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FluidsFluids

5050--60% of body60% of bodyweight is waterweight is water

Location:Location:

Within the cellsWithin the cells

Outside the cellsOutside the cells

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Within the cells = Intracellular fluidsWithin the cells = Intracellular fluids

Outside the cells = Extracellular fluidsOutside the cells = Extracellular fluids

60% of Body Weight is WATER

IntracellularFluid (40%)

ExtracellularFluid (20%)

Interstitial Fluid(15%)

Intravascular Fluid

(5%)

Transcellular Fluid CSF, Pleural, Peritoneal,

Synovial Fluids

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The volume of fluid in each locationThe volume of fluid in each location

varies with age and sexvaries with age and sex

Infants have higher proportion of bodyInfants have higher proportion of body

water than adultswater than adults

Infants have higher fluid turnInfants have higher fluid turn--over dueover due

to immature kidney and rapid RRto immature kidney and rapid RR

Water content of the body decreasesWater content of the body decreaseswith agewith age

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Gender & Body SizeGender & Body Size

Lean body has higher water contentLean body has higher water content

Women have higher body fatWomen have higher body fat

content but lesser water contentcontent but lesser water content

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Fluid IntakeFluid Intake

Average oral fluid intake in a healthyAverage oral fluid intake in a healthyadult : 2,500ml/dayadult : 2,500ml/day (1500(1500--3000 ml/ day)3000 ml/ day)

Daily fluid intakeDaily fluid intakestandard formulastandard formula (Kayser(Kayser--Jones et al., 1999;Mentes, 2000)Jones et al., 1999;Mentes, 2000)

100ml/kg for the 1100ml/kg for the 1stst

10 kg of wt, plus10 kg of wt, plus 50ml/kg for the next 10 kg of wt, plus50ml/kg for the next 10 kg of wt, plus

15ml/kg per remaining kg of wt15ml/kg per remaining kg of wt

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Sources of Body FluidsSources of Body Fluids

LiquidsLiquids

FoodFood

Other sources: IVF, TPN, Blood productsOther sources: IVF, TPN, Blood products

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Fluid OutputFluid Output

Average fluid loss amounts toAverage fluid loss amounts to2500ml/day2500ml/day counterbalancing thecounterbalancing theinput to maintain equilibriuminput to maintain equilibrium

RoutesRoutesUrinationUrination (1500ml/day: 30(1500ml/day: 30--50ml/hr: 0.550ml/hr: 0.5--1ml/kg/hr)1ml/kg/hr),,bowel eliminationbowel elimination (200ml),(200ml), perspiration &perspiration &breathingbreathing

Sensible lossSensible loss

Insensible loss = unnoticeable/Insensible loss = unnoticeable/unmeasurableunmeasurable

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Functions of the Body FluidsFunctions of the Body Fluids

Transporter of nutrients, etcTransporter of nutrients, etc

Medium or milieu forMedium or milieu for

metabolic processesmetabolic processesBody temperature regulationBody temperature regulation

Lubricant of musculoskeletalLubricant of musculoskeletaljointsjoints

Insulator and shock absorberInsulator and shock absorber

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Composition of Body FluidsComposition of Body Fluids

Composed ofComposed ofsolutesolute,, solventssolvents,,electrolytes, proteins,electrolytes, proteins, etcetc

Plasma and interstitial fluids containPlasma and interstitial fluids containessentially the same electrolytes andessentially the same electrolytes and

solutes, but plasma has a highersolutes, but plasma has a higher

protein contentprotein contentTheThe major ICFmajor ICF areare KK++, PO, PO--44 & Mg& Mg++++

TheThe major ECFmajor ECF areare NaNa++, HCO, HCO--33 & Cl& Cl--

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TranslocationTranslocationMovement back and forth of fluid andMovement back and forth of fluid and

exchange of chemicals from one locationexchange of chemicals from one location

to anotherto another

A continuous process in and among allA continuous process in and among all

areas where water is locatedareas where water is located

Chemicals involved:Chemicals involved:

ElectrolytesElectrolytes-- substances that when dissolvedsubstances that when dissolved

in fluid carry an electrical chargein fluid carry an electrical charge AcidsAcids-- substances that release Hsubstances that release H++ into fluidinto fluid

BasesBases-- substances that bind w/ Hsubstances that bind w/ H++

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The delicate balance of fluid,The delicate balance of fluid,

electrolytes, acids, and bases iselectrolytes, acids, and bases is

ensured by anensured by an Adequate intake of water and nutrientsAdequate intake of water and nutrients

Physiologic mechanisms that regulatePhysiologic mechanisms that regulate

fluid volumefluid volume

Chemical processes that buffer theChemical processes that buffer theblood to keep its pH nearly neutralblood to keep its pH nearly neutral

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Tonicity of Body FluidsTonicity of Body Fluids

Refers to the concentration of particles in aRefers to the concentration of particles in asolutionsolution

Body fluids are ISOTONIC comparable withBody fluids are ISOTONIC comparable with0.9% NaCl0.9% NaCl

HHYPERTONICYPERTONIC fluids have a higher orfluids have a higher orgreater conc. of solutes (usually sodium)greater conc. of solutes (usually sodium)

compared with plasma; ex. is 3%NaClcompared with plasma; ex. is 3%NaCl

HHYPOTONICYPOTONIC fluids have a lesser orfluids have a lesser orlower solute conc. than plasma; ex. islower solute conc. than plasma; ex. is

0.45%, 0.33%NaCl soln0.45%, 0.33%NaCl soln

TThe normal tonicity orhe normal tonicity or

osmolarity of body fluidsosmolarity of body fluidsisis 270270--300 mOsm/L300 mOsm/L

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Using the formula forUsing the formula for

calculating fluid intakecalculating fluid intakerequirementsrequirements

according to weight,according to weight,

how much oral fluidhow much oral fluid

per day is consideredper day is considered

adequate for a clientadequate for a clientwho weighs 176 lb?who weighs 176 lb?

