Fluid and electrolytes

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VCH Acute Medical & Surgical Nursing Fluid & Electrolyte Workshop – Pre-reading Revised 2011

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Developed by Joanne Beestra, December 1988 Revised by Cindy Hartley & Laurie McLauchlin, September 2008

TABLE of CONTENTS

Learning Outcomes for the Module and the Workshop…………………… 3

Introduction……………………………………………………........................ 4

General Principles of Fluid & Electrolyte Imbalance……………………….. 6

Identify Patients at Risk……………………………………………………….. 7

Diffusion and Osmosis………………………………………………….......... 9

Assess Volume Status………………………………………………………… 11

Serum Electrolytes…………………………………………………………….. 12

Additional Assessments……………………………………………………….. 15

Volume Imbalance……………………………………………………………… 16

Volume Deficit…………………………………………………………………… 17

Treatment for Volume Deficit………………………………………………….. 20

Volume Excess…………………………………………………………………. 22

Treatment for Volume Excess………………………………………………… 23

Appendix A……………………………………………………………………… 25

References……………………………………………………………………… 27

Answer Key……………………………………………………………………… 28


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DIRECTIONS

This module is a pre-requisite activity for the VCH Acute Medical & Surgical

Nursing (AMSN) Program AMSN - Level 2 Fluid & Electrolytes Workshop. As

you work through this module please complete the exercises to enhance your

learning. If you are having difficulty with any section please contact your Nurse

Clinician and/or Clinical Educator for assistance. The module will take

approximately two hours to complete.

Exercises are indicated by the following icon:

LEARNING OBJECTIVES (Learning Module and Workshop)

Before you begin this module please review the glossary found in Appendix A on

page 25 and ensure you have a solid understanding of the terms used within this

module. In addition, please review the anatomy & physiology of the renal system,

the gastrointestinal (GI) system, and the neuroendocrine system and their role in

fluid and electrolyte balance.

At the end of the learning module and workshop, you will have participated in a

review of Fluid and Electrolytes (F & E) allowing you an opportunity to apply your

knowledge and skills addressing F & E imbalances commonly seen in an acute

medical/surgical setting.

Specifically, you will:

1. Accurately interpret lab results in relation to fluid and electrolyte balance. 2. Articulate key electrolytes and symptoms of imbalance.

3. Identify and explain appropriate intravenous solutions related to patient

condition.

4. Identify patients who are at risk for disturbance of fluid and electrolytes.


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INTRODUCTION

What are we talking about when we mention fluids and electrolytes? Fluid refers

to body fluid which is water and substances dissolved in water such as

electrolytes, non-electrolytes, acids, bases, and proteins. The regulation of the

body’s water is controlled by hydrostatic pressure, osmotic pressure and

hormones.

Electrolytes refer to charged particles found in body fluids that are required for

the transmission of electrical impulses for proper nerve, heart and muscle

function (Astle 2005).

Every organ system in the body participates in fluid and electrolyte regulation and

every organ system relies on fluid and electrolyte balance for normal function.

The body works very hard to maintain fluid and electrolyte balance. When

imbalance occurs, a number of compensatory mechanisms are available to

restore balance. When a patient becomes acutely ill it becomes increasingly

difficult for the body to compensate which means a fluid and electrolyte

imbalance can become rapidly life threatening.


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Poor fluid balance management as well as poor documentation of fluid balance

records have been recognized as contributing factors in poor patient outcomes

(Scales & Pilsworth 2006). The ability to recognize and respond to actual or

potential imbalance is a key aspect of your nursing assessment.

The goal of this module and the workshop is to further develop your skills in

recognizing normal and abnormal physiology of fluid and electrolytes thereby

increasing your ability to respond prior to an imbalance in either fluid balance

and/or electrolyte imbalance becoming life threatening.

