Fluids and Electrolytes

INTRODUCTION Nephrotic syndrome in children:

Man - a biological being Cells - 40% Water-60% • For in renal failure in children: massive albuminemia,
Functions: drop in colloid osmotic pressure
• Vehicle transport Function of albumin:
• Vehicle for chemical reactions • Counteract outward
• Direction of water
FLUIDS
Concepts: PH triad:
Fluid = water = solution • Proteinuria
Solution composed of solute & solvent • Edema
• Insensible: Cannot measure fluid in lungs • Hypertusin
Water = Weight:
• e.g. Kidney disease, renal failure Liver cirrhosis:
Weight as best indicator of actual twin status • Failure of liver to produce albumin
Fluid in the body goes down with age • Develop ascites
• Risk in Vulnerable age: eg. Older people
CONCENTRATION
Mechanisms
COMPARTMENTS Osmosis:
Intracellular - 2/3 or 70% • Movement of water
• More stable • Lower to higher concentration
Extracellular - 1/3 or 30% • Water in cell moves out because blood has higher
• First to be consumed concentration
• Onti to dami
Sub compartments: • Cells shrink
• Intravascular/ intravenous only 5% is lost: failure Diffusion:
circulation • Movement of particles
• Interstitial: 25% of ECF • Dami to onti
Shock-often to burn patient
Burn patient- fluid replacement through IV SIADH → increased ICP
SIADH
• Water intoxication
FLUID DYNAMICS • ADH retains water
Concept: balance
Shifting - restore balance Neurons - most sensitive; cerebral edema
Movement occurs to restore balance
Movement/ shif ting between compartments ours due Ante gastroenteritis (AGE)
to changes in: • Severe dehydration due to diarrhea
• Pressure • Altered LOC
• Concentration • Drain intravascular fluids
PRESSURE
Hydrostatic pressure IV THERAPY
• Water force or water pressure • Hypotonic and hypertonic fluid requires physician's
• Rushing force order
Colloid osmotic pressure • Involve in nurse's scope of practice
• Oncotic pressure • Mannitol cause cells to think → hypertonic IV fluids
• Pulling force
FACTORS THAT AFFECT FLUID BALANCE
Edema management: • Fluid Volume and Intake (Thirst)
• Elevate head of the bed except it musculoskeletal • Kidney functioning and RAAS
trauma RAAS (activated by hypoperfusion of kidneys
• Happens when hydrostatic pressure exceeds colloid Cardiac output = kidney perfusion
osmotic pressure • Cardiac functioning
• Hormonal Influence (ADH/Aldosterone/ANP)
SIADH: retaining fluid
Cushing's: hyperaldosteronism What organ produces ANP?
• Retention of sodium in water leading to hydrostatic • Brain and heart
pressure
Physical activity
• Irreversible losses through skin & lungs INTRAVENOUS FLUID SOLUTIONS
Age Isotonic
• Fluid goes down with it • 0.9 % NaCi - NSS (fluid expander)
• D5W- cardiac conditions; increased ICP, Brain injury
INDICATORS OF FLUID BALANCE • LRS (plain) - preferred for replacement (N/V) burns
• Weight ◦If massive blood loss, use PNSS
• Thirst mechanism Hypertonic - hypoglycemia, hyper alimentation (TPN);
• Urine output side effect: hyperglycemia
• Sensorium/mental status • D5NSS, DSLRS, D10W, D50W etc.
• Skin Turgor Hypotonic
• 0.45 % NaCl, 0.35 % NaCl
LABORATORY EXAMS ELECTROLYTES
• Urine specific gravity (NV-1.010-1025) SODIUM
◦The kidneys ability to excrete or conserve
water, compared to the weight of distilled Hyponatremia Hypernatremia
water Assessment <135mEq/L; nausea, >145mEq/L; Inc. temp,
