Fluid and electrolyte balance play an important role in homeostasis, and critical care nurses assume a vital role in identifying and treating the physiologic stressors experienced by critically ill patients that disrupt homeostasis

Fluid and electrolyte balance play an important role in homeostasis, and critical care nurses assume a vital role in identifying and treating the physiologic stressors experienced by critically ill patients that disrupt homeostasis.

Electrolytes, found in body fluids, are electrically charged particles (ions). Cations are positively charged ions; anions are negatively charged ions. Electrolytes play a crucial role in transmitting impulses for proper heart, nerve, and muscle function. The number of positively and negatively charged ions should be equal; when this balance is upset, electrolyte abnormalities can occur. Electrolytes can further be classified as extracellular (EC, outside the cell) or intracellular (IC, inside the cell). Sodium is the most abundant EC electrolyte; potassium is the most abundant IC electrolyte. Just as too little or too much of any one electrolyte can become a problem in maintaining a critically ill patient's stability, imbalances in fluid homeostasis can also present unique challenges for both you and your patient.

Fluidsare in constant motion in the body. Total body water (TBW) normally accounts for about 60% of an adult's body weight. Forty percent of TBW is in the IC space, and EC water accounts for 20% of body weight: 14% in the interstitial space, and 5% in the intravascular space. Transcellular fluid (cerebral spinal fluid and fluid contained in other body spaces such as joint spaces, and the pleural, peritoneal, and pericardial spaces) make up about 1% of total body weight.

To maintain homeostasis, fluids need to be stable in the intravascular, interstitial, and IC spaces. The amount of IC fluid is rather stable in the body; intravascular fluid is the least stable and fluctuates in response to fluid intake and loss. Interstitial fluid is the reserve fluid, replacing fluid in the intravascular and IC spaces as needed.

Almost all pathologies affect the fluid balance within the body, especially in critically ill patients. Fluid movement within the various body spaces depends onosmosis-movement of water through a selectively permeable or semipermeable membrane from a solution that has a lower solute concentration to one with a higher solute concentration-anddiffusion, or the free movement of molecules or other particles in solution across a permeable membrane from an area of higher concentration to an area of lower concentration, resulting in an even distribution of the particles in fluid. Fluid balance also is regulated by certain hormones:

* Aldosterone, the principal mineralcorticoid produced by the adrenal cortex, promotes sodium retention by the distal tubules, while increasing urinary losses of potassium. This helps to prevent water and sodium losses through the kidneys.

* Antidiuretic hormone (ADH), also known as vasopressin, is synthesized in the hypothalamus and stored in and released by the posterior pituitary gland. ADH triggers the renal tubules to reabsorb water and return it to the intravascular space.

* Natriuretic peptides, such as atrial natriuretic peptide, released from the heart in response to cardiac chamber stretch and overfilling, increase sodium and water excretion by the renal distal and collecting tubules.

Because the kidneys are the major organs involved in electrolyte and fluid homeostasis, the nurse must determine the patient's renal function before attempting to correct a patient's electrolyte or fluid imbalance.Also, a nurse must not let lab numbers or the numerous equations used for fluid replacement override sound clinical judgment. If the patient's clinical condition doesn't support the numbers, the nurse must perform a follow-up test-an error could have occurred in the lab, blood draw, or be the result of blood sample hemolysis.INTAKE AND OUTPUT

One of the most basic methods of monitoring a client's health is measuring intake and output , commonly called I and O. By monitoring the amount of fluids a client takes in and comparing this to the amount of fluid a client puts out. The health care team can gain valuable insights into the client's general health as well as monitor specific disease conditions.

INTAKE- all those fluids entering the client's body such as water, ice chips, juice, milk, coffee and ice cream. Artificial fluids include: parenteral, central lines, feeding tubes, irrigation and blood transfusion.OUTPUT- all fluid that leaves the client's body such as: urine, perspiration, exhalation, diarrhea, vomiting, drainage from all tubes and bleeding.

