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Fluids and Electrolytes Balance. Josierina Y. Sarmiento, M.D. Nephrologists Asian Hospital and Medical Center. Body Fluids. Man have 60% Woman have 50% Fat contains little water % of body weight that is water decreases with age. Body Fluid Compartment. Extracellular Fluids (ECF).

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fluids and electrolytes balance

Fluids and Electrolytes Balance

Josierina Y. Sarmiento, M.D.

Nephrologists

Asian Hospital and Medical Center

body fluids
Body Fluids
  • Man have 60%
  • Woman have 50%
  • Fat contains little water
  • % of body weight that is water decreases with age
extracellular fluids ecf
Extracellular Fluids (ECF)
  • Supplies the food, oxygen, water, vitamins and electrolytes and takes away body waste.
fluid spacing
Fluid Spacing
  • First spacing – normal amount of fluids in both the extracellular and intracellular compartments.
  • Second spacing – an excess accumulation of intestinal fluid (edema).
  • Third spacing – fluid accumulation in areas that normal have no fluids or minimal amount of fluids. (Ascites)
electrolytes
Electrolytes
  • Solutes and substances that are dissolved in body fluids.
  • Electrolytes
  • Non – electrolytes
    • Compounds that do not separate into charged particles when dissolved in water……GLUCOSE
electrolytes1
Electrolytes
  • Electrolytes are compounds that do not separate into charged particles called ions.
    • Cations – positively charged ions such as Na+.
    • Anions – negatively charged ions such as Cl-.
electrolytes2
Electrolytes
  • Electrolytes are found inside and outside of the cell.
diffusion
Diffusion
  • Molecules and ions flow through a semi permeable membrane from an area of higher concentration to an area of lower concentration.
osmosis
Osmosis
  • Movement of water through a semi permeable membrane from a weaker solution to the more concentrated solution
  • The in intent is to equalize the strength of solution.
osmotic pressure
Osmotic Pressure
  • Osmotic pressure – is the pulling of water in the process of osmosis.
  • Osmolarity – an indication of whether a person is adequately hydrated, over by drated or dehydrated.

Normal: 275 – 295 mOsm/kg

osmotic movement of fluids
Osmotic Movement of Fluids
  • Isotonic – fluids that have the same osmolarity as the fluid inside the cell.

Example: Plain LR and plain NSS

  • Has the same concentration as inside the cells
hypotonic hypoosmolar
Hypotonic / Hypoosmolar
  • Hypotonic – fluids that contain more water than the intercellular fluids.

Example: ½ NSS

    • Hypotonic fluid surrounds the cells and causes the water to move inside the cell until it burns.
hypertonic solution
Hypertonic Solution
  • Hypertonic solutions – are fluids that contain less water (more concentrated) than intracellular fluids.
    • Hypertonic solution around the cells draws water from the cell until it shrinks.
hypotonic solution
Hypotonic Solution

Water

½ NSS

Burst

hypertonic solution1
Hypertonic Solution

3% NaCl

Shrinks

hydrostatic pressure
Hydrostatic Pressure
  • Hydrostatic Pressure – is the force exerted by fluids against the wall of it containers.
  • Hydrostatic Pressure – is the major force in the movement of water out of the capillaries.
oncotic pressure
Oncotic Pressure
  • Oncotic pressure – is also known as colloidal osmotic pressure that is the presence caused by colloids in the solution.
  • Colloids – are particles that are too large to pair through a semi permeable membrane.

Example: protein

capillary fluid movement
Capillary Fluid Movement
  • The amount and direction of fluid movement is based on the hydrostatic pressure and oncotic pressure.
capillaries
Capillaries

