FLUID AND FLUID AND ELECTROLYTESELECTROLYTES

Anatomy and PhysiologyAnatomy and Physiology

TOTAL BODY WATER (TBW)TOTAL BODY WATER (TBW)60% Body Weight60% Body Weight

• • INTRACELLULAR FLUIDINTRACELLULAR FLUID (ICF)(ICF) 40%40%•• EXTRACELLULAR FLUIDEXTRACELLULAR FLUID (ECF)20%(ECF)20%

InterstitialInterstitialIntravascular Intravascular TrancellularTrancellular

•• THIRD SPACE FLUIDTHIRD SPACE FLUIDDisease; injuryDisease; injury

ElectrolytesElectrolytes

NaNa Extracellular CATIONExtracellular CATION ClCl Extracellular ANIONExtracellular ANION KK Intracellular CATIONIntracellular CATION PO4PO4 Intracellular ANIONIntracellular ANION

Body Fluid TransportBody Fluid Transport

• • DIFFUSIONDIFFUSION Higher to lower concentrationHigher to lower concentration

•• OSMOSISOSMOSIS Lower to higher concentration Lower to higher concentration

Semi permeable membraneSemi permeable membrane

•• FILTRATIONFILTRATIONParticlesParticles

•• ACTIVE TRANSPORTACTIVE TRANSPORTNa-K PumpNa-K PumpRequires ATPRequires ATP

FluidsFluids

• • BODY INPUTBODY INPUTFluidsFluids 1500mL 1500mL

FoodFood 500mL 500mL

DigestionDigestion 500mL 500mL

TotalTotal >2500mL >2500mL

  

•• BODY OUTPUTBODY OUTPUTUrineUrine 1500mL 1500mL

FecesFeces 200-400mL 200-400mL

Respiration200-400mLRespiration200-400mL

SkinSkin 200-400mL 200-400mL

TotalTotal >2500mL >2500mL

Intravenous FluidsIntravenous Fluids

ISOTONIC:ISOTONIC:

Equal in concentrationEqual in concentration

• • 0.9% NaCl or NSS0.9% NaCl or NSS

•• D5 Water, Lactated Ringer’sD5 Water, Lactated Ringer’s

Intravenous FluidsIntravenous Fluids

HYPOTONIC:HYPOTONIC:↓ ↓ Salt or soluteSalt or soluteCellular swellingCellular swelling •• 0.45% NaCl, Distilled water0.45% NaCl, Distilled water

HYPERTONIC:HYPERTONIC:↑ ↑ SoluteSoluteCellular shrinkageCellular shrinkage •• D5 NSS, D10 WaterD5 NSS, D10 Water •• D5 0.45 % NaCl, D5 LRSD5 0.45 % NaCl, D5 LRS

FLUID VOLUME DEFICITFLUID VOLUME DEFICIT

DEHYDRATIONDEHYDRATIONInadequate IntakeInadequate IntakeExcessive LossExcessive Loss

Types:Types:• • ISOTONIC DehydrationISOTONIC Dehydration•• HYPERTONIC DehydrationHYPERTONIC Dehydration•• HYPOTONIC DehydrationHYPOTONIC Dehydration

FLUID VOLUME DEFICITFLUID VOLUME DEFICIT

Assessment:Assessment:

↓ ↓ BP; BP; ↑ ↑ PR PR

Weak and thready pulsesWeak and thready pulses

Flat neck veinsFlat neck veins

Lethargic to comaLethargic to coma

Dry skin; poor skin turgorDry skin; poor skin turgor

Oliguria (Oliguria (↓↓ UO) UO)

↑↑ Urine specific gravityUrine specific gravity

ThirstThirst

FLUID VOLUME DEFICITFLUID VOLUME DEFICIT

Management:Management:Monitor VS; BP and PRMonitor VS; BP and PRMild:Mild: Oral Rehydrating Solution (ORS)Oral Rehydrating Solution (ORS)Severe:Severe: IV fluid IV fluid Administer prescribed meds Administer prescribed meds

• • AntibioticsAntibiotics•• AntiemeticsAntiemetics•• AntipyreticsAntipyretics

Monitor/ correct electrolyte imbalancesMonitor/ correct electrolyte imbalances

FLUID VOLUME EXCESSFLUID VOLUME EXCESS

FLUID OVERLOADFLUID OVERLOAD

  

Types:Types:

