fluid, electrolyte and acid-base balance by m,abd elmotaal

Fluid, Electrolyte and Fluid, Electrolyte and Acid-Base BalanceAcid-Base Balance

ByBy

M,ABD ELMOTAALM,ABD ELMOTAAL

Fluid BalanceFluid Balance

General ConceptsGeneral Concepts Intake = Output = Fluid BalanceIntake = Output = Fluid Balance Sensible lossesSensible losses

UrinationUrination DefecationDefecation Wound drainageWound drainage

Insensible lossesInsensible losses Evaporation from skinEvaporation from skin Respiratory loss from lungsRespiratory loss from lungs

Fluid CompartmentsFluid Compartments

Intracellular Intracellular 40% of body weight40% of body weight

ExtracellularExtracellular 20% of body weight20% of body weight Two typesTwo types

INTERSTITIALINTERSTITIAL (between) (between) INTRAVASCULARINTRAVASCULAR (inside) (inside)

Age-Related Fluid ChangesAge-Related Fluid Changes

Full-term baby - 80%Full-term baby - 80% Lean Adult Male - 60%Lean Adult Male - 60% Aged client - 40%Aged client - 40%

Fluid and Electrolyte TransportFluid and Electrolyte Transport

PASSIVE PASSIVE TRANSPORT TRANSPORT SYSTEMSSYSTEMS DiffusionDiffusion FiltrationFiltration OsmosisOsmosis

ACTIVE ACTIVE TRANSPORT TRANSPORT SYSTEMSYSTEM PumpingPumping Requires Requires

energy energy expenditureexpenditure

DiffusionDiffusion Molecules move across a biological Molecules move across a biological

membrane from an area of higher membrane from an area of higher to an area of lower concentrationto an area of lower concentration

Membrane typesMembrane types PermeablePermeable Semi-permeableSemi-permeable ImpermeableImpermeable

FiltrationFiltration Movement of solute and solvent Movement of solute and solvent

across a membrane caused by across a membrane caused by hydrostatic (water pushing) pressurehydrostatic (water pushing) pressure

Occurs at the capillary levelOccurs at the capillary level If normal pressure gradient changes If normal pressure gradient changes

(as occurs with right-sided heart (as occurs with right-sided heart failure) edema results from “third failure) edema results from “third spacing”spacing”

OsmosisOsmosis

Movement of solvent from an area Movement of solvent from an area of lower solute concentration to of lower solute concentration to one of higher concentrationone of higher concentration

Occurs through a semipermeable Occurs through a semipermeable membrane using osmotic (water membrane using osmotic (water pulling) pressurepulling) pressure

Active Transport SystemActive Transport System

Solutes can be moved against a Solutes can be moved against a

concentration gradientconcentration gradient Also called “pumping”Also called “pumping” Dependent on the presence of ATPDependent on the presence of ATP

Fluid TypesFluid Types

IsotonicIsotonic

HypotonicHypotonic

HypertonicHypertonic

Isotonic SolutionIsotonic Solution

No fluid shift because solutions No fluid shift because solutions

are equally concentratedare equally concentrated Normal saline solution (0.9% NaCl)Normal saline solution (0.9% NaCl)

Hypotonic SolutionHypotonic Solution

Lower solute concentrationLower solute concentration Fluid shifts from hypotonic solution Fluid shifts from hypotonic solution

into the more concentrated into the more concentrated

solution to create a balance (cells solution to create a balance (cells

swell)swell) Half-normal saline solution (0.45% Half-normal saline solution (0.45%

NaCl)NaCl)

Hypertonic SolutionHypertonic Solution

Higher solute concentrationHigher solute concentration

Fluid is drawn into the hypertonic Fluid is drawn into the hypertonic

solution to create a balance (cells solution to create a balance (cells

shrink)shrink)

5% dextrose in normal saline 5% dextrose in normal saline

(D5/0.9% NaCl)(D5/0.9% NaCl)

Regulatory MechanismsRegulatory Mechanisms

Baroreceptor reflexBaroreceptor reflex

Volume receptorsVolume receptors

Renin-angiotensin-aldosterone Renin-angiotensin-aldosterone

mechanismmechanism

Antidiuretic hormoneAntidiuretic hormone

Baroreceptor ReflexBaroreceptor Reflex

Respond to a fall in arterial blood Respond to a fall in arterial blood pressurepressure

Located in the atrial walls, vena Located in the atrial walls, vena cava, aortic arch and carotid sinuscava, aortic arch and carotid sinus

Constricts afferent arterioles of the Constricts afferent arterioles of the kidney resulting in retention of fluidkidney resulting in retention of fluid

Volume ReceptorsVolume Receptors

Respond to fluid excess in the atria Respond to fluid excess in the atria and great vesselsand great vessels

Stimulation of these receptors Stimulation of these receptors creates a strong renal response creates a strong renal response that increases urine outputthat increases urine output

Renin-Angiotensin-AldosteroneRenin-Angiotensin-Aldosterone

ReninRenin Enzyme secreted by kidneys when Enzyme secreted by kidneys when

arterial pressure or volume dropsarterial pressure or volume drops Interacts with angiotensinogen to Interacts with angiotensinogen to

form angiotensin I form angiotensin I (vasoconstrictor)(vasoconstrictor)


