fluids & electrolytes

Nio Cruzada Noveno, RN, MAN, MSN

Fluids & Electrolytes

2

FLUIDS and ELECTROLYTES

BODY FLUIDSFunctions of Fluids

o Body fluids:o Facilitate in the transport

[nutrients, hormones proteins, & others…]

o Aid in removal of cellular metabolic wastes

o Provide medium for cellular metabolism

o Regulate body temperatureo Provide lubrication of musculoskeletal

jointso Component in all body cavities

[parietal, pleural fluids]

Water is the principal body fluid & essential for life.

Renal [email protected]

3

FLUIDS and ELECTROLYTESFLUIDS and ELECTROLYTES

BODY FLUIDS

ICF ECF

40% TBW 20% TBW

P IS

Distribution of Body Fluids: 50-70% of total body weight;

infant [70-80%], elderly [45-50%]

60-kg manTBW = 0.6 x 60 kg = 3.6 L

ICF = 0.4 x 60 kg = 24 L ECF =12 L

3L 9L


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BODY FLUIDS

Factors that Dictate Body Water Requirement

1) Amount needed to give the proper osmotic concentration

2) Amount needed to replace water lost excretionNormal Routes of water gain and loss

INTAKE OUTPUTml/day ml/day

Fluid intake 1,500Food 800Metabolic water 300

TOTAL 2,600

Insensible loss 400Sweat 600Feces 100Urine 1,500

TOTAL 2,600Renal [email protected]

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FLUID EXCHANGE BETWEEN BODY FLUID COMPARTMENTS

Osmotic Pressure Gradient

Oncotic P (Colloid osmotic P)

Capillary P (Hydrostatic P)

ICF ECF

P ISFRenal [email protected]

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Control of Osmotic Pressure, Volume & Electrolyte Concentration

OBLIGATORY Reabsorptiono occurs in the proximal tubuleso 178 L/day of glomerular filtrate (80%

reabsorbed)o 2 to solute reabsorptiono independent of the water requirement

FACULTATIVE Reabsorptiono occurs in the distal & collecting tubuleso independent of the active solute transporto dependent of body’s need of watero under the control of ADH Renal [email protected]

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DISTURBANCES IN FLUID BALANCE

EDEMA (Dropsy)

in the interstitial fluid volume of about 2 L or more due to increase transudation of fluid from capillaries 2° to:

o Increased HP [pregnancy, CHF]

o Decreased OP [malnutrition, end-stage liver disease,

nephrotic syndrome]


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CELL OVERHYDRATION

o excess of water in the ECC w/ a normal amount of solute or a deficient amount of solute

o occurs in prolonged and excessive diuresis, forcing hypotonic fluids to produce diuresis in the presence of renal impairment

o fluid overload from production of adrenal corticoid hormones [Cushing’s syndrome]


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CELL OVERHYDRATION

o Symptomso Weight gain & edemao Cough, moist rales, dyspnea

[fluid congestion in lungs]o CVP, bounding pulse, neck vein

engorgement [fluid excess in the vascular system]

o Bulging fontanelles Hg and Hcto Nausea & vomiting


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CELL OVERHYDRATION

o Managemento Restrict fluids to lower fluid volumeo Diuretics or hypertonic salineo Continuous assessments to prevent skin

breakdowno Record daily weight to assess progress of

treatment


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CELL DEHYDRATION (DHN)

o loss of body fluids, particularly from the extracellular fluid compartment

o water loss > water intake

o Causeso Fevero Insufficient water intakeo Diarrhea, vomitingo Excess urine output [Diabetes insipidus,

diuretics]o Excessive perspiration, burnso Hemorrhage, shock, metabolic acidosisRenal [email protected]

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CELL DEHYDRATION (DHN)

o Symptomso Thirst, dry mucus membranes, sunken

eyeballso “Doughy“ abdomen, dry skin w/ poor

turgor temp, weight loss HR, RR, BPo Restlessness,irritability, disorientation,

convulsion, coma [22-30% body H20 loss]o Management

o Fluid replacement therapy & continued fluid maintenance


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Volume Disorders 2° Alteration in Sodium Balance

Expansion Isotonic Inc N No net change Isotonic fluid

ingestion Hypertonic Inc Dec ICF ECF Sea water

ingestion Hypotonic Inc Inc ECF ICF Hypotonic IVF

Contraction Isotonic Dec N No net change Diarrhea Hypertonic Dec Dec ICF ECF Diabetes insipidus Hypotonic Dec Inc ECF ICF Addison’s dse

