Fundamentals of fluid and electrolyte balance parenteral solutions
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Fundamentals of Fluid and Electrolyte Balance Parenteral Solutions. ADN136 Fall 09. Fluid Balance. Body fluid is body water in which electrolytes are dissolved Bodywater makes up 60% of Total Body weight in young men 50-55% in women 70-80% in infants. Fluid Balance.

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Fundamentals of fluid and electrolyte balance parenteral solutions

Fundamentals of Fluid and Electrolyte BalanceParenteral Solutions


Fall 09

Fluid balance
Fluid Balance

  • Body fluid is body water in which electrolytes are dissolved

  • Bodywater makes up

    • 60% of Total Body weight in young men

    • 50-55% in women

    • 70-80% in infants

Fluid balance cont
Fluid Balance (cont)

  • Homeostasis- Dependent on fluid and electrolyte intake physiologic factors, disease state factors, external environmental factors and pharmacologic intervention.

    • Intracellular fluid (ICF) water in the cells = 40%

    • Extractracellular fluid (ECF) fluid out side the cells = 20%

      • 15% in tissue space (interstitial) outside the blood vessel, between cells

      • 5% in plasma (intravascular space)

Fluid balance2
Fluid Balance

  • Normal intake 1-3 L/day

  • 200-300 ml produced by oxidation

  • Normal intake and output will balance approximately every 72 hours

Fluid balance3
Fluid Balance

  • Elimination of fluids is considered

    • Sensible (measurable) loss

      • Skin, Kidneys, Bowels, lungs lose fluid

      • 300-500ml lost through lungs every 24 hrs.

      • 500ml lost with perspiration

    • Insensible (not measurable) loss

      • Considered to be 500-1000ml/day

        • Lost through GI tract only 100-200 ml/day

Fluid balance cont1
Fluid Balance (cont)

  • Loss from Diarrhea or intestinal fistula

  • Significant sweat loss when body temp >101F-38.3C or room temp > 90F

  • When respirations > 20/min

  • Formula to calculate insensible loss

    • 300-400ml/m2/day

Fluid function
Fluid Function

The fluid in the body has the following function:

  • Maintains blood volume

  • Regulates body temperature

  • Transports material to and from cells

  • Serves as an aqueous medium for cellular metabloism

  • Assists digestion of food through hydrolysis

  • Acts as a solvent in which solutes are available for cell function

  • Serves as a medium for the excretion of waste

Fluid transport
Fluid Transport

  • 4 transport mechanisms

    • Passive transport

      • Passive diffusion-

      • Osmosis

      • Filtration

    • Active transport

Fluid transport1
Fluid Transport

  • Passive transport- non carrier mediated transport- Fluid moves through membranes with out the expenditure of energy

    • Passive diffusion - movement of water and other elements in all directions from high concentration to low concentration

    • Osmosis – passage of water from low particle concentration toward one of higher particle concentration

      • Normal osmolarity – 280-295 mOsm/L

        • Osmolarity of ICF and ECF is always equal

Fluid transport cont
Fluid Transport (cont)

  • Filtration – the transfer of water and a dissolved substance from a region of high pressure to a region of low pressure. Force behind it is hydrostatic pressure (the pressure of water at rest)

    • Pumping heat provides hydrostatic pressure in the movement of water and electrolytes from the arterial capillary bed to the interstitial fluid.

Fluid transport cont1
Fluid Transport (cont)

  • Plasma protein creates and osmotic pressure at the capillary membrane, preventing fluid from plasma leaking into interstitial spaces

  • Osmotic pressure (created within the plasma) keeps water in the vascular system

Fluid transport cont2
Fluid Transport (cont)

  • Starling’s law of capillaries

    • Under normal circumstances fluid filtered out of the arterial end of a capillary bed and reabsorbed at the venous end is exactly the same, creating a state of near equilibrium

Fluid transport cont3
Fluid Transport (cont)

  • Active Transport – acts as a concentration gradient

    • ATP – released from the cell to enable substances to acquire the energy needed to pass through the cell membrane

    • Active Transport is vital for maintaining the unique composition of both the intracellular and intracellular compartments