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Answer: 2400mlAnswer: 2400ml

100ml/kg for the 1100ml/kg for the 1stst 10 kg of wt, plus10 kg of wt, plus

50ml/kg for the next 10 kg of wt, plus50ml/kg for the next 10 kg of wt, plus

15ml/kg per remaining kg of wt15ml/kg per remaining kg of wt

176 lb x 1 kg/2.2 lb = approx. 80kg176 lb x 1 kg/2.2 lb = approx. 80kg

11stst

10 kg x 100ml = 1000ml10 kg x 100ml = 1000mlNext 10 kg x 50ml = 500mlNext 10 kg x 50ml = 500ml

80kg80kg 20 kg = 60kg x 15ml = 900ml20 kg = 60kg x 15ml = 900ml

TOTAL: 1000ml+500ml+900ml = _____TOTAL: 1000ml+500ml+900ml = _____

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Fluid and Electrolyte RegulationFluid and Electrolyte Regulation

Under normal conditions, the followingUnder normal conditions, the followingmechanisms regulates normal fluid volumemechanisms regulates normal fluid volume

and electrolyte concentrationsand electrolyte concentrations

OsmoreceptorsOsmoreceptors

RAASRAAS

ANPANP

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Primarily, fluid volume is regulated byPrimarily, fluid volume is regulated by

intakeintake (thirst) and(thirst) and outputoutput (urine)(urine)

HOW?

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Specialized neurons in the hypothalamusSpecialized neurons in the hypothalamus

Highly sensitive toHighly sensitive to serum osmolalityserum osmolality Increased osmolalityIncreased osmolality osmoreceptors stimulatesosmoreceptors stimulates

hypothalamus to synthesize ADHhypothalamus to synthesize ADH

Decreased osmolalityDecreased osmolality ADH is inhibitedADH is inhibited

TriggersTriggers thirstthirst promoting increased fluidpromoting increased fluidintakeintake

Thirsty when ECF volume decreases by approxThirsty when ECF volume decreases by approx

700ml (2% of body weight)700ml (2% of body weight)

Also sensitive to changes in BV & BP throughAlso sensitive to changes in BV & BP through

the info relayed by baroreceptors (stretch)the info relayed by baroreceptors (stretch)

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A decrease in BV by 10%A decrease in BV by 10%

Systolic BP falls below 90 mm HgSystolic BP falls below 90 mm Hg

RA

is underfilledRA

is underfilled


ADH release

ADH is suppressed when BV, BP

increases and RA is overfilled

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ReninRenin--AngiotensinAngiotensin--Aldosterone SystemAldosterone System

(RAAS)(RAAS)

RENINA

ngiotensinogen

Angiotensin I

Angiotensin II

Blood vesselA

drenal gland (cortex)

ECF (BV)

BP

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ReninRenin--AngiotensinAngiotensin--Aldosterone SystemAldosterone System

(RAAS)(RAAS)

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Natriuretic PeptidesNatriuretic Peptides

HormoneHormone--like substances that act inlike substances that act in

oppositionopposition to the RAASto the RAAS3 types:3 types:

Atrial NPAtrial NP (hearts atrial muscle)(hearts atrial muscle)

Brain NPBrain NP ((ventricles of the heart)ventricles of the heart) CC--type NP (brain)type NP (brain)

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Natriuretic PeptidesNatriuretic Peptides

Overstretching (atrial &Overstretching (atrial &ventricular walls)ventricular walls) ANP &ANP &

BNP are releasedBNP are released

ANP & BNP inhibit theANP & BNP inhibit the

release of RENIN,release of RENIN,

ALDOSTERONE andALDOSTERONE and

ADH =ADH = Blood volumeBlood volume POTENT diureticPOTENT diuretic

NaNa--wastingwasting

((--) thirst) thirst

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GastroGastro--intestinal regulation:intestinal regulation:

The GIT digests foodThe GIT digests food

andand absorbsabsorbs waterwater

Passive & activePassive & active

transport oftransport of

, H, H22O,O,&& solutionssolutions,,

maintain themaintain the

fluid balancefluid balancein the body.in the body.

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Fluids & electrolytes moveFluids & electrolytes move

among cells, compartments,among cells, compartments,tissue spaces, and plasma bytissue spaces, and plasma by

the processes ofthe processes of

OsmosisOsmosis

FiltrationFiltration

Diffusion andDiffusion and

Active transportActive transport

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OsmosisOsmosisMovement ofMovement ofwater/liquid/solventwater/liquid/solvent across aacross a

semipermeable membrane from asemipermeable membrane from a lesserlesserconcentration to a higher concentrationconcentration to a higher concentration

Osmotic pressureOsmotic pressure -- the power of a solutionthe power of a solution

to draw water toward an area of greaterto draw water toward an area of greater

concentrationconcentration

Colloidal osmotic pressureColloidal osmotic pressure -- the osmoticthe osmoticpull exerted by plasma proteins (e.g.,pull exerted by plasma proteins (e.g.,

albumin, globulin, fibrinogen)albumin, globulin, fibrinogen)

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Blood vessel

(Intravascular fluid)

