FLUID AND FLUID AND ELECTROLYTES ELECTROLYTES
FLUID AND FLUID AND ELECTROLYTESELECTROLYTES
Anatomy and PhysiologyAnatomy and Physiology
TOTAL BODY WATER (TBW)TOTAL BODY WATER (TBW)60% Body Weight60% Body Weight
• • INTRACELLULAR FLUIDINTRACELLULAR FLUID (ICF)(ICF) 40%40%•• EXTRACELLULAR FLUIDEXTRACELLULAR FLUID (ECF)20%(ECF)20%
InterstitialInterstitialIntravascular Intravascular TrancellularTrancellular
•• THIRD SPACE FLUIDTHIRD SPACE FLUIDDisease; injuryDisease; injury
ElectrolytesElectrolytes
NaNa Extracellular CATIONExtracellular CATION ClCl Extracellular ANIONExtracellular ANION KK Intracellular CATIONIntracellular CATION PO4PO4 Intracellular ANIONIntracellular ANION
Body Fluid TransportBody Fluid Transport
• • DIFFUSIONDIFFUSION Higher to lower concentrationHigher to lower concentration
•• OSMOSISOSMOSIS Lower to higher concentration Lower to higher concentration
Semi permeable membraneSemi permeable membrane
•• FILTRATIONFILTRATIONParticlesParticles
•• ACTIVE TRANSPORTACTIVE TRANSPORTNa-K PumpNa-K PumpRequires ATPRequires ATP
FluidsFluids
• • BODY INPUTBODY INPUTFluidsFluids 1500mL 1500mL
FoodFood 500mL 500mL
DigestionDigestion 500mL 500mL
TotalTotal >2500mL >2500mL
•• BODY OUTPUTBODY OUTPUTUrineUrine 1500mL 1500mL
FecesFeces 200-400mL 200-400mL
Respiration200-400mLRespiration200-400mL
SkinSkin 200-400mL 200-400mL
TotalTotal >2500mL >2500mL
Intravenous FluidsIntravenous Fluids
ISOTONIC:ISOTONIC:
Equal in concentrationEqual in concentration
• • 0.9% NaCl or NSS0.9% NaCl or NSS
•• D5 Water, Lactated Ringer’sD5 Water, Lactated Ringer’s
Intravenous FluidsIntravenous Fluids
HYPOTONIC:HYPOTONIC:↓ ↓ Salt or soluteSalt or soluteCellular swellingCellular swelling •• 0.45% NaCl, Distilled water0.45% NaCl, Distilled water
HYPERTONIC:HYPERTONIC:↑ ↑ SoluteSoluteCellular shrinkageCellular shrinkage •• D5 NSS, D10 WaterD5 NSS, D10 Water •• D5 0.45 % NaCl, D5 LRSD5 0.45 % NaCl, D5 LRS
FLUID VOLUME DEFICITFLUID VOLUME DEFICIT
DEHYDRATIONDEHYDRATIONInadequate IntakeInadequate IntakeExcessive LossExcessive Loss
Types:Types:• • ISOTONIC DehydrationISOTONIC Dehydration•• HYPERTONIC DehydrationHYPERTONIC Dehydration•• HYPOTONIC DehydrationHYPOTONIC Dehydration
FLUID VOLUME DEFICITFLUID VOLUME DEFICIT
Assessment:Assessment:
↓ ↓ BP; BP; ↑ ↑ PR PR
Weak and thready pulsesWeak and thready pulses
Flat neck veinsFlat neck veins
Lethargic to comaLethargic to coma
Dry skin; poor skin turgorDry skin; poor skin turgor
Oliguria (Oliguria (↓↓ UO) UO)
↑↑ Urine specific gravityUrine specific gravity
ThirstThirst
FLUID VOLUME DEFICITFLUID VOLUME DEFICIT
Management:Management:Monitor VS; BP and PRMonitor VS; BP and PRMild:Mild: Oral Rehydrating Solution (ORS)Oral Rehydrating Solution (ORS)Severe:Severe: IV fluid IV fluid Administer prescribed meds Administer prescribed meds
• • AntibioticsAntibiotics•• AntiemeticsAntiemetics•• AntipyreticsAntipyretics
Monitor/ correct electrolyte imbalancesMonitor/ correct electrolyte imbalances
FLUID VOLUME EXCESSFLUID VOLUME EXCESS
FLUID OVERLOADFLUID OVERLOAD
Types:Types:
• • ISOTONICISOTONIC
•• HYPOTONICHYPOTONIC
•• HYPERTONICHYPERTONIC
FLUID VOLUME EXCESSFLUID VOLUME EXCESS
