8 Fluids and Electrolytes

8/8/2019 8 Fluids and Electrolytes

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FLUIDS AND ELECTROLYTES

IRENE L. GARDINER, MDPharmacology

FEU Institute of Nursing


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fluids & electrolytes IRENE L. GARDINER, MD 2

ADULT BODY FLUID VOLUME

FLUID COMPARTMENT PERCENTAGE

Intracellular (ICF) 40%

Extracellular (ECF) 20%

Interstitial Fluid ( tissue spaces) 15%

Intravascular Fluid (vessels) 5% Total Body Fluid 60%


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ELECTROLYTES

Substance in the body that carry either a positivecharge (CATION) or a negative charge (ANION)

CATIONS transmits nerve impulses tomuscles & contract skeletal & smooth muscles

Potassium, Sodium, Calcium, Magnesium

ANIONS attached to cations

Chloride, Bicarbonate, Phosphate, Sulfate

POTASSIUM & PHOSPHATE majorelectrolytes in the ICF

SODIUM & CHLORIDE major electrolytes inthe ECF


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BODY FLUIDS

The concentration of body fluids is describedas osmolality or osmolarity

OSMOLALITY the osmotic pull exerted by

all particles (solutes) per unit of water,expresses as osmoles or milliosmoles per kg(mOsm/kg) of water

OSMOSIS fluid shifting through the

membrane from an area ofLOW SOLUTEconcentration to an area of HIGHERSOLUTE concentration in an attempt toachieve homeostasis


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BODY FLUIDS

3 types of fluid concentration based onosmolality

ISO-OSMOLAR FLUID has same

proportion of weight of particles (sodium,glucose, urea, protein) and water

HYPO OSMOLAR FLUID has fewerparticles than water

HYPEROSMOLAR FLUID has moreparticles than water

Normal Value : 275 to 295 mOsm/kg


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IMBALANCE

HYPO-OSMOLALITY of body fluid (295 mOsm/kg) Severe diarrhea, increased salt and solutes

(protein) intake, diabetes, inadequate waterintake, sweating


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SOURCES OF NORMAL FLUID LOSS

Fluid loss constantly occurs as a normal result ofbody functions

The kidneys normally produce fluid output of 1-2

L / day From the skin, SENSIBLE LOSSES (ex. visibleperspiration) ranges from 0-1L /hr depending ontemperature

INSENSIBLE LOSSES form skin (ex. water lossby evaporation) = 600 ml/day ; from the lungs(ex. exhaled water vapor) = 300-400 ml/day

Losses from the GI tract = 100-200 ml/day


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FLUID VOLUME DEFICIT

Dehydration in which the bodys fluid

intake is not sufficient to meet the bodysfluid needs

The goal of treatment is to restore fluid

volume, replace electrolytes as needed

and eliminate the cause of the deficit


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FLUID VOLUME DEFICIT

Common causes :

Inadequate intake of fluids and solutes

Fluid shifts between compartment

Excessive perspiration, hyperventilation,prolonged fever and diarrhea

S/S : tented skin turgor, dry mucous

membrane, postural hypotension,increased HR, extreme thirst, weakness,change in mental status, weight loss,renal shutdown


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FLUID VOLUME EXCESS

Fluid intake or fluid retention exceeds the

bodys fluid needs

Also called overhydration or fluidoverload

The goal of treatment is to restore fluid

balance, correct any electrolyteimbalance, eliminate or control the cause

of the overload


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FLUID VOLUME EXCESS

Common causes :

Poorly controlled IV therapy; excessive fluid

intake Excessive sodium ingestion

Renal failure, CHF, abnormal fluid retention

S/S : weight gain, dependent edema,

dyspnea & crackles, change in mentalstatus, bounding pulse, jugular veindistention