AngiotensinAngiotensin Angiotensin I is converted in Angiotensin I is converted in

lungs to angiotensin II using ACE lungs to angiotensin II using ACE (angiotensin converting enzyme)(angiotensin converting enzyme)

Produces vasoconstriction to Produces vasoconstriction to elevate blood pressureelevate blood pressure

Stimulates adrenal cortex to Stimulates adrenal cortex to secrete aldosteronesecrete aldosterone


AldosteroneAldosterone Mineralocorticoid that controls Na+ Mineralocorticoid that controls Na+

and K+ blood levelsand K+ blood levels Increases Cl- and HCO3- Increases Cl- and HCO3-

concentrations and fluid volumeconcentrations and fluid volume

Aldosterone Negative Feedback Aldosterone Negative Feedback MechanismMechanism

ECF & Na+ levels drop ECF & Na+ levels drop secretion secretion

of ACTH by the anterior pituitary of ACTH by the anterior pituitary

release of aldosterone by the release of aldosterone by the

adrenal cortex adrenal cortex fluid and Na+ fluid and Na+

retentionretention

Antidiuretic HormoneAntidiuretic Hormone

Also called vasopressinAlso called vasopressin Released by posterior pituitary when Released by posterior pituitary when

there is a need to restore intravascular there is a need to restore intravascular fluid volume fluid volume

Release is triggered by osmoreceptors Release is triggered by osmoreceptors in the thirst center of the hypothalamusin the thirst center of the hypothalamus

Fluid volume excess Fluid volume excess decreased ADH decreased ADH Fluid volume deficit Fluid volume deficit increased ADH increased ADH

Fluid ImbalancesFluid Imbalances

DehydrationDehydration HypovolemiaHypovolemia HypervolemiaHypervolemia Water intoxicationWater intoxication

DehydrationDehydration

Loss of body fluids Loss of body fluids increased increased concentration of solutes in the concentration of solutes in the blood and a rise in serum Na+ blood and a rise in serum Na+ levelslevels

Fluid shifts out of cells into the Fluid shifts out of cells into the blood to restore balanceblood to restore balance

Cells shrink from fluid loss and can Cells shrink from fluid loss and can no longer function properlyno longer function properly

Clients at RiskClients at Risk

ConfusedConfused ComatoseComatose BedriddenBedridden InfantsInfants ElderlyElderly Enterally fedEnterally fed

What Do You See?What Do You See?

IrritabilityIrritability ConfusionConfusion DizzinessDizziness WeaknessWeakness Extreme thirstExtreme thirst urine outputurine output

FeverFever Dry Dry

skin/mucous skin/mucous membranesmembranes

Sunken eyesSunken eyes Poor skin turgorPoor skin turgor TachycardiaTachycardia

What Do We Do?What Do We Do?

Fluid Replacement - oral or IV over Fluid Replacement - oral or IV over 48 hrs.48 hrs.

Monitor symptoms and vital signsMonitor symptoms and vital signs Maintain I&OMaintain I&O Maintain IV accessMaintain IV access Daily weightsDaily weights Skin and mouth careSkin and mouth care

HypovolemiaHypovolemia

Isotonic fluid Isotonic fluid loss from the loss from the extracellular extracellular spacespace

Can progress to Can progress to hypovolemic hypovolemic shockshock

Caused by:Caused by: Excessive Excessive

fluid loss fluid loss (hemorrhage)(hemorrhage)

Decreased Decreased fluid intakefluid intake

Third space Third space fluid shiftingfluid shifting


Mental status Mental status deteriorationdeterioration

ThirstThirst TachycardiaTachycardia Delayed Delayed

capillary refillcapillary refill

Orthostatic Orthostatic hypotensionhypotension

Urine output < Urine output < 30 ml/hr30 ml/hr

Cool, pale Cool, pale extremitiesextremities

Weight lossWeight loss


Fluid Fluid replacementreplacement

Albumin Albumin replacementreplacement

Blood Blood transfusions for transfusions for hemorrhagehemorrhage

Dopamine to Dopamine to maintain BPmaintain BP

MAST trousers MAST trousers for severe for severe shockshock

Assess for fluid Assess for fluid overload with overload with treatmenttreatment

HypervolemiaHypervolemia

Excess fluid in the extracellular Excess fluid in the extracellular compartment as a result of fluid or compartment as a result of fluid or sodium retention, excessive intake, sodium retention, excessive intake, or renal failureor renal failure

Occurs when compensatory Occurs when compensatory mechanisms fail to restore fluid mechanisms fail to restore fluid balancebalance

Leads to CHF and pulmonary edemaLeads to CHF and pulmonary edema


TachypneaTachypnea DyspneaDyspnea CracklesCrackles Rapid, bounding Rapid, bounding

pulsepulse HypertensionHypertension S3 gallopS3 gallop

Increased CVP, Increased CVP, pulmonary artery pulmonary artery pressure and pressure and pulmonary artery pulmonary artery wedge pressure wedge pressure (Swan-Ganz)(Swan-Ganz)

