Fluids and Electrolytes

FLUIDS and ELECTROLYTES
BODY FLUIDS
Functions of Fluids
Body fluids:
Facilitate in the transport [nutrients,
hormones, proteins, & others]
Aid in removal of cellular metabolic wastes
Provide medium for cellular metabolism
Regulate body temperature
Provide lubrication of musculoskeletal jts.
Component in all body cavities [parietal,
pleural fluids]
Water is the principal body fluid & essential for life.

BODY FLUIDS
Distribution of Body Fluids 50-70% of total body weight;
infant [70-80%], elderly [45-50%]
ICF
ECF
60-kg man
TBW = 0.6 x 60 kg = 3.6 L
IS
ICF = 0.4 x 60 kg
= 24 L
ECF
= 12 L
3L 9L
40% TBW
20% TBW

BODY FLUIDS
Factors that Dictate Body Water Requirement
1) Amount needed to give the proper osmotic
concentration
2) Amount needed to replace water lost excretion
Normal Routes of water gain and loss
INTAKE
ml/day
Fluid intake
Food
Metabolic water
TOTAL
1,200
1,000
300
2,500
OUTPUT
Insensible loss
Sweat
Feces
Urine
TOTAL
ml/day
700
100
200
1,500
2,500

FLUID EXCHANGE BETWEEN BODY FLUID
COMPARTMENTS
ICF
ECF
Osmotic Pressure Gradient
Oncotic P (Colloid osmotic P)

Capillary P (Hydrostatic P)
P
ISF

Control of Osmotic Pressure, Volume &
Electrolyte Concentration
OBLIGATORY Reabsorption
occurs in the proximal tubules
178 L/day of glomerular filtrate (80%
reabsorbed)
2 to solute reabsorption
independent of the water requirement
FACULTATIVE Reabsorption
occurs in the distal & collecting tubules
independent of the active solute transport
dependent of bodys need of water
under the control of ADH

DISTURBANCES IN FLUID BALANCE
EDEMA (Dropsy)
in the interstitial fluid volume of about 2 L or

more due to increase transudation of fluid from
capillaries 2 to:
Increased HP [pregnancy, CHF]
Decreased OP [malnutrition, end-stage liver
dse, nephrotic syndrome]

CELL OVERHYDRATION
excess of water in the ECC w/ a normal amount

of solute or a deficient amount of solute
occurs in prolonged and excessive diuresis,
forcing hypotonic fluids to produce diuresis in
the presence of renal impairment
fluid overload from production of adrenal
corticoid hormones [Cushings syndrome]

CELL OVERHYDRATION
Symptoms
Weight gain & edema
Cough, moist rales, dyspnea [fluid congestion in
lungs]
CVP, bounding pulse,neck vein engorgement
[fluid excess in the vascular system]
Bulging fontanelles
Hg and Hct
Nausea & vomiting

CELL OVERHYDRATION
Management
Restrict fluids to lower fluid volume
Diuretics or hypertonic saline
Continuous assessments to prevent skin
breakdown
Record daily weight to assess progress of
treatment

CELL DEHYDRATION (DHN)
loss of body fluids, particularly from the
extracellular fluid compartment
water loss > water intake
Causes
Fever
Insufficient water intake
Diarrhea, vomiting
Excess urine output [Diabetes insipidus,
diuretics]
Excessive perspiration, burns
Hemorrhage, shock, metabolic acidosis

CELL DEHYDRATION (DHN)
Symptoms
Thirst, dry mucus membranes, sunken
eyeballs
Doughy abdomen, dry skin w/ poor turgor
temp, weight loss
HR, RR, BP
Restlessness,irritability, disorientation,
convulsion, coma [22-30% body H20 loss]
Management
Fluid replacement therapy & continued fluid
maintenance

