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Fluid and Electrolytes

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42% of body weight; 2/3 of body water. Potassium (K ): most prevalent intracellular cation ... Diaphoresis leads to loss of water and electrolytes. 7/31/09. 13. Sodium ... – PowerPoint PPT presentation

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Title: Fluid and Electrolytes


1
Fluid and Electrolytes
2
Compartments
  • Intracellular fluid (ICF)
  • Extracellular fluid (ECF)
  • Intravascular (plasma)
  • Interstitial (between cells lymph)
  • Transcellular
  • See Figure 16-2 in Lewis 6th ed.

3
Intracellular Fluid (ICF)
  • Fluid located within cells
  • 42 of body weight 2/3 of body water
  • Potassium (K) most prevalent intracellular
    cation
  • Phosphate (PO4-) most prevalent intracellular
    anion

4
Extracellular Fluid (ECF)
  • Interstitial (between cells lymph)
  • (Cl-) most prevalent anion
  • (Na)most prevalent cation
  • 2/3 of ECF is in interstitial
  • Intravascular (IV)
  • Within vascular space
  • Measured with blood tests
  • 1/3 of ECF is intravascular

5
Transcellular
  • Small but important fluid compartment
  • Approximately 1 Litre
  • Includes
  • CSF
  • GI tract
  • Pleural space
  • Synovial spaces
  • Peritoneal space

6
Mechanisms Controlling Fluid and Electrolyte
Movement
  • Diffusion
  • molecules move from high to low concentration
  • Facilitated diffusion
  • involves carrier molecules
  • Active transport
  • movement against concentration gradient
  • requires energy
  • E.g. keeping Na out and K in the cells (requires
    ATP)

7
Mechanisms Controlling Fluid and Electrolyte
Movement
  • Osmosis
  • H2O movement between compartments separated by
    membrane from area of high to low solute
    concentration
  • Membrane is permeable to water, not solutes
  • Hydrostatic pressure
  • Force within fluid compartment
  • Oncotic pressure colloid osmotic pressure
  • Osmotic pressure exerted by colloids e.g.,
    protein n solution pulls fluid into vascular
    space

8
Fluid Shifts Plasma to interstitial space
  • Results in edema
  • Due to
  • Elevated venous hydrostatic pressure
  • e.g., CHF, varicose veins
  • Decreased plasma oncotic pressure
  • e.g., low plasma protein r/t malnutrition
  • Elevated interstitial oncotic pressure
  • plasma proteins accumulated in interstitium,
    pulling water - e.g., burns

9
Fluid Movement Between Extracellular and
Intracellular
  • Excess water in ECF
  • Cells are more concentrated. Thus
  • Water moves into cells ? Cells swell
  • Water deficit in ECF water is pulled from cells
    ? Cells shrink
  • Both of above cause neurological symptoms

10
Fluid Spacing
  • First spacing
  • Normal distribution of fluid in ICF and ECF
  • Second spacing
  • Abnormal accumulation of interstitial fluid
    (e.g., edema associated with varicose veins,
    pulmonary edema)
  • Third spacing
  • Fluid accumulation in part of body where it is
    not easily exchanged with rest of ECF (e.g.,
    edema due to burns, ascites in peritoneal space)

11
Regulation of Water Balance
  • Hypothalamic regulation (controls pituitary)
  • Pituitary regulation (ADH)
  • Adrenal cortical regulation (aldosterone
    enhances Na and H20 retention)
  • Renal regulation
  • Cardiac regulation
  • Gastrointestinal regulation (fluid intake)
  • Insensible water loss

12
Insensible Water Loss
  • Invisible vaporization from lungs and skin
  • Approximately 900 ml per day is lost
  • No electrolytes are lost with insensible water
    loss
  • Excessive sweating is not an insensible loss.
    Diaphoresis leads to loss of water and
    electrolytes.

