rsq solutions fluid and electrolyte balance 2014

Fluid and Electrolyte Review

Shelley Flasch

3

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Objectives

At the end of this course the learner will be able to:

Describe signs, symptoms and nursing implications in

the treatment of hypovolemic and hypervolemic

presentations.

Differentiate signs, symptoms, nursing care and

implications for patients presenting with the following

electrolyte imbalances:

Hypo/Hypernatremia

Hypo/Hyperkalemia

Hypo/Hyperchloremia

Hypo/Hypercalcemia

Hypo/Hypermagnesemia

Section 1- Basic review of

fluid homeostasis

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Put yourself in this situation!

Case study on hypervolemia, hypovolemia

I still need to come up with this, but according to

Gagne’s instructions, I want to do a thought

provoking intro.

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Body Fluid Homeostasis

Maintenance of body fluid homeostasis is crucial

for normal functions of every system in our bodies

Some important functions of body fluids:

Serves as a solvent for the chemicals of metabolism

Transports oxygen, nutrients, chemical messengers

and waste products to their appropriate destination

Major role in temperature regulation

Serves as a lubricant for joints

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2 Compartments of fluids

Extracellular compartment: “Outside” the cells

1/3 of all body fluid is extracellular

Locations:

Interstitial spaces between the cells

Intravascular- within the blood vessels

In dense connective tissue and bone

Synovial fluid, cerebrospinal fluid, and gastrointestinal fluids

Intracellular Compartment- Inside the cells

2/3 of all body fluid is intracellular

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Composition of fluids

All fluids have the same concentration of particles,

even though the compositions are different

Extracellular fluids are rich in sodium, chloride and

bicarbonate ions

Intracellular fluids are rich in potassium and

magnesium ions, inorganic and organic phosphates

and proteins

The vascular portion of extracellular fluid contains

many proteins whereas the interstitial compartment

has very few proteins.

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Fluid homeostasis as a Dynamic process

Homeostasis- A dynamic steady state, representing

the net effect of all the turnover reactions.

Relies on the following sub-processes:

Fluid intake/absorption

Fluid excretion

Fluid distribution

Alterations in these can cause a hypovolemic state

or hypervolemic state.

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Fluid Intake/Absorption

Normal ingestion of fluid by eating and drinking

Additional routes of fluid intake (often times

controlled by the health care provider):

IV fluids

G tubes/Feeding tubes

Subcutaneous tissue

Bone Marrow

Rectal Intake

Lungs (near drowning)

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Fluid Excretion/Fluid loss

Normal mechanisms of fluid loss:

Largest volume of loss is from urinary output

Urine output is dependent on adequate blood pressure

The hormones ADH, ANH and aldosterone also affect

adequate urine output

Insensible losses through sweat, lungs as a person

exhales.

The bowel excretes fluid in the stool. If diarrhea occurs

dramatic fluid loss can occur.

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Fluid Distribution-Very important in homeostasis of volume

Distribution between the vascular compartment and

interstitial compartments is the result of Filtration

across permeable capillaries

Distribution between interstitial compartments and

intracellular compartments occurs by Osmosis

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The forces of filtration work between the capillary bed and the interstitium

Primary mechanism that fluid moves from the

capillary to the interstitium:

*Capillary Hydrostatic pressure*-outward push of fluid

against the capillary wall-

Conversely, fluid moves from the interstitium into

the capillary

*Capillary osmotic pressure*- the inward pulling force

of particles in the vascular fluid. This is often called

“plasma oncotic pressure” Fluid will follow the highest

concentration of large particles. In this case, large

protein molecules (primarily albumin) in the vascular

compartment attract the fluid from the interstitial space.

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Hydrostatic Pressure

The most basic definition: The blood pressure of

the capillary

The strength of the hydrostatic pressure actually

depends on 2 things:

Blood pressure- net effect of arterial systems

Resistance of the arterial and venous systems

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Capillary osmotic pressure AKA, Plasma colloid oncotic pressure

Plasma proteins are the key factor in influencing

capillary osmotic pressure.

Albumin is the primary protein in the vascular

compartment. These protein molecules are so large

they normally cannot move through the semi permeable

capillary membrane.

Fluid will follow the highest concentration of these

large protein molecules.

Normally plasma has 4 times the concentration of

protein over the interstitial space. This keeps fluid in

the vascular compartment.

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Capillary osmotic pressure AKA, Plasma colloid oncotic pressure (contd)

If the capillary membrane becomes more permeable than it

should be due to injury: burns, allergic reaction, ARDS etc.

the large protein molecules can leak through causing more

fluid to follow into the interstitial spaces. This causes

edema in the interstitial space which can be in the lungs,

brain, skeletal tissue, GI spaces, etc.

These changes also contribute to generalized hypo and

hypervolemic states.

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Fluid distribution between the vascular and interstitial compartments

Would like to put a pictorial explanation here from

my pathophysiology text.

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Cellular Fluid Homeostasis

Distribution of fluid between the interstitial

and the intracellular compartments is called

Osmosis.

