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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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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