Fluid and Electrolite

7/27/2019 Fluid and Electrolite

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ASUHAN KEPERAWATAN

PADA GANGGUAN

KESEIMBANGAN CAIRAN,ELEKTROLIT & ASAM-BASA

TUTI HERAWATI, MN


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Fungsi Air dalam Fisiologi Manusia

1. Media semua reaksi kimia tubuh

2. Berperan dalam pengaturan distribusi kimia &

biolistrik dalam sel3. Alat transport hormon & nutrien

4. Membawa O2 dari paru-paru ke sel tubuh

5. Membawa CO2 dari sel ke paru-paru

6. Mengencerkan zat toksik dan waste productserta membawanya ke ginjal dan hati

7. Distribusi panas ke seluruh tubuh


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DISTRIBUSI CAIRAN TUBUH

Komponen terbesar

dipengaruhi usia, jenis kelamin & jml lemak

Neonatus 80 %, Dewasa 60% BB, lansia 45-50% BB

wanita (17-39 th) : 50% BB

pria (17-39 th): 60% BB


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4


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Elektrolit

Zat yang terlarut dalam cairan yang

terpisah dalam ion-ion yg mengandung

muatan elektrik

CATIONion bermuatan +

ANIONion bermuatan -

Cations = Anions satuan : milliequivalents / liter (mEq/L)


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PERPINDAHAN CAIRAN &


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PERPINDAHAN CAIRAN &

ELEKTROLIT

Diffusion

Active Transport

Osmosis Filtration


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DIFFUSION

perpindahan molekul dari

tekanan/konsentrasi tinggi ke

tekanan/konsentrasi rendah Transport Pasif& tdk memerlukan energi


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ACTIVE TRANSPORT


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ACTIVE TRANSPORT

SYSTEM

perpindahan molekul dari tekanan/

konsentrasi rendah ke konsntrasi tinggi dgn

menggunakan energi (ATP) Requires specific carrier molecule as well

as specific enzyme (ATPase)

Sodium, potassium, calcium, magnesium,plus some sugars, & amino acids use it


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OSMOSIS

perpindahan air dari konsentrasi zat terlarut

rendah ke konsentrasi zat terlarut tinggi

melalui membran

osmolaritas: ukuran konsentrasi suatu larutan

- isotonus konsentrasi larutan = plasma

darah


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Pengukuran Osmolality di klinik

Serum 280-300mOsm/kg; Urine 50-

1400mOsm/kg

Osmolality = 2 * Na + Glu + BUN mg/dl18 2.8


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Isotonik

Tekanan osmolaritas plasma?

280-300 mosm/kg

Osmolaritas ECF ditentukan oleh Na

NaCl 0,9 %, RL


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HYPOTONIC HYPERTONIC

Rendah Na atau tinggi

h2O dari isotonik

Jika di infuskan ke

darah, cairan akan

pindah ke intra sel &

menyebabkan edema

sel 0,45 % NaCl

Jika diinfuskan ke

darah, cairan intra sel

ke intravaskular

menyebabkan selmengecil

NaCl 3 %, whole

blood, Albumin,koloid, dextrose 10 %,

dextrose 40 %, Total

parenteral Nutrition


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Tekanan Cairan

1. Tekanan osmotik & onkotikTekanan osmotik: tekanan untuk mencegah

aliran osmotik cairanTekanan onkotik (osmotik koloid): gaya tarik s/

koloid (albumin)agar air tetap berada dalam

plasma darah.


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PLASMA PROTEINS (albumin)

mempengaruhi serum osmolarity

berupa anion

Diseimbangkan dg Na Mempertahankan cairan di dlm

vascular dan dppt menarik cairan dari

interstitial


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Tekanan Hidrostatik

Tekanan cairan melawan

dinding vaskuler

Tekanan hidrostatik (

filtration force)

tekanan yang digunakan oleh

air dalam sistem tertutup


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FILTRATION

Perpindahan cairan melalui mebran

semipermeabel dari area tekanan hidrostatik

tinggi ke area yg lebih rendah. Arterial end of capillary has hydrostatic

pressure > than osmotic pressure so fluid

& diffusible solutes move out of capillary


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THIRD SPACING

Large quantities of fluid from the

intravascular compartment shift into the

interstitial space; is inaccessible to thebody

May be caused by lowered plasma proteins,

increased capillary permeability &lymphatic blockage

Can be seen with trauma, inflammation,

disease


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INTAKE & OUTPUT

INTAKE

Oral fluids -

including ice, gelatin,etc.