Volume Disorders 2 Alteration in Sodium Balance
Volume
Disorder
ECF
Vol.
ICF
Vol.
Water
Shift
Conditions
Expansion
Isotonic
Inc
No net change
Hypertonic
Inc
Dec
ICF ECF
Hypotonic
Inc
Inc
ECF ICF
Contraction
Isotonic
Hypertonic
Hypotonic
Dec
Dec
Dec
N
No net change
Diarrhea
Dec
ICF ECF Diabetes insipidus
Inc
ECF ICF
Addisons dse
Isotonic fluid
ingestion
Sea water
ingestion
Hypotonic IVF

ELECTROLYTES
salts or minerals in extracellular or intracellular
body fluids
Sodium major cation of ECF
Potassium major cation of ICF

Chloride - major anion of ICF
Protein in ICF > ISF

ELECTROLYTE Composition
Electrolyte Conc
Plasma (mEq/L)
ISF
ICF
Sodium, Na+
Potassium, K+
Calcium, Ca++
Magnesium, Mg++
142
5
5
3
(155)
103
27
2
1
16
6
(155)
141
4.1
4.1
3
10
150
40
115
29
2
1
1
3.4
15
10
100
20
60
-
Chloride, ClBicarbonate, HCO3Biphosphate, HPO4Sulfate, SO4-2

Protein
Organic foods

ELECTROLYTES
Functions of Electrolytes
Contribute most of the osmotically active
particles in body fluids
Provide buffer systems for pH regulation
Provide the proper ionic environment for
normal neuromuscular irritability & tissue
function

ELECTROLYTES
Hyponatremia [Na+ < 135 mEq/L; Normal = 135-145 mEq/L]
Causes
Na+ intake
Na+ excretion [diaphoresis, GI suctioning]
Adrenal insufficiency
Assessment
N & V, abdominal cramps, weight loss
Cold, clammy skin, skin turgor
Apprehension, HA, convulsions, focal
neurologic deficit, coma [cerebral edema]
Fatigue, postural hypotension
Rapid thready pulse

ELECTROLYTES
Hyponatremia [Na+ < 135 mEq/L; Normal = 135-145 mEq/L]
Management
Provide foods high in sodium
Administer NSS IV
Assess blood pressure frequently
[measure lying down, sitting & standing]

ELECTROLYTES
Hypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L]
Causes
Excessive, rapid IV admn of NSS
Inadequate water intake
Kidney disease
Assessment
Dry, sticky mucus membranes
Flushed skin
Rough dry tongue, firm skin turgor
Intense thirst
Edema, oliguria to anuria
Restlessness, irritability [cerebral DHN]

ELECTROLYTES
Hypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L]
Nursing Intervention
Weigh daily
Assess degree of edema frequently
Measure I & O
Assess skin frequently & institute nursing
measures to prevent breakdown
Encourage sodium-restricted diet

ELECTROLYTES
Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L]
Causes
Renal insufficiency
Adrenocortical insufficiency
Cellulose damage [burns]
Infection
Acidotic states
Rapid infusion of IV soln w/ potassiumconserving diuretics

ELECTROLYTES
Assessment
Thready, slow pulse
Shallow breathing
N & V, diarrhea, intestinal colic
Irritability
Muscle weakness, flaccid paralysis
Numbness, tingling
Difficulty w/ phonation, respiration

ELECTROLYTES
Nursing Interventions
Administer kayexalate as ordered
Administer/monitor IV infusion of glucose
& insulin
Control infection
Provide adequate calories & carbohydrates
Discontinue IV or oral sources of K+

ELECTROLYTES
Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L]
Causes
Renal insufficiency
Adrenocortical insufficiency
Cellulose damage [burns]
Infection
Acidotic states
Rapid infusion of IV soln w/ potassiumconserving diuretics

ELECTROLYTES
Assessment
Thready, rapid, weak pulse
Faint heart sounds
BP
Skeletal muscle weakness
or absent reflexes
Shallow respirations
Malaise, apathy, lethargy
Loss of orientation
Anorexia, vomiting, weight loss
Gaseous intestinal distention