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FLUID REPLACEMENT or

INTRAVENOUS THERAPY

Fluid volume deficit results in loss of fluid

from the interstitial & vascular space IV Solutions in various concentrations are

available to replace body fluid loss

The tonicity of many IV fluids are similar toserum osmolality


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FLUID REPLACEMENT or

INTRAVENOUS THERAPY

Used to sustain clients who are unable to takesubstances orally

Replaces water, electrolytes, and nutrients morerapidly than oral route

Provides an immediate access to the vascularsystem for the rapid delivery of specificsolutions without the time required for GI tractabsorption

Provides a vascular route for administration ofmedication or blood components


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TYPES OF SOLUTIONS

ISOTONIC SOLUTIONS Solutions with the same osmolality as body

fluids Increases intravascular fluid volume. Monitorfor fluid overload

These solutions do not enter cells because

there is no osmotic force to shift the fluids 0.9 Saline (NSS) ; 5% Dextrose in Water

(D5W) ; 5% Dextrose in 0.225% Saline (5%D/ NS) ; Lactated Ringers solution (LR)


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TYPES OF SOLUTIONS

HYPOTONIC SOLUTIONS

Solutions that are more dilute or have a

lower osmolality than body fluids Cause movement of water into the cells

by osmosis

These solutions should be administeredslowly to prevent cellular edema

0.45% Saline ( NS) ; 0.33% saline


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TYPES OF SOLUTIONS

HYPERTONIC SOLUTIONS

Solutions that are more concentrated or have

a higher osmolality than body fluids Concentrates the ECF and cause movement

of water from cells into the ECF by osmosis

3% Saline ; 5% Saline ; 10% Dextrose in

Water (D10W) ; 5% Dextrose in 0.9% saline (

D5 D/NS) ; 5% Dextrose in Lactated Ringers

Soln (D5LR)


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CLASSIFICATION OF IV

SOLUTIONSCRYSTALLOIDS Named so because they are substances that

form crystals like salt

It easily dissociates in water, small-sizedparticles can easily pass in and out of cellmembrane

Solutions that contain electrolytes

Saline and Lactated Ringers solution mainstay of resuscitation therapy

May be used for fluid volume replacementand maintenance therapy


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SOLUTIONSCOLLOIDS Also called volume or plasma expanders

Large-sized particles tend to stay in thevascular bed

Pull fluid from the interstitial compartmentinto the vascular compartment

Used to increase the vascular volumerapidly, such as in hemorrhage or severehypovolemia

Dextran solution ; amino acids ; humanalbumin ; Hetastarch , Plasmanate


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SOLUTIONS

LIPIDS

Administered as fat emulsion solution

and are usually indicated when IV

therapy lasts longer than 5 days

Balances patients nutritional needs

BLOOD and BLOOD PRODUCTS (See

discussion below)


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SIGNS AND COMPLICATION

OF IV THERAPY INFILTRATION / EXTRAVASATION

seepage of IV fluid out of the vein; edema,

pain, coolness at site EMBOLISM catheter / air ; tachycardia,dyspnea, hypotension, decreased level ofconsciousness, cyanosis

HEMATOMA ecchymosis, immediate

swelling and leakage of blood at the site Circulatory overload, electrolyte overload,

catheter embolism


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SIGNS AND COMPLICATION

OF IV THERAPY INFECTION LOCAL- redness, swelling,

drainage at site; SYSTEMIC chills, fever,

malaise, tachycardia TISSUE DAMAGE skin color changes,

sloughing of skin, discomfort at site

PHLEBITIS heat, redness, tenderness at

site; not swollen or hard

THROMBOPHLEBITIS hard and cordlike

vein; heat, redness, tenderness


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ACCOUNTABILITY WITH IV

INFUSIONNURSE MUST KNOW : What is ordered

Why it is indicated

Its intended impact on the patient Any possible side effects or adverse reactions thatmay occur

NURSE IS EXPECTED TO : Prepare patient physically and psychologically

Administer the IV infusion correctly : right IV solutionand rate

Maintain and monitor patient

Discontinue it properly

Proper documentation


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ELECTROLYTE IMBALANCE

SODIUM

NV : 135 145 mEq/L Major cation in the ECF the primary

determinant of ECF concentration

Major electrolyte that regulates body

fluids; promote transmission and

conduction of nerve impulses


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HYPONATREMIA Serum Na+ level of < 135 mEq/L