Assessment:Assessment:↑ ↑ BP and CVPBP and CVPBounding pulseBounding pulse↑ ↑ RR, Dyspnea RR, Dyspnea CracklesCracklesDistended neck veinDistended neck veinAltered level of consciousnessAltered level of consciousnessWeight gainWeight gain Ascites; pedal edemaAscites; pedal edemaPolyuriaPolyuria
FLUID VOLUME EXCESSFLUID VOLUME EXCESS
Management:Management:
Monitor VS: BP and RRMonitor VS: BP and RR
Monitor I and OMonitor I and O
Restrict fluid and Na intakeRestrict fluid and Na intake
Weight and AC OD pre-breakfastWeight and AC OD pre-breakfast
Administer prescribed diureticsAdminister prescribed diuretics
Monitor/treat electrolyte imbalancesMonitor/treat electrolyte imbalances
HYPOKALEMIAHYPOKALEMIA
Normal K Normal K 3.5-5.0 meq/L3.5-5.0 meq/LK K ↓ ↓ 3.5 meq/L3.5 meq/L Causes:Causes:
Diuretics, digitalis, and steroidsDiuretics, digitalis, and steroidsCushing’s syndromeCushing’s syndromeMetabolic AlkalosisMetabolic AlkalosisDiarrhea, NPO Diarrhea, NPO ↑ ↑ InsulinInsulin
HYPOKALEMIAHYPOKALEMIA
Assessment:Assessment:Weak irregular pulsesWeak irregular pulsesECG: ECG:
• • U waveU wave•• Inverted T wavesInverted T waves
Altered LOCAltered LOCShallow respirationShallow respirationWeakness; hyporeflexiaWeakness; hyporeflexiaIleus; constipationIleus; constipation
HYPOKALEMIAHYPOKALEMIA
Management:Management:Monitor VS; PRMonitor VS; PRMonitor serum K valuesMonitor serum K valuesBed restBed restEncourage K-rich foods:Encourage K-rich foods:
• • Banana, avocado, raisins, Banana, avocado, raisins, orange, potatoesorange, potatoes
Diet: High fiber foods Diet: High fiber foods K- sparing diuretics K- sparing diuretics
•• Spirinolactone (Aldactone)Spirinolactone (Aldactone)
HYPOKALEMIAHYPOKALEMIA
Management:Management:• • Oral PotassiumOral Potassium
Kalium Durule (PC)Kalium Durule (PC)K-LorK-Lor
•• IV PotassiumIV PotassiumNEVER given by IV push, IM nor SCNEVER given by IV push, IM nor SC5-10 meq/hr5-10 meq/hrUse of cardiac monitorUse of cardiac monitorAssess IV siteAssess IV site
HYPERKALEMIAHYPERKALEMIA
KK ↑ ↑ 5.5 meq/L5.5 meq/L
Causes:Causes:Excessive K intake Excessive K intake K sparing diureticsK sparing diureticsAddison’s diseaseAddison’s diseaseChronic renal failure (CRF)Chronic renal failure (CRF)Metabolic AcidosisMetabolic AcidosisTissue damage; injuryTissue damage; injury
HYPERKALEMIAHYPERKALEMIA
Assessment:Assessment:
Irregular weak pulses, Irregular weak pulses, ↓ ↓ BPBP
ECG:ECG:
• • Tall T waveTall T wave
•• Flat P waveFlat P wave
Muscular weaknessMuscular weakness
ParesthesiaParesthesia
DiarrheaDiarrhea
HYPERKALEMIAHYPERKALEMIA
Management:Management:Monitor VSMonitor VSRestrict K rich foodsRestrict K rich foodsDiscontinue K supplements PO/ IVDiscontinue K supplements PO/ IVIf no renal disease; Diuretics If no renal disease; Diuretics Na polystyrene sulfonate (KAYEXALATE)Na polystyrene sulfonate (KAYEXALATE)
→ → K excretionK excretionPrepare for dialysisPrepare for dialysisAdminister NaHCO3Administer NaHCO3Glucose with insulinGlucose with insulin
HYPONATREMIAHYPONATREMIA
Serum Na Serum Na 135-145meq/L135-145meq/LNa Na ↓ ↓ 135 meq/L135 meq/L