13
Sodium
  • Plays major role in maintaining ECF concentration
    (osmolality) and volume
  • Main cation in ECF primary determinant of
    osmolality (a measure of solute concentration)
  • Important in generation and transmission of nerve
    impulses
  • Important in acid-base balance

14
Hypernatremia
  • Hypernatremia due to
  • Water loss or
  • Sodium gain
  • Hypernatremia results in
  • Hyperosmolality ? water shifts out of cells ?
    cellular dehydration
  • Primary protection against hypernatremia is
    thirst

15
Hypernatremia
  • Manifestations include thirst, lethargy,
    agitation, seizures, and coma
  • Hypernatremia secondary to water deficiency often
    due to impaired LOC or inability to get fluids
  • Also due to deficiency in ADH

16
Hypernatremia
  • Management includes
  • Treating the underlying cause
  • Hypotonic IV fluids if oral fluids cannot be
    ingested
  • Administering diuretics (promotes excretion of
    sodium)
  • Serum sodium levels must be reduced gradually to
    avoid cerebral edema

17
Hyponatremia
  • Due to
  • loss of Na-containing fluids, or
  • water excess (dilutional hyponatremia)
  • Hyponatremia ? hypoosmolality ? water moves into
    cells
  • Clinical manifestations include confusion,
    nausea, vomiting, seizures, and coma

18
Hyponatremia
  • If caused by water excess, fluid restriction is
    needed
  • If severe symptoms (seizures) occur, small amount
    of intravenous hypertonic saline solution (3
    NaCl) is given

19
Hyponatremia
  • If associated with abnormal fluid loss (diarrhea,
    polyuria, etc.)
  • fluid replacement with Na-containing solution
    (eg. Normal saline 0.9 NaCl)

20
Potassium
  • Potassium major ICF cation
  • Potassium is necessary for
  • Transmission and conduction of nerve impulses
  • Normal cardiac rhythms
  • Skeletal muscle contraction
  • Acid-base balance

21
Potassium
  • Critical to action membrane potential
  • Sources of potassium
  • Fruits and vegetables (bananas and oranges)
  • Salt substitutes
  • Potassium medications (PO, IV)
  • Stored blood

22
Hyperkalemia
  • Causes
  • Increased retention
  • Renal failure
  • Potassium sparing diuretics
  • Increased intake
  • Mobilization from ICF
  • Tissue destruction
  • Acidosis

23
Hyperkalemia
  • Clinical Manifestations
  • Skeletal muscles weak or paralyzed
  • Ventricular fibrillation or cardiac standstill
  • Abdominal cramping or diarrhea

24
Nursing Management of Hyperkalemia
  • Eliminate oral and parenteral K intake
  • Increase elimination of K (diuretics, dialysis,
    Kayexalate)
  • Force K from ECF to ICF with IV insulin (or
    sodium bicarbonate if hyperkalemia is due to
    acidosis)

25
Hypokalemia
  • Causes
  • Increased loss
  • Certain diuretics
  • GI losses
  • Associated with Mg deficiency
  • Movement into cells

26
HypokalemiaClinical Manifestations
  • Potentially lethal ventricular arrhythmias
  • Increased digoxin toxicity in those taking the
    drug
  • ECG changes
  • Skeletal muscle weakness and paralysis
  • Muscle cell breakdown

27
HypokalemiaClinical Manifestations
  • Decreased GI motility
  • Altered airway responsiveness
  • Impaired regulation of arterial blood flow
  • Diuresis
  • Hyperglycemia

28
Nursing Management of Hypokalemia
  • Replacement PO or IV
  • Never push IV
  • Painful in peripheral veins
  • Never give with anuric renal failure
  • Teach prevention methods (e.g. diet)

29
Electrolyte Disorders SummarySigns and Symptoms
30
Electrolyte DisordersSigns and Symptoms
31
Protein Imbalances
  • Plasma proteins(especially albumin) are important
    determinants of plasma volume
  • Hyperproteinemia is rare
  • Occurs with dehydration-induced hemoconcentration

32
Hypoproteinemia
  • Caused by
  • Anorexia
  • Malnutrition
  • Starvation
  • Fad dieting
  • Poorly balanced vegetarian diets

33
Hypoproteinemia
  • Poor absorption d/t GI malabsorptive diseases
  • Inflammation ? protein can shift out of
    intravascular space
  • Hemorrhage