GENERAL PRINCIPLES OF FLUID & ELECTROLYTE IMBALANCE

There are three basic categories of fluid and electrolyte disturbance:

Volume Imbalance is a loss or gain of isotonic fluid

Concentration Imbalance is a loss or gain of hypotonic fluid

Composition Imbalance is a loss or gain of electrolytes Although each of these imbalances may be present simultaneously, they are

separate entities and must be considered as such when undertaking diagnosis

and treatment. For practical purposes, these imbalances occur first in the

extracellular (interstitial and intravascular) compartment. The intracellular

compartment may not be affected.

When we talk about fluids we must also consider intravenous (IV) fluids, most

hospitalized patients have some form of IV fluid therapy (David, 2007) initiated.

There are several different reasons why patients require IV fluid, it may be to

maintain a water balance or it may be to replace lost fluids. Whatever the reason

you need to know why your patient is receiving therapy to ensure that they are

receiving the correct type of fluid.

Assessment

Assessment of fluid and electrolyte balance is based on determining the quantity

(volume) of fluid in the patient followed by a determination of the quality

(concentration and composition) of the fluid.


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Identify patients at risk

Virtually any disease or injury is capable of producing a disturbance in fluid and

electrolyte equilibrium. Imbalance may occur as a primary effect of the disease;

as a result of compensation to the disease; or, as a result of therapy for the

disease. Because the GI tract, the renal system, and the neuroendocrine system

are the major organs of fluid and electrolyte homeostasis, any disease or therapy

affecting these organs will have an immediate impact on fluid and electrolyte

balance. For example, acid-base status affects both renal excretion and internal

distribution of potassium, calcium and chloride; the integrity of the cell membrane

influences distribution of electrolytes and water between the intracellular and

extracellular compartments; metabolism of glucose impacts on cellular uptake of

potassium and phosphate as well as water balance and so forth.

As you review your patient’s history and current clinical status ask yourself the

following questions:

1. Does the patient have any disease that would cause a fluid and electrolyte

imbalance? If so, what imbalance is most likely to occur?

2. Is the patient receiving any medication or therapy that would cause a fluid

and electrolyte imbalance? Be very suspicious of patients receiving

diuretic therapy.

3. Is there an abnormal loss of body fluid? Where are the losses coming

from? Does the fluid contain electrolytes and if so, which ones?

4. How does the total intake of fluid compare to the total fluid output?


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Where do we store body fluids?

There are three compartments can you name them?

1. ___________________________________________________________

2. ___________________________________________________________

3. ___________________________________________________________

Intravascular and interstitial are considered Extracellular

Self Check

1. Fluid inside the cell is _________________________________________

2. Fluid outside the cell is ________________________________________

3. Extracelluar fluid is divided into ______________ and ________________

Body fluids are made up of dissolved substances and a good example of this

would be sodium chloride. When added to a solution it separates into Sodium

(Na+) and Chloride (Cl-). A positive charge is a cation and a negative charge is

called an anion, to maintain balance there has to be an equal number of positive

and negative ions. The fluid in each compartment contains electrolytes which are

measured in milliequivalents (mEq)/L. Each of these compartments has its own

unique composition of electrolytes. A specific kind and amount of certain

electrolytes must be available for normal cell function (Weldy 1996).


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If potassium is lost from a cell what is the danger?

Each compartment is surrounded by a semipermeable membrane, this allows for

mixing of extracellular (EC) fluids and intracellular (IC) fluids. These membranes

are considered selectively permeable in the fact that they allow some substance

through but not all. For example water moves freely through all fluid

compartments but the particles dissolved in the water (solutes) for example

sodium or chloride may not be able to pass.

DIFFUSION There are different mechanisms within the body that allow for movement of

solutes through the body. This movement is from an area of higher concentration

to an area of lower concentration. One such mechanism is diffusion. Diffusion

occurs within the fluid compartments and from one compartment to another if the

membrane allows. This is also referred to as simple diffusion. Sometimes solutes

need help to get across a membrane, or they need a carrier substance, this is

known as facilitated diffusion.

OSMOSIS Osmosis is defined as the movement of water across a membrane. During the

process of osmosis the water will move to the higher concentration of solute (a

lower concentration of water).


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When the concentration is equal on

both sides it is considered isotonic.

Therefore when giving an isotonic IV

fluid such as 0.9% Normal Saline

(NS) there will be no fluid shift into or

out of the cells.