Plasma

CHON = Pulls H2O from ISto IV

ICFInterstitial fluid

H2O

H2O

H2O

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FiltrationFiltration

Movement of

Movement ofboth solute andboth solute andsolventsolvent across a semipermeableacross a semipermeable

membrane from anmembrane from an area of higherarea of higher

pressure to lower pressurepressure to lower pressureHydrostatic pressureHydrostatic pressure thethe

pressure exerted by the fluidspressure exerted by the fluids

within the closed system; pusheswithin the closed system; pusheswaterwater

If HP > OP = FiltrationIf HP > OP = Filtration

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DID you knowDID you know

180 L of fluid180 L of fluid

from the bloodfrom the bloodis filtered byis filtered by

the kidneythe kidneyeach dayeach day

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DIFFUSIONDIFFUSION Brownian orDownhill movementBrownian orDownhill movement

MMovementovement ofofparticles, solutes,particles, solutes,

moleculesmolecules from an area of higherfrom an area of higherconcentration to an area of a lowerconcentration to an area of a lowerconcentrationconcentration through a semipermeablethrough a semipermeablemembranemembrane

Factors affecting rate of diffusion:Factors affecting rate of diffusion:

a.a. SizeSize of the moleculesof the molecules-- larger size moves slowerlarger size moves slowerthan smaller sizethan smaller size

b.b. ConcentrationConcentration of solutionof solution-- wide difference inwide difference inconc. has a faster rate of diffusionconc. has a faster rate of diffusion

c.c. TemperatureTemperature -- in Tin Too == rate of diffusionrate of diffusion

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Facilitated DiffusionFacilitated Diffusion

Require assistanceRequire assistancefrom a carrierfrom a carrier

molecule to passmolecule to pass

through athrough a

semipermeablesemipermeable

membranemembrane E.g., insulinE.g., insulin--

glucoseglucose

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Active TransportActive Transport uphill movementuphill movement

Movement of solute from lowerMovement of solute from lowerconcentration to higher concentration usingconcentration to higher concentration using

energy (ATP)energy (ATP)

e.g., Na-K pump

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Electrolytes ionsElectrolytes ions

Substances present inSubstances present in

ICF & ECF that carryICF & ECF that carry

electrical chargeelectrical charge

cationscations

anionsanions

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Sources of ElectrolytesSources of Electrolytes

Food intake/ ingestedFood intake/ ingested

fluidsfluidsMedicationsMedications

IVF, TPN solutionsIVF, TPN solutions

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Dynamics of Electrolyte BalanceDynamics of Electrolyte Balance

DistributionDistribution Na, Ca, Cl concentration are higher in ECFNa, Ca, Cl concentration are higher in ECF

K, Mg, PO4 concentrations are higher in ICFK, Mg, PO4 concentrations are higher in ICF

ExcretionExcretion Urine, feces, surgical/wound drainage,Urine, feces, surgical/wound drainage,

pathological conditionspathological conditions

RegulationRegulation Kidneys, GIT, hormones (aldosterone,Kidneys, GIT, hormones (aldosterone,

ANF, PTH, calcitonin)ANF, PTH, calcitonin)

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1 tsp of table salt = 2000 mg

1 tsp soy sauce = 1029 mg

Average dietary

intake of sodium isabout 6-14 g/day

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Sodium (NaSodium (Na++)) 135135--145mEq/L (mmol/L)145mEq/L (mmol/L)

Major cation in ECF; major contributor ofMajor cation in ECF; major contributor of

plasma osmolalityplasma osmolality

ECF NaECF Na++ level determines whether water islevel determines whether water is

retained, excreted or translocatedretained, excreted or translocated

Regulated by kidney (aldosterone, ADH, NP)Regulated by kidney (aldosterone, ADH, NP)

serum Na = (serum Na = (--) aldosterone, (+) ADH & NP) aldosterone, (+) ADH & NP

serum Na = (+) aldosterone, (serum Na = (+) aldosterone, (--) ADH & NP) ADH & NP

Functions:Functions: Skeletal/ heart muscle contraction, nerve impulseSkeletal/ heart muscle contraction, nerve impulse

transmission, Normal ECF osmolality, Normaltransmission, Normal ECF osmolality, Normal

ECF volumeECF volume

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1 medium 1097 mg

1 medium banana = 451 mg

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CalciumCalcium++++ 99--10.5 mg/dl (2.2510.5 mg/dl (2.25--2.75 mmol/L)2.75 mmol/L)

2 forms: bound & unbound (ionized)2 forms: bound & unbound (ionized) BoundBound attached to CHON (albumin)attached to CHON (albumin)

IonizedIonized free calcium; active form; ECFfree calcium; active form; ECF

Functions:Functions: Bone strength & density, activation ofBone strength & density, activation of

enzymes or reactions, skeletal/ cardiacenzymes or reactions, skeletal/ cardiac

muscle contraction, nerve impulsemuscle contraction, nerve impulsetransmission, blood clottingtransmission, blood clotting

Regulated by: Vitamin D, PTH, thyrocalcitoninRegulated by: Vitamin D, PTH, thyrocalcitonin

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Phosphorus (P)Phosphorus (P) 33--4.5 mg/dl (0.974.5 mg/dl (0.97--1.45 mmol/L1.45 mmol/L

Major anion ICF (80% is in bones)

Major anion ICF (80% is in bones)

Functions:Functions:

Activating BActivating B--complex vitamins, ATP,complex vitamins, ATP,

assisting in cell division, cooperating inassisting in cell division, cooperating inCHO, CHON & FAT metabolism, acidCHO, CHON & FAT metabolism, acid--

base buffering, calcium homeostasis;base buffering, calcium homeostasis;

balanced & reciprocal relationship w/balanced & reciprocal relationship w/Ca++Ca++

Regulated by PTH:Regulated by PTH: PTH =PTH = PP

PTH =PTH = PP

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MagnesiumMagnesium (Mg(Mg++++)) 1.31.3--2.1 mg/dl (0.652.1 mg/dl (0.65--1.051.05mmol/L)mmol/L)

60% stored in bones & cartilages; much more60% stored in bones & cartilages; much moreis stored in ICF (heart, liver, skeletal muscles)is stored in ICF (heart, liver, skeletal muscles)

Functions:Functions:

ICFICF skeletal muscle contractions, CHOskeletal muscle contractions, CHOmetabolism, ATP formation, Vit.Bmetabolism, ATP formation, Vit.B--complexcomplex

activation, DNA synthesis, CHON synthesisactivation, DNA synthesis, CHON synthesis

ECFECF regulates blood coagulation & skeletalregulates blood coagulation & skeletal

muscle contractilitymuscle contractilityRegulated by the kidney & GIT (exactRegulated by the kidney & GIT (exact

mechanism are not known)mechanism are not known)

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ChlorideChloride (Cl(Cl--)) 9898--106 meq/L (mmol/L)106 meq/L (mmol/L)

Major ECF anion; work w/ NaMajor ECF anion; work w/ Na++to maintain ECF osmoticto maintain ECF osmotic

pressurepressure

Important in the formation ofImportant in the formation of

HCL in the stomachHCL in the stomach

Participates in chloride shiftParticipates in chloride shift(exchange between Cl(exchange between Cl-- &&

HCOHCO33--

))

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Fluid & ElectrolyteFluid & Electrolyte

ImbalancesImbalances

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Fluid ImbalancesFluid Imbalances

HypovolemiaHypovolemia

HypervolemiaHypervolemia

Third spacingThird spacing

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Hypovolemia (Fluid Volume Deficit)Hypovolemia (Fluid Volume Deficit)

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Hypovolemia (Fluid Volume Deficit)Hypovolemia (Fluid Volume Deficit)

Assessment findingsAssessment findings

Thirst = one of the earliest symptomsThirst = one of the earliest symptoms

Weight lossWeight loss 2lb/24 hr2lb/24 hr

BP,BP,

TT, rapid & weak thready pulse,, rapid & weak thready pulse,rapid & shallow respiration, scant & darkrapid & shallow respiration, scant & dark

yellow urine, dry & small volume stool,yellow urine, dry & small volume stool,

warm & flushed dry skin, poor skin turgorwarm & flushed dry skin, poor skin turgor

tents, sunken eyes, clear lungs,tents, sunken eyes, clear lungs,effortless breathing, weakness, flat jugulareffortless breathing, weakness, flat jugular

veins, reduced cognition, sleepyveins, reduced cognition, sleepy

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Medical ManagementMedical Management

Fluid deficit is restored by:Fluid deficit is restored by:

Treating its etiologyTreating its etiology

Increasing the volume ofIncreasing the volume oforal intakeoral intake

Administering IVF

Administering IVFreplacementreplacement

Controlling fluid lossesControlling fluid losses

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Nursing ManagementNursing Management

Gathers assessment dataGathers assessment dataPlans measures to restorePlans measures to restore

fluid balancefluid balanceEvaluates the outcomes ofEvaluates the outcomes of

interventionsinterventionsProvide health teachingProvide health teaching

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Health TeachingHealth Teaching

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Health TeachingHealth TeachingRespond to THIRST because it is an earlyRespond to THIRST because it is an early

indication of reduced fluid volumeindication of reduced fluid volume

Consume at least 8Consume at least 8--10 (8 ounce) glasses of fluid10 (8 ounce) glasses of fluid

each day, and more during hot, humid weathereach day, and more during hot, humid weather

Drink water as an inexpensive means to meetDrink water as an inexpensive means to meetfluid requirementsfluid requirements

Avoid beverages with alcohol & caffeineAvoid beverages with alcohol & caffeine

Include a moderate amount of table salt or foodsInclude a moderate amount of table salt or foodscontaining sodium each daycontaining sodium each day

Rise slowly from a sitting or lying position toRise slowly from a sitting or lying position to

avoid dizziness and potential injuryavoid dizziness and potential injury

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HypervolemiaHypervolemia

High volume of water in the IV compartmentHigh volume of water in the IV compartmentEtiology:Etiology:

Excessive oral intake, rapid IV infusionExcessive oral intake, rapid IV infusion

Heart failureHeart failure Kidney diseaseKidney disease

Excessive salt intakeExcessive salt intake

Adrenal gland dysfunctionAdrenal gland dysfunction Administration of corticosteroidsAdministration of corticosteroids

(prednisolone)(prednisolone)

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PathophysiologyPathophysiology

Circulatory overload;Circulatory overload;compromises cardiopulmonarycompromises cardiopulmonary

functionfunctionThe heart compensates:The heart compensates: BP,BP,

force of contractionforce of contraction

Pitting edema develops (if therePitting edema develops (if there

is 3L excess in IV volume)is 3L excess in IV volume)

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Diagnostic FindingsDiagnostic Findings

Hemodilution (Hemodilution ( blood cell count,blood cell count,

hematocrit)hematocrit)

Low Urine SGLow Urine SG

CVP (>10 cm HCVP (>10 cm H22O)O)