JVDJVD Acute weight gainAcute weight gain EdemaEdema

EdemaEdema

Fluid is forced into tissues by the Fluid is forced into tissues by the hydrostatic pressurehydrostatic pressure

First seen in dependent areasFirst seen in dependent areas Anasarca - severe generalized edemaAnasarca - severe generalized edema Pitting edemaPitting edema Pulmonary edemaPulmonary edema


Fluid and Na+ Fluid and Na+ restrictionrestriction

DiureticsDiuretics Monitor vital signsMonitor vital signs Hourly I&OHourly I&O Breath soundsBreath sounds

Monitor ABGs and Monitor ABGs and labslabs

Elevate HOB and Elevate HOB and give O2 as orderedgive O2 as ordered

Maintain IV accessMaintain IV access Skin & mouth careSkin & mouth care Daily weightsDaily weights

Water IntoxicationWater Intoxication

Hypotonic Hypotonic extracellular extracellular fluid shifts into fluid shifts into cells to attempt cells to attempt to restore to restore balancebalance

Cells swellCells swell

Causes:Causes: SIADHSIADH Rapid infusion of Rapid infusion of

hypotonic solutionhypotonic solution Excessive tap Excessive tap

water NG irrigation water NG irrigation or enemasor enemas

Psychogenic Psychogenic polydipsiapolydipsia


Signs and symptoms of increased Signs and symptoms of increased

intracranial pressureintracranial pressure Early: change in LOC, N/V, muscle Early: change in LOC, N/V, muscle

weakness, twitching, crampingweakness, twitching, cramping

Late: bradycardia, widened pulse Late: bradycardia, widened pulse

pressure, seizures, comapressure, seizures, coma


Prevention is the Prevention is the

best treatmentbest treatment Assess neuro Assess neuro

statusstatus Monitor I&O and Monitor I&O and

vital signsvital signs Fluid restrictionsFluid restrictions

IV accessIV access

Daily weightsDaily weights

Monitor serum Na+Monitor serum Na+

Seizure Seizure

precautionsprecautions

ElectrolytesElectrolytes

ElectrolytesElectrolytes

Charged particles in solutionCharged particles in solution Cations (+)Cations (+) Anions (-)Anions (-) Integral part of metabolic and Integral part of metabolic and

cellular processescellular processes

Positive or Negative?Positive or Negative?

Cations (+)Cations (+) SodiumSodium PotassiumPotassium CalciumCalcium MagnesiumMagnesium

Anions (-)Anions (-) ChlorideChloride BicarbonateBicarbonate PhosphatePhosphate SulfateSulfate

Major CationsMajor Cations

EXTRACELLULAR EXTRACELLULAR SODIUM (Na+)SODIUM (Na+)

INTRACELLULARINTRACELLULAR POTASSIUM POTASSIUM

(K+)(K+)

Electrolyte ImbalancesElectrolyte Imbalances

Hyponatremia/ Hyponatremia/

hypernatremiahypernatremia

Hypokalemia/ Hypokalemia/

HyperkalemiaHyperkalemia

Hypomagnesemia/ Hypomagnesemia/

HypermagnesemiaHypermagnesemia

Hypocalcemia/ Hypocalcemia/

HypercalcemiaHypercalcemia

Hypophosphatemia/ Hypophosphatemia/

HyperphosphatemiaHyperphosphatemia

Hypochloremia/ Hypochloremia/

HyperchloremiaHyperchloremia

SodiumSodium

Major extracellular cationMajor extracellular cation

Attracts fluid and helps preserve fluid Attracts fluid and helps preserve fluid

volumevolume

Combines with chloride and bicarbonate to Combines with chloride and bicarbonate to

help regulate acid-base balancehelp regulate acid-base balance

Normal range of serum sodium 135 - 145 Normal range of serum sodium 135 - 145

mEq/LmEq/L

Sodium and WaterSodium and Water

If sodium intake suddenly increases, If sodium intake suddenly increases, extracellular fluid concentration also extracellular fluid concentration also risesrises

Increased serum Na+ increases thirst Increased serum Na+ increases thirst and the release of ADH, which and the release of ADH, which triggers kidneys to retain watertriggers kidneys to retain water

Aldosterone also has a function in Aldosterone also has a function in water and sodium conservation when water and sodium conservation when serum Na+ levels are lowserum Na+ levels are low

Sodium-Potassium PumpSodium-Potassium Pump

Sodium (abundant Sodium (abundant outside cells) tries to outside cells) tries to get into cellsget into cells

Potassium (abundant Potassium (abundant inside cells) tries to inside cells) tries to get out of cellsget out of cells

Sodium-potassium Sodium-potassium pump maintains pump maintains normal normal concentrationsconcentrations

Pump uses ATP, Pump uses ATP, magnesium and an magnesium and an enzyme to maintain enzyme to maintain sodium-potassium sodium-potassium concentrationsconcentrations

Pump prevents cell Pump prevents cell swelling and swelling and creates an creates an electrical charge electrical charge allowing allowing neuromuscular neuromuscular impulse impulse transmissiontransmission