When a solution contains a lower

concentration of salt it is called

hypotonic. Two common hypotonic

solutions are 0.45% Normal Saline (NS)

and Dextrose 5% in Water (D5W). With

this type of solution the water will shift

out of the vascular bed and into the

cells.

Hypertonic fluids which have more

solute than the body’s water will pull the

water from the cells and interstitial

spaces and back into the circulation.

This can shrink cells.


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Diffusion and Osmosis are passive processes; there is a flow from a higher

concentration to a lower concentration without any expenditure of energy from

the cells. With the active transport system you require energy or adenosine

triphosphate (ATP), as you are moving from a lower concentration to a higher

concentration. An example would be the sodium potassium pump, where the

potassium is greater inside the cell than outside. Sodium, potassium, calcium,

and magnesium all require active transport to move across the membrane.

ASSESS VOLUME STATUS

Volume disorders affect the intravascular and interstitial spaces and signs and

symptoms of volume imbalance will reflect changes in these:

1. Blood Pressure (BP): Hypotension reflects ____________________;

whereas hypertension reflects ____________________.

2. Heart Rate (HR): The HR will ____________________ in response to

volume deficit and may ____________________ in response to volume

excess

3. Pulse Quality: A full bounding pulse is seen in ____________________ ;

and a weak, thready, obliterated pulse occurs with __________________

4. Filling Pressures: Central Venous Pressure (CVP) will be ___________

in response to volume excess and would be ______________ in response

to volume deficit.

Assess Concentration Status:

The concentration of body fluid is determined primarily by _________ although

other substances that exert an osmotic force – especially serum glucose – may


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impact as well. Concentration imbalances affect the intracellular compartment,

especially the cerebral cells:

Serum Sodium: Will be ____________in hypertonic states and ____________

in hypotonic states

Assess Neuromuscular Status:

Cellular edema associated with hypotonicity appears as neuromuscular

irritability; cellular dehydration associated with hypertonicity appears as

neuromuscular depression.

The acutely ill patient may have a decreased level of consciousness or be

irritable for any number of reasons.

Correlate the serum sodium with the clinical presentation.

ASSESS THE COMPOSITIONAL STATUS

Serum Electrolytes


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Serum electrolytes should be monitored as ordered. In general, sodium,

potassium, hematocrit, glucose, BUN and creatinine are the most frequently

monitored. In the critically ill patient, serum electrolyte monitoring is performed

frequently as the patient’s condition warrants. For the acutely ill patient on the

other hand, they may have bloodwork monitored on a daily basis or perhaps as

needed (prn). Magnesium, calcium and serum proteins are monitored on a prn

basis. The patient should have “baseline” bloodwork drawn on admission, and

post-op day 1 following surgical procedures. Remember to include your patient’s

bloodwork results as part of your physical assessment especially if you have

identified the patient as being high risk for imbalance.

What are the normal values for the following electrolytes and

bloodwork?

Sodium ____________________________________________________

Potassium__________________________________________________

Calcium____________________________________________________

Magnesium__________________________________________________

Chloride___________________________________________________

BUN_______________________________________________________

Creatinine___________________________________________________

Hematocrit__________________________________________________

Glucose____________________________________________________

Arterial Blood Gas Analysis

pH__________

PaCO²__________

PaO²__________

HCO³__________

SaO²__________

SpO²__________

What are plasma proteins? __________________________________________

Can you name them and add normal values? ____________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________


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What is the difference between these 2 parameters? __________________ ______________________________

When only one component of fluid and electrolyte balance is disturbed, it is fairly

easy to identify the imbalance. However, some acutely ill patients have mixed

imbalances. Be aware of the following common patterns as you analyze your

patient’s lab results:

What’s my problem? _________________________________

Na+ 165

K+ 5.0

BiCarb 30

BUN 18

Glucose 5.5

Creatinine 140

What’s my problem? __________________________________

Na+ 135

K+ 7.0

BUN 28

Glucose is 5. 5

Creatinine 900

Compositional disorders primarily affect excitable cells such as the muscle,

nerves and cardiac cells. Neuromuscular irritability or depression may be masked

or be caused by other clinical conditions. The ECG may reflect some

compositional imbalances, especially a potassium imbalance.