Hydrostatic

Pressure

Oncotic

Pressure

Venous

End

Arterial

End

fluid shift
Fluid Shift
  • Edema – imbalance between hydrostatic and oncotic pressure.
  •  Hydrostatic pressure
  • CHF, tourniquet
  •  Oncotic pressure
  • Malnutrition
  • Nephrotic syndrome
regulation of fluids and electrolytes
Regulation of Fluids and Electrolytes
  • Hypothalamus – the thirst mechanism that stimulates us to drive. It is stimulated by increased in serum osmolality.
  • Hormones:
    • ADH (antidiuretic hormone) – acts on the renal tubules to retain water and decrease urinal outputs
    • Aldosterone – increases sodium and water reabsorption.
fluids and electrolytes imbalances
Fluids and Electrolytes Imbalances
  • Hypovolemia – decreased in intravascular fluid volume.
    • Occurs when water and electrolytes are lost or unavailable to circulation.
    • Diarrhea, massive bleeding, excessive sweating (marathon, runners), vomiting.
assessment of hypovolemia
Decreased body temperature

Low blood pressure

Tachycardia

Weak pulse

Increased respiration

Weakness

Weight loss

Decreased urine output

Increased Hab/Hct

Assessment of Hypovolemia
hypervolemia
Hypervolemia

Hypervolemia is the excess of water and electrolytes in the ECF.

  • Renal failure
  • Congestive heart failure
assessment of hypervolemia
Acute weight gain

Cardiac enlargement, cyanosis

Decreased Hct, Hab, RBC’s

Skin warm and moise

Pitting edema

Puffy eyelids

Bounding pulse

Dyspnea, increased respiratory rate

Distended neck vein

Assessment of Hypervolemia
treatment for hypervolemia
Treatment for Hypervolemia
  • Sodium restriction
  • Limit fluid intake
  • Diuretics
electrolyte balance
Electrolyte Balance
  • Each electrolyte has its very own function.
  • Too much or too little may alter the function.
  • Electrolytes concentration may be altered by changing the quantity of the electrolyte or by altering the quantity of water in the ECF in which electrolytes is found.
sodium
Sodium
  • Sodium is the chief cat ion in the ECF.