• OBUN (NV - 10-20 mg/dL) muscle cramps; Inc. weakness, CNS
◦End product of protein metabolism ICP, confusion, Changes (disoriented,
• Creatinine (NV - 0.7-1.4 mg/dL) muscular twitching, delusions,
◦End product of muscle metabolism convulsions, poor hallucinations) thirst,
• Hematocrit (NV M- 42-52%, F- 35-47%) skin turgor, dryness dry. swollen tongue;
◦Volume percentage of RBC in whole blood in the mucosa, sticky mucous
◦Measure how solid your blood is membrane,
hypotension,
Urine specific gravity tachycardia,
• Dark write - high specific gravity increased muscle tone
BUN & Creatinine - by product of metabolism; affects and DTR
kidney function
FLUID IMBALANCES Analysis Causes: vomiting, Causes: hypertonic
Fluid Volume Excess diuretics, excessive tube feedings,
• Causes: Renal Failure, CHF, Liver Dysfunction, SIADH, IV’s prolonged low diarrhea,
Cushing's Disease etc. Na diet, excessive hyperventilation, DI,
• 5&5x: Inc.BP, wt gain, edema, headache, crackles, water intake, heat stroke, near
DOB, ascites adrenal drowning, excessive
Hormonal - contribute to fluid imbalance insufficiency, use of NaHCO3, inadequate
• Mgt: fluid resuscitation some Fluid intake
• e.g. 1L of fluid taken on specified time; same anticonvulsants
measurement; record
• Medical mgt: diuretics Plan/imp Oral admin of Na IV of hypotonic
Worst cases: dialysis (kidney impairment) rich foods; IV 0.9 solution (.3%Nacl or
NaCl; LR; I/O, water 45% Nacl; D5W; offer
Fluid Volume Deficit restriction, daily wt fluids at regular
• Causes: Diarrhea, n/v, Diabetes Insipidus, Addison's interval Dec. Na diet,
Disease, Poor Intake, latrogenic daily weight
• S&sx: Thirst, dry oral mucosa, ALOC, dec.BP, Desmopressin for DI
tachycardía, wt.loss, weakness, poor skin turgor
• Nursing Care: Inc. fluid intake, I&O monitoring, Hypernatremia
wt.check • Common in older persons
• Common in older people specially CNS - meaning its, • Associated with heat stroke
Alzheimer's, dementia • Common cause: feeding formulas
• Massive input of fluids • ALOC
• Iatrogenic- problem resulted from a treatment • Increase blood concentration
• Treatment: isotonic fluid replacement
Hyperthyroidism
• Hypermetabolism
• Methimazole
• PTU - suppress formation of T3&T4
POTASSIUM Hypokalemia
• Major intracellular cation • Treatment: lethal injection
• Regulates cellular polaring ◦incorporated
◦Emergency > 5.5 ◦WOF: burning sensation
◦Every time you Pee you lose Potassium ◦Potassium chloride is a vesicant
• Regulates musKle activity
◦Skeletal Hyperkalemia
◦Smooth • MOST DANGEROUS electrolyte imbalance
◦Cardiac Muscles • Kidney disease
◦Change in peristalsis • Most prominent: Arrhythmia
• Cardiac electrolyte (EKG) • Increase bowel sound
• Trades with hydrogen • Hyperactive muscle irritability
Hypoactive bowel sounds - constipation • Mgt: dietary modification
Hyperactive vowel sounds - diarrhea • Medication: kayexalate
• Causes:
Potassium ◦chemotherapy
• Normal: 3.5 - 5.5 mEq/L • Avoid fruits - elevate potassium
• Eliminated by the Kidneys
• Life-threatening arrhythmia If > 5.5 - 6
• Sodium bicarbonate - correct hypokalemia • Emergency treatment:
• Effect: muscles - cardiac ◦Sodium bicarbonate
• Hormone that facilitate in elimination of potassium: ◦Calcium gluconate
Aldosterone ◦Insulin IV: check serum electrolytes, SE:
hypokalemia