ELECTROLYTES
Administer K+ supplements to replace
losses
Be cautious in administering drugs that
are not potassium-sparing
Monitor acid-base balance
Monitor pulse, BP and ECG

ELECTROLYTES
Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L]
Causes
Hyperparathyroidism
Immobility
Increased vitamin D intake
Osteoporosis & osteomalacia [early stages]
Assessment
N & V, anorexia, constipation
Headache, confusion
Lethargy, stupor
Decreased muscle tone
Deep bone/flank pain

ELECTROLYTES
Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L]
Encourage mobilization
Limit vitamin D intake
Limit calcium intake
Normal saline
Administer diuretics
Calcitonin

ELECTROLYTES
Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L]
Causes
Acute pancreatitis
Diarrhea
Hypoparathyroidism
Lack of vitamin D I the diet
Long-term steroid therapy
Assessment
Painful tonic muscle & facial spasms
Fatigue, dyspnea
Laryngospasm, convulsions
(+) Trousseaus and Chvosteks signs

ELECTROLYTES
Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L]
Administer oral Ca lactate or IV CaCl2 or
gluconate
Providing safety by padding side rails
Administer dietary sources of calcium
Vitamin D
Provide quiet environment

ELECTROLYTES
Hyermagnesemia [Mg > 3.0 mEq/L; Normal = 1.5-3.0 mEq/L]
Causes
Renal insufficiency, dehydration
Excessive use of Mg-containing antacids or
laxatives
Assessment
Lethargy, somnolence, confusion
N&V
Muscle weakness, depressed reflexes
pulse and respirations
Withhold Mg-contg drugs/foods; Ca admn
fluid intake, unless CI

ELECTROLYTES
Hypomagnesemia [Mg < 1.50 mEq/L; Normal = 1.5-3.0 mEq/L]
Causes
Low intake of Mg in the diet
Prolonged diarrhea
Massive diuresis
Hypoparathyroidism
Assessment
Paresthesias, muscle spasm
Confusion, hallucination, convulsions
Ataxia, tremors, hyperactive deep reflexes
Flushing of the face, diaphoresis
Provide good dietary sources of Mg

IV FLUID REPLACEMENT THERAPY
Indications
Replacement of abnormal fluid & electrolyte
losses [surgery, trauma, burns, GI bleeding]
Maintenance of daily fluid & electrolyte needs
Correction of fluid disorders
Correction of electrolyte disorders

IV FLUID REPLACEMENT THERAPY
Types of Solutions
Isotonic
0.9% sodium chloride (NSS)
Lactated Ringers soln
Hypotonic
5% dextrose and water (D5W)
0.45% sodium chloride
0.33% sodium chloride
Hypertonic
3% NaCl
Protein solns
Colloids
Salt pour albumin Plasmanate, Dextran
BURNS
BURNS
wounds caused by excessive exposure to the

following agents or causes:
Causes of Burns:
Thermal [moist or dry heat]