(

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Medical ManagementMedical Management

Treat the underlying causeTreat the underlying cause

Restriction of oral & parenteral fluid intakeRestriction of oral & parenteral fluid intake

Nursing Management

Implements prescribed interventions (limiting

Na+ & water intake)

Administering ordered medications

Elevates client head, legs, change position

q2, apply elastic stockings

Third SpacingThird Spacing

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Third SpacingThird Spacing

Translocation of fluid from the IV orTranslocation of fluid from the IV or

intercellular space to tissue compartmentsintercellular space to tissue compartments

& becomes trapped & useless& becomes trapped & useless

Associated withAssociated with

loss of colloids (hypoalbuminemia)loss of colloids (hypoalbuminemia)

BurnsBurns

severe allergic reaction that alter capillary &severe allergic reaction that alter capillary &

cellular membrane permeabilitycellular membrane permeability

It can lead to hypotension, shock &It can lead to hypotension, shock &

circulatory failurecirculatory failure

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Assessment FindingsAssessment Findings

S/sx of hypovolemia except weight lossS/sx of hypovolemia except weight lossEnlargement of organ cavities (ascites)Enlargement of organ cavities (ascites)

Anasarca brawny edemaAnasarca brawny edema

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ManagementManagement

Restoration of colloidalRestoration of colloidalosmotic pressure (albumin),osmotic pressure (albumin),

then diureticsthen diureticsNursing care combines theNursing care combines the

assessment techniques forassessment techniques for

detecting both hypovolemia &detecting both hypovolemia &

hypervolemiahypervolemia

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HyponatremiaHyponatremia

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Causes;Causes;

Profuse diaphoresis & diuresisProfuse diaphoresis & diuresis

Excessive ingestion of plainExcessive ingestion of plainwaterwater

Administration of electrolyte IVAdministration of electrolyte IVfluidsfluids

Prolonged vomiting, GIProlonged vomiting, GIsuctioning, draining fistulassuctioning, draining fistulas

Addisons diseaseAddisons disease


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Manifestations:Manifestations:Mental confusion, personalityMental confusion, personality

changeschanges

Muscular weaknessMuscular weakness

Anorexia, restlessnessAnorexia, restlessness

Elevated BT, tachycardia, N&VElevated BT, tachycardia, N&V

Severe: convulsions & comaSevere: convulsions & coma


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Management:Management:Underlying cause is correctedUnderlying cause is corrected

Mild deficits: oralMild deficits: oraladministration of Na+administration of Na+

Severe deficits: IV solutionsSevere deficits: IV solutions

HypernatremiaHypernatremia

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HypernatremiaHypernatremiaCauses:Causes: Profuse watery diarrheaProfuse watery diarrhea Excessive salt intake without sufficientExcessive salt intake without sufficient

water intakewater intake

High feverHigh fever Decreased water intake (elderly,Decreased water intake (elderly,

debilitated, unconscious clients)debilitated, unconscious clients)

Excessive administration of solutionsExcessive administration of solutions

containing Na+containing Na+ Excessive water loss withoutExcessive water loss without

accompanying loss of sodiumaccompanying loss of sodium

Severe burnsSevere burns


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Results inResults in ThirstThirst

Dry, sticky mucous membranesDry, sticky mucous membranes

Decreased UODecreased UO

FeverFever

Rough, dry toungeRough, dry tounge LethargyLethargy

Coma if severeComa if severe


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Treatment:Treatment:Depends on the causeDepends on the cause

Oral administration of plainOral administration of plainwaterwater

IV administration of hypotonicIV administration of hypotonicsolutionssolutions

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HypokalemiaHypokalemia

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Causes:Causes: KK++--wasting diuretics (furosemidewasting diuretics (furosemide [Lasix],[Lasix],

ethacrynic acid [Edecrin],ethacrynic acid [Edecrin],

hydrochlorothiazide [HydroDIURIL]hydrochlorothiazide [HydroDIURIL]

Severe vomiting & diarrhea, drainingSevere vomiting & diarrhea, draining

intestinal fistula, prolonged suctioningintestinal fistula, prolonged suctioning

Large doses of corticosteroidsLarge doses of corticosteroids

IV administration of insulin & glucoseIV administration of insulin & glucose

Prolonged administration of nonelectrolyteProlonged administration of nonelectrolyte

parenteral fluidsparenteral fluids


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Signs & symptoms:Signs & symptoms:

FatigueFatigue

WeaknessWeakness

AnorexiaAnorexia

N&VN&V

Cardiac dysrhythmiasCardiac dysrhythmias

Leg crampsLeg cramps

Muscle weakness, paresthesiasMuscle weakness, paresthesias

Severe: hypotension, flaccid paralysis,Severe: hypotension, flaccid paralysis,

DEATH from cardiac arrest/ respiratory arrestDEATH from cardiac arrest/ respiratory arrest


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HypokalemiaHypokalemiaECG changesECG changes

STST--segment depressionsegment depression

Flat or inverted T waveFlat or inverted T wave

Increased U waveIncreased U wave


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Treatment:Treatment:

Elimination of the causeElimination of the cause

Substitute KSubstitute K--wasting with Kwasting with K--

sparing diureticssparing diuretics(Spirinolactone(Spirinolactone [Aldactone][Aldactone]

Increase oral intake of KIncrease oral intake of K--richrich

foods/ K supplements (mildfoods/ K supplements (mildcases)cases)

KCL (severe cases)KCL (severe cases)

HyperkalemiaHyperkalemia

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Causes:Causes:

Renal failureRenal failure


Administration of KAdministration of K--sparing diureticssparing diuretics

Overuse of K supplements, saltOveruse of K supplements, saltsubstitutes (which contain K instead ofsubstitutes (which contain K instead ofNa), potassium rich foodsNa), potassium rich foods

Crushing injuriesCrushing injuries Addisons diseaseAddisons disease

Rapid administration of parenteral K saltsRapid administration of parenteral K salts


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Signs/Symptoms:Signs/Symptoms:

DiarrheaDiarrhea

NauseaNausea

Muscle weaknessMuscle weakness

ParesthesiasParesthesias


Peak T wavesPeak T waves

Prolonged PR intervalsProlonged PR intervals

Flat or absent P waveFlat or absent P wave

Wide QRS complexWide QRS complex


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Treatment: depends on the cause andTreatment: depends on the cause andseverityseverity

Decrease KDecrease K--rich food intake, d/c oralrich food intake, d/c oralpotassium replacement until laboratorypotassium replacement until laboratory

values are normal (mild cases)values are normal (mild cases) Administration of cationAdministration of cation--exchange resinexchange resin

like sodium polystyrene sulfonatelike sodium polystyrene sulfonate

(kayexalate) or combination of IV regular(kayexalate) or combination of IV regularinsulin & glucose (severe cases)insulin & glucose (severe cases)

Peritoneal dialysis/ hemodialysis forPeritoneal dialysis/ hemodialysis forremoving toxic substances from the bloodremoving toxic substances from the blood

Nursing ManagementNursing Management (K+ Imbalances)(K+ Imbalances)

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Nursing ManagementNursing Management (K+ Imbalances)(K+ Imbalances)

Assess clients for conditions with theAssess clients for conditions with the

potential to cause potassiumpotential to cause potassium

imbalancesimbalances

Identifies signs & symptomsIdentifies signs & symptomsMonitors laboratory findingsMonitors laboratory findings

Administer medicationsAdminister medications

KCLKCL diluted in an IV solution &diluted in an IV solution &

administered at a rate below 10mEq/hradministered at a rate below 10mEq/hr

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HypocalcemiaHypocalcemia

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ypyp

Causes:Causes:

Vit D deficiencyVit D deficiency

HypoparathyroidismHypoparathyroidism


Acute pancreatitisAcute pancreatitis

CorticosteroidsCorticosteroids

Rapid administration of multiple units ofRapid administration of multiple units of

blood that contain an anticalcium additiveblood that contain an anticalcium additive Intestinal malabsoprtion d/oIntestinal malabsoprtion d/o

Accidental removal of parathyroid glandsAccidental removal of parathyroid glands


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HypocalcemiaHypocalcemiaSigns & symptoms:Signs & symptoms: Tingling sensations (extremities, aroundTingling sensations (extremities, around

the mouth)the mouth)

Muscle & abdominal crampsMuscle & abdominal cramps

Carpopedal spasms (+ Trousseaus sign)Carpopedal spasms (+ Trousseaus sign)

Mental changesMental changes

+ Chvosteks sign (spasm of facial muscle)+ Chvosteks sign (spasm of facial muscle)

Laryngeal spasmsLaryngeal spasms

Tetany (muscle twisting)Tetany (muscle twisting) SeizuresSeizures

BleedingBleeding


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Treatment:Treatment: Administration of oral CaAdministration of oral Ca++++ & Vitamin D& Vitamin D

(mild cases)(mild cases)

IV administration of CaIV administration of Ca++++

salts (Calciumsalts (Calciumgluconate)gluconate) severe casessevere cases

HypercalcemiaHypercalcemia

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Associated withAssociated with

Parathyroid gland tumorsParathyroid gland tumors

Multiple fracturesMultiple fractures

Pagets diseasePagets disease HyperparathyroidismHyperparathyroidism

Excessive doses of vitamin DExcessive doses of vitamin D

Prolonged immobilizationProlonged immobilization some chemotherapeutic agentssome chemotherapeutic agents

Certain malignant diseases (multipleCertain malignant diseases (multiplemyeloma, acute leukemia, lymphomas)myeloma, acute leukemia, lymphomas)

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ManagementManagement

Determining & correcting the causeDetermining & correcting the cause

Increase fluid intake & limit CaIncrease fluid intake & limit Ca++++

consumption (mild cases)consumption (mild cases)

0.45% or 0.9%NaCL (acute cases)0.45% or 0.9%NaCL (acute cases)and diuretics: furosemide (Lasix); oraland diuretics: furosemide (Lasix); oralphosphates; calcitonin (Cibacalcin)phosphates; calcitonin (Cibacalcin)

Corticosteroids or plicamycinCorticosteroids or plicamycin(Mithracin)(Mithracin) used for malignantused for malignantdiseases that do not respond to otherdiseases that do not respond to other

forms of therapyforms of therapy

Nursing Management:Nursing Management: Ca++ ImbalancesCa++ Imbalances

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HypoCaHypoCa++++::

Closely monitor for neurologicClosely monitor for neurologicmanifestationsmanifestations (tetany, seizures, spasms)(tetany, seizures, spasms)

Seizure precautionsSeizure precautions

Provide bed rest for comfort, avoidProvide bed rest for comfort, avoidfallsfalls

Cardiac dysrhythmias & airwayCardiac dysrhythmias & airwayobstructionobstruction

Check for signs of bruising or bleedingCheck for signs of bruising or bleeding


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Nursing Management:Nursing Management: Ca ImbalancesCa Imbalances

HyperCaHyperCa++++

Encourage increased fluid intakeEncourage increased fluid intake

Collaborates with dietitian to limitCollaborates with dietitian to limit

food sources of Cafood sources of Ca++++

Ambulation as tolerated!!!Ambulation as tolerated!!!