Equipment: I & O form at bedside

I & O graphic record in chart

Pencil and paper

Calibrated drinking glass

Bedside pan, commode or urinal

Calibrated container to measure outputs

Weighing scale

Non-sterile gloves

Sign at bedside stating patient is for I & O monitoring

Ideal Daily fluid Intake and OutputSource

|AMOUNT| Route of excretion |AMOUNT

H2O consumed as fluid| 1500ml|urine

| 1400-1500mlH2O present in food |750ml

| insensible losses|350-400ml

H2O produced by oxidation |350ml

| lungs

|350-400ml

skin

|100ml

sweat

|100-200ml

TOTAL

2600ml| TOTAL|2300-2600ml

Purpose:

helps evaluate client's fluid and electrolyte balance

suggests various diagnosis

influence the choice of fluid therapy

document the client's ability to tolerate oral fluids

recognize significant fluid losses

Mandatory for clients with burns, electrolyte imbalance, recent surgical procedure, severe vomiting or diarrhea, taking diuretics or corticosteroids, renal failure, congestive heart failure, NGT, drainage collection device and IV therapy.

Deviations:

Other sources of fluid loss and excessive losses from normal routes:

drainage from catheter or tubes

vomitus

Diarrhea

Diaphoresis

Hemorrhage

ileostomy/colostomy

excessive urine output

Average daily water requirement by age and weight:AGE

ml/

ml/kg3days

250-350ml

80-1001year

1350-1500ml

115-1254years

1600-1800ml

100-11010years

2000-2500ml

70-8514years

2200-2700ml

50-6018years

2200-2700ml

40-60adult

2400-2600ml

20-30

Nursing Interventions:

Intervention/ Rationale:1. Ideally intake and output should be monitored/ To obtain an accurate record

2. In critical situations, intake and output should be monitored on an hourly basis/ Urine output less than 500ml in 24 hours or less than 30cc/hour indicates renal failure

3. Daily weights are often done/ Indicate fluid retention or loss

4. Identify if patient undergone surgery or with medical problem / May affect fluid loss

5. Make sure you know the total amount and fluid sources once you delegate this task/To get an accurate measurement

6. Record the type and amount of all fluids and describe the route at least every 8 hours

7. If irrigating a nasogastric or another tube or bladder, measure the amount instilled and subtract it from the total output/ To get exact amount

8. Keep toilet paper out of client urine output/ For an accurate measurement

9. Measure drainage in a calibrated container and observe it at eye level.

A significant change in a client's weight or a significant difference in a client's total intake and output should be reported immediately to the physician.

WEIGHT CHANGES

mild dehydration- 2 to 5% loss

moderate dehydration- 6 to 9% loss

severe dehydration - 10 to 14% loss

death- 20% loss

mild volume overload- 2% gain

moderate volume overload - 5% gain

severe volume overload - 8% gain

Clinical Signs of Dehydration:

dry skin and mucous membrane

concentrated urine

poor skin turger

depressed periorbital space

sunken fontanel

dry conjunctiva

cracked lips

decreased saliva

weak pulse

Client's signs of fluid excess:

peripheral edema

puffy eyelids

sudden weight gain

ascites

rales in lungs

blurred vision

excessive salivation

distended neck veinCLINICAL DO'S & DON'TS

INTAKE AND OUTPUT gauge fluid balance and give valuable information about your patient's condition.

DO Identify whether your patient has undergone surgery or if he has a medical condition or takes medications that can affect fluid intake or loss. Measure and record all intake and output. If you delegate this task, make sure you know the totals and the fluid sources. At least every 8 hours, record the type and amount of all fluids he's received and describe the route as oral, parenteral, rectal, or by enteric tube. Record ice chips as fluid at approximately half their volume. Record the type and amount of all fluids the patient has lost and the route. Describe them as urine, liquid stool, vomitus, tube drainage (including from chest, closed wound drainage, and nasogastric tubes), and any fluid aspirated from a body cavity. If irrigating a nasogastric or another tube or the bladder, measure the amount instilled and subtract it from total output. For an accurate measurement, keep toilet paper out of your patient's urine. Measure drainage in a calibrated container. Observe it at eye level and take the reading at the bottom of the meniscus. Evaluate patterns and values outside the normal range, keeping in mind the typical 24-hour intake and output. When looking at 8-hour urine output, ask how many times the patient voided, to identify problems. For example, was a total of 300 and from 2 voids of 150 ml, or from 10 voids of 30 ml each Regard intake and output holistically because age, diagnosis, medical problem, and type of surgical procedure can affect the amounts. Evaluate trends over 24 to 48 hours.DON'T Don't delegate the task of recording intake and output until you're sure the person who's going to do it understands its importance. Don't assess output by amount only. Consider color, color changes, and odor too. Don't use the same graduated container for more than one patient.0WEIGHT MONITORING Percuss from the level of the umbilicus and repeat moving laterally towards one side.

When the sound becomes dull, keep the fingers there to mark the spot and ask the patient to move on to the opposite side.