Cells have semi-permeable membranes

which allow water to cross, but not

electrolytes.

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Cellular fluid homeostasis contd:

Electrolytes are also considered particles

but require specialized transport

mechanisms to pass through the semi-

permeable cell membrane.

Electrolytes do not travel by osmosis

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Fluid shifts in relation to cellular structure:

Osmosis is the process where

WATER moves in and out through

a semipermeable membrane in an

attempt to equalize

CONCENTRATIONS of particles.

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Cellular Shrinkage (Crenation)

If there is too little water in the extracellular

compartment (hypovolemia) causing a high

concentration of particles (i.e. sodium molecules),

water from within the cell will cross the cellular

membrane in an effort to balance the concentration

between the extracellular and intracellular

compartments.

This will cause the cell to shrink, additionally the

water needed for cellular processes won’t be there

causing cell death.

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Cellular Swelling

If there is too much water diluting the extracellular

compartment, water will enter the cell in an effort to

balance the concentrations of solutes and

depending on how big of a disparity, the swelling

may grow so large that the cell bursts and dies.

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Normal/Abnormal fluid distribution between the capillary bed and interstitium

Fluid distribution is an ongoing process to change

out wastes, bring in nutrients, etc. Normally only

10% of the fluid stays in the interstitial space and is

then drained into the lymphatic system to be

returned to the circulation later.

Abnormal amount of fluid stays in the interstitial

space in the form of edema if:

Lymphatic flow is impaired

Capillaries become more permeable and “leak”

Additionally, high BP and changes in the vascular

system can contribute

Section 1 review

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Review Question #1: Which of the following conditions will not cause an increase in the hydrostatic pressure within the capillary bed?

a) Hemorrhage with hypotension

b) Large amounts of IV fluids

c) Heart failure with increases in venous pressure

d) Peripheral venous obstruction from a clot, emboli

or Peripheral vascular disease.

Answer: a- Hemorrhage with hypotension would

cause a decrease in arterial BP therefore a

decrease in hydrostatic pressure.

b, c and d all result in an increase in venous

pressures which increase net capillary hydrostatic

pressure.

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Review Question #2: Capillary osmotic pressure is important in regulating extracellular volume homeostasis. Based on this, answer the following questions:

1. Body fluid will follow large concentrations of

proteins in the extracellular compartment.

a) True

b) False

1. Damage to capillary membranes will increase

permeability to large protein molecules.

a) True

b) False

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Review question #2 contd.

1. When protein molecules seep into the interstitial

space, fluid will follow, causing edema

a) True

b) False

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Review question #3: Edema can occur in any interstitial space. Which of the following factors can contribute to edema?

a) Alterations in Lymphatic flow

b) Elevated venous pressures

c) Damage to capillary membranes

d) Elevated arterial blood pressures

e) All of the above

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Review Question #3 contd

Answer: e. All of the above

I will add more specific rationale

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Review Question #4

Electrolytes move in and out of the cell by osmosis.

a) True

b) False

Section 2-

Hypovolemic/Hypervolemic

presentations

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Fluid Imbalances

3 categories of fluid imbalance:

1. Imbalances of Extracellular Volume (ECF)

May be hypervolemic or hypovolemic as related to the

actual volume of the ECF.

The concentrations (particles/electrolytes) are normal,

the volumes are just either too little or too much.

2. Imbalances of Body Water Concentration

1. These disorders are the result of the concentration of

the ECF rather than the amount of fluid.

2. Serum sodium concentration is normally 135-145

meq/L

3. Combination of Volume and Concentration imbalances

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Common types of abnormal Vascular/interstitial fluid shifts (Extracellular Volume)

Hypervolemia:

Edema

Acites

Hypovolemia:

Loss of fluid through burns

Hemorrhage

Emesis

Diarhea

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Hypovolemia- ECF Volume Deficit

In the Vascular and interstitial compartments,

sodium-containing fluid of the body has been

depleted or displaced, also can be referred to as a

saline deficit

Causes:

GI Loss- Emesis, diarrhea, Gastric suction, Fistula

drainage

Renal Loss- Adrenal insufficiency, renal disorders,

extensive diuretic use, prolonged bedrest

Other Losses- Hemorrhage, diaphoresis, Third spacing,

paracentesis, burns.

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Clinical Manifestations of Hypovolemia

Increased Heart Rate

Postural hypotension

Dizzyness, syncope

Concentrated urine/oliguria

Dry mucous membranes, skin tenting, sunken

eyeballs, decreased capillary refill time (CRT)

Absence of tears or sweat

Weight loss (1 liter of saline weighs 1 kg)

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Nursing Implications in the RX of Hypovolemia

Ensure rapid vascular access- Ideally 16-18 G IV

placement in the upper extremities: antecubital,

forearm, hand.

Skin prep for 30 seconds with bactericidal agent of your

hospitals choice.

Apply occlusive dressings as outlined by your

institution.