Tonicity of solution
Tonicity of Solution

  • Isotonic - .9% saline, 5% dextrose

    • same as body fluids

    • Osmolarity of 250-375mOsm/L

    • Remains within the ECF space

    • Used to expand ECF compartment

Tonicity of solution1
Tonicity of Solution

  • Hypotonic – contains less salt than the intracellular space 2.5% DW

    • Osmolarity below 250mOsm/L

      • Hydrates cells

      • Depletes the circulatory system

Tonicity of solution2
Tonicity of Solution

  • Hypertonic – causes water from within a cell to move to the ECF compartment

    • Osmolarity of 375mOsm/l or greater

    • Used to replace electrolytes

    • Used to shift EDF from interstitial tissue to plasma

    • D5W, .9 Normal Saline

Homeostatic mechanism
Homeostatic Mechanism

  • Regulation of body water is maintained

    • Exogenous sources - Intake of food & Fluids (nurse’s responsibility)

    • Endogenous sources – produce with in the body through chemical exidation process (various body systems responsible)

Homeostatic mechanisms
Homeostatic Mechanisms

  • Renal System – Kidneys filter 170L l of plasma/day and excrete 1.5L of urine

    • Regulation of fluid volume and osmolarity by selective retention and secretion of body fluid

    • Regulation of electrolyte levels by selective retention of needed substances and excretion of unneeded substances

    • Regulation of pH of ECF by excretion or retention of hydrogen ions

    • Excretion of metabolic wastes (primarily acids) and toxic substances

Homeostatic mechanism1
Homeostatic Mechanism

  • Cardiovascular System –

    • Pumping action of the heartprovides circulation of blood through the kidneys under pressure

    • Allow urine to form

    • Renal perfusion makes renal function possible

Homeostatic mechanism2
Homeostatic Mechanism

  • Lymphatic system –

    • Serves as an adjunct to the cardio vascular system by removing excess interstitial fluid (lymph) and returning it to the circulatory system

    • Prevents fluid overload

Homeostatic mechanism3
Homeostatic Mechanism

  • Respiratory System

    • Lungs are vital for maintaining homeostasis and constitute one of the main regulatory orgnas of fluid and acid base balance

    • Functions of the lungs

      • Regulation of metabolic alkalosis by compensatory hypoventilation

      • Regulation of metabolic acidosis by causing compensatory hyperventilation

      • Removal of 300-500 ml of water daily through exhalation

Homeostatic mechanism4
Homeostatic Mechanism

  • Nervous system

    • Master controller in fluid and electrolyte balance through the regulation of sodium and water

  • Endocrine system

    • Responsible for aiding homeostasis through production of various hormones

      • Antidiuretic hormones (ADH)

      • Parathyroid Hormones

      • Aldosterone

      • Epinephrine

Physical assessment
Physical Assessment

  • Vital signs, infusion rate of IV fluids, intake and output.

  • Neurological - Changes in orientation, irritability, lethargy, confusion, seizures or coma

  • Cardiovascular –

    • Quality and rate of pulse

    • Peripheral vein filling

    • Orthostatic hypertension

    • Distended or Flat neck veins

Physical assessment2
Physical Assessment

  • Respiratory

    • Changes in respiratory rate

      • Tachypnea > 20/min or dysphnea indicate excess Fluid Volume (FVE)

      • Moist crackles (FVE)

      • Shallow Slow breathing- Metabolic Acidosis

      • Deep rapid Breathing – Metabolic Alkalosis

Physical assessment3
Physical Assessment

  • Skin Appearance & Temperature

    • Access skin turgor

    • Appearance of the tongue

Physical assessment4
Physical Assessment

  • Body Weight

    • Weigh Daily – better indicator than I&O records

    • Loss or gain of 1 kg indicates a loss or gain of 1 L of body fluid

    • 15% flucation is considered sever

Fluid volume imbalance
Fluid Volume Imbalance

  • Fluid Volume Deficit

  • Common Causes of Isotonic Dehydration

    • Hemorrhage resulting in loss of fluid, electrolytes, proteins and blood cells resulting in inadequate vascular volume

    • Gastrointestinal losses

    • Fever, environmental heat, profuse sweating

    • Burns

    • Diuretics

    • Third spaced fluids

Fluid volume imbalance1
Fluid Volume Imbalance

  • Causes of Hypertonic Fluid Dehydration

    • Inadequate fluid intake

    • Decreased water intake results in ECF solute concentration and leads to cellular dehydration