NV = 135 – 145 mEq/L

  • Sodium function include transmission of nerve impulses, maintain acid-base balance, regulate water reabsorption and excretion in kidney tubules.
sodium1
Sodium
  • Normal Na intakes is 2 to 4 grams
  • Hypernatremia – too much Na in the intravascular space; cause cell to shrink
  • Hyponatremia – too little Na in the intravascular space, cause the cell to swell.
  • Aldosterone – reabsorbs Na in the kidney tubules
defining characteristics of hyponatremia
Defining Characteristics of Hyponatremia
  • Serum Na < 135 mEq/L
  •  Serum osmolality
  • Anorexia and nausea
  • Lethargy
  • Confusion, seizures, coma
  • Muscle twitching
nursing intervention for hyponatremia
Nursing Intervention for Hyponatremia
  • Encourage diet high sodium
  • Weigh daily
  • Monitor neurological status
  • Monitor serum Na levels
  • Maintain free water intake
food high in sodium
Food High in Sodium
  • Potato chips
  • Bacon / catsup
  • Table salt
  • Crackers
  • Cheese
  • Pretzels, etc.
  • Luncheon meat
hypernatremia
Hypernatremia
  • Serum Na greater than 145 mEq/L
  • Due to water deficit
  • Serum osmolality > 295 mOsm/kg.
defining characteristic of hypernatremia
Defining Characteristic of Hypernatremia
  • Dry tongue
  • Thirst
  • Fever
  • Oliguria
  • CNS symptoms including focal or grand mal seizures
nursing intervention for hypernatremia
Nursing Intervention for Hypernatremia
  • Encourage low Na diet
  • Accurate I;O
  • Hypotonic fluids
  • Observe for seizure
chloride
Chloride
  • Chloride is the major extracellular anion
  • Part of hydrochloric acid in the stomach
  • When Na is reabsorbed so is Cl
potassium
Potassium
  • Potassium is the major intracellular cat ion.
  • Function:
    • ICF balance
    • Maintain regular heart rhythm
    • Conducts neuromuscular impulses
    • Regulation of acid-base balance
  • Normal potassium range: 3.5 – 5.0 mEq/L
reasons for hypokalemia
Reasons for Hypokalemia
  • Diarrhea
  • Ostomies
  • Loop diuretics
  • Poor intake of K rich foods
  • Stress
defining characteristics hypokalemia
Defining Characteristics Hypokalemia
  • Serum K+ level less than 3.5 mEq/L
  • Muscle weakness
  • Cardiac arrhythmias
  • Increased sensitivity to digitalis toxicity
  • Muscle weakness
  • Fatigue
  • ECG changes: ST depression / U wave
nursing intervention for hypokalemia
Nursing Intervention for Hypokalemia
  • Encourage high K foods
  • Monitor EKG results
  • IV/oral Potassium replacement
foods high in potassium
Foods high in Potassium
  • All dried fruits/banana
  • Spinach
  • Beef
  • Chocolate
  • Potato’s
  • Tomato’s
hyperkalemia
Hyperkalemia
  • Renal insufficiency.
  • High potassium intake.
  • Shift of potassium out of the cell as in acidosis.
defining characteristics of hyperkalemia
Defining Characteristics of Hyperkalemia
  • Potassium levels greater than 5.0 mEq/L
  • Neuromuscular weakness
  • EKG changes – peaked T waves widened QRS complex
  • Flaccid muscles paralysis
  • Heart block
nursing intervention for hyperkalemia
Nursing Intervention for Hyperkalemia
  • Monitor EKG changes
  • Administer calcium solutions to neutralize the potassium
  • Monitor muscle tone
  • Give kayexalate
  • Glucose + insulin solution
  • Diuretics
calcium
Calcium
  • For transmission for nerve impulses
  • For muscle contraction
  • Blood clotting
  • Bone and tooth formation
  • Normal level: 8.6 – 10.6 mg/dl
  • 2 hormones:
    • Parathormone
    • Calcitonin
reasons for hypocalcemia
Reasons for Hypocalcemia
  • Vitamin D deficiency
  • Malabsorption
  • Excessive GI loss
  • hypoparathyroidism
defining characteristic of hypocalcemia
Defining Characteristic of Hypocalcemia
  • Membranes, tingling of fingers
  • Tetany and cramps
  • Trosseau’s sign – carpal spasms
  • Chvostek’s sign – cheek twitching
  • Seizures, mental changes
  • EKG shows prolonged QT intervals
    • Treatment: Calcium carbonate / calcium gluconate
hypercalcemia
Hypercalcemia
  • Hyperparathyroidism
  • Thiazide diuretics
  • Malignancy
  • Renal failure
  • Antacids
  • Serum calcium: > 10.5 mg/dl
  • EKG: shorted QT intervals
    • Treatment: calcium from the diet
acid base balance
Acid Base Balance
  • Acids – substance that can release hydrogen ions
  • Bases – substance that can accept hydrogen ions
    • Hydrogen ions determine whether a solution is acidic, basic or neutral
      • Normal pH: 7.35 – 7.45
      • Buffer system: carbonic acid / bicarbonate
metabolic acidosis
Metabolic Acidosis
  • a base bicarbonate deficit
  • Normal HCO3; 22 – 26 mEq/L
  • Comes from too much acid and loss of bicarbonate
  • S/s: pH < 7.35, increased K+ levels DKA (Kussmaul’s, breathing)
  • Shock, stupor, coma
  • Nursing intervention – give HCO3
metabolic alkaloses
Metabolic Alkaloses
  • A base bicarbonate excess
  • A result of a loss of acid and a accumulation of base.
  • S/s: serum pH > 7.45, increased serum HCO3, serum K levels > 5.0 tetany, convulsions, seizures
  • Nursing intervention – watch for S/s of hypokalemia
respiratory alkalosis
Respiratory Alkalosis
  • A deficit of carbonic acid caused by hyperventilation
  • Normal pCO2: 35 – 45
  • Decreased levels of pCO2, increased levels of pH, HCO3 = normal.
  • Nursing intervention – monitor for anxiety (breath in brown paper bag).
respiratory acidosis
Respiratory Acidosis
  • A carbonic acid excess
  • Caused by condition that interferes with the release of CO2 from the lungs (sedatives, COPD, narcotics)
  • S/s: serum pH < 7.35,  pCO2 levels, cyanosis
  • Nursing intervention: provide O2
interpretation of arterial blood gases
Interpretation of Arterial Blood Gases
  • Pyramid points:
    • If acidosis the pH is down
    • If alkolosis the pH is up
    • The reparatory function indicator is the pCO2
    • The metabolic function indicator is the HCO3
step i
Step I
  • Look at the pH
  • Is it up or down?
  • If it is up: it reflects alkalosis
  • If it is down: it reflects acidosis
step ii
Step II
  • Look at the pCO2.
  • Is it up or down.
  • If it reflects an opposite response as the pH, then you know that the condition is a respiratory imbalance.
  • If it does not reflect as opposite response as the pH – move to step III.
step iii
Step III
  • Look at the HCO3
  • Does the HCO3 reflect a corresponding response with the pH?
  • If it does then the condition is a metabolic imbalance
example 1
Example # 1
  • PO2 99.5
  • pH 7.29
  • pCO2 41 meq/L
  • HCO3 19
  • BE - 17
  • RR 22
  • O2 2L/NC
answer
Answer

