fluid n electrolytes
TRANSCRIPT
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FLUID & ELECTROLYTES
ACID BASE IMBALANCES
CHAPTER 17
Megan McClintock
Winter 2012
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HOMEOSTASIS
Maintained by the intake and output of waterand electrolytes and regulation by the renal andpulmonary systems
Acid-base balance is necessary for manyphysiologic processes (respiration, metabolism,function of the CNS)
Many disease and treatmentsaffect this balance
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WATER
More important to life than any other nutrient
60% of an adults body weight, more in a
child, less in the elderly
Found in foods (but not in alcohol)
Daily need is about 2000 mL
1 liter of water weighs 1 kg
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URINE SPECIFIC GRAVITY
Measures the kidneys ability to concentrate
or dilute urine 1.002 1.028
High is dehydrated
Low is overhydrated (or unable to concentrate)Kidney failure often causes a fixed specific
gravity
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ELECTROLYTES
Cations (positively charged)
K+, Na+, Ca+, Mg+
Transmit nerve impulses to muscles and contract
skeletal and smooth musclesAnions (negatively charged)
Attached to cations
Cl-, HCO3-, PO4-, SO4-Are always kept in
balance
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DISTRIBUTION OF BODY FLUIDS &
ELECTROLYTES
Intracellular (2/3) K+, PO4-
Extracellular (1/3) Na+, Cl-
Interstitial (lymph)
Intravascular (blood plasma)
Transcellular (cerebrospinal, pleural, peritoneal,
synovial fluids)
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REGULATION OF FLUID & ELECTROLYTE
MOVEMENT
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OSMOLALITY
Indicates the water balance of the body
Serum osmolality (275 - 295)
High is water deficit
Low is water excess
Urine osmolality (100-1300)
High is concentrated
Low is dilute
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FLUID SPACING
First spacing
Normal
Second spacing
Edema
Third spacing
Ascites
Burn edema
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REGULATION OF WATER BALANCE
Hypothalmic Regulation Thirst is stimulated
ADH (vasopressin) release is stimulated
Pituitary RegulationADH (vasopressin) is released
Adrenal Cortical Regulation Glucocorticoids & mineralocorticoids are released
Renal RegulationAdjust urine volume and electrolyte excretion
Normal is 1.5 Liters of urine/day
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REGULATION OF WATER BALANCE (CONT.)
Cardiac Regulation
ANP & BNP will stop the action of the adrenalcortex and the kidney
GI Regulation Intake and output are reabsorbed here
Diarrhea and vomiting can lead to significantlosses
Insensible Water Loss
600-900 mL/day from the lungs and skin
Increases with fever, exercise
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GERONTOLOGIC CONSIDERATIONS
Structural changes in the kidney and decreased renalblood flow
Decreased GFR
Decreased creatinine clearance
Loss of ability to concentrate urine and thus conservewater
Decrease in renin and aldosterone
Increase in ADH and ANP
Loss of subcutaneous tissue
Decrease in thirst mechanism
Musculoskeletal changes
Mental status changes
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FLUID VOLUME DEFICIT
What causes
it?
What can
you do?
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FLUID VOLUME EXCESS
What causes
it?
What can
you do?
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NURSING INTERVENTIONS
Strict I/O Intake oral, IV, tube feedings, retained irrigants
Output urine, excess sweating, wound/tubedrainage, vomitus, diarrhea
Urine specific gravityAssessment of CV, Resp, Neuro, Skin status
Daily weight under standardized conditions
Dont catch up IV fluids No water with NG suction, use isotonic saline
Keep fluids accessible and within reach
Give warm or cold fluids (not room temperature)
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SERUM ELECTROLYTES Sodium (Na) 135 - 145
Primarily responsible for maintaining osmotic pressure(intracellular and extracellular fluids)
Increased with fluid deficitDecreased with fluid excess
Potassium (K) 3.5 5.0
Major component of cardiac function Increased with poor kidney function Decreased with excessive urination, diarrhea or vomiting
Chloride (Cl) 96 106 Works with Na to maintain osmotic pressure Increased with poor kidney function
Decreased with excessive vomiting or diarrhea Calcium (Ca) 8.6 10.2
Transmission of nerve impulses, heart and muscle contractions,blood clotting, formation of teeth and bone
Phosphate (PO4) 2.4 4.4 Function of muscle, RBCs, and the nervous system
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THE MAGIC FOURS
Electrolyte Range Magic 4
Potassium 3.5 - 5.0 4
Chloride 96 - 106 104Sodium 135 - 145 140
pH 7.35 - 7.45 7.4
CO2 35 - 45 40HCO3 22 - 26
24
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SODIUM (135 - 145)
Major cation of ECF
Primary determinant of osmolality
GI tract absorbs sodium from foodRegulated by kidneys, ADH, aldosterone
Sodium level reflects the ratio of sodium to
water Imbalances are typically associated with fluid
volume problems
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HYPERNATREMIA (HIGH SODIUM)
What can you
do?
What causes
it?
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HYPONATREMIA (LOW SODIUM)
What causes
it?
What can
you do?
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POTASSIUM (3.5 - 5.0)
Major cation of ICF
Sodium-potassium pump requires
magnesium
Moves into cells during formation of new
tissues and leaves the cell during tissue
breakdown
Diet is the source of potassium
Kidneys are primary route of loss
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HYPERKALEMIA (HIGH POTASSIUM)
What can
you do?
What causes
it?
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HYPOKALEMIA (LOW POTASSIUM)
What causes
it?
What can
you do?