Sodium imbalance is usually associated withfluid imbalance

Causes : Na+ excretion (excessivediaphoresis, vomiting, diarrhea) , inadequateNa+ intake (NPO, low salt diet) , dilution ofserum Na+ (CHF)

S/S : muscular weakness, headaches,abdominal cramps, n/v, altered consciousness

Mgt : maintain fluid balance (weight pt daily,monitor I&O), administer sodium supplements,strict fluid restriction, seizure precaution


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HYPERNATREMIA Serum Na+ level of > 145 mq/L

Causes : Na+ excretion (corticosteroids) , sodium intake , water intake water loss(fever, diarrhea, hyperventilation)

S/S : thirst, flushed skin, elevated body temp

& BP, and rough, dry tongue Mgt : maintain normal fluid balance, increase

fluid intake as appropriate


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fluids & electrolytesIRENE L. GARDINER, MD 26


POTASSIUM

NV : 3.5 5.3 mEq/L Necessary for transmission &

conduction of nerve impulses,

contraction of skeletal, cardiac and

smooth muscle


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HYPOKALEMIA Serum K+ level of < 3.5 mEq/L

Potentially life-threatening because every bodysystem is affected

Causes : Actual total body K+ loss (vomiting,diarrhea) , inadequate K+ intake , movement of K+from ECF to ICF (alkalosis) , dilution of serum K+(water intoxication)

S/S : nausea, vomiting, arrhythmias, abdominaldistention and soft, flabby muscles

TX : oral very irritating to the gastric mucosa give lots of fluid ; IV never given as a bolusbecause it can cause cardiac arrest. Always dilute!


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HYPERKALEMIA Serum K+ level of > 5.3 mEq/L

Causes : excessive K+ intake , K+excretion (use of K+ sparring diuretics) ,movement of K+ from ICF to ECF (acidosis)

S/S : nausea, abdominal cramps, weakness,numbness, tingling sensation

Tx : Cation exchange resin (Kayexalate)orally or by retention enema w/c would drawthe K+ into the bowel so it may be excreted


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CALCIUM NV : 4.5 5.5 mEq/L or 8.5 10.5 mg/dL

Promots normal nerve and muscle activity,

increases contraction of the heart muscle,

maintains normal cellular permeability,

promotes blood clotting Vitamin D is needed for Ca++ absorption in

the GI tract


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HYPOCALCEMIA Serum Ca++ level of < 4.4 mEq/L

Causes : inhibition of Ca++ absorption fromthe GI tract ( Vit D intake) , Ca++ excretion( renal failure) , conditions that the ionizedfraction of Ca++ ( acute pancreatitis)

S/S : anxiety, irritability, tetany, fractures, (+)Trousseau & Chvostek sign

TX : oral and IV preparation (can cause tissuenecrosis if it infiltrates the subcutaneous area),vit D


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HYPERCALCEMIA Serum Ca++ level of > 5.5 mEq/L

Causes : Ca++ absorption (excessive oralintake of Ca++) , Ca++ excretion (renalfailure) , bone resorption of Ca++(hyperparathyroidism) , hemoconcentration (dehydration)

TX : calcitonin or IV saline solutionadministered rapidly could promote urinaryexcretion of Ca++


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MAGNESIUM NV : 1.5 2.5 mEq/L

Sister cation of K+ : loss of K+ = loss ofMg++

Promotes transmission ofneuromuscular activity, important

mediator of neural transmission in theCNS, promotes contraction of themyocardium


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HYPOMAGNESEMIA Serum Mg++ level of < 1.5 mg/dL

The most undiagmosed electrolyte deficiency

because it is asymptomatic

Causes : insufficient Mg++ intake , Mg++

secretion (citrate in blood products) ,intracellular movement of Mg++ (sepsis)