Fluid volume imbalance2
Fluid Volume Imbalance

  • Fluid Volume Excess

    • Primary cause – Cardiovascular dysfunction secondary to an increase in total body sodium content

  • Causes of isotonic over hydration

    • Renal failure leading to decrease excretion of water and sodium

    • Heart failure leading to stasis of blood

    • Excess fluid intake of isotonic IV solution

    • High corticosteroid levels

  • High Aldosterone levels

Fluid volume imbalance3
Fluid Volume Imbalance

  • Common causes of Hypotonic Over hydration (Water intoxication)

    • More fluid is gained than solute

    • Serum osmolality falls causing cells to swell

    • Repeated water enemas

    • Overuse of hypotonic IV fluids

    • Ingestion of inappropriately prepared formula

    • SIADH causes kidneys to retain large amounts of water without sodium

  • Treatment- sodium and fluid restriction, diuretics, treat underlying cause.

Electrolyte balance
Electrolyte Balance

  • Major electrolytes in body fluid are sodium, potassium, calcium, magnesium, chloride, phosphorus and bicarb

  • Expressed in meq/liter. Measures chemical activity or combining power rather than weight

  • Each water compartment of the body contains electrolytes

    • Concentration and composition vary from compartment to compartment

Electrolyte balance cont
Electrolyte Balance (cont)

  • Physiological role of electrolytes

    • Maintaining electroneutrality in fluid compartments

    • Mediating enzyme reactions

    • Altering cell membrane permeability

    • Regulating muscle contraction and relaxation

    • Regulating nerve impulse transmission

    • Influencing blood clotting time

Electrolyte balance cont1
Electrolyte Balance (cont)

  • Sodium- 135 -145 mEq/L

  • Physiologic role of sodium:

    • Regulation of fluid distribution in body: water follows sodium

    • Maintenance of body fluid osmolarity

    • Promotion of neuromuscular response: Transmission of nerve and muscle impulses depends on sodium, gradient between ECF and ICF

    • Regulation of acid-base balance: Sodium combines with chloride and bicarbonate to alter pH

Electrolyte balance cont2
Electrolyte Balance (cont)

  • Sodium represents 90% of the extracellular cations

  • Serum plasma levels of electrolytes are important in the assessment and management of patients with electrolyte imbalances

  • Normal daily requirement 100mEq

  • Hyponatermia is a common complication of adrenal insufficiency

  • Hypernatermia – Serum Sodium excess great that 145mEq/L can occur with deprivation of water

Electrolyte balance cont3
Electrolyte Balance (cont)

  • Signs and Symptoms - Marked thirst, elevated body temperature, swollen tongue.

    • Chronic Hyponatremia: impaired sensation of taste, anorexia, muscle cramps, feeling of exhaustion, apprehension, feeling of impending doom and focal weakness.

  • Treatment: Gradually lower seum sodium level by infusion of hypotonic electrolyte solution .45 Normal Saline or D5W. Level lowered no more than 15 mEq/L in 8 hr.

Electrolyte balance cont4
Electrolyte Balance (cont)

  • Potassium: Physiological role

    • Regulation of fluid volume within the cell

    • Promotion of nerve impulse transmission

    • Contraction of skeletal smooth and cardiac muscle

    • Control of hydrogen ion concentration, acid-base balance

    • Role of enzyme action for cellular energy production.

Electrolyte balance cont5
Electrolyte Balance (cont)

  • Potassium is an intracellular electrolyte with 98% in ICF and 2% in the ECF

  • Acquired thru diet and must be ingested daily

  • Daily requirement is 40 mEq

  • Involved in muscle activity and transmission of nerve impulses.

Electrolyte balance cont6
Electrolyte Balance (cont)

  • Hypokalemia (cont)– Can cause alkalosis

    • S&S fatigue, muscle weakness, anorexia, nausea and vomiting, irregularity

    • Treatment – at level less than 3.5mEq/L replacement must be slow to prevent hyperkalemia

Electrolyte balance cont7
Electrolyte Balance (cont)

  • Hyperkalemia- Serum plasma level greater than 5.5mEq/L

    • Increased intake of potassium

    • Decreased urinary excretion

    • Movement out of cells into extra cellular space.