Causes:Causes:DiureticsDiureticsDiaphoresisDiaphoresisAddison’s DiseaseAddison’s DiseaseSIADHSIADHNPO, NPO, ↓↓ Salt diet Salt dietFreshwater drowningFreshwater drowning
HYPONATREMIAHYPONATREMIA
Assessment:Assessment:
↑ ↑ Pulse ratePulse rate
Shallow respirationShallow respiration
Headache; altered LOCHeadache; altered LOC
Seizures Seizures
WeaknessWeakness
Polyuria (Polyuria (↑ ↑ UO)UO)
HYPONATREMIAHYPONATREMIA
Management:Management:Monitor VSMonitor VSMonitor LOCMonitor LOCIntake of Na rich foods:Intake of Na rich foods:→→Table salt, soy sauce, cured pork, Table salt, soy sauce, cured pork,
canned and processed foods canned and processed foods Hypovolemia: IVF NSS (ISOTONIC)Hypovolemia: IVF NSS (ISOTONIC)Fluid excess: Osmotic diureticsFluid excess: Osmotic diureticsSIADH: Lithium and DemeclocyclineSIADH: Lithium and Demeclocycline
→→ Antagonize ADHAntagonize ADHSeizure precautionsSeizure precautions
HYPERNATREMIAHYPERNATREMIA
Na Na ↑↑145 meq/L145 meq/L
Causes:Causes:
Steroids Steroids
↑↑ Na intakeNa intake
↓ ↓ WWater intakeater intake
Cushing’s syndromeCushing’s syndrome
Chronic renal failure (CRF)Chronic renal failure (CRF)
HYPERNATREMIAHYPERNATREMIA
Assessment:Assessment:
↓ ↓ PRPR
Shallow respirationShallow respiration
WeaknessWeakness
Dry flaky skinDry flaky skin
Altered LOCAltered LOC
Oliguria (Oliguria (↓↓ UO) UO)
HYPERNATREMIAHYPERNATREMIA
Management:Management:
Monitor VSMonitor VS
Restrict Na and fluid Restrict Na and fluid
DiureticsDiuretics
Hypovolemia: D5W and HYPOTONIC IVFHypovolemia: D5W and HYPOTONIC IVF
HYPOCALCEMIAHYPOCALCEMIA
Serum Ca Serum Ca 8-10.5 mg/dL8-10.5 mg/dL4.5-5.5 meq/L4.5-5.5 meq/L
CaCa ↓ ↓ 8 mg/dL8 mg/dL
Causes:Causes:↓↓ Intake of Ca and vitamin DIntake of Ca and vitamin DLactose intoleranceLactose intoleranceParathyroidectomyParathyroidectomyCRFCRFDiureticsDiuretics
HYPOCALCEMIAHYPOCALCEMIA
Assessment:Assessment:Irregular pulsesIrregular pulsesECGECG Prolonged ST intervalProlonged ST interval
Prolonged QT intervalProlonged QT intervalParesthesia; numbnessParesthesia; numbnessWeaknessWeaknessTetany; carpopedal spasmTetany; carpopedal spasm(+) Trosseau’s sign(+) Trosseau’s sign(+) Chvostek’s sign(+) Chvostek’s sign
HYPOCALCEMIAHYPOCALCEMIA
Management:Management:
Monitor VS; PR/ CRMonitor VS; PR/ CR
Monitor serum Ca and MgMonitor serum Ca and Mg
Encourage Ca-rich foods:Encourage Ca-rich foods:
Milk and poultry, cheese, eggsMilk and poultry, cheese, eggs
Oral Ca supplement:Oral Ca supplement:
• • CaCO3 (Calci-Aid)CaCO3 (Calci-Aid)
1-2 hrs PC or HS1-2 hrs PC or HS
HYPOCALCEMIAHYPOCALCEMIAManagement:Management:
IV Ca: IV Ca:
• • Calcium GluconateCalcium Gluconate
Given very SLOWLYGiven very SLOWLY
Never thru IV push, IM or SQNever thru IV push, IM or SQ
Use of cardiac monitorUse of cardiac monitor
Assess PR/ CRAssess PR/ CR
HYPERCALCEMIAHYPERCALCEMIA
Ca Ca ↑↑10.5mg/dL10.5mg/dL
Causes:Causes:
Excessive intake of Ca or Vitamin DExcessive intake of Ca or Vitamin D
Use of Thiazides; LithiumUse of Thiazides; Lithium
HyperparathyroidismHyperparathyroidism
MalignancyMalignancy
Immobility; FractureImmobility; Fracture
HYPERCALCEMIAHYPERCALCEMIA