34
Hypoproteinemia Clinical Manifestations
  • Edema (b/c insufficient oncotic pressure to
    hold water in vascular space)
  • Slow healing
  • Anorexia
  • Fatigue
  • Anemia
  • Muscle loss
  • Ascites (same reason as edema)

35
Hypoproteinemia
  • Management
  • High-carbohydrate, high-protein diet
  • Dietary protein supplements
  • Enteral nutrition or total parenteral nutrition

36
Extracellular Fluid Volume Imbalances
  • Hypovolemia due to
  • loss of normal body fluids (diarrhea, fistula
    drainage, hemorrhage)
  • decreased intake
  • or plasma-to-interstitial fluid shift
  • Hypervolemia due to
  • excessive intake of fluids
  • abnormal retention of fluids (CHF)
  • or interstitial-to-plasma fluid shift

37
Extracellular Fluid Volume Imbalances
  • Hypovolemia
  • Treat with fluid replacement (NS, Ringers,
    blood)
  • Hypervolemia
  • Remove excess fluid (diuretics, dialysis)
  • Fluid restriction, sodium restriction

38
Nursing Diagnoses Hypervolemia
  • Excess fluid volume
  • Ineffective airway clearance
  • Risk for impaired skin integrity
  • Disturbed body image
  • PC pulmonary edema, ascites

39
Nursing Diagnoses Hypovolemia
  • Fluid volume deficit
  • Decreased cardiac output
  • PC hypovolemic shock

40
Nursing Implementation for Volume Imbalances
  • IO
  • Cardiovascular status (BP, pulse strength, JVD,
    HR, orthostatic hypotension)
  • Respiratory status (crackles, RR)
  • Neurological function
  • Daily weights (1 kg 1000 ml)
  • Skin assessment (turgor, edema)

41
Nursing Implementation for Volume Imbalances
  • Neurologic function
  • LOC
  • PERLA
  • Voluntary movement of extremities
  • Muscle strength
  • Reflexes

42
IV Fluids
  • Purposes
  • Maintenance
  • When oral intake is not adequate
  • Replacement
  • When losses have occurred

43
Solution Types
  • Hypotonic
  • Provides more water than electrolytes
  • Dilutes ECF, thus water moves from ECF ? ICF
  • Examples 0.45 NaCl

44
Solution Types
  • Isotonic
  • Same osmolality as ECF
  • Expands only ECF (what goes in ECF stays in ECF
    no shifting to ICF)
  • Examples Normal saline (0.9 NaCl), Lactated
    Ringers (Ringers Lactate)

45
Solution Types
  • Hypertonic
  • More concentrated than ECF
  • Expands ECF volume
  • Increased osmolality draws water from cells into
    ECF

46
D5W
  • Isotonic
  • But becomes hypotonic after dextrose is
    metabolized b/c only water remains
  • A source of calories
  • A source of free water (as above b/c of
    metabolism of glucose)
  • Moves into ICF

47
D5W
  • Prevents ketosis
  • Supports edema formation do not use in clients
    with cerebral edema!
  • Decreased chance of IV fluid overload
  • Usually compatible with medications

48
Normal Saline (NS 0.9 NaCl)
  • Isotonic
  • No calories
  • More NaCl than ECF (could cause hypernatremia,
    hyperchloremia)

49
Normal Saline (NS 0.9 NaCl)
  • Expands IV volume
  • Preferred fluid for immediate response
  • Risk for fluid overload higher
  • Does not change ICF Volume
  • Blood products
  • Compatible with most medications

50
Lactated Ringers
  • Isotonic
  • More similar to plasma than NS (b/c has
    electrolytes)
  • Commonly used postoperatively
  • Expands ECF, IV
  • Common replacement fluid

51
D5 ½ NS
  • Hypertonic (becomes Hypotonic in body after
    dextose is absorbed)
  • Common maintenance fluid
  • KCl added for maintenance or replacement

52
D5 ½ NS (Hypertonic)
  • Provides calories
  • Prevents ketosis
  • Moves into ICF
  • Usually compatible with medications

53
Plasma Expanders (Hypertonic)
  • Pull fluid from interstitium into vascular space
  • Colloids
  • Packed RBCs
  • Albumin
  • Plasma
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