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FLUID AND ELECTROLYTES
Anatomy and Physiology
TOTAL BODY WATER (TBW)60% Body Weight
• INTRACELLULAR FLUID (ICF) 40%• EXTRACELLULAR FLUID (ECF)20%
InterstitialIntravascular Trancellular
• THIRD SPACE FLUIDDisease; injury
Electrolytes
Na Extracellular CATION Cl Extracellular ANION K Intracellular CATION PO4 Intracellular ANION
Body Fluid Transport
• DIFFUSION Higher to lower concentration
• OSMOSIS Lower to higher concentration
Semi permeable membrane
• FILTRATIONParticles
• ACTIVE TRANSPORTNa-K PumpRequires ATP
Fluids
• BODY INPUTFluids 1500mL
Food 500mL
Digestion 500mL
Total >2500mL
• BODY OUTPUTUrine 1500mL
Feces 200-400mL
Respiration200-400mL
Skin 200-400mL
Total >2500mL
Intravenous Fluids
ISOTONIC:
Equal in concentration
• 0.9% NaCl or NSS
• D5 Water, Lactated Ringer’s
Intravenous Fluids
HYPOTONIC:↓ Salt or soluteCellular swelling • 0.45% NaCl, Distilled water
HYPERTONIC:↑ SoluteCellular shrinkage • D5 NSS, D10 Water • D5 0.45 % NaCl, D5 LRS
FLUID VOLUME DEFICIT
DEHYDRATIONInadequate IntakeExcessive Loss
Types:• ISOTONIC Dehydration• HYPERTONIC Dehydration• HYPOTONIC Dehydration
FLUID VOLUME DEFICIT
Assessment:
↓ BP; ↑ PR
Weak and thready pulses
Flat neck veins
Lethargic to coma
Dry skin; poor skin turgor
Oliguria (↓ UO)
↑ Urine specific gravity
Thirst
FLUID VOLUME DEFICIT
Management:Monitor VS; BP and PRMild: Oral Rehydrating Solution (ORS)Severe: IV fluid Administer prescribed meds
• Antibiotics• Antiemetics• Antipyretics
Monitor/ correct electrolyte imbalances
FLUID VOLUME EXCESS
FLUID OVERLOAD
Types:
• ISOTONIC
• HYPOTONIC
• HYPERTONIC
FLUID VOLUME EXCESS
Assessment:↑ BP and CVPBounding pulse↑ RR, Dyspnea CracklesDistended neck veinAltered level of consciousnessWeight gain Ascites; pedal edemaPolyuria
FLUID VOLUME EXCESS
Management:
Monitor VS: BP and RR
Monitor I and O
Restrict fluid and Na intake
Weight and AC OD pre-breakfast
Administer prescribed diuretics
Monitor/treat electrolyte imbalances
HYPOKALEMIA
Normal K 3.5-5.0 meq/LK ↓ 3.5 meq/L Causes:
Diuretics, digitalis, and steroidsCushing’s syndromeMetabolic AlkalosisDiarrhea, NPO ↑ Insulin
HYPOKALEMIA
Assessment:Weak irregular pulsesECG:
• U wave• Inverted T waves
Altered LOCShallow respirationWeakness; hyporeflexiaIleus; constipation
HYPOKALEMIA
Management:Monitor VS; PRMonitor serum K valuesBed restEncourage K-rich foods:
• Banana, avocado, raisins, orange, potatoes
Diet: High fiber foods K- sparing diuretics
• Spirinolactone (Aldactone)
HYPOKALEMIA
Management:• Oral Potassium
Kalium Durule (PC)K-Lor
• IV PotassiumNEVER given by IV push, IM nor SC5-10 meq/hrUse of cardiac monitorAssess IV site
HYPERKALEMIA
K ↑ 5.5 meq/L
Causes:Excessive K intake K sparing diureticsAddison’s diseaseChronic renal failure (CRF)Metabolic AcidosisTissue damage; injury
HYPERKALEMIA
Assessment:
Irregular weak pulses, ↓ BP
ECG:
• Tall T wave
• Flat P wave
Muscular weakness
Paresthesia
Diarrhea
HYPERKALEMIA
Management:Monitor VSRestrict K rich foodsDiscontinue K supplements PO/ IVIf no renal disease; Diuretics Na polystyrene sulfonate (KAYEXALATE)
→ K excretionPrepare for dialysisAdminister NaHCO3Glucose with insulin
HYPONATREMIA
Serum Na 135-145meq/LNa ↓ 135 meq/L
Causes:DiureticsDiaphoresisAddison’s DiseaseSIADHNPO, ↓ Salt dietFreshwater drowning
HYPONATREMIA
Assessment:
↑ Pulse rate
Shallow respiration
Headache; altered LOC
Seizures
Weakness
Polyuria (↑ UO)
HYPONATREMIA
Management:Monitor VSMonitor LOCIntake of Na rich foods:→Table salt, soy sauce, cured pork,
canned and processed foods Hypovolemia: IVF NSS (ISOTONIC)Fluid excess: Osmotic diureticsSIADH: Lithium and Demeclocycline
→ Antagonize ADHSeizure precautions
HYPERNATREMIA
Na ↑145 meq/L
Causes:
Steroids
↑ Na intake
↓ Water intake
Cushing’s syndrome
Chronic renal failure (CRF)
HYPERNATREMIA
Assessment:
↓ PR
Shallow respiration
Weakness
Dry flaky skin
Altered LOC
Oliguria (↓ UO)
HYPERNATREMIA
Management:
Monitor VS
Restrict Na and fluid
Diuretics
Hypovolemia: D5W and HYPOTONIC IVF
