis, widened bone cavitation, urinary stones, elevated BUN 25mg/100ml, elevated creatinine1.5mg /100ml 1.IV normal saline, given rapidly with Lasix promotes urinary excretion of calcium 2.Plicamycin an antitumor antibiotics decrease the plasma calcium level 3.Calcitonin decreases serum calcium level 4.Corticosteroid drugs compete with vitamin D and decreases intestinal absorption of calcium 5. If cause is excessive use of calcium or vitamin D supplements reduce or avoid the same

42. Acid-Base imbalance DefinitionCauses Clinical manifestation Lab findingsManagement Respiratory acidosis Hypoventilation & excessive CO2 production It is a clinical disorder in which the pH is less than 7.35 and the paCO2 is greater than 42mmHg COPD, neuromuscular disorder, Guillian- Barre syndrome, Myssthenia gravis, Respiratory center depression, Drugs, late ARDS, Dyspnea, disorientation, coma PH lesser than 7.35, Paco2 greater than 45mmHg, Hyperkalemia, Hypoxemia 1.Treat underlying cause 2.Support ventilation 3.Correct electrolyte imbalance 4.Intravenous NaHCO3 Respiratory Alkalosis Hyperventilation It is a clinical condition in which the arterial Ph is greater than7.45 and the paCO2 is less than 38mmHg Hypoxemia, impaired lung expansion, thickened alveolar – capillary membrane, Chemical stimulation of respiratory center, traumatic stimulation of respiratory center Tachypnea, giddiness, dizziness, syncope, convulsions, coma, weakness, paresthesia, tetany PH greater than 7.35 PaCO2 lesser than 35 mmHg, Hypokalemia, Hypocalcemia Increase CO2 retention through CO2 rebreathing & sedation and mechanical hypoventilation

43. DefinitioncausesClinical manifestation Lab findingsManagement Metabolic Acidosis It is a clinical condition in which the HCO3 & pH is decreased Renal failure, Diabetic ketoacidosis, Lactic acidosis, ingested toxins, renal tubular acidosis Hyperventilation confusion, drowsiness, coma, headache PH< 7.35, HCO3< 22mEq/L 1.Treat the underlying cause 2.Intravenous NaHCO3 3.correct electrolyte imbalance Metabolic Alkalosis It is a clinical condition in which PH is raised Hypokalemia, gatric fluid loss, massive correction of whole blood, Overcorrection of acidosis with NaCO3 Hypoventilation Dysrythmias PH >7.45 Hypokalemia Hypocalcemia PaCO2 normal or increased 1.Treat the underlying cause 2.Administer KCL 3.intravenous acidifying salts[NH4CL] 4.Administer acetazolamide

44. CONCLUSION CONCLUSION