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Chapter 41: Fluid, Electrolyte, and Acid-Base Balance

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Chapter 41: Fluid, Electrolyte, and Acid-Base Balance Bonnie M. Wivell, MS, RN, CNS – PowerPoint PPT presentation

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Title: Chapter 41: Fluid, Electrolyte, and Acid-Base Balance


1
Chapter 41 Fluid, Electrolyte, and Acid-Base
Balance
  • Bonnie M. Wivell, MS, RN, CNS

2
Distribution of Body Fluids
  • Intracellular inside the cell 42 of body
    weight
  • Extracellular outside the cell, 17 of body
    weight
  • Interstitial contains lymph fluid between
    cells and outside blood vessels
  • Intravascular blood plasma found inside blood
    vessels
  • Transcellular fluid that is separated by
    cellular barrier,

3
Body Fluid Compartments
4
Functions of Body Fluid
  • Major component of blood plasma
  • Solvent for nutrients and waste products
  • Necessary for hydrolysis of nutrients
  • Essential for metabolism
  • Lubricant in joints and GI tract
  • Cools the body through perspiration
  • Provides some mineral elements

5
Composition of Body Fluids
  • Body fluids contain Electrolytes
  • Anions negative charge
  • Cl, HCO3, SO4
  • Cations positive charge
  • Na, K, Ca
  • Electrolytes are measured in mEq
  • Minerals are ingested as compounds and are
    constituents of all body tissues and fluids
  • Minerals act as catalysts

6
Electrolytes in Body Fluids
  • Normal Values
  • Sodium (Na) 35 145 mEq/L
  • Potassium (K) 3.5 5.0 mEq/L
  • Ionized Calcium (Ca) 4.5 5.5 mg/dL
  • Calcium (Ca) 8.5 10.5 mg/dL
  • Bicarbonate (HCO3) 24 30 mEq/L
  • Chloride (Cl--) 95 105 mEq/L
  • Magnesium (Mg) 1.5 2.5 mEq/L
  • Phosphate (PO4---) 2.8 4.5 mg/dL

7
Movement of Body Fluids
  • Osmosis movement across a semi-permeable
    membrane from area of lesser concentration to are
    of higher concentration high solute
    concentration has a high osmotic pressure and
    draws water toward itself
  • Osmotic pressure drawing power of water
    (Osmolality)
  • Osmolarity concentration of solution

8
Movement of Body Fluids
  • Colloid or Oncotic pressure keeps fluid in the
    intravascular compartment by pulling water from
    the interstitial space back into the capillaries

9
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10
Solutions
  • Isotonic Solution
  • The same concentration as blood plasma expand
    fluid volume without causing fluid shift
  • Hypotonic Solution
  • Lower concentration than blood plasma moves
    fluid into the cells causing them to enlarge
  • Hypertonic solution
  • Higher concentration than blood plasma pulls
    fluid from cells causing them to shrink

11
Movement of Body Fluids Contd.
  • Diffusion Molecules move from higher
    concentration to lower
  • Concentration gradient
  • Filtration water and diffusible substances move
    together across a membrane moving from higher
    pressure to lower pressure
  • Edema results from accumulation of excess fluid
    in the interstitial space
  • Hydrostatic pressure causes the movement of
    fluids from an area of higher pressure to area of
    lower pressure

12
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13
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14
Active Transport
  • Requires metabolic activity and uses energy to
    move substances across cell membranes
  • Enables larger substances to move into cells
  • Molecules can also move to an area of higher
    concentration (Uphill)
  • Sodium-Potassium Pump
  • Potassium pumped in higher concentration in ICF
  • Sodium pumped out higher concentration in ECF

15
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16
Regulation of Body Fluids
  • Homeostasis is maintained through
  • Fluid intake
  • Hormonal regulation
  • Fluid output regulation

17
Fluid Intake
  • Thirst control center located in the hypothalamus
  • Osmoreceptors monitor the serum osmotic pressure
  • When osmolarity increases (blood becomes more
    concentrated), the hypothalamus is stimulated
    resulting in thirst sensation
  • Salt increases serum osmolarity
  • Hypovolemia occurs when excess fluid is lost