Metabolic Acidosis

example 2
Example # 2
  • PO2 98
  • pH 7.50
  • pCO2 30 meq/L
  • HCO3 29 meq/L
  • BE + 20
  • RR 28
  • Room air
answer1
Answer

Respiratory Alkalosis

total parental nutrition tpn hyperalimentation
Total Parental Nutrition (TPN)Hyperalimentation
  • Provide life sustaining therapy for patients who cannot take adequate food by mouth and who consequently are at risk for malnutrition and its effects.
indications for tpn
Perioperative nutrition

Critical illness

Cancer cachexia

Liver failure

Renal failure

Inflammatory bowel disease

Short bowel syndrome

Pulmonary disease

HIV

Pregnancy

Indications for TPN
energy requirement
Energy Requirement

Hypometabolic state

20 Kcal/kg

x

e.g. 70 kg man

1, 400 Kcal

Hypermetabolic state

(sepsis trauma)

40 Kcal/kg

x

e.g. 70 kg man

1, 800 Kcal

conditionally essential nutrients
Conditionally Essential Nutrients
  • Glutamine – fuel for enterocyte and immunocyte
  • Nucleotides – mediators for many metabolic process
  • Branched chain – regulates muscle amino acid, protein breakdown
conditionally essential nutrients1
Conditionally Essential Nutrients
  • SAM (S-adenosyl methionine) – normalizes cell wall fluidity
  • Short chain fatty acid – fuel for colonocyses
  • Omega 3 fatty acids – promotes production of prostaglandin
commercially available tpn
Commercially Available TPN
  • Nutripack 1, 200 Kcal, 1, 900 Kcal
  • Nutroflex 1, 200 Kcal, 1, 900 Kcal
  • Kabiven 1, 400 Kcal
  • Vitrimix
  • Intralipids
  • Vamin glucose
  • Vamin 14
  • Nephrosteril
infusion technique and patient monitoring
Infusion Technique and Patient Monitoring
  • Peripheral line: isotonic fat solution, short-term
  • Central venous line: long-term, using glucose as the chief energy source
fluids
Fluids
  • Isotonic Fluids (Crystalloids)
    • Saline (Plain NSS)
      • 154 meq Na
      • 0.9%

 Hypovolemic shock

fluids1
Fluids
  • Hypotonic Fluids
    • ½ NSS = 77 meq Na

= 0.45%

    • Dextrose in water

D5water = 5 grams glucose

D10water = 10 grams glucose

    • For hypernatremic patients
fluids2
Fluids
  • Hypertonic solution
    • 3% NaCl

 Use in hyponatremic patients

    • NaHCO3

 For acidotic patients

fluids3
Fluids
  • Polyionic solutions
    • Ringers (Plain LR)
    • Lactated ringers
    • KCl
    • Use for diarrhea
fluids4
Fluids
  • Colloids
  • Starch (Hydroxyethyc Starch)
    • Haeteril (10% or 5%)
    • Haemacel
    • Gelafurdin

 Hypovolemic shock