Hypokalemia Hyperkalemia CALCIUM

• Function: 5 C's
Assessment <3.5mEq/L or 8.5mg/ >5.0 mEq/L; ECG • Cell membrane potential regulation
dL; Anorexia, n/v, changes, • Contraction of muscles
muscle weakness, dysrhythmias, • Concrete of the bone
decreased Gl cardiac arrest, • Clotting factor
motility and muscle weakness, • Concentration of blood
paresthesia, muscle paralysis, • N= 4.5-5.5 mEq/L or 8.5-10mg/dL
dysrhythmias, ECG nausea, colic and • Regulated by hormones (PTH/Calcitonin)
changes, vomiting, diarrhea • Women are at risk of osteoporosis
What makes the bone hard? Calcium
Pathophysio vomiting, gastric Decreased renal Natural tendency of the human body: Store calcium
suction, diarrhea, excretion - Renal
diuretics steroids, Failure; Rapid
inadeq. Intake, Administration-
hyperaldosteronism latrogenic causes, Hypocalcemia Hypercalcemia
use of potassium
supplements Assessment <4.5mEq/L or <8.5mg/ >5.2mEq/L or
Movement from ICF dL; Excited nervous >10.2mg/dL
to ECF - burns, system, Tetany, Depressed CNS and
crushing injuries Seizures, confusion, PNS; Muscle
paresthesia; weakness, lack
irritability, coordination,
Plan/imp Increased K intake K restriction; Trousseau's sign confusion, depressed
IV supplements Kayexalate; improve; (2-5min. Carpal or abs. DTR GI
(40m-80 mEq/L) taste; Rectally spasm ), Chvostek's constipation,
NEVER IN PUSH (sarbitol); ER: Ca sign (twitching of abdominal pain and
Monitoring of I and gluconate, NaHCO3 facial muscles ); distention, Cardiac
O and intake from given IV; Regular Chronic- dry brittle dysrhythmias
various sources Insulin,; Hema/ hair, nails and Bone pain
peritoneal dialysis abnormal clotting
Diuretics; Insulin+D50W
 3. A client with a diagnosis of chronic renal failure has
Hypocalcemia Hypercalcemia pH of 7.35, PCO2 of 29 mmHg, and bicarbonate level of 16
mEq/L. The nurse interprets these ABG results as
Pathophysio hypoparathyroidism, malignancy, A. Uncompensated metabolic acidosis
pancreatitis; RF, hyperparathyardism B. Compensated metabolic acidosis
steroids; diuretics, Excessive intake, C. Uncompensated respiratory acidosis
inadeq. Intake, immobility, Thiazide D. Compensated respiratory acidosis
Massive blood diuretics, Antacids,
transfusion

Impending signs of irritability

• Spasm, tremor, TETANY
Medical equipment to prepare in administering
calcium gluconate:
• Cardiac monitor
Hypercalcemia → cancer

ABG’s
CO2: natural byproduct of cellular respiration
• Carbonic acid - acidosis
• Bicarbonate (base) - secreted to maintain normal
acid-base balance
Organ most demanding for oxygen - BRAIN
Alkalosis: when pH goes up, consciousness goes up
Acidosis: when pH goes down - lethargic
ABG ANALYSIS
Step 1: Identify pH
• Determine if acidosis or alkalosis
Step 2: Identify cause
• Determine if respiratory or metabolic
Step 3: Identify presence of compensation
• Determine if compensated or uncompensated
SAMPLE QUESTIONS:
1. The nurse assesses that the client admitted in
respiratory acidosis has compensated. The arterial
blood gas readings that indicate compensatory are
PaCO2 of
A. 50 mm Hg an bicarbonate level of 30 mEq/L
B. 50 mm Hg an bicarbonate level of 20 mEq/L
c. 30 mm Hg an bicarbonate level of 30 mEq/L
D. 30 mm Hg an bicarbonate level of 24 mEq/L
2. A client is brought to the ER in cardiac arrest. The
nurse is aware that the associated acid-base
imbalance that will require treatment is
A. Respiratory acidosis
B. Respiratory alkalosis
C. Both respiratory and metabolic acidosis
D. Both respiratory and metabolic alkalosis