18
Fluid Intake
  • Average adult intake
  • 2200 2700 mL per day
  • Oral intake accounts for 1100 1400 mL per day
  • Solid foods about 800 1000 mL per day
  • Oxidative metabolism 300 mL per day
  • Those unable to respond to the thirst mechanism
    are at risk for dehydration
  • Infants, patients with neuro or psych problems,
    and older adults

19
Hormonal Regulation
  • ADH (Antidiuretic hormone)
  • Stored in the posterior pituitary and released in
    response to serum osmolarity
  • Pain, stress, circulating blood volume effect the
    release of ADH
  • Increase in ADH Decrease in urine output Body
    saves water
  • Makes renal tubules and ducts more permeable to
    water

20
Hormonal Regulation Contd.
  • Renin-angiotensin-aldosterone mechanism
  • Changes in renal perfusion initiates this
    mechanism
  • Renin responds to decrease in renal perfusion
    secondary to decrease in extracellular volume
  • Renin acts to produce angiotensin I which
    converts to angiotensin II which causes
    vasoconstriction, increasing renal perfusion
  • Angiotensin II stimulates the release of
    aldosterone when sodium concentration is low

21
Hormonal Regulation Contd.
  • Aldosterone
  • Released in response to increased plasma
    potassium levels or as part of the
    renin-angiotensin-aldosterone mechanism to
    counteract hypovolemia
  • Acts on the distal portion of the renal tubules
    to increase the reabsorption of sodium and the
    secretion and excretion of potassium and hydrogen
  • Water is retained because sodium is retained
  • Volume regulator resulting in restoration of
    blood volume

22
Hormonal Regulation Contd.
  • Atrial Natriuretic Peptide (ANP)
  • ANP is a hormone secreted from atrial cells of
    the heart in response to atrial stretching and an
    increase in circulating blood volume
  • ANP acts like a diuretic that causes sodium loss
    and inhibits the thirst mechanism
  • Monitored in CHF

23
Fluid Output Regulation
  • Organs of water loss
  • Kidneys
  • Lungs
  • Skin
  • GI tract

24
Fluid Output Regulation Contd.
  • Kidneys are major regulatory organ of fluid
    balance
  • Receive about 180 liters of plasma to filter
    daily
  • 1200 1500 mL of urine produced daily
  • Urine volume changes related to variation in the
    amount and type of fluid ingested
  • Skin
  • Insensible Water Loss
  • Continuous and occurs through the skin and lungs
  • Can significantly increase with fever or burns
  • Sensible Water Loss occurs through excess
    perspiration
  • Can be sensible or insensible via diffusion or
    perspiration
  • 500 600 mL of insensible and sensible fluid
    lost through skin each day

25
Fluid Output Regulation Contd.
  • Lungs
  • Expire approx 500 mL of water daily
  • Insensible water loss increases in response to
    changes in resp rate and depth and oxygen
    administration
  • GI Tract
  • 3 6 liters of isotonic fluid moves into the GI
    tract and then returns to the ECF
  • 200 mL of fluid is lost in the feces each day
  • Diarrhea can increase this loss significantly

26
Regulation of Electrolytes
  • Major Cations in body fluids
  • Sodium (Na)
  • Potassium (K)
  • Calcium (Ca)
  • Magnesium (Mg)

27
Sodium Regulation
  • Most abundant cation in the extracellular fluid
  • Major contributor to maintaining water balance
  • Nerve transmission
  • Regulation of acid-base balance
  • Contributes to cellular chemical reactions
  • Sodium is taken in via food and balance is
    maintained through aldosterone

28
Potassium Regulation
  • Major electrolyte and principle cation in the
    extracellular fluid
  • Regulates metabolic activities
  • Required for glycogen deposits in the liver and
    skeletal muscle
  • Required for transmission of nerve impulses,
    normal cardiac conduction and normal smooth and
    skeletal muscle contraction
  • Regulated by dietary intake and renal excretion

29
Calcium Regulation
  • Stored in the bone, plasma and body cells
  • 99 of calcium is in the bones and teeth
  • 1 is in ECF
  • 50 of calcium in the ECF is bound to protein
    (albumin)
  • 40 is free ionized calcium
  • Is necessary for
  • Bone and teeth formation
  • Blood clotting
  • Hormone secretion
  • Cell membrane integrity
  • Cardiac conduction
  • Transmission of nerve impulses
  • Muscle contraction