Assessment:Assessment:
Irregular CRIrregular CR cardiac arrestcardiac arrest
ECG:ECG:
• • Shortened ST intervalShortened ST interval
Altered LOCAltered LOC
Muscle weaknessMuscle weakness
Colic painColic pain → → Renal stonesRenal stones
ConstipationConstipation
HYPERCALCEMIAHYPERCALCEMIA
Management:Management:Monitor VS; CRMonitor VS; CRRestrict Ca rich foods Restrict Ca rich foods Discontinue PO and IV Ca Discontinue PO and IV Ca Give prescribed DiureticsGive prescribed Diuretics↑ ↑ Fluid intakeFluid intake• • Calcitonin; Biphosphanates Calcitonin; Biphosphanates • • ASA and NSAIDSASA and NSAIDS
→→Inhibit Ca resorption from bonesInhibit Ca resorption from bonesPrepare for dialysisPrepare for dialysis
ACID BASE BALANCEACID BASE BALANCE
Hydrogen ions (H)Hydrogen ions (H) → → pHpH
ACIDSACIDS →→ Hydrogen donors Hydrogen donors BASESBASES →→ Hydrogen acceptors Hydrogen acceptors
CARBONIC ACID/ CARBONIC ACID/ BICARBONATE SYSTEMBICARBONATE SYSTEM
Maintains pH of 7.4Maintains pH of 7.4
Bicarbonate to Carbonic Acid Ratio Bicarbonate to Carbonic Acid Ratio 20:120:1
CARBONIC ACIDCARBONIC ACID LungsLungs BICARBONATEBICARBONATE KidneysKidneys
ACID BASE BALANCEACID BASE BALANCE
ACIDOSISACIDOSIS → → Hyperkalemia (Hyperkalemia (↑ K)↑ K) ALKALOSISALKALOSIS →→ Hypokalemia ( Hypokalemia (↓ K)↓ K)
ARTERIAL BLOOD GASARTERIAL BLOOD GAS
PHPH 7.35- 7.457.35- 7.45
PCO2PCO2 35- 45 mmHg35- 45 mmHg
HCO3HCO3 22- 26 meq/L22- 26 meq/L
PO2PO2 80- 100 mmHg80- 100 mmHg
ARTERIAL BLOOD GASARTERIAL BLOOD GAS
ROMEROME• • Respiratory AcidosisRespiratory Acidosis ↓↓pHpH ↑↑pCO2pCO2
•• Respiratory AlkalosisRespiratory Alkalosis ↑↑pHpH ↓↓pCO2pCO2
•• Metabolic AcidosisMetabolic Acidosis ↓↓pHpH ↓↓HCO3HCO3
•• Metabolic AlkalosisMetabolic Alkalosis ↑↑pHpH ↑↑HCO3HCO3
ARTERIAL BLOOD GASARTERIAL BLOOD GAS
Pre-op care:Pre-op care: ALLEN’S TestALLEN’S Test
Rest x 30 minRest x 30 min NO SUCTION NO SUCTION Note O2 therapyNote O2 therapy
Room air:Room air: → No O2→ No O2 Prepare heparinized syringePrepare heparinized syringe
ARTERIAL BLOOD GASARTERIAL BLOOD GAS
Post-op care:Post-op care:
Container with iceContainer with ice
Client’s temperatureClient’s temperature O2 and respirator set upO2 and respirator set up Pressure dressing x 5-10 minPressure dressing x 5-10 min
RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS
↓↓pHpH ↑↑pCO2pCO2
Causes:Causes: Pulmonary Diseases:Pulmonary Diseases:
• • PTB, PneumoniaPTB, Pneumonia
•• COPD, B. AsthmaCOPD, B. Asthma Brain Injury Brain Injury Medications: Medications:
• • Sedatives, Narcotics, AnestheticsSedatives, Narcotics, Anesthetics
RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS
Assessment:Assessment: HYPOVENTILATIONHYPOVENTILATION
(Rapid, shallow breathing)(Rapid, shallow breathing)
↑ ↑ PRPR
HeadacheHeadache Blurring of visionBlurring of vision RestlessnessRestlessness CyanosisCyanosis
RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS
Management:Management: Semi to high fowlers Semi to high fowlers Monitor VS; RRMonitor VS; RR Administer O2 Administer O2 Coughing and deep breathing exercisesCoughing and deep breathing exercises
Turning from side to sideTurning from side to side