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ADDITIONAL ASSESSMENTS

Renal function Renal function as reflected by urine output may be a symptom or cause of fluid

and electrolyte imbalance. Hypovolemia is the most common cause of decreased

urine output but it may also be caused by oliguric renal failure or an excess of

anti-diuretic hormone (ADH). A urine output of less than 30 ml/hour should be

investigated. A general rule of thumb for a healthy adult is 1mL/kg/hr (Scales,

Pilsworth 2008).

High urine output may occur with hypervolemia but it may also be caused by but

not limited to hyperglycemia, renal failure in the diuretic phase, or inadequate

ADH. Generally speaking, the hourly urine output is a good overall guide to fluid

balance.

Intake and Output

A record of intake versus a record of output is determined for each shift and

calculated daily. A cumulative balance of fluid gains and losses determines the

response to therapy. Continued gain or loss that is not explained by therapy (i.e.

volume change, diuretics) or normalization process (diuresis on 3rd postoperative

day) should be investigated.

Daily Weights

If this is a routine assessment parameter for your patient population it should be

done at the same time everyday, using the same scale and the patient should

have an empty bladder. Rapid weight gain or loss usually indicates changes in

fluid balance. A weight gain may be associated with a fluid shift from the

intravascular space to the interstitial space and is, therefore not a reliable

indicator of intravascular volume status.

VOLUME IMBALANCE Volume imbalance is an excess or deficit of water and electrolytes in the

extracellular (EC) compartment. Because the chief electrolyte of the EC fluid is

sodium, volume imbalance is primarily a loss or gain of sodium

When an isotonic saline solution is lost from or added to body fluid, only the

VOLUME of the EC compartment is changed. Intracellular (IC) volume will not be

affected because osmolarity or tonicity remains the same between the IC and EC

compartment.


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Because there are no changes in concentration or composition of the EC fluid,

there are no readily available lab tests to aid in the diagnosis of volume

imbalance. Therefore, diagnosis is made on the basis of clinical signs and

symptoms. Signs and symptoms of volume imbalance usually appear first in the

intravascular space and are reflected as changes in blood pressure and

hemodynamic values. Symptoms associated with interstitial volume imbalance;

for example edema; generally occur later unless the change is rapid and severe.

VOLUME DEFICIT

Hypovolemia may result from either internal or external loss of isotonic fluid from

the extracellular compartment. The most common causes are associated with

external volume loss are:

Haemorrhage

Loss of GI fluid from vomiting, NG suction or diarrhea

Internal loss occurs when isotonic EC fluid moves into a non-functional

compartment such as tissue spaces or body cavities – the so-called Third Space

phenomena. The term non-functional is used because the fluid remains in the

body but cannot participate in the normal functions of the EC compartment.

Therefore, initial clinical outcomes are the same as those for external loss. In the

critically ill, third spacing is most often associated with conditions that cause

permeability changes in the microcirculation such as:

Burn injury

Septic Shock

Major fractures

Major surgery especially abdominal and thoracic


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In these conditions, the capillaries become very leaky and allow intravascular

volume including water electrolytes, and serum proteins to escape into the

interstitium or into potential spaces such as the peritoneum and the pleural and

pericardial spaces. For example, a fractured hip is capable of sequestering up to

15 litres of fluid in the adjacent area. In most cases, this fluid will remobilize back

into the vascular space within 3 to 5 days as capillary integrity recovers. At this

time, if the patient has a limited cardiac reserve or impaired renal function volume

overload may occur. The problem with third space losses is that they are

invisible. The patient may have all the signs and symptoms of shock with no

evidence of overt volume loss. Therefore, you have to be aware of conditions

associated with third space loss and assess your patient accordingly.

Clinical Signs of Volume Deficit

Symptoms of volume deficit reflect contraction of the EC compartment. Because

there is a loss of isotonic fluid the intravascular and interstitial compartments

share the loss and intracellular volume is unchanged.