Wait briefly for the fluid to sink and percuss again. If it is now resonant, that is a positive sign. Percuss down until dullness is reached again.

Repeat on the other side.

False positives do occur, probably from dilated coils of small intestine reacting to gravity.

At least 1500 ml of fluid must be present for a result. An ultrasound scan will detect much less fluid with greater certainty.Positive result: Probability of Ascites

Monitoring

Simple assessment of the progress of ascites may be made by:

Serial measurements of the abdominal girth - ensure the tape measure is placed in the same position each time.

Serial measurement of weight - rapid changes indicate fluid gain or loss which are much faster than gain or loss of fat or lean body mass.

When Weighing, the Patient Must:1. Use the same scale every day.

2. Wear similar clothing each time he weighs himself.

3. Weigh himself at the same time each day (for example, when he gets up on the morning).

4. Weigh himself before eating and after urinating.

5. Record his weight in a diary or on a calendar.

6. Learn what his dry weight is. This is his weight without extra water (fluid).

7. Weigh himself in the morning after he is discharged from the hospital. One pound less than this will be his dry weight. His goal is to keep his weight within four pounds of his dry weight.

8. Compare his actual daily weight to his dry weightKIDNEYS, URETERS, AND BLADDER (KUB) X-RAYA KUB is a plain frontal supineradiographof the abdomen. It is often supplemented by an upright PA view of the chest (to rule out air under the diaphragm or thoracic etiologies presenting as abdominal complaints) and a standing view of the abdomen (to differentiate obstruction from ileus by examining gastrointestinal air/water levels).Despite its name, a KUB is not typically used to investigate pathology of the kidneys, ureters, or bladder, since these structures are difficult to assess (for example, the kidneys may not be visible due to overlying bowel gas.) In order to assess these structures radiographically, a technique called anintravenous pyelogramwas historically utilized, and today at many institutions CT urography is the technique of choice.

KUB is typically used to investigate gastrointestinal conditions such as a bowel obstruction andgallstones, and can detect the presence ofkidney stones. The KUB is often used to diagnose constipation as stool can be seen readily. The KUB is also used to assess positioning of indwelling devices such as ureteric stents and nasogastric tubes. KUB is also done as a scout film for other procedures such as barium enemas.It should include on the upright projections both right and left visualizations of the diaphragm. In at least one projection, thepubic symphysismust be present as the lower end of the area of interest. If the patient is large, more than one film loaded in the Bucky in a "landscape" direction may be used for each projection. This is done to ensure that the majority of bowel can be reviewed.

INTRAVENOUS PYELOGRAM (IVP)Historically, before the introduction and widespread adoption of computed tomography (CT) imaging, the intravenous pyelogram, or IVP, was the most commonly utilizedradiographicstudy of the urinary tract. The IVP is an x-ray test in which a contrast agent (also termed "x-ray dye") is injected into a patient's vein; the contrast agent acts to outline the patient's kidneys,ureters, and bladder when x-rays are subsequently taken. Doctors would order an IVP for a number of reasons, including the evaluation of pain in their side, blood in the urine (hematuria), or otherstone-related symptoms. In the present day, though, IVP is becoming less and less used (although there are still certain cases where it may be a helpful study), primarily as a result of the introduction of CT imaging. CT has become the x-ray study of choice for the evaluation of the urinary tract, because it can rapidly (even in a single breath-hold) image the entirety of the urinary tract. Since a CT scan presents its images as a cross-sectional view of the patient, oftentimes CT provides a greater amount of information than an IVP does, making CT a more cost-effective study. Furthermore, in many cases a CT imaging study does not require the administration of a contrast agent.

An IVP is generally performed in a hospital radiology department or a physician's office by an X-ray technologist and under the supervision of a radiologist or urologist. The patient will commonly be placed on a restricted diet 24 hours prior to the test and will be asked to urinate immediately prior to the test to ensure that the bladder is empty. The patient will then be asked to lie on their back and to remain still. A preliminary film, also called a "scout" film, of the abdomen and pelvis is obtained prior to the administration of intravenous contrast. The preliminary film ensures that the x-ray machine is calibrated correctly for the patient's size, and that there are no small stones present. Following intravenous injection of the contrast agent, a series of x-rays will be obtained, following the contrast material as it filters through the kidneys. Once the agent has filtered through the kidneys, it will pass down theuretersand into the bladder. Again, x-rays are obtained throughout this process, following the course of the contrast agent. The x-rays will be reviewed for evidence of tumors, cysts, stones or other structural and functional abnormalities.