30
Magnesium Regulation
  • Essential for enzyme activities
  • Neurochemical activities
  • Cardiac and skeletal muscle excitability
  • Regulation
  • Dietary
  • Renal mechanisms
  • Parathyroid hormone action
  • 50 60 of magnesium contained in bones
  • 1 in ECF
  • Minimal amount in cell

31
Anions
  • Chloride (Cl-)
  • Major anion in ECF
  • Follows sodium
  • Bicarbonate (HCO3-)
  • Is the major chemical base buffer
  • Is found in ECF and ICF
  • Regulated by kidneys

32
Anions Contd.
  • Phosphate (PO4---)
  • Buffer ion found in ICF
  • Assists in acid-base regulation
  • Helps to develop and maintain bones and teeth
  • Calcium and phosphate are inversely proportional
  • Promotes normal neuromuscular action and
    participates in carbohydrate metabolism
  • Absorbed through GI tract
  • Regulated by diet, renal excretion, intestinal
    absorption and PTH

33
Regulation of Acid-Base Balance
  • Lungs and kidneys are our buffering systems
  • A buffer is a substance that can absorb or
    release H to correct an acid-base imbalance
  • Arterial pH is an indirect measure of hydrogen
    ion concentration
  • Greater concentration of H, more acidic, lower pH

34
Regulation of Acid-Base Balance
  • Lower concentration of H, more alkaline, higher
    pH
  • The pH is also a reflection of the balance
    between CO2 (regulated by lungs) and bicarb
    (regulated by kidneys)
  • Normal H level is necessary to
  • Maintain cell membrane integrity
  • Maintain speed of cellular enzymatic actions

35
Chemical Regulation
  • Carbonic acid-bicarbonate buffer system is the
    first to react to change in the pH of ECF
  • H and CO2 concentrations are directly related
  • ECF becomes more acidic, the pH decreases,
    producing acidosis
  • ECF receives more base substances, the pH rises,
    producing alkalosis
  • Lungs primarily control excretion of CO2
    resulting from metabolism
  • Kidneys control excretion of hydrogen and bicarb

36
Biological Regulation
  1. Buffer actions that occur
  2. Exchange of K and H
  3. Carbon dioxide goes into RBC?carbonic acid
    (HCO3-)
  4. HCO3 ready to exchange with Cl-
  5. Chloride shift within RBC

H
H
K
K
K
H
H
H
37
Acidosis vs Alkalosis
  • Acidosis
  • Acids have high H ions in solution
  • Alkalosis
  • Bases have low H ion concentration
  • Acidity or Alkalinity of a solution measured by pH

38
Physiological Regulators
H
H
  • Lungs
  • Regulate by altering H ions
  • Metabolic acidosis
  • Metabolic alkalosis
  • Kidneys
  • Regulate by altering HCO3 and H ions

H
H
HCO3
HCO3
HCO3
HCO3
39
Causes of Electrolyte Imbalances
  • Excessive sweating
  • Fluid loss leading to dehydration
  • Excessive vomiting
  • Diuretics like Lasix (K depletion)
  • Massive blood loss
  • Dehydration may go unnoticed in hot, dry climates
  • Renal failure

40
Sodium
  • Most abundant in extracellular space
  • Moves among three fluid compartments
  • Found in most body secretions

Na
Na
Na
Na
Na
41
Hyponatremia Low Sodium
  • Seizures
  • Personality changes
  • Nausea/vomiting
  • Tachycardia
  • Convulsion
  • Normal Na (135-145)

42
Hypernatremia
  • Excessive Na in ECF
  • Loss of water
  • Diarrhea
  • Insensible water loss
  • Water deprivation
  • Gain of Sodium
  • Diabetes insipidus
  • Heat stroke

43
Hypokalemia Low Potassium
  • Severe leg cramps
  • Flaccid muscles
  • Fatigue
  • Irregular pulse
  • Chest discomfort
  • EKG changes
  • T wave flattens
  • Normal Potassium-3.5-5

44
Hyperkalemia
  • CNS
  • Nausea and vomiting
  • Peripheral Nervous System
  • Tremors, twitching
  • Heart
  • Bradycardia, peaked T wave