Symptoms of volume deficit will be quite familiar to you as these patients present

with the classic signs of hypovolemic shock. Cardiovascular (CVS) and central

nervous system (CNS) changes occur early with acute rapid loss. Changes in

tissue turgour may not appear until the deficit has existed for more than 24 hours.

CVS symptoms reflect depletion of circulating blood volume as well as the body’s

attempt to compensate for the deficit:

Primary

Hypotension (may be postural initially)

Decreased CVP

Flat hand veins

Prolonged capillary refill

Weak, thready pulses

Compensatory

Tachycardia to increase cardiac output

Peripheral vasoconstriction to shunt volume from non-vital organs such

as kidneys, gut and skin to vital organs such as the lung, heart and

brain


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Compensatory Cont’d

Oliguria to preserve body fluid and as a result of decreased renal

perfusion

Aldosterone secretion to promote renal uptake of salt and water

ADH secretion to promote renal uptake of water

CNS symptoms reflect diminished perfusion of cerebral cells:

Initial anxiety and restlessness

Confusion

Stupor

Coma

Other organs suffer from the circulatory shunt that accompanies hypovolemia

Ileus

Oliguria progressing to renal failure

Cold, clammy extremities

Interstitial depletion is reflected primarily as changes in tissue turgour. These

changes are usually not evident until the deficit has existed for more than 24

hours and include:

Decreased turgour

Dry tongue and mucous membranes

Absence of sweating


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Treatment of Volume Deficit

In the clinical setting, treatment of volume deficit is usually the number one

priority because of the stress it imposes on the heart and the systemic impact of

inadequate organ perfusion. Treatment of volume deficit is determined by the

patient’s cardiovascular and renal status, the cause of the deficit, and the nature

of the fluid that has been lost. Generally speaking, since isotonic fluid has been

lost, isotonic fluid should be replaced. Options include:

Red blood Cells

Packed red blood cells (PRBC) or whole blood is the obvious choice when

volume deficit is due to acute hemorrhage. You may also need PRBC when the

patient is having difficulty oxygenating/ventilating due to an acute loss of

haemoglobin. When infusing large amounts of PRBC, be alert for symptoms of

hypocalcemia.

Crystalloids


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Since sodium is the primary ion of the EC compartment, the replacement solution

should contain sodium in relatively isotonic proportions. An isotonic salt-

containing solution will equilibrate with EC water in accordance with normal fluid

distribution i.e. 2/3 will pass in the interstitial space and 1/3 will stay in the

intravascular (IV) space. For example if 1 litre of NS is infused – 750 mL will

enter the interstitium and 250 mL will remain in the vessels. Solutions of choice

are Normal Saline and Ringers Lactate. These solutions expand the total EC

compartment; overload with crystalloid is more likely to result in tissue edema and diuresis than in circulatory overload. 5% DW is not an effective solution

treating volume deficit. This solution is hypotonic and will distribute itself

throughout the EC and the IC compartment. You’ll need a lot more 5% DW to

achieve the desired result and the patient will end up with a concentration

imbalance.

Colloids Colloid infusions consist of a balanced salt solution and protein, usually albumin.

Unlike crystalloid, these solutions remain in the intravascular space and produce

a greater intravascular expansion than the equivalent amount of crystalloid

because they draw the fluid from the interstitial space. For example 100 mL of a

25% albumin solution will increase intravascular volume by 450 mL by drawing

350 mL of fluid out of the interstitium into the vessels. Colloids are a good option

when rapid volume expansion is needed or when increased capillary permeability

is causing the deficit. Two precautions must be observed when infusing colloid

solutions:

Colloids produce a greater degree of intravascular volume expansion than

interstitial expansion. Therefore, they are likely to cause circulatory overload

in the vulnerable patient

When capillary permeability is at maximum, colloids may leak out of the

vessels into the interstitium as an osmotic gradient is established that draws

fluid out of the IV space and exacerbates IV volume depletion.