At the conclusion of the study, the patient will be asked to urinate, so that a final set of images can be obtained to document how well the bladder empties. Once the IVP is over, the patient can immediately resume their daily activities.

ULTRASOUND SPECIFIC TO CONDITIONS LEADING TO F&E IMBALANCE Abdominal ultrasound.In abdominal ultrasound, the health care provider applies a gel to the persons abdomen and moves a hand-held transducer over the skin. The gel allows the transducer to glide easily, and it improves the transmission of the signals.

The procedure is performed in a health care providers office, outpatient center, or hospital by a specially trained technician, and the images are interpreted by a radiologist; anesthesia is not needed. An abdominal ultrasound can create images of the entire urinary tract. The images can show damage or abnormalities in the urinary tract. Abdominal ultrasounds are also commonly used to take pictures of fetuses in the womb and of a womans ovaries and uterus. Transrectal ultrasound with prostate biopsyTransrectal ultrasound is most often used to examine the prostate. In a transrectal ultrasound, the health care provider inserts a transducer slightly larger than a pen into the mans rectum next to the prostate. The ultrasound image shows the size of the prostate and any abnormal-looking areas, such as tumors. Transrectal ultrasound cannot be used to definitively diagnose prostate cancer.To determine whether a tumor is cancerous, the health care provider performs a biopsy. For the biopsy, the health care provider uses the transducer and ultrasound images to guide a needle to the prostate. The needle is then used to remove a few pieces of prostate tissue for examination with a microscope. A transrectal ultrasound with prostate biopsy is usually performed in a health care providers office, outpatient facility, or hospital by a doctor; light sedation and local anesthesia are used. The biopsied prostate tissue is examined in a laboratory by a pathologista doctor who specializes in diagnosing diseases. The biopsy can reveal whether prostate cancer is present. MRI

Magnetic resonance imaging is a test that takes pictures of the bodys internal organs and soft tissues without using x rays. MRI machines use radio waves and magnets to produce detailed pictures of the bodys internal organs and soft tissues. An MRI may include the injection of contrast medium. With most MRI machines, the person lies on a table that slides into a tunnel-shaped device where the images are taken. The device may be open ended or closed at one end; some newer machines are designed to allow the person to lie in a more open space. During an MRI, the person is usually awake but must remain perfectly still while the images are being taken. A sequence of images taken from different angles may be needed to create a detailed picture of the urinary tract. During the sequencing, the person will hear loud, mechanical knocking and humming noises. The procedure is performed in an outpatient center or hospital by a specially trained technician, and the images are interpreted by a radiologist; anesthesia is not needed, though light sedation may be used for people with a fear of confined spaces.

Magnetic resonance angiogram (MRA).An MRA is a type of MRI that provides the most detailed view of kidney arteriesthe blood vessels that supply blood to the kidneys. An MRA can show kidney artery stenosis, which is the narrowing of a kidney artery that restricts blood flow to the kidney. Kidney artery stenosis can cause high blood pressure and lead to reduced kidney function and eventually kidney failure CT ScansComputerized tomography scans use a combination of x rays and computer technology to create three-dimensional (3-D) images. A CT scan may include the injection of contrast medium. CT scans require the person to lie on a table that slides into a tunnel-shaped device where the x rays are taken. The procedure is performed in an outpatient center or hospital by a specially trained technician, and the images are interpreted by a radiologist; anesthesia is not needed. CT scans can show stones in the urinary tract, obstructions, infections, cysts, tumors, and traumatic injuries. Radionuclide Scans