  • Signs & Symptoms

    • Changes shown on ECG

    • Vague muscle weakness

    • Flaccid paralysis

    • Anxiety

    • Nausea and vomiting

    • Cramping and diaherrea

Electrolyte balance cont8
Electrolyte Balance (cont)

  • Calcium: Physiological role

    • Maintaining skeletal elements; calcium is needed for strong bones and teeth

    • Regulating neuromuscular activity

    • Influencing enzyme activity

    • Converting prothrombin to thrombin, a necessary part of clotting.

  • 99% resides in bones and teeth

Electrolyte balance cont9
Electrolyte Balance (cont)

  • Hypocalcemia: reduction in total body calcium levels

    • Because of increase calcium loss, reduced intake secondary to altered intestinal absorption, altered regulation hypoparathyroidism

  • S & S:

    • Numbness of fingers, muscle cramps, hyperactive deep tendon reflexes, positive Trousseaus’s sign and Chevostek’s sign

  • Treatment with Calcium Gluconate oral or IV

Electrolyte balance cont10
Electrolyte Balance (cont)

  • Hyperclacemia: Excessive release of calcium from bone

  • S & S Neuromuscular symptoms, lethargy, bone pain, flank pain, pathological fractures, constipation, anorexia, N & V, Stone formation.

Electrolyte balance cont11
Electrolyte Balance (cont)

  • Magnesium: Physiological role

    • Enzyme action

    • Regulation of neuromuscular activity

    • Regulation of electrolyte balance, including facilitating transport of sodium and potassium across cell membranes, influencing the utilization of calcium, potassium, and protein.

  • A major intracellular electrolyte

Electrolyte balance cont12
Electrolyte Balance (cont)

  • Hypomagnesemia: often overlooked in critically ill patients

  • Results from:

    • Chronic alcoholism

    • Malabsorption syndrome

    • Prolonged malnutrition or starvation

    • Prolonged diarrhea

    • Acute pancreatitis

    • Administration of magnesium-free solutions for more than one week

    • Prolonged NG tube suctioning

Electrolyte balance cont13
Electrolyte Balance (cont)

  • S & S

    • Neuromuscular symptoms

      • Hyperactive reflexes,

      • Coarse tremors

      • Muscle cramps

      • Positive Chvostek’s and Trousseau’s signs

      • Seizures

      • Paresthesia of the feet and legs

      • Painfully cold hands and feet

      • Disorientation dysrhythmias tachycardia and indreased potential for digitalis toxicity

Electrolyte balance cont14
Electrolyte Balance (cont)

  • Hypermagnesemia: renal failure, addison’s disease, and inadequate excretion of magnesium by kidneys

  • S & S:

    • Neuromuscular symptoms

      • Flushing and sense of skin warmth

    • Lethargy

    • Sedation

    • Hypoactive deep tendon reflexes,

    • Depressed respiration

    • Weak or absent new born cry

Electrolyte balance cont15
Electrolyte Balance (cont)

  • Phosphorus: physiologic role:

    • Essential to all cells

    • Role in metabolism of proteins, carbohydrates and fats

    • Essential to energy, necessary in the formation of high energy compounds adenosine triphosphate (ATP) and adenosine diphosphate (ADP)

    • As a cellular building block, it is the backbone of nucleic acids and is essential to cell membrane formation’

    • Delivery of oxygen; functions information of red blood cell enzyme.

Electrolyte balance cont16
Electrolyte Balance (cont)

  • Approximately 80% is contained in the bones and teeth

  • 20% is abundant in the ICF

  • Plays and important role in delivery of oxygen to tissues by regulating the level of 2,3-DPG

  • Hyphphosphatemia: results from

    • Overzealous refeeding,

    • TPN administered without adequate phosphorus

    • Malabsorption

    • Alcohol withdrawal

    • Vomiting, chronic diarrhea, and malabsorption syndromes

Electrolyte balance cont17
Electrolyte Balance (cont)

  • Other Electrolyte imbalance:

    • Hyperphosphatemia

    • Hypochloremia

    • Hyperchloremia