Synthetic Volume Expanders Consist of a balanced salt solution and synthetic substance such as a polymer or

polysaccharide. The most common solution of this nature is Pentaspan® Like

albumin, this solution remains in the vascular compartment. Pentaspan®

produces plasma expansion for approximately 18 - 24 hours. An IV infusion of

500 mL of Pentaspan® expands plasma volume by up to 750 mL.


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The 2 main goals of therapy in volume deficit are to restore circulating blood

volume and maintain organ perfusion. 4 to 6 litres of replacement volume will be

required in patients with a moderate deficit and up to 10 litres may be needed in

severely depleted patients. All patients require close monitoring until the problem

is corrected. Watch for signs of hypervolemia that indicate that the deficit has

been overcorrected and decrease IV rate accordingly. Replacement is

considered adequate when:

Vital signs are within normal limits for that patient

Urine output is approximately _________mL/kg body wt. per hour

(average adult).

Volume Excess Hypervolemia usually occurs iatrogenically or secondary to renal insufficiency.

Iatrogenic volume excess is a frequent event in the acutely ill patient and results

from excessive administration of isotonic fluid such as Normal Saline (NS) to a

person, especially those with compromised cardiac or renal function. These

patients are also vulnerable to volume excess as third space fluid gets

remobilized back into the intravascular space. Especially vulnerable are patients

with Congestive Heart Failure (CHF) and chronic liver failure. These conditions

are characterized by progressive retention of salt and water due to over secretion

of aldosterone. Volume equilibrium is very tenuous in these patients and they can

easily get into trouble from overaggressive or inappropriate removal of and/or

additions of total body fluids.

Clinical signs of hypervolemia reflect overexpansion of the extracellular

compartment. Because there is a net gain of isotonic fluid the intravascular and

interstitial compartments share the excess therefore intracellular volume is

unchanged.


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Signs of Circulatory overload predominate initially and include:

Hypertension * Full bounding Pulse

Increased CVP * Diuresis (if adequate renal function)

Distended hand veins

With adequate renal function diuresis will occur and the patient will be able to

remove the excess fluid.

Signs of interstitial overload appear later unless the excess is severe or the

patient has impaired cardiac and/or renal function:

Pulmonary edema

Peripheral edema

Overt tissue edema is a relatively late event in hypervolemia. A patient may

retain 4 – 8 litres of fluid before tissue edema is evident.

In the elderly or patients with pre-existing heart disease such as congestive heart

failure, pulmonary edema can develop quickly with only a moderate increase in

extracellular fluid volume.

Treatment of Volume excess

The goal of therapy is based on removing both fluid and salt from the body:

Simple restriction of sodium and water intake (with adequate renal

function)


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If pulmonary edema is suspected, you may anticipate that diuretic therapy may

be necessary and ordered by the physician. Lasix® is a potent loop diuretic,


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which will cause a salt and water diuresis but will also remove other electrolytes

from the body in the process. Potassium deficiency is a common complication of

loop diuretic therapy.

Supportive measures for treatment of hypervolemia include:

Maintain oxygenation – until pulmonary congestion is relieved as the

patient is at risk for hypoxia and will require supplemental oxygen. If

severely compromised the patient may require intubation.

Improve cardiac, renal and hepatic function – as indicated by the patient’s

clinical status

Remember high risk patients can experience hypovolemia if treatment is

overaggressive

APPENDIX A Glossary Define the following terms related to fluid and electrolytes

Acid _______________________________________________________

___________________________________________________________

Acidosis ____________________________________________________

___________________________________________________________

Active Transport _____________________________________________

___________________________________________________________

Alkalosis ___________________________________________________

___________________________________________________________

Base ______________________________________________________

___________________________________________________________

Buffer ______________________________________________________

___________________________________________________________

Capillary Hydrostatic pressure __________________________________

___________________________________________________________

Capillary Osmotic pressure _____________________________________

___________________________________________________________

Colloid _____________________________________________________

___________________________________________________________

Concentration Gradient ________________________________________

___________________________________________________________

Crystalloid __________________________________________________

___________________________________________________________

Diffusion ___________________________________________________

___________________________________________________________

Electrolytes _________________________________________________

___________________________________________________________

Evaporation _________________________________________________


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___________________________________________________________