Parenteral fluids

Tube feedings with

flushes

Catheter irrigants

that are not

withdrawn

OUTPUT

Urine output

Liquid feces

Vomitus

NG drainage

Excessive sweating Wound drainage

Draining fistula

Rapid or labored RR


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Normal fluid and electrolyte requirements

Daily water requirements

Weight (kg) x 25-35 mL = mL fluid required daily25 mL/kg for CHF or renal disease

30 mL/kg for average adults35 mL/kg for patients with infection or drainingwounds

Daily electrolyte requirements

Sodium 2 - 3 mEq/100ml H2O /day

Potassium 1 - 2 mEq/100ml H2O /day

Chloride 2 - 3 mEq/100ml H2O /day


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Electrolytes This provides information about serum Na+, K+, Cl-, HCO3-

BUN and Cr These measures provide an indication of renal perfusion. An elevatedBUN generally reflects intravascular depletion. Creatinine is a usefulindicator of acute renal failure.

CBC The CBC may provide some indication of hemoconcentration in cases ofdehydration. The WBCs and differential cell count are useful indicatorsof infection. Platelets can elevate as acute phase reactants.

Urine

AnalysisThe specific gravity of the urine is related to the patient's hydrationstate. In cases of renal disease, it can help classify the condition. Urine

ions can be specifically requested, and are helpful in determining

whether sodium is being retained or not.

Examinations to identify fluid/electrolyte problems


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Serum/UrineOsmolarity

A true measure of serum osmolarity can be compared to the calculated

osmolarity. Normally, true osmolarity is about 10 mEq/L higher than calculated

due to the presence of particles which are not in the basic osmolarity equation.

If there is a greater "osmolar gap" than this, the presence of additional particlesshould be considered (such as alcohol or mannitol). The osmolarity of serum

determines whether a patient is in an isotonic state or if this state has been

disturbed. Urine osmolarity is helpful in determining if the kidney is doing its

job of concentrating urine.Total Protein Total protein, and sometimes albumin levels, are indirect measures of both liver

function (where they are produced), dietary protein intake, and renal loss. If

serum protein levels fall, the intravascular oncotic pressure falls and fluid

migrates to "third spaces". This can be seen in liver disease, nephrotic

syndromes, malnutrition and other cases.

Arterial BloodGas In addition to providing information about the patient's blood gases andassisting in classification of acidosis or alkylosis, the ABG yields information

about bicarbonate levels. Usually, STAT electrolytes can also be obtained from

a blood gas sample, with turn around time better than serum chemistry.


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Fluid Imbalances

Fluid excess:

CHF

Kidney failure

Fluid deficit:

Diarrhea

Blood loss


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Assessment of Fluid Balance

Health History

Daily Weight

Intake and Output Vital Signs

Skin Turgor

Mucous Membranes

Hand Vein Filling/Emptying

LabsUrine SG; Hb&Ht; Sodium; Total Protein;Albumin; Serum Osmolarity; BUN; Creatinine


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Responses to imbalances ?

R l ti f b d t l (d h d ti )


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Regulation of body water loss (dehydration)

Aldosterone

Na

+&Water reabsorbtion

in renal tubules

Release ADH

Water retention


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Neuro Endocrine Mechanisms

Central Nervous System Ischemic

Response- massive hemorrhage causes dec.

in ECF volume & response that constrictsafferent arterioles & dec. GFR

Baroreceptor Reflex- stretch receptors in

large arteries that react to a dec. in ECF &respond with dec. in GFR

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CAUSES OF FVD

Abnormal GI fluid

loss such as N&V or

drainage of GI tract Abnormal fluid loss

from skin such as

high temperature or

burns Increased water

vapor from the lungs

such as hyperpnea

Conditions that

increase renal

excretion of fluidssuch as diuretics &

hypersomolar tube

feedings

Decrease in fluidintake

Third-space shift

such as ascites or

trauma


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SIGNS & SYMPTOMS OF FVD

Dry mucous membranes

Weight loss -mild at 2%,moderate at 5%, &

severe deficit at 8%

Orthostatic hypotension& increase in

pulse rate

Body temperature usually subnormal

Flat neck veins & decrease in CVP

Decreased urinary output & altered

sensorium


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NURSING MANAGEMEMT OF FVD

Monitoring I&O on a regular schedule

depending on the patient

If urine output is below 30 mL / hr. notifythe physician

May check urine specific gravity q 8hrs.