HyponatremiaHyponatremia Serum Na+ level < 135 mEq/LSerum Na+ level < 135 mEq/L Deficiency in Na+ related to amount of Deficiency in Na+ related to amount of

body fluidbody fluid Several typesSeveral types

DilutionalDilutional DepletionalDepletional HypovolemicHypovolemic HypervolemicHypervolemic IsovolemicIsovolemic

Types of HyponatremiaTypes of Hyponatremia Dilutional - results from Na+ loss, water Dilutional - results from Na+ loss, water

gaingain Depletional - insufficient Na+ intakeDepletional - insufficient Na+ intake Hypovolemic - Na+ loss is greater than Hypovolemic - Na+ loss is greater than

water loss; can be renal (diuretic use) water loss; can be renal (diuretic use) or non-renal (vomiting)or non-renal (vomiting)

Hypervolemic - water gain is greater Hypervolemic - water gain is greater than Na+ gain; edema occursthan Na+ gain; edema occurs

Isovolumic - normal Na+ level, too Isovolumic - normal Na+ level, too much fluidmuch fluid

What Do You See?What Do You See? Primarily neurologic symptomsPrimarily neurologic symptoms

Headache, N/V, muscle twitching, Headache, N/V, muscle twitching, altered mental status, stupor, altered mental status, stupor, seizures, comaseizures, coma

Hypovolemia - poor skin turgor, Hypovolemia - poor skin turgor, tachycardia, decreased BP, tachycardia, decreased BP, orthostatic hypotensionorthostatic hypotension

Hypervolemia - edema, hypertension, Hypervolemia - edema, hypertension, weight gain, bounding tachycardiaweight gain, bounding tachycardia


MILD CASEMILD CASE Restrict fluid intake Restrict fluid intake

for for hyper/isovolemic hyper/isovolemic hyponatremiahyponatremia

IV fluids and/or IV fluids and/or increased po Na+ increased po Na+ intake for intake for hypovolemic hypovolemic hyponatremiahyponatremia

SEVERE CASESEVERE CASE Infuse hypertonic Infuse hypertonic

NaCl solution (3% NaCl solution (3% or 5% NaCl)or 5% NaCl)

Furosemide to Furosemide to remove excess fluidremove excess fluid

Monitor client in Monitor client in ICUICU

HypernatremiaHypernatremia

Excess Na+ relative to body waterExcess Na+ relative to body water Occurs less often than hyponatremiaOccurs less often than hyponatremia Thirst is the body’s main defenseThirst is the body’s main defense When hypernatremia occurs, fluid shifts When hypernatremia occurs, fluid shifts

outside the cellsoutside the cells May be caused by water deficit or over-May be caused by water deficit or over-

ingestion of Na+ingestion of Na+ Also may result from diabetes insipidusAlso may result from diabetes insipidus


Think Think S-A-L-TS-A-L-T SSkin flushedkin flushed AAgitationgitation LLow grade feverow grade fever TThirsthirst

Neurological symptomsNeurological symptoms Signs of hypovolemiaSigns of hypovolemia


Correct underlying Correct underlying disorderdisorder

Gradual fluid Gradual fluid replacementreplacement

Monitor for s/s of Monitor for s/s of cerebral edemacerebral edema

Monitor serum Na+ Monitor serum Na+ levellevel

Seizure Seizure precautionsprecautions

PotassiumPotassium

Major intracellular cationMajor intracellular cation Untreated changes in K+ levels can Untreated changes in K+ levels can

lead to serious neuromuscular and lead to serious neuromuscular and

cardiac problemscardiac problems Normal K+ levels = 3.5 - 5 mEq/LNormal K+ levels = 3.5 - 5 mEq/L

Balancing PotassiumBalancing Potassium

Most K+ ingested is excreted by the Most K+ ingested is excreted by the kidneyskidneys

Three other influential factors in K+ Three other influential factors in K+ balance :balance : Na+/K+ pumpNa+/K+ pump Renal regulationRenal regulation pH levelpH level

Sodium/Potassium PumpSodium/Potassium Pump

Uses ATP to pump potassium into Uses ATP to pump potassium into cellscells

Pumps sodium out of cellsPumps sodium out of cells Creates a balanceCreates a balance

Renal RegulationRenal Regulation

Increased K+ levels Increased K+ levels increased K+ increased K+ loss in urineloss in urine

Aldosterone secretion causes Na+ Aldosterone secretion causes Na+ reabsorption and K+ excretionreabsorption and K+ excretion

pHpH

Potassium ions and hydrogen ions Potassium ions and hydrogen ions exchange freely across cell exchange freely across cell membranesmembranes

Acidosis Acidosis hyperkalemia (K+ moves hyperkalemia (K+ moves out of cells)out of cells)

Alkalosis Alkalosis hypokalemia (K+ moves hypokalemia (K+ moves into cells)into cells)

HypokalemiaHypokalemia

Serum K+ < 3.5 mEq/LSerum K+ < 3.5 mEq/L Can be caused by GI losses, diarrhea, Can be caused by GI losses, diarrhea,

insufficient intake, non-K+ sparing insufficient intake, non-K+ sparing

diuretics (thiazide, furosemide)diuretics (thiazide, furosemide)