External Exchange ___________________________________________

___________________________________________________________

Facilitated Diffusion ___________________________________________

___________________________________________________________

Hypertonic __________________________________________________

___________________________________________________________

Hypotonic __________________________________________________

___________________________________________________________

Insensible loss _______________________________________________

___________________________________________________________

Internal Exchange ____________________________________________

___________________________________________________________

Isotonic ____________________________________________________

___________________________________________________________

Non-electrolyte ______________________________________________

___________________________________________________________

Osmolality __________________________________________________

___________________________________________________________

Osmosis ___________________________________________________

___________________________________________________________

Permeability ________________________________________________

___________________________________________________________

pH ________________________________________________________

___________________________________________________________

Plasma Proteins (name them) ___________________________________

___________________________________________________________

Specific Gravity (what is normal) _________________________________

___________________________________________________________

Tonicity ____________________________________________________

___________________________________________________________

REFERENCES

Astle, S. (2005), Restoring electrolytes. RN May 68(5) pg 34-39 David, K (2007) IV fluids: do you know what’s hanging and why? RN October

pages 35-40. Day, R., Paul, P., Williams, B., Smeltzer, S., and Bare, B. (2007). Brunner &

Suddarths Textbook of Medical Surgical Nursing, First Canadian Edition. Lippincott and Williams

Jarvis, C. (2009) Physical Examination & Health Assessment First Canadian

Edition; Saunders, Elsevier. Scales, K.;Pilsworth J (2008). The importance of fluid balance in clinical practice.

Nursing Standard, 22,(47), 50-57 Weldy, N. (1996) Body fluids and electrolytes a programmed presentation

seventh edition. Mosby, St. Louis Missouri. http://vchconnect.vch.ca/policies_manuals/reg_policy_clinical/clinical_care/transfusion_medicine/_docs/binary_44109.pdf


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http://vchconnect.vch.ca/policies_manuals/reg_policy_clinical/clinical_care/transfusion_medicine/_docs/binary_44109.pdf

http://vchconnect.vch.ca/policies_manuals/reg_policy_clinical/clinical_care/transfusion_medicine/_docs/binary_44109.pdf

ANSWER KEY

Page 8

There are three compartments name them:

1. Intracellular

2. Intravascular

3. Interstitial

Self Check

1. Fluid inside the cell is intracellular

2. Fluid outside the cell is extracellular

3. Extracelluar fluid is divided into interstitial and intravascular

Page 11

BP: Hypotension reflects volume deficit; hypertension volume excess

Heart Rate: Will increase in response to volume deficit and may decrease

in response to volume excess

Pulse Quality: A weak, thready, obliterated pulse occurs with volume

deficit; a full bounding pulse is seen in volume excess

Assess Concentration Status: The concentration of body fluid is

determined primarily by sodium although other substances that exert an

osmotic force – especially serum glucose –may impact as well.

Concentration imbalances affect the intracellular compartment, especially

the cerebral cells:


28

Serum Sodium: Will be elevated in hypertonic states and decreased in

hypotonic states


29

Page 13

Lab Values

Sodium (Na+) 135 – 145 mEq/L

Potassium (K+) 3.5 – 5.0 mEq/L

Calcium (Ca+) Serum 4.5 – 5.5 mEq/L Ionized 1.12 – 1.30 mEq/L

Magnesium (Mg) 0.70 – 1.10 mEq/L

Chloride (Cl-) 95 – 107 mEq/L

BUN 2.0 – 8.2

Creatinine 60 – 115 mmol/L

Hematocrit Female 36 – 46%, Male 41 – 53%

Glucose 3.9 – 11.0

Arterial Blood Gas

pH 7.35 – 7.45

PaCO² 35 – 45

PaO² 80 – 100

HCO³ 22 – 26 mmol/L (mEq/L)

What are plasma proteins?

Albumin 60 – 80 g/L

Globulin 20 – 35 g/L

Page 14

What’s my problem?

Dehydration

Renal failure

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