Volume ECF ICF Water Conditions Disorder Vol. Vol. Shift


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ELECTROLYTES

o salts or minerals in extracellular or intracellular body fluids

o Sodium – major cation of ECF

o Potassium – major cation of ICF

o Chloride - major anion of ICF

o Protein – in ICF > ISF


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ELECTROLYTE Composition

Electrolyte Conc Plasma (mEq/L) ISF ICF

Sodium, Na+ 142 141 10 Potassium, K+ 5 4.1 150Calcium, Ca++ 5 4.1 -Magnesium, Mg++ 3 3 40

(155)Chloride, Cl- 103 115 15Bicarbonate, HCO3

- 27 29 10Biphosphate, HPO4

- 2 2 100Sulfate, SO4

- 1 1 20Protein 16 1 60Organic foods 6 3.4 -

(155) Renal [email protected]

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ELECTROLYTES

Functions of Electrolytes

o Contribute most of the osmotically active particles in body fluids

o Provide buffer systems for pH regulation

o Provide the proper ionic environment for normal neuromuscular irritability & tissue function


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Hyponatremia [Na+ < 135 mEq/L; Normal = 135-145 mEq/L]

o Causes Na+ intake Na+ excretion [diaphoresis, GI

suctioning]o Adrenal insufficiency

o Assessmento N & V, abdominal cramps, weight losso Cold, clammy skin, skin turgoro Apprehension, HA, convulsions, focal

neurologic deficit, coma [cerebral edema]

o Fatigue, postural hypotensiono Rapid thready pulse

ELECTROLYTES


HyponatremiaDrugs that cause decreased sodium

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Anti-convulsant:Carbamazepine

Antidiabetics:ChlorpropramideTolbutamide

Antipsychotics:FluphenazineThiozoridazineThiothixene

Antineoplastics:CyclophosphamideVincristine

Diuretics:BumetanideEthacrynic acidFurosemideThiazides

Sedatives:BarbituratesMorphine


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Hyponatremia [Na+ < 135 mEq/L; Normal = 135-145 mEq/L]

Managemento Provide foods high in sodiumo Administer NSS IVo Assess blood pressure frequently

[measure lying down, sitting & standing]o High sodium foods

o Celeryo Cheeses o Condimentso Processed foodso Smoked meatso Snack foods

ELECTROLYTES


Treatment

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InterventionsMild

Water restriction if water retention problem Increase Na in foods if loss of Na

ModerateIV 0.9% NS, 0.45% NS, LR

Severe3% NS – short-term therapy in ICU setting


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Hypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L]

o Causeso Excessive, rapid IV adm’n of NSSo Inadequate water intakeo Kidney disease

o Assessment o Dry, sticky mucus membraneso Flushed skino Rough dry tongue, firm skin turgoro Intense thirsto Edema, oliguria to anuriao Restlessness, irritability [cerebral DHN]

ELECTROLYTES


Hypernatremia

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Skin flushedAgitationLow-grade feverThirst


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Hypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L]

o Nursing Interventiono Weigh dailyo Assess degree of edema frequentlyo Measure I & Oo Assess skin frequently & institute nursing

measures to prevent breakdowno Encourage sodium-restricted diet

ELECTROLYTES


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Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L]

o Causeso Renal insufficiencyo Adrenocortical insufficiencyo Cellulose damage [burns]o Infectiono Acidotic stateso Rapid infusion of IV sol’n w/ potassium-

conserving diuretics

ELECTROLYTES


HyperkalemiaDrugs that increase potassium

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ACE inhibitors

Antibiotics

Beta blockers

NSAIDs

Spironolactone

Chemotherapeutics


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o Assessmento Thready, slow pulseo Shallow breathingo N & V, diarrhea, intestinal colico Irritabilityo Muscle weakness, flaccid

paralysiso Numbness, tinglingo Difficulty w/ phonation,

respiration

ELECTROLYTES


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o Nursing Interventionso Administer kayexalate as orderedo Administer/monitor IV infusion of

glucose & insulino Control infectiono Provide adequate calories &

carbohydrateso Discontinue IV or oral sources of K+

ELECTROLYTES


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Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L]

o Causeso Renal tubule defectso Prolonged diuretic therapy o Prolonged vomiting, diarrhea, laxative

use, NG suctioning, severe diaphoresiso Anorexiao Acute alcoholismo Hyperaldosteronism, excessive steroids o Metabolic alkalosiso Administration of potassium-deficient

hyperalimentation sol’n, hypertonic glucose

o Excessive amounts of insulin

ELECTROLYTES


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o Assessmento Thready, rapid, weak pulseo Faint heart sounds BPo Skeletal muscle weakness or absent reflexeso Shallow respirationso Malaise, apathy, lethargyo Loss of orientationo Anorexia, vomiting, weight losso Gaseous intestinal distention