Electrical
Chemical [strong acids and strong alkali
Radiation [UV, x-rays, radium, sunburns]
BURNS
CLASSIFICATION OF BURNS
Superficial Partial thickness (1st degree)
Outer layer of dermis
Erythema, pain up to 48 hrs
Healing 1-2 wks [sunburn]
Deep Partial thickness (2nd degree)
Epidermis & dermis
Blisters & edema, frequently quite painful
Healing 14-21 days
Full thickness (3rd degree)
Epidermis, dermis, subcutaneous fat
Dry, pearly white or charred in appearance
Not painful
Eschar must be removed; may need grafting
BURNS
STAGES OF BURNS
1st: Shock/Fluid Accumulation Phase
1st 48 hrs
IVC ISC
Generalized DHN [fluid shifting]
Hypovolemia [plasma loss], BP, C.O.
Hemoconcentration, Hct [liquid blood
component ISC]
Oliguria [ renal perfusion], ADH release &
aldosterone
HyperK, hypoNa
Metabolic acidosis
BURNS
STAGES OF BURNS
2nd: Diuretic/Fluid Remobilization Phase
After 48 hrs
ISC IVC
Hypervolemia,
Hemodilution, Hct
Diuresis [ renal perfusion], ADH &
aldosterone secretion
HypoK, hypoNa [K moves back into the cells,
Na+ still trapped in the edema fluids
Metabolic acidosis
BURNS
STAGES OF BURNS
3rd: Recovery Phase
5th day onwards
Hypocalcemia
Ca is lost on the exudates
Ca is utilized in the granulation tissue
formation
Negative nitrogen balance
Due to stress response
protein catabolism
Protein intake is lesser than the demand
HypoK
BURNS
ASSESSMENT
1. Assess extent of body surface burned
Greater morbidity & mortality for burns
affecting face, hands & perineum
Assess for dyspnea, stridor, hoarseness
2. Assess extent of burn injury
Rule of nine immediate appraisal
Lund-Browder chart more accurate
Berkows method based on clients age &
changes that occur in proportion of head & legs
to the rest of the body as one grows
BURNS
ASSESSMENT
9%
9%
Front=18%
Back=18%
9%
1%
18% 18%
Burn Evaluation
Chart
BURNS
ASSESSMENT
3. Assess depth of burn
Major burns 2nd degree over 30% of body
Hospitalization - eyes, face, neck, hands,
perineum, genitalia
4. Assess unique contributing factors
Age of client
Health history
Diabetes, preexisting ulcers
Tetanus immunization
BURNS
EMERGENCY MANAGEMENT
Stop the burning process
Remove patient from source of injury
Advise client to roll on the ground if clothing is
in flame [STOP-DROP-ROLL]
Throw a blanket over the client to smother the
flame
Remove clothing only if hot or for scald burn
Immerse affected part in cold water [10 min]
Irrigate copiuosly w/ large amount of running
water w/ chemical burns [except w/
phosphorus]
Interrupt power source w/ electrical burn
BURNS
MANAGEMENT
Maintenance of adequate airway
Promoting comfort: relieve pain
Promoting fluid-electrolyte, acid-base balance
Preventing infection
Maintaining adequate nutrition
Wound care
BURNS
METHODS OF TREATING BURNS
Open method or Exposure method
Face, neck, perineum, trunk
Allowing exudate to dry in 3 days
Occlusive
Less pain, absorption of secretion, comfort,
transportability, accelerated debridement
Aesthetic considerations
Semi-open method
Covering of wound w/ topical antimicrobials:
Silver sulfadiazine 1% (Flamazine)
Silver nitrate 0.5% soln
Mafenide acetate (sulfamylon acetate)
BURNS
BIOLOGIC DRESSING (Skin Graft)
Allograft
Skin taken from other person [cadaver]
Autograft
Same person
Heterograft
Different species
Xenograft [segment of skin from animal
such as pig or dog]
BURNS
FLUID REPLACEMENT
Types of fluids:
Colloids
Blood
Plasma & plasma expanders
Electrolytes
Lactated Ringers
Non-electrolyte
D5W
BURNS
FLUID REPLACEMENT
EVANS Formula:
C 1ml x % burns x kgBW
E - 1ml x % burns x kgBW
Glucose 5% for insensible loss 2,000ml D5W
Administer soln 1st 24 hrs [1st 8hrs], [16hrs]
BROOKE Formula: [Administer as in Evans]
C 0.5ml x % burn x kgBW
E - 1.5ml x % burns x kgBW
Water 1000ml D5W
BURNS
FLUID REPLACEMENT
MOORES BURN BUDGET:
75 ml of plasma, 75 ml of electrolyte-contg
fluid for q 1%TBSA plus 2000 D5W
HYPERTONIC RESUSCITATION Formula:
Hypertonic salt containing 300mEq of Na+,
100mEq of Cl-, 200mEq lactate
Administered to maintain urinary output of 3040 ml/hr

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FLUIDS and ELECTROLYTES