• • ISOTONICISOTONIC

•• HYPOTONICHYPOTONIC

•• HYPERTONICHYPERTONIC

FLUID VOLUME EXCESSFLUID VOLUME EXCESS

Assessment:Assessment:↑ ↑ BP and CVPBP and CVPBounding pulseBounding pulse↑ ↑ RR, Dyspnea RR, Dyspnea CracklesCracklesDistended neck veinDistended neck veinAltered level of consciousnessAltered level of consciousnessWeight gainWeight gain Ascites; pedal edemaAscites; pedal edemaPolyuriaPolyuria

FLUID VOLUME EXCESSFLUID VOLUME EXCESS

Management:Management:

Monitor VS: BP and RRMonitor VS: BP and RR

Monitor I and OMonitor I and O

Restrict fluid and Na intakeRestrict fluid and Na intake

Weight and AC OD pre-breakfastWeight and AC OD pre-breakfast

Administer prescribed diureticsAdminister prescribed diuretics

Monitor/treat electrolyte imbalancesMonitor/treat electrolyte imbalances

HYPOKALEMIAHYPOKALEMIA

Normal K Normal K 3.5-5.0 meq/L3.5-5.0 meq/LK K ↓ ↓ 3.5 meq/L3.5 meq/L  Causes:Causes:

Diuretics, digitalis, and steroidsDiuretics, digitalis, and steroidsCushing’s syndromeCushing’s syndromeMetabolic AlkalosisMetabolic AlkalosisDiarrhea, NPO Diarrhea, NPO ↑ ↑ InsulinInsulin

HYPOKALEMIAHYPOKALEMIA

Assessment:Assessment:Weak irregular pulsesWeak irregular pulsesECG: ECG:

• • U waveU wave•• Inverted T wavesInverted T waves

Altered LOCAltered LOCShallow respirationShallow respirationWeakness; hyporeflexiaWeakness; hyporeflexiaIleus; constipationIleus; constipation

HYPOKALEMIAHYPOKALEMIA

Management:Management:Monitor VS; PRMonitor VS; PRMonitor serum K valuesMonitor serum K valuesBed restBed restEncourage K-rich foods:Encourage K-rich foods:

• • Banana, avocado, raisins, Banana, avocado, raisins, orange, potatoesorange, potatoes

Diet: High fiber foods Diet: High fiber foods K- sparing diuretics K- sparing diuretics

•• Spirinolactone (Aldactone)Spirinolactone (Aldactone)

HYPOKALEMIAHYPOKALEMIA

Management:Management:• • Oral PotassiumOral Potassium

Kalium Durule (PC)Kalium Durule (PC)K-LorK-Lor

•• IV PotassiumIV PotassiumNEVER given by IV push, IM nor SCNEVER given by IV push, IM nor SC5-10 meq/hr5-10 meq/hrUse of cardiac monitorUse of cardiac monitorAssess IV siteAssess IV site

HYPERKALEMIAHYPERKALEMIA

KK ↑ ↑ 5.5 meq/L5.5 meq/L

Causes:Causes:Excessive K intake Excessive K intake K sparing diureticsK sparing diureticsAddison’s diseaseAddison’s diseaseChronic renal failure (CRF)Chronic renal failure (CRF)Metabolic AcidosisMetabolic AcidosisTissue damage; injuryTissue damage; injury

HYPERKALEMIAHYPERKALEMIA

Assessment:Assessment:

Irregular weak pulses, Irregular weak pulses, ↓ ↓ BPBP

ECG:ECG:

• • Tall T waveTall T wave

•• Flat P waveFlat P wave

Muscular weaknessMuscular weakness

ParesthesiaParesthesia

DiarrheaDiarrhea

HYPERKALEMIAHYPERKALEMIA

Management:Management:Monitor VSMonitor VSRestrict K rich foodsRestrict K rich foodsDiscontinue K supplements PO/ IVDiscontinue K supplements PO/ IVIf no renal disease; Diuretics If no renal disease; Diuretics Na polystyrene sulfonate (KAYEXALATE)Na polystyrene sulfonate (KAYEXALATE)

→ → K excretionK excretionPrepare for dialysisPrepare for dialysisAdminister NaHCO3Administer NaHCO3Glucose with insulinGlucose with insulin

  