Weigh patient daily at the same time &recognize that a change of 2.2 lbs.

represents a loss of 1000 mL

Monitorskin turgor, oral membranes, lab


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FLUID VOLUME EXCESS

Hypervolemia or FVE is result of

expansion of fluid compartment from an

increase in total sodium content Kidney receives signal to save sodium &

water to compensate for cirrhosis, CHF,

renal failure, excessive Na-containing fluid Labs may show dec.:hematocrit, serum

Na, serum osmolality, urine sp. Gr; inc.

BUN


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SIGNS & SYMPTOMS OF FVE

SOB & orthopnea

Edema & weight gain

Distended neck veins & tachycardia

Increased blood pressure

Crackles & wheezes

Maybe ascites & pleural effusion

Increase in CVP

NURSING MANAGEMENT OF


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NURSING MANAGEMENT OFFVE

MonitorI & O plus monitor for physical

signs of hypervolemia

Check foredema & weigh patient daily

Restrict sodium intake as prescribed

Limit intake of fluids

Watch for signs ofpotassium imbalance

Monitor for signs ofpulmonary edema

Place patient in semi-Fowlers position


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SODIUM (NA)*

Main extracellular fluid (ECF) cation

Helps govern normal ECF osmolality

Helps maintain acid-base balance

Activates nerve & muscle cells

Influences water distribution (with chloride)

N: 135-145 mEq/L


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Hyponatremia: serum Na < 130 mEq/L

Sodium deficit calculation: [(normal Na(mEq/L))(measured Na(mEq/L)] x TBW (L)


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Hypernatremia: serum Na > 150 mEq/L


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Hypernatremia: serum Na > 150 mEq/L

Significant neurological effects usually seen withNa > 160 mEq/L

Free water deficit calculation:

measured Na (mEq/L)

desired Na (mEq/L) X TBW (L)} - TBW (L)

Use 145mEq/L as desired Na; estimate TBW as

0.6L/kg x body weight (kg)


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POTASSIUM (K)*

Dominant cation in intracellular fluid (ICF)

Regulates cell excitability

Permeates cell membranes, thereby

affecting cells electrical status

Helps control ICF osmolality & ICF

osmotic pressure


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POTASSIUM (K+)

MOVEMENT

INFLUENCED

BY:Changes in pH

Insulin

Adrenal hormones

Changes in serum

sodium

IMPORTANT IN:

Neuromuscular

irritability

Intracellular

osmotic activity

Acid-base balance


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Fluid electrolyte management

Estimating the fluid problem1) Check the weightRapid changes in weight likely represent changes in TBW.(2)History

Ask about losses (diarrhea, vomiting, how much, how often),attempts at replacement (what fluids used, how much given,how successful), urine output.

(3)Physical exam findingsMental status, pulse, BP, body weight, mucous membranes, skin

turgor, skin color.

(4)Laboratory evaluationSerum chemistries, hematocrit, and urine studies can guidetherapy and check forcomplications.


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HYPERNATREMIA

Collaborative management tries to

gradually lower serum sodium by

*infusion of 0.45% NaCl

*monitoring U/O & serum sodium levels

*administering fluids carefully

*restricting sodium intake


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HYPONATREMIA

Collaborative management seeks to correct

cause & give sodium with caution due to

possible rebound fluid excess by :*infusing isotonic saline in IV fluids

*restricting oral & IV water intake

*increasing dietary sodium*monitoring for signs of hypervolemia

HYPERKALEMIA


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TREATMENT

Watch EKG for fatal dysrthymias or

cardiac arrest

Collaborative management may include:Calcium to counteract effect on heart

Sodium bicarbonate to alkalinize fluids

Hemodialysis or peritoneal dialysis

Cation exchange resins (Kayexalate) by

mouth or enema

Small dose of insulin & dextrose

Restrict dietary K+


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HYPOKALEMIA TX

Correct the cause

Oral or IV administration of potassium

(dilutes in IV fluids) Salt substitutes containing K+

Foods high in potassium : bananas, pears,

dried apricots; fruit juices; tea, colabeverages; milk; meat, fish; baked potato;

dried beans (cooked); ANYTHING THAT

TASTES GOOD LIKE CHOCOLATE !!


