Fluids and ElectrolytesFluids and ElectrolytesReviewReview

Philippine Integrated Nurse Licensure Examination

Sample QuestionSample Question

The nurse is caring for a client with Congestive Heart Failure. On assessment, the nurse finds the client complaining of dyspnea and that rales are heard on auscultation. The nurse suspects fluid volume excess. Which additional sign would the nurse expect if fluid volume excess is present?

A. Flat neck and hand veinsB. Weight lossC. Increased central venous pressureD. Hypotension

Key to Success!Key to Success!

Confidence +Adequate test Preparation and review +Effective test taking strategy +Good study habits +Working Knowledge of Basic Nursing concepts = Success

in passing PINLE

Fluids and Electrolytes OutlineFluids and Electrolytes Outline

FluidsElectrolytesAcids and Bases

3 concepts

Important ConceptsImportant Concepts

Remember the ABCSafety of the patientMaslow’s Hierarchy of needsUtilize the NURSING PROCESS

◦A-D-P-I-E

Summary of SubtopicsSummary of Subtopics

Basic DefinitionBody Proportions and DistributionsSourcesDynamicsRegulation by 3 systems- renal, endocrine & GITBalance ImbalancesApplication of the Nursing Process in the discussion

THE BODY FLUIDSTHE BODY FLUIDS

A solution of solvent and solutesOur body is made up of fluids and solidsAbout 50-60% of the body weight is WATERIn a 70 Kg adult male: 60% X 70= 40-42 LitersNote that 1 kg body weight= 1 liter of waterThe body has two major compartments:

1 Intracellular2. Extracellular

The Proportion of Body FluidsThe Proportion of Body Fluids

Intracellular Intracellular fluid fluid

40%40%

InterstitialInterstitial

15%15%

IntravasculaIntravascularr

5%5%Transcellular Transcellular

1-2%1-2%

The Intracellular FluidThe Intracellular Fluid

Found inside the cell surrounded by a membrane.

This is compartment with the highest percentageof water in adults.

The Extracellular FluidThe Extracellular Fluid

Fluid found outside the cells

1. INTERSTITIAL FLUIDFound in between the cells

2. INTRAVASCULAR FLUIDFound inside the blood vessels and lymphatic vessels

3. TRANSCELLULAR FLUIDFound inside body cavities like pleura, peritoneum, CSF

Sample questionSample question

1. A client with CHF is assessed by the nurse. Upon reviewing the chart, it is determined that his weight increased by 4.5 pounds. The nurse estimates that client has gained how many liters of fluid? A. 3 B. 1 C. 2 D. 0.5

Sources of Fluids:Sources of Fluids: Fluid Input Fluid Input

1. Exogenous sourcesFluid intake- water from foodstuffsIVFMedicationsBlood products2. Endogenous sourcesBy products of metabolismsecretions

Fluid LossesFluid Losses

Routes of Fluid outputUrineFecal lossesSweatInsensible losses though the skin and lungs as

water vapor

Sensible losses

Sample questionSample question

2. A nurse reads a doctor’s progress notes in the client’s chart which states “insensible fluid loss approximately 800 ml.” The nurse understands that this fluid loss may occur through:

A. The Gastrointestinal tract B. Urinary output C. Wound drainage D. The skin

Sample questionSample question

A nurse is administering IVF as ordered to a patient who sustained second-degree burns. In evaluating the adequacy of fluid resuscitation, the nurse understands that the most reliable indicator for fluid adequacy is the:

A. Blood pressure

B. Mental status C. Urine output D. Peripheral pulses

Sample questionSample question

The nurse receives the following endorsements. She is certain that which patient is at most risk for the development of fluid volume deficit?

A. The client who came from the OR after a hemorroidectomy.

B. The client who has Renal failure undergoing dialysis.

C. The client with AIDS taking corticosteroids. D. The client with Rheumatic fever taking

diuretics.

Fluid DynamicsFluid Dynamics

The movement of fluids (solutes and solvents) inthe body compartment

DiffusionOsmosisFiltrationActive transport

The Concept of TONICITYThe Concept of TONICITY

This is the concentration of solutes in a solution.A solution with high solute concentration is considered as

HYPERTONIC.A solution with low solute concentration is considered as

HYPOTONIC.A solution having the same tonicity as that of body fluid or

plasma is considered ISOTONIC.