HYPONATREMIAHYPONATREMIA

Serum Na Serum Na 135-145meq/L135-145meq/LNa Na ↓ ↓ 135 meq/L135 meq/L

Causes:Causes:DiureticsDiureticsDiaphoresisDiaphoresisAddison’s DiseaseAddison’s DiseaseSIADHSIADHNPO, NPO, ↓↓ Salt diet Salt dietFreshwater drowningFreshwater drowning

HYPONATREMIAHYPONATREMIA

Assessment:Assessment:

↑ ↑ Pulse ratePulse rate

Shallow respirationShallow respiration

Headache; altered LOCHeadache; altered LOC

Seizures Seizures

WeaknessWeakness

Polyuria (Polyuria (↑ ↑ UO)UO)

  

HYPONATREMIAHYPONATREMIA

Management:Management:Monitor VSMonitor VSMonitor LOCMonitor LOCIntake of Na rich foods:Intake of Na rich foods:→→Table salt, soy sauce, cured pork, Table salt, soy sauce, cured pork,

canned and processed foods canned and processed foods Hypovolemia: IVF NSS (ISOTONIC)Hypovolemia: IVF NSS (ISOTONIC)Fluid excess: Osmotic diureticsFluid excess: Osmotic diureticsSIADH: Lithium and DemeclocyclineSIADH: Lithium and Demeclocycline

→→ Antagonize ADHAntagonize ADHSeizure precautionsSeizure precautions

HYPERNATREMIAHYPERNATREMIA

Na Na ↑↑145 meq/L145 meq/L

Causes:Causes:

Steroids Steroids

↑↑ Na intakeNa intake

↓ ↓ WWater intakeater intake

Cushing’s syndromeCushing’s syndrome

Chronic renal failure (CRF)Chronic renal failure (CRF)

HYPERNATREMIAHYPERNATREMIA

Assessment:Assessment:

↓ ↓ PRPR

Shallow respirationShallow respiration

WeaknessWeakness

Dry flaky skinDry flaky skin

Altered LOCAltered LOC

Oliguria (Oliguria (↓↓ UO) UO)

HYPERNATREMIAHYPERNATREMIA

Management:Management:

Monitor VSMonitor VS

Restrict Na and fluid Restrict Na and fluid

DiureticsDiuretics

Hypovolemia: D5W and HYPOTONIC IVFHypovolemia: D5W and HYPOTONIC IVF

HYPOCALCEMIAHYPOCALCEMIA

Serum Ca Serum Ca 8-10.5 mg/dL8-10.5 mg/dL4.5-5.5 meq/L4.5-5.5 meq/L

CaCa ↓ ↓ 8 mg/dL8 mg/dL

Causes:Causes:↓↓ Intake of Ca and vitamin DIntake of Ca and vitamin DLactose intoleranceLactose intoleranceParathyroidectomyParathyroidectomyCRFCRFDiureticsDiuretics

HYPOCALCEMIAHYPOCALCEMIA

Assessment:Assessment:Irregular pulsesIrregular pulsesECGECG Prolonged ST intervalProlonged ST interval

Prolonged QT intervalProlonged QT intervalParesthesia; numbnessParesthesia; numbnessWeaknessWeaknessTetany; carpopedal spasmTetany; carpopedal spasm(+) Trosseau’s sign(+) Trosseau’s sign(+) Chvostek’s sign(+) Chvostek’s sign

HYPOCALCEMIAHYPOCALCEMIA

Management:Management:

Monitor VS; PR/ CRMonitor VS; PR/ CR

Monitor serum Ca and MgMonitor serum Ca and Mg

Encourage Ca-rich foods:Encourage Ca-rich foods:

Milk and poultry, cheese, eggsMilk and poultry, cheese, eggs

Oral Ca supplement:Oral Ca supplement:

• • CaCO3 (Calci-Aid)CaCO3 (Calci-Aid)

1-2 hrs PC or HS1-2 hrs PC or HS

HYPOCALCEMIAHYPOCALCEMIAManagement:Management:

IV Ca: IV Ca:

• • Calcium GluconateCalcium Gluconate

Given very SLOWLYGiven very SLOWLY

Never thru IV push, IM or SQNever thru IV push, IM or SQ

Use of cardiac monitorUse of cardiac monitor

Assess PR/ CRAssess PR/ CR

HYPERCALCEMIAHYPERCALCEMIA

Ca Ca ↑↑10.5mg/dL10.5mg/dL

Causes:Causes:

Excessive intake of Ca or Vitamin DExcessive intake of Ca or Vitamin D

Use of Thiazides; LithiumUse of Thiazides; Lithium

HyperparathyroidismHyperparathyroidism

MalignancyMalignancy

Immobility; FractureImmobility; Fracture

HYPERCALCEMIAHYPERCALCEMIA

Assessment:Assessment:

Irregular CRIrregular CR cardiac arrestcardiac arrest

ECG:ECG:

• • Shortened ST intervalShortened ST interval

Altered LOCAltered LOC

Muscle weaknessMuscle weakness

Colic painColic pain → → Renal stonesRenal stones

ConstipationConstipation

HYPERCALCEMIAHYPERCALCEMIA

Management:Management:Monitor VS; CRMonitor VS; CRRestrict Ca rich foods Restrict Ca rich foods Discontinue PO and IV Ca Discontinue PO and IV Ca Give prescribed DiureticsGive prescribed Diuretics↑ ↑ Fluid intakeFluid intake• • Calcitonin; Biphosphanates Calcitonin; Biphosphanates • • ASA and NSAIDSASA and NSAIDS

→→Inhibit Ca resorption from bonesInhibit Ca resorption from bonesPrepare for dialysisPrepare for dialysis

ACID BASE BALANCEACID BASE BALANCE

Hydrogen ions (H)Hydrogen ions (H) → → pHpH

   ACIDSACIDS →→ Hydrogen donors Hydrogen donors BASESBASES →→ Hydrogen acceptors Hydrogen acceptors

  

CARBONIC ACID/ CARBONIC ACID/ BICARBONATE SYSTEMBICARBONATE SYSTEM

Maintains pH of 7.4Maintains pH of 7.4

Bicarbonate to Carbonic Acid Ratio Bicarbonate to Carbonic Acid Ratio 20:120:1

CARBONIC ACIDCARBONIC ACID LungsLungs BICARBONATEBICARBONATE KidneysKidneys

ACID BASE BALANCEACID BASE BALANCE

ACIDOSISACIDOSIS → → Hyperkalemia (Hyperkalemia (↑ K)↑ K) ALKALOSISALKALOSIS →→ Hypokalemia ( Hypokalemia (↓ K)↓ K)

ARTERIAL BLOOD GASARTERIAL BLOOD GAS

PHPH 7.35- 7.457.35- 7.45

PCO2PCO2 35- 45 mmHg35- 45 mmHg

HCO3HCO3 22- 26 meq/L22- 26 meq/L

PO2PO2 80- 100 mmHg80- 100 mmHg

  

ARTERIAL BLOOD GASARTERIAL BLOOD GAS

ROMEROME• • Respiratory AcidosisRespiratory Acidosis ↓↓pHpH ↑↑pCO2pCO2

•• Respiratory AlkalosisRespiratory Alkalosis ↑↑pHpH ↓↓pCO2pCO2

•• Metabolic AcidosisMetabolic Acidosis ↓↓pHpH ↓↓HCO3HCO3

•• Metabolic AlkalosisMetabolic Alkalosis ↑↑pHpH ↑↑HCO3HCO3

ARTERIAL BLOOD GASARTERIAL BLOOD GAS

Pre-op care:Pre-op care: ALLEN’S TestALLEN’S Test

Rest x 30 minRest x 30 min NO SUCTION NO SUCTION Note O2 therapyNote O2 therapy

Room air:Room air: → No O2→ No O2 Prepare heparinized syringePrepare heparinized syringe

ARTERIAL BLOOD GASARTERIAL BLOOD GAS

Post-op care:Post-op care:

Container with iceContainer with ice

Client’s temperatureClient’s temperature O2 and respirator set upO2 and respirator set up Pressure dressing x 5-10 minPressure dressing x 5-10 min

RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS

↓↓pHpH ↑↑pCO2pCO2

  

Causes:Causes: Pulmonary Diseases:Pulmonary Diseases:

• • PTB, PneumoniaPTB, Pneumonia

•• COPD, B. AsthmaCOPD, B. Asthma Brain Injury Brain Injury Medications: Medications:

• • Sedatives, Narcotics, AnestheticsSedatives, Narcotics, Anesthetics

RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS

Assessment:Assessment: HYPOVENTILATIONHYPOVENTILATION

(Rapid, shallow breathing)(Rapid, shallow breathing)