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NORMAL

HIPERKALEMIA

HIPOKALEMIA


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Oral therapy

Oral rehydration with electrolyte solutions is safe, efficacious and convenient. Can be used as

first line therapy in nearly all fluid and electrolyte aberrations except severe circulatorycompromise.


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IV therapy reestablish effective circulating volume

a) What IV fluid should be used?

Initial IV therapy should be with isotonic fluid to improve effective circulating volume.


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b) How much IV flui d should I give ini ti al ly?

Use clinical findings to determine if patient is responding (mental status, vital signs, urine

output). Repeat this infusion if necessary.

c) How should continue IV fl uids?

do not require continued IV fluids after effective circulation has been restored.

Continue IV fluids in situations where oral

rehydration will be difficult, such as high ongoing losses, severe electrolyte abnormalities,

poor mental status or inability to tolerate enteral fluids.


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(a)Estimate remaining deficits

Volume: Check current weight and compare to desired

baseline. If using preresuscitationweight, consider the amount

of volume given in resuscitation.

(b)Estimate daily needsEstimate daily needs for water and electrolytes, as for any

patient. Adjust based on the clinical situation (e.g., fever, coma,

ventilator, etc.)

(c) Consider ongoing losses

Monitor for losses such as stool, drains, etc. Consider replacingthese as needed.

(d)Provide therapy

Add up water and electrolyte needs from deficits and daily

requirements.

Continuing IV therapy considers:


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ACID-BASE BALANCE

Governed by the regulation ofhydrgen ion

(H+) concentration in the body

pH = negative logarithm of the H+concentration

Acids - proton donors & give up H+

Bases - H+ acceptors

Acidic - inc. in concentration of H+

Basic - dec. in concentration of H+

HENDERSON -


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HASSELBALCH EQUATION

Expresses that the

ratio of base to acid or

HCO3

- to H2

CO2

*

( 20: 1) determines the

pH

pH < 7.35

ACIDOSIS pH > 7.45

ALKALOSIS


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ACID-BASE REGULATORY


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MECHANISMS

CHEMICAL BUFFER SYSTEMS -

bicarbonate, phosphate, protein,

hemoglobin LUNGS - carbonic acid broken down into

CO2 & H2O

KIDNEYS - increasing or decreasingbicarbonate ions


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Arterial Blood Gases (ABGs)

pH 7.35-7.45

PaCO2 35-45 mm Hg

Pa O2 80-100 mm Hg

O2 sat. 95-99%

HCO3- 22-26mEq/L


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ACID-BASE PARAMETERS

ACID

pH 45 HCO3 7.45

PaCO2 26


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Respiratory Acidosis*

pH < 7.35

PaCO2 > 45mm Hg

Due to inadequate alveolar ventilation

Tx aimed at improving ventilation

Respiratory Opposite


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Respiratory Alkalosis*

pH > 7.45

PaCO2 < 35mm Hg

Due to alveolar hyperventilation &hypocapnia

Tx depends on underlying cause


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Metabolic Acidosis*

pH < 7.35

HCO3 < 22mEq/L

Due to gain of acids or loss of base (likeexcessive GI loss from diarrhea)

May have associated hyperkalemia

Tx aimed at correcting metabolic defect

Metabolic Even


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Metabolic Alkalosis*

pH > 7.45

HCO3 > 26 mEq/L

Due to loss of acid or gain of base (mostcommon is vomiting or gastric suction)

Hypokalemia may produce alkalosis

Tx aimed at underlying disorder


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ABG ASSESSMENT*

36 yo pt. complains of

acute SOB, R sided

pleuritic pain

pH 7.50

PaCO2 29 mmHg

PaO2 60 mmHg

HCO3- 24 mEq/l

SaO2 78%

? Meaning ?

32 yo pt. with drug

OD & breathing 5

times / minute

pH 7.25

PaCO2 61 mmHg

PaO2 74 mmHg

HCO3- 26 mEq/l

SaO2 89%

? Meaning ?


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ABGs*

70 year old diabetic

with hx of not taking

insulin

pH 7.26

PaCO2 42

HCO3 17

????

58 year old pt. With

CHF for 6 mos. &

placed on digoxin &

Lasix

pH 7.48

PaCO2 45

HCO3 26

????


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HATURNUHUN

TERIMA KASIH

Fluid and Electrolite

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