Think Think S-U-C-T-I-O-NS-U-C-T-I-O-N SSkeletal muscle weaknesskeletal muscle weakness UU wave (EKG changes) wave (EKG changes) CConstipation, ileusonstipation, ileus TToxicity of digitalis glycosidesoxicity of digitalis glycosides IIrregular, weak pulserregular, weak pulse OOrthostatic hypotensionrthostatic hypotension NNumbness (paresthesias)umbness (paresthesias)


Increase dietary K+Increase dietary K+ Oral KCl supplementsOral KCl supplements IV K+ replacement( infusion)IV K+ replacement( infusion) Change to K+-sparing diureticChange to K+-sparing diuretic Monitor EKG changesMonitor EKG changes

IV K+ ReplacementIV K+ Replacement Mix well when Mix well when

adding to an IV adding to an IV solution bagsolution bag

Concentrations Concentrations should not should not exceed 40-60 exceed 40-60 mEq/LmEq/L

Rates usually Rates usually 10-20 mEq/hr10-20 mEq/hr

NEVER GIVE IV NEVER GIVE IV PUSH PUSH

POTASSIUMPOTASSIUM

HyperkalemiaHyperkalemia

Serum K+ > 5 Serum K+ > 5

mEq/LmEq/L

Less common than Less common than

hypokalemiahypokalemia

Caused by altered Caused by altered

kidney function, kidney function,

increased intake increased intake

(salt substitutes), (salt substitutes),

blood transfusions, blood transfusions,

meds (K+-sparing meds (K+-sparing

diuretics), cell diuretics), cell

death (trauma)death (trauma)

What Do You See?What Do You See? IrritabilityIrritability ParesthesiaParesthesia Muscle weakness (especially legs)Muscle weakness (especially legs) EKG changes (tented T wave)EKG changes (tented T wave) Irregular pulseIrregular pulse HypotensionHypotension Nausea, abdominal cramps, diarrheaNausea, abdominal cramps, diarrhea


MildMild Loop diuretics Loop diuretics

(Lasix)(Lasix) Dietary restrictionDietary restriction

ModerateModerate KayexalateKayexalate

EmergencyEmergency 10% calcium 10% calcium

gluconate for gluconate for

cardiac effectscardiac effects Sodium bicarbonate Sodium bicarbonate

for acidosisfor acidosis

CalciumCalcium

99% in bones, 1% in serum and soft 99% in bones, 1% in serum and soft tissue (measured by serum Ca++)tissue (measured by serum Ca++)

Works with phosphorus to form bones Works with phosphorus to form bones and teethand teeth

Role in cell membrane permeabilityRole in cell membrane permeability Affects cardiac muscle contractionAffects cardiac muscle contraction Participates in blood clottingParticipates in blood clotting

Calcium RegulationCalcium Regulation Affected by body stores of Ca++ and Affected by body stores of Ca++ and

by dietary intake & Vitamin D intakeby dietary intake & Vitamin D intake Parathyroid hormone draws Ca++ Parathyroid hormone draws Ca++

from bones increasing low serum from bones increasing low serum levels levels (Parathyroid pulls)(Parathyroid pulls)

With high Ca++ levels, calcitonin is With high Ca++ levels, calcitonin is released by the thyroid to inhibit released by the thyroid to inhibit calcium loss from bone calcium loss from bone (Calcitonin (Calcitonin keeps)keeps)

HypocalcemiaHypocalcemia

Serum calcium < 8.9 mg/dlSerum calcium < 8.9 mg/dl Ionized calcium level < 4.5 mg/DlIonized calcium level < 4.5 mg/Dl Caused by inadequate intake, Caused by inadequate intake,

malabsorption, pancreatitis, thyroid malabsorption, pancreatitis, thyroid or parathyroid surgery, loop or parathyroid surgery, loop diuretics, low magnesium levelsdiuretics, low magnesium levels


NeuromuscularNeuromuscular Anxiety, confusion, irritability, muscle Anxiety, confusion, irritability, muscle

twitching, paresthesias (mouth, twitching, paresthesias (mouth, fingers, toes), tetanyfingers, toes), tetany

FracturesFractures DiarrheaDiarrhea Diminished response to digoxinDiminished response to digoxin EKG changes EKG changes


Calcium gluconate for postop thyroid Calcium gluconate for postop thyroid

or parathyroid clientor parathyroid client

Cardiac monitoringCardiac monitoring

Oral or IV calcium replacementOral or IV calcium replacement

HypercalcemiaHypercalcemia

Serum calcium > 10.1 mg/dlSerum calcium > 10.1 mg/dl Ionized calcium > 5.1 mg/dlIonized calcium > 5.1 mg/dl Two major causesTwo major causes

CancerCancer HyperparathyroidismHyperparathyroidism


Fatigue, confusion, lethargy, comaFatigue, confusion, lethargy, coma Muscle weakness, hyporeflexiaMuscle weakness, hyporeflexia Bradycardia Bradycardia cardiac arrest cardiac arrest Anorexia, nausea/vomiting, Anorexia, nausea/vomiting,

decreased bowel sounds, decreased bowel sounds, constipationconstipation

Polyuria, renal calculi, renal failurePolyuria, renal calculi, renal failure


If asymptomatic, treat underlying If asymptomatic, treat underlying

causecause Hydrate the patient to encourage Hydrate the patient to encourage

diuresisdiuresis Loop diureticsLoop diuretics CorticosteroidsCorticosteroids

PhosphorusPhosphorus

The primary anion in the intracellular The primary anion in the intracellular fluidfluid