ELECTROLYTES


Hypokalemia

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Skeletal muscle weaknessU-waveConstipation; ileusToxic effects of digoxinIrregular, weak pulseOrthostatic hypotensionNumbness [paresthesia]


HypokalemiaDrugs that decrease potassium

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Adrenergics:AlbuterolEpinephrine

Antibiotics:Amphotericin BCarbenicillinGentamicin

Insulin

CisplatinCosticosteroidsDiuretics:

Furosemide Thiazides

Laxatives [excess use]


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o Nursing Interventionso Administer K+ supplements to replace losseso Be cautious in administering drugs that are

not potassium-sparingo Monitor acid-base balanceo Monitor pulse, BP and ECGo High potassium foods

o Avocadoso Bananaso Dateso Orangeso Potatoeso Raisins

ELECTROLYTES


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Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L]

o Causeso Hyperparathyroidismo Immobilityo Increased vitamin D intakeo Osteoporosis & osteomalacia [early

stages]

o Assessmento N & V, anorexia, constipationo Headache, confusiono Lethargy, stuporo Decreased muscle toneo Deep bone/flank pain

ELECTROLYTES


HypercalcemiaDrugs that increase calcium

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Calcium-containing antacidsCalcium preparations

LithiumThiazide diuretics

Vitamin AVitamin D


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Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L]

o Nursing Interventionso Encourage mobilizationo Limit vitamin D intakeo Limit calcium intakeo Normal salineo Administer diureticso Calcitonin

ELECTROLYTES


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Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L]

o Causeso Acute pancreatitiso Diarrheao Hypoparathyroidismo Lack of vitamin D in the dieto Long-term steroid therapy

o Assessmento Painful tonic muscle & facial spasmso Fatigue, dyspneao Laryngospasm, convulsionso (+) Trousseau’s and Chvostek’s signs

ELECTROLYTES


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Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L]

o Nursing Interventionso Administer oral Ca lactate or IV CaCl2

or gluconateo Providing safety by padding side railso Administer dietary sources of calciumo Vitamin Do Provide quiet environmento High calcium foods

o Milko Dairy products

ELECTROLYTES


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Hyermagnesemia [Mg > 3.0 mEq/L; Normal = 1.5-3.0 mEq/L]

o Causeso Renal insufficiency, dehydrationo Excessive use of Mg-containing antacids or

laxativeso Assessment

o Lethargy, somnolence, confusiono N & Vo Muscle weakness, depressed reflexes pulse and respirations

o Nursing Interventiono Withhold Mg-cont’g drugs/foods; Ca adm’n fluid intake, unless CI

ELECTROLYTES


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Hypomagnesemia [Mg < 1.50 mEq/L; Normal = 1.5-3.0 mEq/L]

o Causeso Low intake of Mg in the dieto Prolonged diarrhea o Massive diuresiso Hypoparathyroidism

o Assessmento Paresthesias, muscle spasmo Confusion, hallucination, convulsionso Ataxia, tremors, hyperactive deep reflexeso Flushing of the face, diaphoresis

o Nursing Interventiono Provide good dietary sources of Mg

ELECTROLYTES


HypomagnesemiaDrugs that decrease magnesium

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Aminoglycoside:Amikacin,

gentamicin, streptomycin,

tobramycin

Amphotericin B

Cisplatin

Cyclosporine

Insulin

Laxative

Loop diuretics

Pentamidine isethionate


Hypomagnesemia

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SeizuresTetanyAnorexia & arrhythmiasRapid heart rateVomitingEmotional labilityDeep tendon reflexes increased[tremors, twitching, tetany]


Dietary sources

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ChocolatesDry beans and peas

Green, leafy vegetablesMeatsNuts

SeafoodWhole grains


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IV FLUID REPLACEMENT THERAPY

Indications

o Replacement of abnormal fluid & electrolyte losses [surgery, trauma, burns, GI bleeding]

o Maintenance of daily fluid & electrolyte needs

o Correction of fluid disorders

o Correction of electrolyte disordersRenal [email protected]