45
Hypocalcemia Low Calcium
  • Tingling of fingers
  • Tetany
  • Muscle cramps
  • Positive Trousseaus
  • Carpal spasm
  • Positive Chvosteks
  • Contraction of facial muscle when facial nerve
    tapped

46
Hypercalcemia
  • Causes
  • Prolonged immobility
  • Osteoporosis
  • Thiazide diuretics
  • Acidosis
  • Signs/symptoms
  • N/V, weakness
  • Hypoactive reflexes
  • Cardiac arrest

47
Hypomagnesemia
  • Causes
  • Malnutrition
  • Alcoholism
  • Polyuria
  • Pre-ecclampsia
  • Signs/symptoms
  • Muscle tremor
  • Hyperactive deep reflexes
  • Chvosteks/Trousseaus
  • Difficulty breathing

48
Hypermagnesemia
  • Causes
  • Renal failure
  • Excessive intake
  • Signs/symptoms
  • Low BP
  • Muscle weakness
  • Absent reflexes
  • Bradycardia

49
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50
Respiratory acidosis pH ? PaCO2 ? HCO3 ?
Respiratory alkalosis pH ? PaCO2 ? HCO3 ?
Metabolic acidosis pH ? PaCO2 HCO3 ?
Metabolic alkalosis pH ? PaCO2 HCO3 ?
51
Cheat Sheet
  • Increase pH alkalosis
  • Decrease pH acidosis
  • Respiratory CO2
  • Metabolic (kidneys) HCO3
  • CO2 has an inverse relationship with pH
  • When pH goes down, CO2 goes up
  • HCO3 follows pH. If pH goes up so does HCO3
  • CO2 increases, pH decreases resp. acidosis
  • CO2 decreases, pH increases resp. alkalosis
  • HCO3 increases, pH increases metabolic
    alkalosis
  • HCO3 decreases, pH decreases metabolic acidosis

52
Question
  • An older client comes to the emergency
    department experiencing chest pain and shortness
    of breath. An arterial blood gas is ordered.
    Which of the following ABG results indicates
    respiratory acidosis?
  • 1. pH - 7.54, PaCO2 28, HCO3 22
  • 2. pH 7.32, PaCO2 46, HCO3 24
  • 3. pH 7.31, PaCO2 35, HCO3 20
  • 4. pH 7.5, PaCO2 37, HCO3 - 28

53
Review
  • Acid/Base Imbalance Tutorial
  • How do we assess for acid-base balance?

54
Assessment
  • Nursing history
  • Age
  • Prior Medical History
  • Acute illness
  • Surgery
  • Burns increase fluid loss
  • Resp. disorder predisposes to resp. acidosis
  • Head Injury can alter ADH secretion
  • Chronic illness
  • Cancer
  • CVD
  • Renal disorders
  • GI disturbances

55
Assessment Contd.
  • Environmental factors affecting fluid/electrolyte
    alterations
  • Diet
  • Lifestyle smoking, ETOH
  • Medications
  • Physical Assessment
  • Daily weights
  • IO
  • Vital signs
  • Laboratory Studies

56
Nursing Diagnosis
  • Decreased cardiac output
  • Acute confusion
  • Deficient fluid volume
  • Excess fluid volume
  • Impaired gas exchange
  • Risk for injury
  • Deficient knowledge regarding disease management
  • Impaired oral mucous membrane
  • Impaired skin integrity
  • Ineffective tissue perfusion

57
Planning
  • Determine goals and outcomes
  • Set priorities
  • Collaborative care
  • MD
  • Dietician
  • Pharmacy

58
Implementation
  • Health promotion
  • Education
  • Acute care
  • Enteral replacement of fluids
  • Restriction of fluids
  • Parenteral replacement of fluids and electrolytes
  • TPN
  • IV fluids and electrolyte therapy (crystalloids)
  • Blood and blood components (colloids)
  • Blood groups and types
  • Autologous transfusion
  • Transfusion reactions
  • ABGs

59
Restorative Care
  • Home IV therapy
  • Nutritional support
  • Medication safety
  • Pt. education

60
Evaluation
  • Have goals been met?
  • Have changes in assessment occurred?
  • Progress determines need to continue or revise
    plan of care
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