Fluid and Electrolytes

FLUID AND ELECTROLYTES

Anatomy and Physiology

TOTAL BODY WATER (TBW)60% Body Weight

• INTRACELLULAR FLUID (ICF) 40%• EXTRACELLULAR FLUID (ECF)20%

InterstitialIntravascular Trancellular

• THIRD SPACE FLUIDDisease; injury

Electrolytes

Na Extracellular CATION Cl Extracellular ANION K Intracellular CATION PO4 Intracellular ANION

Body Fluid Transport

• DIFFUSION Higher to lower concentration

• OSMOSIS Lower to higher concentration

Semi permeable membrane

• FILTRATIONParticles

• ACTIVE TRANSPORTNa-K PumpRequires ATP

Fluids

• BODY INPUTFluids 1500mL

Food 500mL

Digestion 500mL

Total >2500mL

• BODY OUTPUTUrine 1500mL

Feces 200-400mL

Respiration200-400mL

Skin 200-400mL

Total >2500mL

Intravenous Fluids

ISOTONIC:

Equal in concentration

• 0.9% NaCl or NSS

• D5 Water, Lactated Ringer’s

Intravenous Fluids

HYPOTONIC:↓ Salt or soluteCellular swelling • 0.45% NaCl, Distilled water

HYPERTONIC:↑ SoluteCellular shrinkage • D5 NSS, D10 Water • D5 0.45 % NaCl, D5 LRS

FLUID VOLUME DEFICIT

DEHYDRATIONInadequate IntakeExcessive Loss

Types:• ISOTONIC Dehydration• HYPERTONIC Dehydration• HYPOTONIC Dehydration


Assessment:

↓ BP; ↑ PR

Weak and thready pulses

Flat neck veins

Lethargic to coma

Dry skin; poor skin turgor

Oliguria (↓ UO)

↑ Urine specific gravity

Thirst


Management:Monitor VS; BP and PRMild: Oral Rehydrating Solution (ORS)Severe: IV fluid Administer prescribed meds

• Antibiotics• Antiemetics• Antipyretics

Monitor/ correct electrolyte imbalances

FLUID VOLUME EXCESS

FLUID OVERLOAD

Types:

• ISOTONIC

• HYPOTONIC

• HYPERTONIC

FLUID VOLUME EXCESS

Assessment:↑ BP and CVPBounding pulse↑ RR, Dyspnea CracklesDistended neck veinAltered level of consciousnessWeight gain Ascites; pedal edemaPolyuria

FLUID VOLUME EXCESS

Management:

Monitor VS: BP and RR

Monitor I and O

Restrict fluid and Na intake

Weight and AC OD pre-breakfast

Administer prescribed diuretics

Monitor/treat electrolyte imbalances

HYPOKALEMIA

Normal K 3.5-5.0 meq/LK ↓ 3.5 meq/L Causes:

Diuretics, digitalis, and steroidsCushing’s syndromeMetabolic AlkalosisDiarrhea, NPO ↑ Insulin

HYPOKALEMIA

Assessment:Weak irregular pulsesECG:

• U wave• Inverted T waves

Altered LOCShallow respirationWeakness; hyporeflexiaIleus; constipation

HYPOKALEMIA

Management:Monitor VS; PRMonitor serum K valuesBed restEncourage K-rich foods:

• Banana, avocado, raisins, orange, potatoes

Diet: High fiber foods K- sparing diuretics

• Spirinolactone (Aldactone)

HYPOKALEMIA

Management:• Oral Potassium

Kalium Durule (PC)K-Lor

• IV PotassiumNEVER given by IV push, IM nor SC5-10 meq/hrUse of cardiac monitorAssess IV site

HYPERKALEMIA

K ↑ 5.5 meq/L

Causes:Excessive K intake K sparing diureticsAddison’s diseaseChronic renal failure (CRF)Metabolic AcidosisTissue damage; injury

HYPERKALEMIA

Assessment:

Irregular weak pulses, ↓ BP

ECG:

• Tall T wave

• Flat P wave

Muscular weakness

Paresthesia

Diarrhea

HYPERKALEMIA

Management:Monitor VSRestrict K rich foodsDiscontinue K supplements PO/ IVIf no renal disease; Diuretics Na polystyrene sulfonate (KAYEXALATE)

→ K excretionPrepare for dialysisAdminister NaHCO3Glucose with insulin

HYPONATREMIA

Serum Na 135-145meq/LNa ↓ 135 meq/L

Causes:DiureticsDiaphoresisAddison’s DiseaseSIADHNPO, ↓ Salt dietFreshwater drowning

HYPONATREMIA

Assessment:

↑ Pulse rate

Shallow respiration

Headache; altered LOC

Seizures

Weakness

Polyuria (↑ UO)

HYPONATREMIA

Management:Monitor VSMonitor LOCIntake of Na rich foods:→Table salt, soy sauce, cured pork,

canned and processed foods Hypovolemia: IVF NSS (ISOTONIC)Fluid excess: Osmotic diureticsSIADH: Lithium and Demeclocycline

→ Antagonize ADHSeizure precautions

HYPERNATREMIA

Na ↑145 meq/L

Causes:

Steroids

↑ Na intake

↓ Water intake

Cushing’s syndrome

Chronic renal failure (CRF)

HYPERNATREMIA

Assessment:

↓ PR

Shallow respiration

Weakness

Dry flaky skin

Altered LOC

Oliguria (↓ UO)

HYPERNATREMIA

Management:

Monitor VS

Restrict Na and fluid

Diuretics

Hypovolemia: D5W and HYPOTONIC IVF

HYPOCALCEMIA

Serum Ca 8-10.5 mg/dL4.5-5.5 meq/L

Ca ↓ 8 mg/dL

Causes:↓ Intake of Ca and vitamin DLactose intoleranceParathyroidectomyCRFDiuretics

HYPOCALCEMIA

Assessment:Irregular pulsesECG Prolonged ST interval

Prolonged QT intervalParesthesia; numbnessWeaknessTetany; carpopedal spasm(+) Trosseau’s sign(+) Chvostek’s sign

HYPOCALCEMIA

Management:

Monitor VS; PR/ CR

Monitor serum Ca and Mg

Encourage Ca-rich foods:

Milk and poultry, cheese, eggs

Oral Ca supplement:

• CaCO3 (Calci-Aid)

1-2 hrs PC or HS

HYPOCALCEMIA

Management:

IV Ca:

• Calcium Gluconate

Given very SLOWLY

Never thru IV push, IM or SQ

Use of cardiac monitor

Assess PR/ CR

HYPERCALCEMIA

Ca ↑10.5mg/dL

Causes:

Excessive intake of Ca or Vitamin D

Use of Thiazides; Lithium

Hyperparathyroidism

Malignancy

Immobility; Fracture

HYPERCALCEMIA

Assessment:

Irregular CR cardiac arrest

ECG:

• Shortened ST interval

Altered LOC

Muscle weakness

Colic pain → Renal stones

Constipation

HYPERCALCEMIA

Management:Monitor VS; CRRestrict Ca rich foods Discontinue PO and IV Ca Give prescribed Diuretics↑ Fluid intake• Calcitonin; Biphosphanates • ASA and NSAIDS

→Inhibit Ca resorption from bonesPrepare for dialysis

ACID BASE BALANCE

Hydrogen ions (H) → pH

ACIDS → Hydrogen donors BASES → Hydrogen acceptors

CARBONIC ACID/ BICARBONATE SYSTEM

Maintains pH of 7.4

Bicarbonate to Carbonic Acid Ratio 20:1

CARBONIC ACID Lungs BICARBONATE Kidneys

ACID BASE BALANCE

ACIDOSIS → Hyperkalemia (↑ K) ALKALOSIS → Hypokalemia (↓ K)

ARTERIAL BLOOD GAS

PH 7.35- 7.45

PCO2 35- 45 mmHg

HCO3 22- 26 meq/L

PO2 80- 100 mmHg

ARTERIAL BLOOD GAS

ROME• Respiratory Acidosis ↓pH ↑pCO2

• Respiratory Alkalosis ↑pH ↓pCO2

• Metabolic Acidosis ↓pH ↓HCO3

• Metabolic Alkalosis ↑pH ↑HCO3

ARTERIAL BLOOD GAS

Pre-op care: ALLEN’S Test

Rest x 30 min NO SUCTION Note O2 therapy

Room air: → No O2 Prepare heparinized syringe

ARTERIAL BLOOD GAS

Post-op care:

Container with ice

Client’s temperature O2 and respirator set up Pressure dressing x 5-10 min

RESPIRATORY ACIDOSIS

↓pH ↑pCO2

Causes: Pulmonary Diseases:

• PTB, Pneumonia

• COPD, B. Asthma Brain Injury Medications:

• Sedatives, Narcotics, Anesthetics


Assessment: HYPOVENTILATION

(Rapid, shallow breathing)

↑ PR

Headache Blurring of vision Restlessness Cyanosis


Management: Semi to high fowlers Monitor VS; RR Administer O2 Coughing and deep breathing exercises

Turning from side to side

Encourage hydration

Suction secretion PRN

Appropriate treatment as prescribed

• Bronchodilators, Antibiotics

• Respirator; CTT/ Thoracentesis

RESPIRATORY ALKALOSIS

↑pH ↓pCO2

Causes: Hysteria Anxious; panic states Severe pain; fever Over- use of respirator


Assessment: HYPERVENTILATION

(Rapid, deep breathing)

Headache; dizziness

Mental status changes Paresthesia Weakness Tetany; carpopedal spasm


Management: Monitor VS; RR Emotional support and reassurance Appropriate breathing patterns: → ↑pCO2

• Brown bag

• Voluntary holding of breath

Monitor electrolytes Cautious care with clients on respirator

Administer prescribed medication

METABOLIC ACIDOSIS

↓pH ↓HCO3

Causes: DM/DKA CRF

Starvation; malnutritionLactic acidosis

ASA and ethanol intoxication Severe diarrhea

METABOLIC ACIDOSIS

Assessment: KUSSMAUL BREATHING

(Rapid, deep breathing)

Irregular pulses

Headache Altered LOC Fruity or ketone breath ↑ Serum K

METABOLIC ACIDOSIS

Management: Monitor VS; RR and PR Assess LOC

Monitor I and O Assess and correct serum K

Safety and seizure precaution Administer NaHCO3 Administer Kayexalate

DM: Give prescribed insulinCRF: Prepare for dialysis

METABOLIC ALKALOSIS

↑pH ↑HCO3

Causes: Excessive NaHCO3 intake Chronic use of diuretics Excessive vomiting/GI suctioning

Several BT with FWB (Citrate)

METABOLIC ALKALOSIS

Assessment: Nausea and vomiting Irregular pulses

Restlessness

Paresthesia ↓ Serum K

METABOLIC ALKALOSIS

Management: Monitor VS; PR

Assess and correct serum K

Safety precautions Discontinue HCO3 Administer prescribed anti-emetics

Fluid and Electrolytes

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