A radionuclide scan is an imaging technique that relies on the detection of small amounts of radiation after injection of radioactive chemicals. Because the dose of the radioactive chemicals is small, the risk of causing damage to cells is low. Special cameras and computers are used to create images of the radioactive chemicals as they pass through the urinary tract. Radionuclide scans are performed at a health care providers office, outpatient center, or hospital by a specially trained technician, and the images are interpreted by a radiologist; anesthesia is not needed. Radioactive chemicals injected into the blood can provide information about kidney function. Radioactive chemicals can also be put into the fluids used to fill the bladder and urethra for x ray, MRI, and CT imaging. Preparations for an imaging test mostly depend on the purpose and type of test. In general, the health care provider will want to know whether the person is allergic to any foods or medications, is pregnant, or has had any recent illnesses or medical conditions. Specific preparations could include any of the following: fasting for 12 hours before the test drinking several glasses of water 2 hours before the test so the bladder is fullfor some ultrasound tests taking a laxative, which is a medication that loosens stool and increases bowel movements, to clear the colonfor a transrectal ultrasound taking an enema, which involves flushing water, laxative, or sometimes a mild soap solution into the anus using a special squirt bottle, about 4 hours before the testfor a transrectal ultrasound talking with the technical staff about any implanted devices that may have metal parts that will affect MRI or MRA images, such as heart pacemakers, intrauterine devices (IUDs), hip replacements, and implanted ports for catheterization; metal plates, pins, screws, and surgical staples, as well as any bullets or shrapnel in the body, may also cause a problem if they have been in place fewer than 4 to 6 weeks taking a sedative before an MRI or CT scan if the person feels anxious or has difficulty holding still in enclosed spacesBLOOD TESTS FOR DIAGNOSING F&E IMBALANCESBlood tests can be used to diagnose and monitor a variety of urologic conditions. In many cases, the results of blood work can help doctors determine if further lab tests or treatments are necessary. Blood testing is a routine procedure. A blood test involves using a needle to collect blood, usually from a vein in the arm. This blood sample is then sent to a laboratory for analysis. Substances in the blood are measured in either milligrams per deciliter (mg/dL) or nanograms per milliliter (ng/mL). Normal ranges are given as guidelines, but these levels can vary among laboratories. Abnormal test results do not necessarily mean that the patient has a urologic condition. Doctors confirm unusual results by repeating the blood test or performing a combination of different diagnostic tests.

Here are some common blood tests that health care providers use to help diagnose urologic conditions: Blood urea nitrogen (BUN)This test, which is used to evaluate kidney function, diagnose kidney problems, and monitor dialysis results, involves measuring the level of nitrogen in the urea of the blood. Urea is a waste product that forms when protein breaks down. Usually, the kidneys filter urea and the substance passes from the body in the urine. However, kidney problems can interfere with this filtering and lead to higher levels of urea nitrogen. The normal range for this test is 7 to 20 mg/dL. Creatinine testCreatinine (Cr) forms when a substance found in muscle tissue breaks down. Like urea nitrogen, the kidneys filter out creatinine and let it pass through urine. A high level of creatinine in the blood may indicate kidney damage caused by kidney infection, kidney stones, or decreased blood flow to the kidneys. Abnormal test results also may suggest dehydration or a urinary blockage. The normal range for this test is 0.8 to 1.4 mg/dL. Prostate-specific antigen (PSA) testThis test may be used in men to screen for prostate cancer (beginning at the age of 50 or at age 40 if at higher risk) and to monitor prostate cancer treatment. PSA is a protein produced by the prostate gland. The PSA test also may be used to diagnose benign prostatic hyperplasia (BPH, enlarged prostate) and or prostate infection (prostatitis) in men. Urinary tract infection (UTI) can affect the results of this test and cause an abnormally high reading.

For most men, the normal range for the PSA test is lower than 4.0 ng/mL; however, there is no specific normal or abnormal level. Men at increased risk for prostate cancer may be retested if their level is higher than 2.5 ng/mL. High PSA levels do not mean that a patient has prostate cancer, but may prompt further testing or a prostate biopsy.

The free PSA test is a variation of the usual PSA test. Normally, the protein PSA can be found in two forms in the bloodeither attached to other proteins or "free" (unattached). The free PSA test measures the amount of PSA that is unattached. The results of this test can provide further clues on the likelihood of prostate cancera high level of overall PSA, but low level of free PSA indicates a greater risk for cancer of the prostate. Calcium testThis test, which measures the level of calcium in the blood, can be used to screen patients for kidney disease. The normal range for this test is 8.5 to 10.2 mg/dL. A lower-than-normal test result might indicate kidney failure. Phosphate (phosphorus) testPhosphate tests, which measure phosphate levels in the blood, are used to diagnose kidney problems and monitor dialysis. The normal range for this test is 2.4 to 4.1 mg/dL. Levels that are higher or lower-than-normal may indicate kidney disease. Alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (beta-hCG) testsThese tests are used to help diagnose testicular cancer. AFP and beta-hCG are substances that are produced in higher-than-normal amounts by testicular cancer cells.REPUBLIC OF THE PHILIPPINES

Mariano Marcos State University

COLLEGE OF HEALTH SCIENCES

Department of Nursing

Batac City, 2906, Ilocos Norte

Report onFluid and Electrolytes

Submitted by:Danielle B. Quigao

Group 4 | BSNIII-ASubmitted to:

Ms. Judith P. ValenzuelaClinical InstructorJuly 2014