Crucial to cell membrane integrity, Crucial to cell membrane integrity, muscle function, neurologic function and muscle function, neurologic function and metabolism of carbs, fats and proteinmetabolism of carbs, fats and protein

Functions in ATP formation, Functions in ATP formation, phagocytosis, platelet function and phagocytosis, platelet function and formation of bones and teethformation of bones and teeth

HypophosphatemiaHypophosphatemia

Serum phosphorus < 2.5 mg/dlSerum phosphorus < 2.5 mg/dl Can lead to organ system failureCan lead to organ system failure Caused by respiratory alkalosis Caused by respiratory alkalosis

(hyperventilation), insulin release, (hyperventilation), insulin release, malabsorption, diuretics, DKA, malabsorption, diuretics, DKA, elevated parathyroid hormone levels, elevated parathyroid hormone levels, extensive burnsextensive burns

What Do You See?What Do You See? MusculoskeletalMusculoskeletal

muscle weaknessmuscle weakness respiratory muscle respiratory muscle

failurefailure osteomalaciaosteomalacia pathological pathological

fracturesfractures CNSCNS

confusion, confusion, anxiety, seizures, anxiety, seizures, comacoma

CardiacCardiac hypotensionhypotension decreased cardiac decreased cardiac

outputoutput HematologicHematologic

hemolytic anemiahemolytic anemia easy bruisingeasy bruising infection riskinfection risk


MILD/MODERATEMILD/MODERATE Dietary Dietary

interventionsinterventions

Oral supplementsOral supplements

SEVERESEVERE IV replacement IV replacement

using potassium using potassium

phosphate or phosphate or

sodium phosphatesodium phosphate

HyperphosphatemiaHyperphosphatemia

Serum phosphorus > 4.5 mg/dlSerum phosphorus > 4.5 mg/dl

Caused by impaired kidney function, Caused by impaired kidney function,

cell damage, hypoparathyroidism, cell damage, hypoparathyroidism,

respiratory acidosis, DKA, increased respiratory acidosis, DKA, increased

dietary intakedietary intake


Think Think C-H-E-M-OC-H-E-M-O CCardiac irregularitiesardiac irregularities HHyperreflexiayperreflexia EEating poorlyating poorly MMuscle weaknessuscle weakness OOligurialiguria


Low-phosphorus dietLow-phosphorus diet Decrease absorption with antacids Decrease absorption with antacids

that bind phosphorusthat bind phosphorus Treat underlying cause of Treat underlying cause of

respiratory acidosis or DKArespiratory acidosis or DKA IV saline for severe IV saline for severe

hyperphosphatemia in patients hyperphosphatemia in patients with good kidney functionwith good kidney function

Acid-Base BalanceAcid-Base Balance

Food Sources of Food Sources of PotassiumPotassium

Sweet Potatoes

Beet GreensBeet Greens

PotatoesPotatoes

White BeansWhite Beans

DatesDates

YogurtYogurt

TomatoesTomatoes

RaisinsRaisins

ClamsClams

AvocadosAvocados

Cocoa Powder and Cocoa Powder and ChocolateChocolate

Pistachios and Other Pistachios and Other NutsNuts

dietary‑magnesium‑sources.jpg

ancient-minerals.comancient-minerals.com- - Magnesium food Magnesium food sourcessources were once were once

commonlycommonly

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SourcesSources of of MagnesiumMagnesium in in FoodFood: The Top 5: The Top 5

Acid-Base BasicsAcid-Base Basics

Balance depends on regulation of Balance depends on regulation of free hydrogen ionsfree hydrogen ions

Concentration of hydrogen ions is Concentration of hydrogen ions is measured in pHmeasured in pH

Arterial blood gases are the Arterial blood gases are the major diagnostic tool for major diagnostic tool for evaluating acid-base balanceevaluating acid-base balance

Arterial Blood GasesArterial Blood Gases

pHpH 7.35 - 7.457.35 - 7.45

PaCO2PaCO2 35 - 45 mmHg35 - 45 mmHg

HCO3HCO3 22-26 mEq/L22-26 mEq/L

AcidosisAcidosis

pH < 7.35pH < 7.35

Caused by accumulation of acids or Caused by accumulation of acids or by a loss of basesby a loss of bases

AlkalosisAlkalosis

pH > 7.45pH > 7.45

Occurs when bases accumulate or Occurs when bases accumulate or acids are lostacids are lost

Regulatory SystemsRegulatory Systems

Three systems come into play when Three systems come into play when pH rises or fallspH rises or falls

Chemical buffersChemical buffers Respiratory systemRespiratory system KidneysKidneys

Chemical BuffersChemical Buffers

Immediate actingImmediate acting

Combine with Combine with

offending acid or offending acid or

base to neutralize base to neutralize

harmful effects harmful effects

until another until another

system takes oversystem takes over

Bicarb buffer - Bicarb buffer - mainly responsible mainly responsible for buffering blood for buffering blood and interstitial fluidand interstitial fluid