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IV FLUID REPLACEMENT THERAPY

Types of Solutions

o Isotonico 0.9% sodium chloride (NSS)o Lactated Ringer’s sol’n

o Hypotonico 5% dextrose and water (D5W)o 0.45% sodium chlorideo 0.33% sodium chloride

o Hypertonico 3% NaClo Protein sol’ns

o Colloidso Salt poor albumin Plasmanate, Dextran Renal [email protected]

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B U R N S

BURNS

wounds caused by excessive exposure to the following agents or causes:

Causes of Burns:

o Thermal [moist or dry heat]o Electrical o Chemical [strong acids and strong

alkali]o Radiation [UV, x-rays, radium,

sunburns]Renal [email protected]

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CLASSIFICATION OF BURNS

o Superficial Partial thickness (1st degree)o Outer layer of dermiso Erythema, pain up to 48 hrso Healing 1-2 wks [sunburn]

o Deep Partial thickness (2nd degree)o Epidermis & dermiso Blisters & edema, frequently quite painfulo Healing 14-21 days

o Full thickness (3rd degree)o Epidermis, dermis, subcutaneous fato Dry, pearly white or charred in appearanceo Not painfulo Eschar must be removed; may need grafting

B U R N S


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STAGES OF BURNS

1st: Shock/Fluid Accumulation Phase

o 1st 48 hrso IVC ISCo Generalized DHN [fluid shifting]o Hypovolemia [plasma loss], BP, C.O.o Hemoconcentration, Hct [liquid blood

component ISC]o Oliguria [ renal perfusion], ADH release &

aldosteroneo HyperK, hypoNao Metabolic acidosis

B U R N S


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STAGES OF BURNS

2nd: Diuretic/Fluid Remobilization Phase

o After 48 hrso ISC IVCo Hypervolemia, o Hemodilution, Hct o Diuresis [ renal perfusion], ADH &

aldosterone secretiono HypoK, hypoNa [K moves back into the

cells, Na+ still trapped in the edema fluidso Metabolic acidosis

B U R N S


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STAGES OF BURNS

3rd: Recovery Phase

o 5th day onwardso Hypocalcemia

o Ca is lost on the exudateso Ca is utilized in the granulation tissue

formationo Negative nitrogen balance

o Due to stress response protein catabolismo Protein intake is lesser than the demand

o HypoK

B U R N S


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ASSESSMENT

1. Assess extent of body surface burnedo Greater morbidity & mortality for burns

affecting face, hands & perineumo Assess for dyspnea, stridor, hoarseness

2. Assess extent of burn injuryo Rule of nine – immediate appraisalo Lund-Browder chart – more accurateo Berkow’s method – based on client’s age &

changes that occur in proportion of head & legs to the rest of the body as one grows

B U R N S


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ASSESSMENT

B U R N S

9%

9% 9%Front=18%Back=18%

18%18%

1%Burn Evaluation

Chart


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ASSESSMENT

3. Assess depth of burno Major burns – 2nd degree over 30% of bodyo Hospitalization - eyes, face, neck, hands,

perineum, genitalia

4. Assess unique contributing factorso Age of cliento Health history

o Diabetes, preexisting ulcerso Tetanus immunization

B U R N S


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EMERGENCY MANAGEMENT

Stop the burning processo Remove patient from source of injuryo Advise client to roll on the ground if clothing

is in flame [STOP-DROP-ROLL]o Throw a blanket over the client to smother

the flameo Remove clothing only if hot or for scald burno Immerse affected part in cold water [10

min]o Irrigate copiuosly w/ large amount of

running water w/ chemical burns [except w/ phosphorus]

o Interrupt power source w/ electrical burn

B U R N S


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MANAGEMENT

o Maintenance of adequate airway

o Promoting comfort: relieve pain

o Promoting fluid-electrolyte, acid-base balance

o Preventing infection

o Maintaining adequate nutrition

o Wound care

B U R N S


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METHODS OF TREATING BURNS

o Open method or Exposure methodo Face, neck, perineum, trunko Allowing exudate to dry in 3 days

o Occlusiveo Less pain, absorption of secretion, comfort,

transportability, accelerated debridemento Aesthetic considerations

o Semi-open methodo Covering of wound w/ topical antimicrobials:

o Silver sulfadiazine 1% (Flamazine)o Silver nitrate 0.5% sol’no Mafenide acetate (sulfamylon acetate)