↑ ↑ PRPR

HeadacheHeadache Blurring of visionBlurring of vision RestlessnessRestlessness CyanosisCyanosis

RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS

Management:Management: Semi to high fowlers Semi to high fowlers Monitor VS; RRMonitor VS; RR Administer O2 Administer O2 Coughing and deep breathing exercisesCoughing and deep breathing exercises

Turning from side to sideTurning from side to side

Encourage hydrationEncourage hydration

Suction secretion PRN Suction secretion PRN

Appropriate treatment as prescribedAppropriate treatment as prescribed

• • Bronchodilators, Antibiotics Bronchodilators, Antibiotics

•• Respirator; CTT/ ThoracentesisRespirator; CTT/ Thoracentesis

RESPIRATORY ALKALOSISRESPIRATORY ALKALOSIS

↑↑pHpH ↓↓pCO2pCO2

  

Causes:Causes: Hysteria Hysteria Anxious; panic statesAnxious; panic states Severe pain; feverSevere pain; fever Over- use of respiratorOver- use of respirator

RESPIRATORY ALKALOSISRESPIRATORY ALKALOSIS

Assessment:Assessment: HYPERVENTILATIONHYPERVENTILATION

(Rapid, deep breathing)(Rapid, deep breathing)

Headache; dizzinessHeadache; dizziness

Mental status changesMental status changes ParesthesiaParesthesia WeaknessWeakness Tetany; carpopedal spasmTetany; carpopedal spasm

RESPIRATORY ALKALOSISRESPIRATORY ALKALOSIS

Management:Management: Monitor VS; RRMonitor VS; RR Emotional support and reassuranceEmotional support and reassurance Appropriate breathing patterns: Appropriate breathing patterns: → ↑pCO2→ ↑pCO2

• • Brown bagBrown bag

• • Voluntary holding of breathVoluntary holding of breath

Monitor electrolytesMonitor electrolytes Cautious care with clients on respiratorCautious care with clients on respirator

Administer prescribed medicationAdminister prescribed medication

METABOLIC ACIDOSISMETABOLIC ACIDOSIS

↓↓pHpH ↓↓HCO3HCO3

Causes:Causes: DM/DKADM/DKA CRFCRF

Starvation; malnutritionStarvation; malnutritionLactic acidosisLactic acidosis

ASA and ethanol intoxicationASA and ethanol intoxication Severe diarrheaSevere diarrhea

METABOLIC ACIDOSISMETABOLIC ACIDOSIS

Assessment:Assessment: KUSSMAUL BREATHINGKUSSMAUL BREATHING

(Rapid, deep breathing)(Rapid, deep breathing)

Irregular pulsesIrregular pulses

HeadacheHeadache Altered LOC Altered LOC Fruity or ketone breathFruity or ketone breath ↑ ↑ Serum Serum KK

METABOLIC ACIDOSISMETABOLIC ACIDOSIS

Management:Management: Monitor VS; RR and PRMonitor VS; RR and PR Assess LOCAssess LOC

Monitor I and OMonitor I and O Assess and correct serum KAssess and correct serum K

Safety and seizure precautionSafety and seizure precaution Administer NaHCO3 Administer NaHCO3 Administer KayexalateAdminister Kayexalate

DM: Give prescribed insulinDM: Give prescribed insulinCRF: Prepare for dialysisCRF: Prepare for dialysis

METABOLIC ALKALOSISMETABOLIC ALKALOSIS

↑↑pHpH ↑↑HCO3HCO3

  

Causes:Causes: Excessive NaHCO3 intakeExcessive NaHCO3 intake Chronic use of diureticsChronic use of diuretics Excessive vomiting/GI suctioningExcessive vomiting/GI suctioning

Several BT with FWB (Citrate)Several BT with FWB (Citrate)

METABOLIC ALKALOSISMETABOLIC ALKALOSIS

Assessment:Assessment: Nausea and vomitingNausea and vomiting Irregular pulsesIrregular pulses

RestlessnessRestlessness

ParesthesiaParesthesia ↓ ↓ Serum KSerum K

METABOLIC ALKALOSISMETABOLIC ALKALOSIS

Management:Management: Monitor VS; PRMonitor VS; PR

Assess and correct serum K Assess and correct serum K

Safety precautionsSafety precautions Discontinue HCO3Discontinue HCO3 Administer prescribed anti-emeticsAdminister prescribed anti-emetics