Phosphate buffer - Phosphate buffer - effective in renal effective in renal tubulestubules

Protein buffers - Protein buffers - most plentiful - most plentiful - hemoglobinhemoglobin

Respiratory SystemRespiratory System Lungs regulate blood levels of CO2Lungs regulate blood levels of CO2 CO2 + H2O = Carbonic acidCO2 + H2O = Carbonic acid High CO2 = slower breathing (hold High CO2 = slower breathing (hold

on to carbonic acid and lower pH)on to carbonic acid and lower pH) Low CO2 = faster breathing (blow Low CO2 = faster breathing (blow

off carbonic acid and raise pH)off carbonic acid and raise pH) Twice as effective as chemical Twice as effective as chemical

buffers, but effects are temporarybuffers, but effects are temporary

KidneysKidneys

Reabsorb or Reabsorb or

excrete excess excrete excess

acids or bases acids or bases

into urineinto urine

Produce Produce

bicarbonatebicarbonate

Adjustments by Adjustments by

the kidneys take the kidneys take

hours to days to hours to days to

accomplishaccomplish Bicarbonate Bicarbonate

levels and pH levels and pH

levels increase or levels increase or

decrease togetherdecrease together

Arterial Blood Gases (ABG)Arterial Blood Gases (ABG)

Uses blood from an arterial punctureUses blood from an arterial puncture Three test results relate to acid-base Three test results relate to acid-base

balancebalance pHpH PaCO2PaCO2 HCO3HCO3

Interpreting ABGsInterpreting ABGs

Step 1 - check the pHStep 1 - check the pH Step 2 - What is the CO2?Step 2 - What is the CO2? Step 3 - Watch the bicarbStep 3 - Watch the bicarb Step 4 - Look for compensationStep 4 - Look for compensation Step 5 - What is the PaO2 and SaO2?Step 5 - What is the PaO2 and SaO2?

Step 1 - Check the pHStep 1 - Check the pH

pH < 7.35 = acidosispH < 7.35 = acidosis

pH > 7.45 = alkalosispH > 7.45 = alkalosis

Move on to Step 2Move on to Step 2

Step 2 - What is the CO2?Step 2 - What is the CO2?

PaCO2 gives info about the PaCO2 gives info about the respiratory component of acid-respiratory component of acid-base balancebase balance

If abnormal, does the change If abnormal, does the change correspond with change in pH?correspond with change in pH? High pH expects low PaCO2 High pH expects low PaCO2

(hypocapnia)(hypocapnia) Low pH expects high PaCO2 Low pH expects high PaCO2

(hypercapnia)(hypercapnia)

Step 3 – Watch the BicarbStep 3 – Watch the Bicarb

Provides info regarding metabolic Provides info regarding metabolic

aspect of acid-base balanceaspect of acid-base balance If pH is high, bicarb expected to be If pH is high, bicarb expected to be

high (metabolic alkalosis)high (metabolic alkalosis) If pH is low, bicarb expected to be If pH is low, bicarb expected to be

low (metabolic acidosis)low (metabolic acidosis)

Step 4 – Look for CompensationStep 4 – Look for Compensation

If a change is seen in If a change is seen in BOTHBOTH PaCO2 PaCO2 andand bicarbonate, the body is trying bicarbonate, the body is trying to compensateto compensate

Compensation occurs as opposites, Compensation occurs as opposites, (Example: for metabolic acidosis, (Example: for metabolic acidosis, compensation shows respiratory compensation shows respiratory alkalosis)alkalosis)

Step 5 – What is the PaO2 and Step 5 – What is the PaO2 and SaO2SaO2

PaO2 reflects ability to pickup O2 PaO2 reflects ability to pickup O2

from lungsfrom lungs

SaO2 less than 95% is inadequate SaO2 less than 95% is inadequate

oxygenationoxygenation

Low PaO2 indicates hypoxemiaLow PaO2 indicates hypoxemia

Acid-Base ImbalancesAcid-Base Imbalances

Respiratory AcidosisRespiratory Acidosis

Respiratory AlkalosisRespiratory Alkalosis

Metabolic AcidosisMetabolic Acidosis

Metabolic AlkalosisMetabolic Alkalosis

Respiratory AcidosisRespiratory Acidosis

Any compromise in breathing can Any compromise in breathing can result in respiratory acidosisresult in respiratory acidosis

Hypoventilation Hypoventilation carbon dioxide carbon dioxide buildup and drop in pHbuildup and drop in pH

Can result from neuromuscular Can result from neuromuscular trouble, depression of the brain’s trouble, depression of the brain’s respiratory center, lung disease or respiratory center, lung disease or airway obstructionairway obstruction

ABG ResultsABG Results

UncompensatedUncompensated pH < 7.35pH < 7.35

PaCO2 >45PaCO2 >45

HCO3 NormalHCO3 Normal

CompensatedCompensated pH NormalpH Normal

PaCO2 >45PaCO2 >45

HCO3 > 26HCO3 > 26


Correct underlying causeCorrect underlying cause BronchodilatorsBronchodilators Supplemental oxygenSupplemental oxygen Treat hyperkalemiaTreat hyperkalemia Antibiotics for infectionAntibiotics for infection Chest PT to remove secretionsChest PT to remove secretions Remove foreign body obstructionRemove foreign body obstruction