Provide assistance; avoid fallsProvide assistance; avoid falls


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Health teaching:Health teaching:

Follow the physicians recommendationsFollow the physicians recommendationsregarding the addition or restriction of Caregarding the addition or restriction of Ca++++ toto

the dietthe diet

Milk & dairy products, turnips, mustard greens,Milk & dairy products, turnips, mustard greens,

collards, kale, brocolli, canned fish with bones, Cacollards, kale, brocolli, canned fish with bones, Ca++++--

fortified orange juicefortified orange juice

LactoseLactose--free milk & nonprescriptions lactasefree milk & nonprescriptions lactase

enzymes are available for lactoseenzymes are available for lactose--intolerantintolerantclientsclients

Take prescribed or physicianTake prescribed or physician--recommendedrecommended

drugs as directed; do not exceed or omit a dosedrugs as directed; do not exceed or omit a dose

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HypomagnesemiaHypomagnesemia

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yp gyp g

Causes:Causes:

Chronic alcoholismChronic alcoholism

Diabetic ketoacidosisDiabetic ketoacidosis

Severe renal diseaseSevere renal disease

Severe burnsSevere burns Severe malnutritionSevere malnutrition

PIHPIH

Intestinal malabsorption syndromesIntestinal malabsorption syndromes Excessive diuresis (drug induced)Excessive diuresis (drug induced)

HyperaldosteronismHyperaldosteronism

Prolonged gastric suctionProlonged gastric suction

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Management:Management:

Oral magnesium salts/Oral magnesium salts/

magnesium rich foodsmagnesium rich foods

IV magnesium sulfateIV magnesium sulfate

HypermagnesemiaHypermagnesemia

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Causes:Causes:

Renal failure, Addisons disease, Excessive useRenal failure, Addisons disease, Excessive useof antacids or laxatives, Hyperaldosteronismof antacids or laxatives, Hyperaldosteronism

Signs & symptoms:Signs & symptoms:

Flushing, warmth, hypotension, lethargy,Flushing, warmth, hypotension, lethargy,drowsiness, bradycardia, muscle weakness,drowsiness, bradycardia, muscle weakness,

depressed respirations, comadepressed respirations, coma

Management:Management:

Decrease oral magnesium intakeDecrease oral magnesium intake

Discontinue parenteral replacementDiscontinue parenteral replacement

Hemodialysis (severe cases)Hemodialysis (severe cases)

Nursing Management:Nursing Management: Mg++ ImbalancesMg++ Imbalances

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Closely observe for dysrhythmias &Closely observe for dysrhythmias &

early signs of neuromuscularearly signs of neuromuscularirritabilityirritability

If giving MgSOIf giving MgSO44, always check the, always check the

BP!!! (vasodilation)BP!!! (vasodilation)

Antidote: Calcium gluconate (keptAntidote: Calcium gluconate (kept

available)available)Monitor vital signsMonitor vital signs

Provide health teachingProvide health teaching

Identify the electrolyte imbalance eachIdentify the electrolyte imbalance each

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client is most likely manifesting:client is most likely manifesting:

Client 1.Client 1. nauseous & weak. The ECGnauseous & weak. The ECG

shows a U waveshows a U wave

Client 2. muscle twitching and tinglingmuscle twitching and tingling

around mouth. When the nurse applies aaround mouth. When the nurse applies aBP cuff to the clients arm and occludesBP cuff to the clients arm and occludes

blood flow for 3 minutes, the fingers andblood flow for 3 minutes, the fingers and

wrist become flexedwrist become flexedClient 3.Client 3. thirsty, lethargic and excretingthirsty, lethargic and excreting

only scant urine.only scant urine.

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ACIDACID--BASE BALANCEBASE BALANCE

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ACIDACID BASE BALANCEBASE BALANCEBody fluids containsBody fluids contains ACIDS & BASESACIDS & BASES asideaside

from electrolytesfrom electrolytes

HH22COCO33 acid & base content influence the pHacid & base content influence the pH

HCOHCO33 of the body (amount of H+ in a solution)of the body (amount of H+ in a solution)

Normal plasma pH is maintained byNormal plasma pH is maintained by

Chemical regulationChemical regulation (bicarbonate(bicarbonate--carbonic acidcarbonic acid

buffer system) 20:1buffer system) 20:1

Adding/ removing H

Adding/ removing H

++

ionsions Respiratory & renal regulationRespiratory & renal regulation

Releasing & conserving COReleasing & conserving CO22

Retaining or excreting HCORetaining or excreting HCO33

ACIDACID--BASE BALANCEBASE BALANCE

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ACIDACID BASE BALANCEBASE BALANCE

pH (7.35 7.45)PaO2 (80 100 mm Hg)

PaCO2 (35 45 mm Hg)

HCO3- (22 26 mEq/L or

mmol/L)

Base excess (-2 to +2 mEq/L)

O2 Saturation (95 98%)

ACIDACID--BASE IMBALANCEBASE IMBALANCE

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ACIDACID BASE IMBALANCEBASE IMBALANCE

pHpH HCOHCO--33 PaCOPaCO22

MetabolicMetabolic

acidosisacidosis

MetabolicMetabolicalkalosisalkalosis

RespiratoryRespiratory

acidosisacidosis

RespiratoryRespiratory

alkalosisalkalosis

METABOLIC ACIDOSISMETABOLIC ACIDOSIS

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There is increased organic acids (other thanThere is increased organic acids (other than

carbonic acid) or decreased bicarbonatecarbonic acid) or decreased bicarbonateCAUSE:CAUSE:

Anaerobic metabolism (formn of byproductAnaerobic metabolism (formn of byproduct

lactic acid) = shock & cardiac arrestlactic acid) = shock & cardiac arrestStarvation, diabetic ketoacidosis = fatty acidsStarvation, diabetic ketoacidosis = fatty acids

accumulationaccumulation

Kidney failure (cannot reabsorption of HCOKidney failure (cannot reabsorption of HCO33))Aspirin overdosage, profuse diarrhea, intestinalAspirin overdosage, profuse diarrhea, intestinal

wound drainage (HCOwound drainage (HCO33 is lost)is lost)


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Assessment findings:Assessment findings:

Kussmauls breathing (deep & rapid breathing)Kussmauls breathing (deep & rapid breathing)

Anorexia, N & V, headache, confusion, flushing,Anorexia, N & V, headache, confusion, flushing,

lethargy, malaise, drowsiness, abdominal pain orlethargy, malaise, drowsiness, abdominal pain or

discomfort, weaknessdiscomfort, weakness cardiac dysrhythmias can develop, force ofcardiac dysrhythmias can develop, force of

cardiac contraction can be weakenedcardiac contraction can be weakened

Stupor & coma (severe cases)Stupor & coma (severe cases)

ABG:ABG: pH,pH, HCO3 (N toHCO3 (N to PaCO2)PaCO2)

Anion gap (>16mEq/L indicates Met.Acid)Anion gap (>16mEq/L indicates Met.Acid)

(Na + K)(Na + K) (Cl + HCO(Cl + HCO33))

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Medical Management:Medical Management:

Treating the cause & replacingTreating the cause & replacing

F&E that may have been lostF&E that may have been lost

IV bicarbonate (severe cases)IV bicarbonate (severe cases)

METABOLIC ALKALOSISMETABOLIC ALKALOSIS

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There is increased bicarbonate or decreasedThere is increased bicarbonate or decreased

HH++ ion concentrationsion concentrations

Excessive oral or parenteral use ofExcessive oral or parenteral use of

bicarbonatebicarbonate--containing drugs or alkalinecontaining drugs or alkaline

saltssalts

Rapid decrease in ECF (diureticRapid decrease in ECF (diuretic

therapy)therapy)

Vomiting, prolonged gastric suctioning,Vomiting, prolonged gastric suctioning,

hypokalemia, hyperaldosteronismhypokalemia, hyperaldosteronism

(retention of sodium bicarbonate)(retention of sodium bicarbonate)

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RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS acute/ chronicacute/ chronicCC

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Causes:Causes:

Pneumothorax,Pneumothorax, Hemothorax,Hemothorax,

Pulmonary edemaPulmonary edema

Acute bronchial asthmaAcute bronchial asthma

AtelectasisAtelectasis

Hyaline membrane disease, RDS in NBHyaline membrane disease, RDS in NB

PneumoniaPneumonia

Drug overdose

Drug overdose

Head injuriesHead injuries

ChronicChronic-- emphysema, bronchiectasis, bronchialemphysema, bronchiectasis, bronchialasthma, cystic fibrosisasthma, cystic fibrosis

RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS

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Assessment findings:Assessment findings:

Client make frantic efforts to breathe, breath slowlyClient make frantic efforts to breathe, breath slowly

or irregularly, or stop breathingor irregularly, or stop breathing

Decreased expiratory volumesDecreased expiratory volumes

Tachycardia (dysrhythmias), CyanosisTachycardia (dysrhythmias), Cyanosis Behavioral changesBehavioral changes-- mental cloudiness, confusion,mental cloudiness, confusion,

disorientation, hallucinations (accumulation of COdisorientation, hallucinations (accumulation of CO22))

Tremors, muscle twitching, flushed skin, headache,Tremors, muscle twitching, flushed skin, headache,

weakness, stupor, comaweakness, stupor, coma

ABG:ABG: pH,pH, PaCO2 (N toPaCO2 (N to HCOHCO33))

RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS

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Medical managementMedical management

Treatment is individualized dependingTreatment is individualized dependingon the cause of imbalanceon the cause of imbalance

Mechanical ventilation (may beMechanical ventilation (may be

necessary to support respiratorynecessary to support respiratoryfunction)function)

IV NaHCOIV NaHCO33 if ventilation efforts do notif ventilation efforts do not

adequately restore a balanced pHadequately restore a balanced pH Bronchodilators, antibiotics, airwayBronchodilators, antibiotics, airway

suctioningsuctioning

RESPIRATORY ALKALOSISRESPIRATORY ALKALOSIS

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Results from carbonic acid deficitResults from carbonic acid deficit

Anxiety, high fever, thyrotoxicosis, early salicylateAnxiety, high fever, thyrotoxicosis, early salicylate

(aspirin) poisoning, hypoxemia, mechanical(aspirin) poisoning, hypoxemia, mechanical

ventilationventilation

Assessment findings:Assessment findings: RRRR

Lightheadedness, numbness & tingling of theLightheadedness, numbness & tingling of the

fingers & the toes, circumoral paresthesias,fingers & the toes, circumoral paresthesias,

sweating, panic, dry mouth, convulsions (severesweating, panic, dry mouth, convulsions (severecases)cases)

ABG:ABG: pH,pH, PaCOPaCO22 (N to(N to HCOHCO33))

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