HYPOCALCEMIA
Serum Ca 8-10.5 mg/dL4.5-5.5 meq/L
Ca ↓ 8 mg/dL
Causes:↓ Intake of Ca and vitamin DLactose intoleranceParathyroidectomyCRFDiuretics
HYPOCALCEMIA
Assessment:Irregular pulsesECG Prolonged ST interval
Prolonged QT intervalParesthesia; numbnessWeaknessTetany; carpopedal spasm(+) Trosseau’s sign(+) Chvostek’s sign
HYPOCALCEMIA
Management:
Monitor VS; PR/ CR
Monitor serum Ca and Mg
Encourage Ca-rich foods:
Milk and poultry, cheese, eggs
Oral Ca supplement:
• CaCO3 (Calci-Aid)
1-2 hrs PC or HS
HYPOCALCEMIA
Management:
IV Ca:
• Calcium Gluconate
Given very SLOWLY
Never thru IV push, IM or SQ
Use of cardiac monitor
Assess PR/ CR
HYPERCALCEMIA
Ca ↑10.5mg/dL
Causes:
Excessive intake of Ca or Vitamin D
Use of Thiazides; Lithium
Hyperparathyroidism
Malignancy
Immobility; Fracture
HYPERCALCEMIA
Assessment:
Irregular CR cardiac arrest
ECG:
• Shortened ST interval
Altered LOC
Muscle weakness
Colic pain → Renal stones
Constipation
HYPERCALCEMIA
Management:Monitor VS; CRRestrict Ca rich foods Discontinue PO and IV Ca Give prescribed Diuretics↑ Fluid intake• Calcitonin; Biphosphanates • ASA and NSAIDS
→Inhibit Ca resorption from bonesPrepare for dialysis
ACID BASE BALANCE
Hydrogen ions (H) → pH
ACIDS → Hydrogen donors BASES → Hydrogen acceptors
CARBONIC ACID/ BICARBONATE SYSTEM
Maintains pH of 7.4
Bicarbonate to Carbonic Acid Ratio 20:1
CARBONIC ACID Lungs BICARBONATE Kidneys
ACID BASE BALANCE
ACIDOSIS → Hyperkalemia (↑ K) ALKALOSIS → Hypokalemia (↓ K)
ARTERIAL BLOOD GAS
PH 7.35- 7.45
PCO2 35- 45 mmHg
HCO3 22- 26 meq/L
PO2 80- 100 mmHg
ARTERIAL BLOOD GAS
ROME• Respiratory Acidosis ↓pH ↑pCO2
• Respiratory Alkalosis ↑pH ↓pCO2
• Metabolic Acidosis ↓pH ↓HCO3
• Metabolic Alkalosis ↑pH ↑HCO3
ARTERIAL BLOOD GAS
Pre-op care: ALLEN’S Test
Rest x 30 min NO SUCTION Note O2 therapy
Room air: → No O2 Prepare heparinized syringe
ARTERIAL BLOOD GAS
Post-op care:
Container with ice
Client’s temperature O2 and respirator set up Pressure dressing x 5-10 min
RESPIRATORY ACIDOSIS
↓pH ↑pCO2
Causes: Pulmonary Diseases:
• PTB, Pneumonia
• COPD, B. Asthma Brain Injury Medications:
• Sedatives, Narcotics, Anesthetics
RESPIRATORY ACIDOSIS
Assessment: HYPOVENTILATION
(Rapid, shallow breathing)
↑ PR
Headache Blurring of vision Restlessness Cyanosis
RESPIRATORY ACIDOSIS
Management: Semi to high fowlers Monitor VS; RR Administer O2 Coughing and deep breathing exercises
Turning from side to side
Encourage hydration
Suction secretion PRN
Appropriate treatment as prescribed
• Bronchodilators, Antibiotics
• Respirator; CTT/ Thoracentesis
RESPIRATORY ALKALOSIS
↑pH ↓pCO2
Causes: Hysteria Anxious; panic states Severe pain; fever Over- use of respirator
RESPIRATORY ALKALOSIS
Assessment: HYPERVENTILATION
(Rapid, deep breathing)
Headache; dizziness
Mental status changes Paresthesia Weakness Tetany; carpopedal spasm
RESPIRATORY ALKALOSIS
Management: Monitor VS; RR Emotional support and reassurance Appropriate breathing patterns: → ↑pCO2
• Brown bag
• Voluntary holding of breath
Monitor electrolytes Cautious care with clients on respirator
Administer prescribed medication
METABOLIC ACIDOSIS
↓pH ↓HCO3
Causes: DM/DKA CRF
Starvation; malnutritionLactic acidosis
ASA and ethanol intoxication Severe diarrhea
METABOLIC ACIDOSIS
Assessment: KUSSMAUL BREATHING
(Rapid, deep breathing)
Irregular pulses
Headache Altered LOC Fruity or ketone breath ↑ Serum K
METABOLIC ACIDOSIS
Management: Monitor VS; RR and PR Assess LOC
Monitor I and O Assess and correct serum K
Safety and seizure precaution Administer NaHCO3 Administer Kayexalate
DM: Give prescribed insulinCRF: Prepare for dialysis
METABOLIC ALKALOSIS
↑pH ↑HCO3
Causes: Excessive NaHCO3 intake Chronic use of diuretics Excessive vomiting/GI suctioning
Several BT with FWB (Citrate)
METABOLIC ALKALOSIS
Assessment: Nausea and vomiting Irregular pulses
Restlessness
Paresthesia ↓ Serum K
METABOLIC ALKALOSIS
Management: Monitor VS; PR
Assess and correct serum K
Safety precautions Discontinue HCO3 Administer prescribed anti-emetics