Helpful HintsHelpful Hints

In a HYPERTONIC solution, fluid will go out from the cell, the cell will shrink.

In a HYPOTONIC solution, fluid will enter the cell, the cell will swell.

In an ISOTONIC solution, there will be no movement of fluid.

DIFFUSIONDIFFUSION

The movement of SOLUTES or particles in a solution from a higher concentration to a lower concentration.

If a sugar is placed in plain water, the glucose molecules will dissolve and diffuse distribute in the solution.

OSMOSISOSMOSIS

The force that draws water or solvent from a less concentrated solution into a more concentrated solution through a semi-permeable membrane.

The pressure that draws water inside the vessel which is more concentrated is called Osmotic pressure.

A special type of osmotic pressure is exerted by the proteins in the plasma. It is called ONCOTIC PRESSSURE.

Sample questionSample question

The nurse is caring for a psychiatric patient who ingested high-sodium containing foods. She suspects hypernatremia in this patient and expect to note:

A. Hyperactive deep tendon reflex

B. Chovstek’s Sign C. Dry skin and sticky mucous membrane D. Decreased muscle tone

FILTRATIONFILTRATION

The movement of both solute and solvent by hydrostatic pressure, ie, from an area of a higher pressure to an area of a lower pressure.

An example of this process is urine formation.Increased hydrostatic pressure is one mechanism producing

edema.

Active transportActive transport

This is the movement of solutes across a membrane from a lower concentration to a higher concentration with utilization of energy.

Example is the Sodium-Potassium pump- a primarily active transport process.

Sample questionSample question

The nurse reviews the laboratory report of a patient with fluid volume deficit. Which of the following laboratory findings will support this condition?

A. WBC count of 9,000

B. Creatinine of 1 mg/dl C. Sodium of 140 mEq/L D. Hematocrit of 58%

Sample questionSample question

The client is taking a high dose of Furosemide. To determine the progress of the therapy, the nurse performs which of the following important action?

A. Monitor urinary pH

B. Check the temperature periodically C. Weight the patient daily D. Obtain a serial serum Sodium level

Regulation of Body fluid balanceRegulation of Body fluid balance

1. The KidneyRegulates primarily fluid output by urine formationReleases RENINRegulates sodium and water balance

Regulation of Body fluid balanceRegulation of Body fluid balance

2. Endocrine regulationRegulates primarily fluid intake by thirst mechanismADH increase water reabsorption on collecting ductAldosterone increases Sodium retention in the distal

nephronANF Promotes Sodium excretion and inhibits thirst

mechanism

Regulation of Body fluid balanceRegulation of Body fluid balance

3. Gastro-intestinal regulationThe GIT digests food and absorbs water Only about 200 ml of water is excreted in the fecal material

per day

The ELECTROLYTESThe ELECTROLYTES

Electrolytes are charged ions capable of conductingelectricity and are solutes in all compartment.

ANIONS are Negatively charged ions: Bicarbonate, chloride, PO4-

CATIONS are positively charged ions: Sodium, Potassium, magnesium, calcium.

Helpful mnemonicsHelpful mnemonics

PI-SOPotassium is insidePhosphate is insideSodium is outsideChloride is outside

Regulation of Electrolyte BalanceRegulation of Electrolyte Balance

1. Renal regulationOccurs by the process of glomerular filtration, tubular

reabsorption and tubular secretion.Urine formation

◦If there is little water in the body, it is conserved.◦If there is water excess, it will be eliminated.