Respiratory AlkalosisRespiratory Alkalosis

Most commonly results from Most commonly results from hyperventilation caused by pain, hyperventilation caused by pain, salicylate poisoning, use of nicotine salicylate poisoning, use of nicotine or aminophylline, hypermetabolic or aminophylline, hypermetabolic states or acute hypoxia states or acute hypoxia (overstimulates the respiratory (overstimulates the respiratory center)center)


Anxiety, restlessnessAnxiety, restlessness DiaphoresisDiaphoresis Dyspnea (Dyspnea ( rate and depth) rate and depth) EKG changesEKG changes Hyperreflexia, paresthesiasHyperreflexia, paresthesias TachycardiaTachycardia TetanyTetany


UncompensatedUncompensated pH > 7.45pH > 7.45

PaCO2 < 35PaCO2 < 35

HCO3 NormalHCO3 Normal



HCO3 < 22HCO3 < 22


Correct underlying disorderCorrect underlying disorder

Oxygen therapy for hypoxemiaOxygen therapy for hypoxemia

Sedatives or antianxiety agentsSedatives or antianxiety agents

Paper bag breathing for Paper bag breathing for

hyperventilationhyperventilation

Metabolic AcidosisMetabolic Acidosis Characterized by gain of acid or Characterized by gain of acid or

loss of bicarb loss of bicarb Associated with ketone bodiesAssociated with ketone bodies

Diabetes mellitus, alcoholism, Diabetes mellitus, alcoholism, starvation, hyperthyroidismstarvation, hyperthyroidism

Other causesOther causes Lactic acidosis secondary to shock, Lactic acidosis secondary to shock,

heart failure, pulmonary disease, heart failure, pulmonary disease, hepatic disease, seizures, strenuous hepatic disease, seizures, strenuous exerciseexercise


Confusion, dull headacheConfusion, dull headache Decreased DTRsDecreased DTRs S/S hyperkalemia (abdominal S/S hyperkalemia (abdominal

cramps, diarrhea, muscle cramps, diarrhea, muscle weakness, EKG changes)weakness, EKG changes)

Hypotension, Kussmaul’s Hypotension, Kussmaul’s respirationsrespirations

Lethargy, warm & dry skinLethargy, warm & dry skin


UncompensatedUncompensated pH < 7.35pH < 7.35

PaCO2 NormalPaCO2 Normal

HCO3 < 22HCO3 < 22



HCO3 < 22HCO3 < 22


Regular insulin to reverse DKARegular insulin to reverse DKA

IV bicarb to correct acidosisIV bicarb to correct acidosis

Fluid replacementFluid replacement

Dialysis for drug toxicityDialysis for drug toxicity

AntidiarrhealsAntidiarrheals

Metabolic AlkalosisMetabolic Alkalosis

Commonly associated with Commonly associated with hypokalemia from diuretic use, hypokalemia from diuretic use, hypochloremia and hypocalcemiahypochloremia and hypocalcemia

Also caused by excessive vomiting, Also caused by excessive vomiting, NG suction, Cushing’s disease, NG suction, Cushing’s disease, kidney disease or drugs containing kidney disease or drugs containing baking sodabaking soda


AnorexiaAnorexia ApathyApathy ConfusionConfusion CyanosisCyanosis HypotensionHypotension Loss of reflexesLoss of reflexes

Muscle twitchingMuscle twitching NauseaNausea ParesthesiaParesthesia PolyuriaPolyuria VomitingVomiting WeaknessWeakness


UncompensatedUncompensated pH > 7.45pH > 7.45

PaCO2 NormalPaCO2 Normal

HCO3 >26HCO3 >26


PaCO2 > 45PaCO2 > 45

HCO3 > 26HCO3 > 26


IV ammonium chlorideIV ammonium chloride

D/C thiazide diuretics and NG D/C thiazide diuretics and NG

suctioningsuctioning

AntiemeticsAntiemetics

IV TherapyIV Therapy

CrystalloidsCrystalloids – – volume expandervolume expander Isotonic (D5W, 0.9% Isotonic (D5W, 0.9%

NaCl or Lactated NaCl or Lactated Ringers)Ringers)

Hypotonic (0.45% Hypotonic (0.45% NaCl)NaCl)

Hypertonic Hypertonic (D5/0.9% NaCl, (D5/0.9% NaCl, D5/0.45% NaCl)D5/0.45% NaCl)

ColloidsColloids – plasma – plasma expander (draw expander (draw fluid into the fluid into the bloodstream)bloodstream) AlbuminAlbumin Plasma proteinPlasma protein DextranDextran

The EndThe End

(Whew!!!!!!)(Whew!!!!!!)

fluid, electrolyte and acid-base balance by m,abd elmotaal

Documents

fluid balance slide

pressure slide

nacl slide

spacing slide

concentrated solution

fluid balance intake

isotonic solution

energy expenditure slide