If IV access is difficult, do not delay treatment by

trying multiple times. Other options include:

Intraosseous Access to humeral head or tibia

Request your physician starts a central line- femoral or

Internal jugular are common sites

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Nursing implications for the hypovolemic patient (contd)

Obtain lab/blood specimens ASAP- In simple ECF

deficit the sodium level will be normal:135-

145meq/L

If the patient is tachycardic, and you are suspecting

a volume deficit, perform orthostatic blood

pressures to confirm the findings. Remember, a

drop in BP of ≥20 mm Hg, or in diastolic BP of ≥10

mm Hg, or experiencing lightheadedness or

dizziness is considered abnormal

Anticipate weakness and fall potential in this group-

ensure call light is available and place patient on

bed rest or “up with assist” only instructions

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Nursing implications for the hypovolemic patient (contd)

In the case of hemorrhage- make all attempts to

stop the hemorrhage by using direct pressure,

tourniquet or other means.

Measure urine output as a direct measure of fluid

volume resuscitation. An adult should have at least

30mls/hour of urine output.

Understand the differences in fluid replacements:

Crystalloids

Colloids

Blood products

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Crystalloids

Crystalloids are the most common fluid

replacement solutions

They can be classified in 3 ways:

1. Isotonic- “same” concentration as normal body saline.

These fluids stay within the intravascular space and

increase intravascular volume.

Normal Saline- Used for dehydration

Lactated Ringers- general volume expander/ used when

patient is at risk for free water loss

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Crystalloids- contd

2. Hypotonic solutions: Used to shift fluid into the

intracellular space

NS 0.45%- Shifts water into intracellular spaces

NS 0.2% - prevents dehydration and assess renal

status

D5W- Use with mixing meds and when the patient is at

risk for free water loss

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Crystalloids Contd

3. Hypertonic solutions: Used to move fluid out of

the cell and promote diuresis

Dextrose 5% NS

Dextrose 10% NS

Dextrose 10% in water

Dextrose 5% in 0.45 Normal saline

Dextrose 20% in Water

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Colloids in Fluid Replacement

Colloids: Pull fluid in from the interstitial space to

increase vascular volume.

May be natural or synthetic products.

Remember the concept of capillary osmotic

pressure/plasma oncotic pressure! Fluid follows

high concentrations of large protein molecules!

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Natural colloids

Fresh Frozen Plasma (FFP)- contains clotting factors

and large protein molecules

Plasma Protein Fraction (no clotting factors)

Whole blood and Packed RBC’s (will be discussed in a

later module)

Risks:

Potential for Blood borne Pathogens

Hypersensitivity reactions

Hypocalcemia, hyperkalemia, and hypothermia

May cause hypotension with rapid infusion

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Clinical Manifestations of Hypervolemia

The patient has an excess of fluid, but that fluid has

normal concentrations. The Sodium level is normal.

If the sodium level is dilute, it means too much free

water, and the sodium concentration is too low:

Hyponatremia…I need to finish this!

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Clinical dehydration- the combination of loss of ECF and the fluids are too concentrated

Infants and older adults are at highest risk for true

clinical dehydration…

Cell shriveling- crenation.

Need to add more here, obviously

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Pediatric Pearls/Geriatric pearls

Signs of hypovolemia: sunken fontanel, neck vein

assessment is not reliable

Also add in how much % is water in their body

Will add just a little more…

Section 2: Review

questions…need to finish

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Alterations in fluid homeostasis of the human body could be influenced by which of the following:

a) Surgical removal of a portion of small bowel

b) Swimming in the ocean

c) Renal failure with oliguria

d) Running a marathon

e) IV fluids running at a high rate for hours

f) Psychological issues with eating or drinking

g) All the above

h) a, c, d, e, f only

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#1. Answer with rationale to review question:

Answer E- a, c, d, e, f only

When a portion of the small bowel is removed,

absorption of fluids and nutrients is altered.

Renal failure with oliguria (no urine output) will

decrease the ability to rid the body of waste

products, metabolites and fluids causing volume

overload and electrolyte imbalances

Running a marathon will produce sweating,

increase insensible losses through breathing, if

fluids and electrolytes are not replaced,

hypovolemia and electrolyte imbalances occur.

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# 1. Review rationale continued:

IV fluid can volume overload any patient, especially

those with heart failure. Infusions of IV fluids must

be regulated to ensure hypervolemia does not

occur

Some psychological disorders such as anorexia,

bingeing, purging and drinking excessive amounts

of water can cause electrolyte and volume

disturbances.

Simply swimming or soaking will not cause fluid

homeostasis changes. However, drowning, or near

drowning would cause changes in the distribution

of fluids, especially in the lungs.

Section 3:Electrolyte

disorders

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This is a HEADING AND CONTENT slide

Bullet one will go here. Bullet one will go here.

Bullet one will go here. Bullet one will go here and

Bullet two will go here.

Bullet three will go here with a bunch of text to see

what it looks like.

Sub bullet

Sub bullet

rsq solutions fluid and electrolyte balance 2014

Internet

bonesynovial fluid

cerebrospinal fluid

powerpoint presentation

differentextracellular

interstitial compartment

hypovolemic state

hypervolemic state

nursing care