Regulation of Electrolyte BalanceRegulation of Electrolyte Balance

2. Endocrinal regulationHormones play a role in electrolyte regulationAldosterone promotes Sodium retention and Potassium

excretionANF promotes Sodium excretionParathormone promotes Calcium retention and

Phosphate excretionCalcitonin promotes Calcium excretion and Phosphate

excretion

THE CATIONSTHE CATIONS

SODIUMPOTASSIUMCALCIUMMAGNESIUM

SODIUMSODIUMThe MOST ABUNDANT cation in the ECFNormal range is 135-145 mEq/LMajor contributor of plasma osmolarityFUNCTIONS1. participates in the Na-K pump2. assists in maintaining blood volume3. assists in nerve transmission and muscle contractionAldosterone increases sodium retention ANF increases sodium excretion

POTASSIUMPOTASSIUM

MOST ABUNDANT cation in the ICFNormal range is 3.5-5.0 mEq/LMajor electrolyte maintaining ICVF balanceFUNCTIONS1. maintains ICF Osmolality2. nerve conduction and muscle contraction3. metabolism of carbohydrates, fats and proteinsAldosterone promotes renal excretion of K+Acidosis promotes exchange of K+ for H+

in the cell

CALCIUMCALCIUMMajority of calcium is in the bones and teethNormal serum range 8.5-10 mg/dLFUNCTIONS1. formation and mineralization of bones/teeth2. muscular contraction and relaxation3. cardiac function4. blood clotting5. enzyme activation

CALCIUMCALCIUM

Regulation:GIT absorbs Ca+ in the intestine with the help of Vit. DKidney Ca+ is filtered in the glomerulus and reabsorbed

in the tubulesPTH increases Ca+ by bone resorption, Ca+ retention

and activation of Vitamin DCalcitonin released when Ca+ is high, it decreases Ca+

by excretion in the kidney

MAGNESIUMMAGNESIUM

Second to K+ in the ICFNormal range is 1.3-2.1 mEq/LFUNCTIONS1. intracellular production and utilization of ATP2. protein and DNA synthesis3. neuromuscular irritability

THE ANIONSTHE ANIONS

CHLORIDEPHOSPHATESBICARBONATES

CHLORIDECHLORIDE

The MAJOR Anion in the ECFNormal range is 95-108 mEq/LFUNCTIONS1. major component of gastric juice aside from H+2. together with Na+, regulates plasma osmolality3. participates in the chloride shift4. acts as chemical buffer

PHOSPHATESPHOSPHATES

The MAJOR Anion in the ICFNormal range is 2.5-4.5 mg/LFUNCTIONS1. component of bones2. needed to generate ATP3. components of DNA and RNAPTH decreases PO4 in blood by renal excretionCalcitonin increases renal excretion of PO4

BICARBONATESBICARBONATES

Present both in ICF and ECFNormal range- 22-26 mEq/LFUNCTION1. regulates acid-base balance2. component of the bicarbonate-carbonic acid

buffer system

IMBALANCE: EXCESSIMBALANCE: EXCESS

1. HYPERNATREMIAMore than 145 mEq/LFluid moves out of cell crenationEtiology:↑ sodium intake, IVF, water loss in excess

of water, diarrheaS/SX: dry, sticky tongue, thirst

IMBALANCE: EXCESSIMBALANCE: EXCESS

2. HYPERKALEMIAK+ more than 5.0 mEq/LEtiology: IVF with K+, acidosis, Hyper-alimentation

and K+ replacementECG: peaked T waves and wide QRS

IMBALANCE: EXCESSIMBALANCE: EXCESS

3. HYPERCALCEMIASerum calcium more than 10.5 mg/dLEtiology: Overuse of calcium supplements, excessive Vit. D,

malignancy, prolonged immobilization, thiazide diureticECG: Shortened QT interval

IMBALANCE: EXCESSIMBALANCE: EXCESS

4. HYPERMAGNESEMIASerum magnesium more than 2.1 mEq/LEtiology: use of Mg antacids, Renal failure, Mg medicationsS/SX: depressed tendon reflexes, oliguria, ↓RR

IMBALANCE: EXCESSIMBALANCE: EXCESS

5. HYPERCHLOREMIASerum chloride more than 108 mEq/LEtiology: sodium chloride excess

IMBALANCE: EXCESSIMBALANCE: EXCESS

HYPERPHOSPHATEMIASerum PO4 more than 4.5 mg/dLEtiology: Tissue trauma, chemotherapy. PO4 containing

medications, osteoporosis

IMBALANCE : DEFICIENCYIMBALANCE : DEFICIENCY

1. HYPONATREMIANa level is less than 135 mEq/LWater is drawn into the cell cell swellingEtiology: prolonged diuretic therapy, excessive burns,

excessive sweating, SIADH, plain water consumptionS/SX: nausea, vomiting, seizures