TX : magnesium sulfate IV


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HYPERMAGNESEMIA

Serum Mg++ level of > 2.5 mg/dL

Causes ; Mg++ intake (antacids) ,

renal excretion

S/S : lethargy, hypoactive reflexes,

absent deep tendon reflex

TX : calcium gluconate


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BLOOD TRANSFUSION / BLOOD

COMPONENT THERAPY

The introduction of whole blood orcomponents of the blood into the

venous circulation

Requires ABO compatibility


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COMPONENT THERAPY


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COMPONENT THERAPY

WHOLE BLOOD TRANSFUSION

FRESH WHOLE BLOOD (450 cc)

rare now that component therapy exists contains RBC and plasma and

anticoagulation preservative

Used to resolve hypovolemia due to

hemorrhage replenishes both the intravascular volume

and the O2-carrying capacity of blood;


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COMPONENT THERAPY

BLOOD COMPONENT THERAPY

Involves the transfusion of a specific

portion or fraction of blood lacking in a

client

Increases the availability of needed

blood products to larger population


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COMPONENT THERAPY

PACKED RED BLOOD CELLS (250 cc)

Treatment of symptomatic anemia

70-85% hematocrit ; 70-80% of plasmawater is removed

restores only the O2 carrying capacity of

blood 1 unit will raise Hct by 3% and Hgb by

1g/dl after 4 6 hrs


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COMPONENT THERAPY

FRESH FROZEN PLASMA (150 -200 cc)

separated from whole blood and frozen to -18 C should not be used as a volume expander

indication is for deficiency of coagulation factors

150-200 cc volume

to be used within 6 hours of thawing


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COMPONENT THERAPY

PLATELET CONCENTRATE removed by sedimentation from fresh whole blood

used to treat or prevent bleeding

(thrombocytopenia or platelet function abnormality) recommendation: give 6-10 units of platelets at the

first sign of diffuse bleeding

1 unit of platelets raises the platelet count by

5,000 - 8,000 platelet count 50-100,000- adequate for surgery

platelet count at or below 20,000- spontaneousbleeding


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COMPONENT THERAPY

GRANULOCYTE CONCENTRATE Used for neutropenia with infection

CRYOPRECIPITATE For treatment of Hemophilia A, vonWillebrand

disease, factor XIII deficiency Provides Factor VIII and XIII, fibrinogen and

vWF


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TRANSFUSION REACTIONS

A transfusion should be stopped

immediately whenever a transfusionreaction is suspected.

Common S/S : chills, fever, headache,

chest pain, dyspnea, flushing, itching,

hypotension, circulatory collapse


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HEMOLYTIC TRANSFUSION REACTION occurs following transfusion of an incompatible blood

component. Most are due to naturally occurringantibodies in the ABO antigen system.

may cause hemoglobin induced renal failure and aconsumptive coagulopathy (DIC).

Signs and symptoms include fever, hypotension,nausea, vomiting, tachycardia, dyspnea, chest or backpain, flushing and severe anxiety.

Hemoglobinuria may be noted and, in theanesthetized patient, may be the first sign ofhemolysis.

Most errors are clerical or due to misidentification of apatient at the bedside.


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DELAYED HEMOLYTICTRANSFUSION REACTION

usually occur in patients who have been previously

sensitized to an antigen through transfusion orpregnancy.

can result in symptomatic or asymptomatichemolysis several days after a subsequenttransfusion due to recall of the antibody.

Transfusion of Rh positive red blood cells to an Rhnegative woman of childbearing age can result insensitization and hemolytic disease of the newbornin future pregnancies.


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ALLERGIC OR URTICARIAL

TRANSFUSION REACTION (MILD)

are the most common usually due to allergies

to specific proteins in the donors plasma

can be avoided with future transfusions by

pretreatment with antihistamines or steroids.

ALLERGIC REACTION (SEVERE)

Antigen antibody reaction


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FEBRILE TRANSFUSION REACTION

usually occur due to sensitization to antigens

on cell components, particularly leukocytes,

platelets or plasma proteins

HYPERVOLEMIA

Blood is administered faster than the

circulation can accomodate

SEPSIS

Administration of contaminated blood

8 Fluids and Electrolytes

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