Encourage hydrationEncourage hydration
Suction secretion PRN Suction secretion PRN
Appropriate treatment as prescribedAppropriate treatment as prescribed
• • Bronchodilators, Antibiotics Bronchodilators, Antibiotics
•• Respirator; CTT/ ThoracentesisRespirator; CTT/ Thoracentesis
RESPIRATORY ALKALOSISRESPIRATORY ALKALOSIS
↑↑pHpH ↓↓pCO2pCO2
Causes:Causes: Hysteria Hysteria Anxious; panic statesAnxious; panic states Severe pain; feverSevere pain; fever Over- use of respiratorOver- use of respirator
RESPIRATORY ALKALOSISRESPIRATORY ALKALOSIS
Assessment:Assessment: HYPERVENTILATIONHYPERVENTILATION
(Rapid, deep breathing)(Rapid, deep breathing)
Headache; dizzinessHeadache; dizziness
Mental status changesMental status changes ParesthesiaParesthesia WeaknessWeakness Tetany; carpopedal spasmTetany; carpopedal spasm
RESPIRATORY ALKALOSISRESPIRATORY ALKALOSIS
Management:Management: Monitor VS; RRMonitor VS; RR Emotional support and reassuranceEmotional support and reassurance Appropriate breathing patterns: Appropriate breathing patterns: → ↑pCO2→ ↑pCO2
• • Brown bagBrown bag
• • Voluntary holding of breathVoluntary holding of breath
Monitor electrolytesMonitor electrolytes Cautious care with clients on respiratorCautious care with clients on respirator
Administer prescribed medicationAdminister prescribed medication
METABOLIC ACIDOSISMETABOLIC ACIDOSIS
↓↓pHpH ↓↓HCO3HCO3
Causes:Causes: DM/DKADM/DKA CRFCRF
Starvation; malnutritionStarvation; malnutritionLactic acidosisLactic acidosis
ASA and ethanol intoxicationASA and ethanol intoxication Severe diarrheaSevere diarrhea
METABOLIC ACIDOSISMETABOLIC ACIDOSIS
Assessment:Assessment: KUSSMAUL BREATHINGKUSSMAUL BREATHING
(Rapid, deep breathing)(Rapid, deep breathing)
Irregular pulsesIrregular pulses
HeadacheHeadache Altered LOC Altered LOC Fruity or ketone breathFruity or ketone breath ↑ ↑ Serum Serum KK
METABOLIC ACIDOSISMETABOLIC ACIDOSIS
Management:Management: Monitor VS; RR and PRMonitor VS; RR and PR Assess LOCAssess LOC
Monitor I and OMonitor I and O Assess and correct serum KAssess and correct serum K
Safety and seizure precautionSafety and seizure precaution Administer NaHCO3 Administer NaHCO3 Administer KayexalateAdminister Kayexalate
DM: Give prescribed insulinDM: Give prescribed insulinCRF: Prepare for dialysisCRF: Prepare for dialysis
METABOLIC ALKALOSISMETABOLIC ALKALOSIS
↑↑pHpH ↑↑HCO3HCO3
Causes:Causes: Excessive NaHCO3 intakeExcessive NaHCO3 intake Chronic use of diureticsChronic use of diuretics Excessive vomiting/GI suctioningExcessive vomiting/GI suctioning
Several BT with FWB (Citrate)Several BT with FWB (Citrate)
METABOLIC ALKALOSISMETABOLIC ALKALOSIS
Assessment:Assessment: Nausea and vomitingNausea and vomiting Irregular pulsesIrregular pulses
RestlessnessRestlessness
ParesthesiaParesthesia ↓ ↓ Serum KSerum K
METABOLIC ALKALOSISMETABOLIC ALKALOSIS
Management:Management: Monitor VS; PRMonitor VS; PR
Assess and correct serum K Assess and correct serum K
Safety precautionsSafety precautions Discontinue HCO3Discontinue HCO3 Administer prescribed anti-emeticsAdminister prescribed anti-emetics