B U R N S


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BIOLOGIC DRESSING (Skin Graft)

o Allograft o Skin taken from other person [cadaver]

o Autograft o Same person

o Heterograft o Different specieso Xenograft

[segment of skin from animal such as pig or dog]

B U R N S


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FLUID REPLACEMENT

Types of fluids:

o Colloids o Bloodo Plasma & plasma expanders

o Electrolyteso Lactated Ringers

o Non-electrolyte o D5W

B U R N S


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FLUID REPLACEMENT

EVAN’S Formula:o C – 1ml x % burns x kg BWo E - 1ml x % burns x kg BWo Glucose 5% for insensible loss – 2,000ml

D5W

Administer sol’n 1st 24 hrs – ½ [1st 8hrs], ½ [16hrs]

BROOKE Formula: [Administer as in Evan’s]o C – 0.5ml x % burn x kg BWo E - 1.5ml x % burn x kg BWo Water – 1000ml D5W

B U R N S


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FLUID REPLACEMENT

MOORES BURN BUDGET:

o 75 ml of plasma, 75 ml of electrolyte-cont’g fluid for q 1% TBSA plus 2000 D5W

HYPERTONIC RESUSCITATION Formula:

o Hypertonic salt containing 300 mEq of Na+, 100 mEq of Cl-, 200mEq lactate

o Administered to maintain urinary output of 30-40 ml/hr

B U R N S


60Renal Disorders

ACID-BASE DISORDERSDisorder Clinical

manifestation Compensation

Respiratory acidosis

↑Paco2, ↑ or normal HCO3

-, ↓ pHKidneys eliminate H+

and retain HCO3-

Respiratory alkalosis

↓ Paco2, ↓ or normal HCO3

-, ↑ pHKidneys conserve H+ and eliminate HCO3

-

Metabolic acidosis↓ or normal Paco2,

↓HCO3-, ↓ pH

Lungs eliminate CO2 and conserve HCO3

-

Metabolic alkalosis↑ or normal Paco2,

↑HCO3-, ↑ pH

Lungs hypoventilate to ↑ Paco2, kidneys conserve H+ excrete

HCO3-

[email protected]

61Renal Disorders

Causes of Acid-Base Disorders

Metabolic acidosisCauses:DKA, uremia,

starvation, diarrhea, severe infections

Manifestations:Headache, nausea

and vomitingSigns of

hyperkalemiaSeizures, coma,

hyperventilation

Nursing management:Administer sodium

bicarbonateMonitor for signs of

hyperkalemiaProvide alkaline mouthwashLubricate lips to prevent

drynessI & OInstitute seizure precautionMonitor ABG & electrolyte

losses

[email protected]

62Renal Disorders


Metabolic alkalosisCauses:Severe vomiting, NGT

suctioning, diuretic therapy, excessive ingestion of NaHCO3, biliary drainage

Manifestations:Nausea and vomitingSigns and symptoms

of hypokalemia

Nursing management:

Decreased respirations

Replace fluids nad electrolytes losses

I & OAssess for signs of

hypokalemiaMonitor ABG &

[email protected]

63Renal Disorders


Respiratory acidosisCauses:Hypoventilation: COPD,

barbiturate or sedative overdose, acute airway obstruction, neuromuscular disorders

Manifestations:Headache, weakness, visual

disturbances, rapid respirations, confusion, drowsiness, tachycardia, coma

Nursing management:

Semi-Fowler’s Patent airwayTurn, cough, deep-

breathAdminister fluidsO2 therapyMonitor ABG

[email protected]

64Renal Disorders


Respiratory alkalosisCauses: Hyperventilation,

mechanical overventilation, encephalitis

Manifestations: Numbness and tingling of

mouth and extremities Inability to concentrate Rapid respirations, dry

mouth, coma

Nursing management:

Offer reassuranceEncourage breathing

into a paper bagProvide sedation as

orderedMonitor mechanical

ventilation and ABG

[email protected]

65Renal Disorders

Interpretation

UC PC FC

pH ↓ or ↑ ↓ or ↑ normal

HCO3- ↓ or ↑

normal ↓ or ↑ ↓ or ↑

Paco2↓ or ↑normal ↓ or ↑ ↓ or ↑

[email protected]

Nio Cruzada Noveno, RN, MAN, MSN

Fluids & Electrolytes

fluids & electrolytes

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