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CALCIUM (8.6 10.2)
Primary source is bones
Regulated by parathyroid hormone,
calcitonin, and vitamin D
Affects transmission of nerve impulses, heart
and muscle contractions, blood clotting, and
forming of teeth and bone
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HYPERCALCEMIA (HIGH CALCIUM)
What can
you do?
What causes
it?What are the
symptoms?
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HYP0CALCEMIA (LOW CALCIUM)
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PHOSPHATE IMBALANCES
Hyperphosphatemia Cause - renal failure
S/S calcium deposits in joints, skin, kidneys, eyes;hypocalcemia, tetany, neuromuscular irritability
Tx decrease intake of dairy products, good hydration,fix hypocalcemia
Hypophosphatemia Cause malnutrition, malabsorption syndrome, alcohol
withdrawal
S/S CNS depression, confusion, muscle weakness,dysrhythmias
Tx oral supplements (Neutra-Phos), lots of dairyproducts, IV phosphate (but this can cause suddenhypocalcemia)
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MAGNESIUM IMBALANCES
Hypermagnesemia Cause increased intake (ie. MOM, Maalox) with chronic
kidney disease
S/S lethargy, n/v, loss of DTRs, can have respiratory andcardiac arrest
Tx avoid magnesium-containing drugs, IV calcium,increased fluid intake, may need dialysis
Hypomagnesemia Cause prolonged fasting or starvation, chronic alcoholism,
diuretics
S/S confusion, hyperactive DTRs, tremors, seizures, cardiacdysrhythmias
Tx oral supplements, increase green veggies, nuts,bananas, oranges, peanut butter, chocolate; IV or IMmagnesium (if given too rapidly can cause cardiac orrespiratory arrest)
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MEDICATIONS
Loop diuretics
Thiazide diuretics
Potassium sparing diuretics
Electrolytes
Kayexolate
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ACID BASE BALANCE
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REGULATION OF ACID-BASE BALANCE
Buffer system (immediate)
Primary regulator
Wont work without good functioning respiratory
and renal symptoms
Respiratory system (minutes, max in hours)
Excretes CO2 and water
Renal system (2-3 days to max respond)
Reabsorbs HCO3
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ARTERIAL BLOOD GAS
pH (7.35 7.45)
CO2 (35 45)
HCO3 (22 26)
Base excess (+2 to -2) If high, metabolic alkalosis
If low, metabolic acidosis
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DETERMINING
ACIDBASE BALANCE
1. Is pH acid, base or normal?
2. Is CO2 acid, base or normal?
3. Is HCO3 acid, base or normal?4. Which of the components match?
5. Is there compensation?Is non-matching reading abnormal? partial compensation
Is non-matching reading normal? no compensation
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RESPIRATORY ALKALOSIS
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RESPIRATORY ALKALOSIS
Causes Hyperventilation
Pulmonary disease
High altitudes
Signs/symptoms Hyperventilation
Feels light-headed
Arrhythmias
Anxiety
Treatment Breathe into paper bag
Rebreather mask
Anti-anxiety medicine
Relaxation techniques Reduce stimulation
Treat pain/fever
Assess:
Resp rate/depth HR & BP
Serum K levels
Hydration status
Check for digitalis toxicity
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RESPIRATORY ACIDOSIS
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RESPIRATORY ACIDOSIS
Causes CNS depression
Loss of lung surface
Neuromuscular disease
Immobility
Mechanical ventilation Signs/symptoms
Dyspnea
Hypoxia
Drowsiness
Tachycardia Seizures
Diaphoresis
Treatment Turn, cough, deep breathe
Semi-Fowlers position
Suction
Incentive spirometer
Seizure precautions Decrease use of sedatives
Bronchodilators
May need ventilator
Assess:
Resp rate/depth HR & BP
Patiency of airway
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METABOLIC ALKALOSIS
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METABOLIC ALKALOSIS
Causes NG suctioning
Prolonged vomiting
Diuretic use
Multiple bloodtransfusions
CPR (given bicarb)
Signs/symptoms Dizziness
Dysrhythmias Convulsions
Confusion
Muscle cramps (late sign)
Treatment Identify and treat the
cause!
IV fluids
Stop giving bicarbonate
Give antiemetics
Give Diamox
Assess: Resp rate/depth
HR & BP
Serum K levels (usuallylow)
Hydration status (tend to bedehydrated)
Check for digitalis toxicity
Parasthesias
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METABOLIC ACIDOSIS
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METABOLIC ACIDOSIS
Causes Diabetic ketoacidosis
Renal or liver failure
Severe diarrhea
Vomiting Starvation
Signs/symptoms Kussmaul respirations
Hypotension
Arrythmias Warm to hot ,flushed skin
Confusion
Treatment Identify and treat the
cause!
Administer insulin (if due toketoacidosis)
Give antiemetics IV fluids
IV bicarbonate
Assess: Renal function (BUN,
creatinine) Serum K levels (tends to go
up but down once insulingiven)
Hydration status
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IV FLUIDS
Isotonic NS
D5W
LR Hypertonic
3% NS
D51/2NS
D10W Hypotonic
1/2NS
Plasma Expanders
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CENTRAL VENOUS ACCESS DEVICES
Centrallyinsertedcatheters(CVCs)
Peripherallyinserted centralcatheters
(PICCs)
Implanted
infusion ports
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NURSING CARE OF CVADS
Inspect site for redness, edema, warmth, drainage,pain
Dressing change/cleaning with sterile technique usingchlorhexidine (back and forth scrub to generate
friction) Maintain transparent dressing c/d/I
Change injection caps using sterile technique
Teach pt to turn head away from insertion site duringcleaning and cap change
Have patient Valsalva during cap change if unable toclamp
Use push-pause method to flush (creates turbulence)
Removal of non-tunneled CVCs and PICCs may be