IMBALANCE : DEFICIENCYIMBALANCE : DEFICIENCY

2. HYPOKALEMIAK+ level less than 3.5 mEq/LEtiology: use of diuretic, vomiting and diarrheaECG: flattened , depressed T waves, presence of “U” waves

IMBALANCE : DEFICIENCYIMBALANCE : DEFICIENCY

3. HYPOCALCEMIACalcium level of less than 8.5 mg/dLEtiology: removal of parathyroid gland during thyroid

surgery, vit. D deficiency, Furosemide, infusion of citrated blood

s/sx: Tetany, (+) Chovstek’s (+) Trousseaus’sECG: prolonged QT interval

ACID-BASE CONCEPTSACID-BASE CONCEPTS

Acid- substance that can donate or releasehydrogen ions◦Carbonic acid, Hydrochloric acid

ACID-BASE CONCEPTSACID-BASE CONCEPTS

Base- substance that can accept hydrogen ions◦Bicarbonate

ACID-BASE CONCEPTSACID-BASE CONCEPTS

Buffer- substance that can accept or donate hydrogen◦Hemoglobin buffer◦Bicarbonate : carbonic acid buffer◦Phosphate buffer

ACID-BASE CONCEPTSACID-BASE CONCEPTS

Acid- substance that can donate or release hydrogen ions◦Carbonic acid, Hydrochloric acid

Base- substance that can accept hydrogen ions◦Bicarbonate

Buffer- substance that can accept or donate hydrogen◦Hemoglobin buffer◦Bicarbonate : carbonic acid buffer◦Phosphate buffer

Helpful HintsHelpful Hints

Carbon dioxide is considered to be ACID because of its relationship with carbonic acid

pH measures the degree of acidity and alkalinity. It is inversely related to Hydrogen. Normal ph 7.35-7.45

Decreased pH- ACIDIC-increased Hydrogen—pH below 7.35

Increased pH- ALKALOSIS-decreased hydrogen—pH above 7.45

RememberRemember

a high hydrogen acidic pH is lowa low hydrogen alkalosis pH is high

a high CO2may mean acidica low CO2 may mean alkalosis

Dynamics of Acid and basesDynamics of Acid and bases

Acids and bases are constantly produced in the body.They must be constantly regulated.CO2 and HCO3 are crucial in the balance.A ratio of 20:1 is maintained (HCO3:H2CO3)Respiratory and renal system are active in regulation.

Ways to balance the acids and basesWays to balance the acids and bases

ExcretionAcid can be excreted, and Hydrogen can be excreted in

ACIDOTIC condition.Bicarbonate can be excreted in ALKALOTIC condition.

Ways to balance the acids and basesWays to balance the acids and bases

ProductionBicarbonate can be produced in ACIDOTIC condition.Hydrogen can be produced in ALKALOTIC condition.

Ways to balance the acids and basesWays to balance the acids and bases

The respiratory system compensates for metabolic problemsCO2 (acid) can be exhaled from the body

to normalize the pH in ACIDOSIS.CO2 (acid) can be retained in the body to

normalize the pH in ALKALOSIS.

Ways to balance the acids and basesWays to balance the acids and bases

The kidney can compensate for problems in therespiratory systemThe Kidney reabsorbs and generates Bicarbonate

(alkaline) in ACIDOSIS.The Kidney can excrete H+ excess (Acidosis) to

normalize the pH in ACIDOSIS.

Ways to balance the acids and basesWays to balance the acids and bases

The kidney can excrete bicarbonate (alkali) inconditions of ALKALOSIS.

The kidney can retain H+ (acid) in conditionsof ALKALOSIS.

Ways to balance the acids and basesWays to balance the acids and bases

Chemical buffers can also participate in thebalance of acid-base

1. Carbonic acid- bicarbonate buffer2. Phosphate buffer3. protein buffer- ICF and hemoglobin

The action is immediate but very limited