Megan McClintock Winter 2012

FLUID & ELECTROLYTES ACID BASE IMBALANCES CHAPTER 17

HOMEOSTASIS

Maintained by the intake and output of water and electrolytes and regulation by the renal and pulmonary systems Acid-base balance is necessary for many physiologic processes (respiration, metabolism, function of the CNS)

Many disease and treatments affect this balance

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

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

ELECTROLYTES

Cations (positively charged)

K+,

Na+, Ca+, Mg+ Transmit nerve impulses to muscles and contract skeletal and smooth muscles

Anions (negatively charged)

Attached

to cations Cl-, HCO3-, PO4-, SO4

Are always kept in balance

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)

REGULATION OF FLUID & ELECTROLYTE MOVEMENT

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

FLUID SPACING

First spacing
Normal

Second spacing
Edema

Third spacing
Ascites Burn

edema

REGULATION OF WATER BALANCE

Hypothalmic Regulation
Thirst is stimulated ADH (vasopressin) release is stimulated

Pituitary Regulation

ADH (vasopressin) is released Glucocorticoids & mineralocorticoids are released

Adrenal Cortical Regulation

Renal Regulation
Adjust urine volume and electrolyte excretion Normal is 1.5 Liters of urine/day

REGULATION OF WATER BALANCE (CONT.)

Cardiac Regulation
ANP

& BNP will stop the action of the adrenal cortex and the kidney

GI Regulation
Intake

and output are reabsorbed here Diarrhea and vomiting can lead to significant losses

Insensible Water Loss

600-900

mL/day from the lungs and skin Increases with fever, exercise

GERONTOLOGIC CONSIDERATIONS

Structural changes in the kidney and decreased renal blood flow

Decreased GFR Decreased creatinine clearance Loss of ability to concentrate urine and thus conserve water Decrease in renin and aldosterone Increase in ADH and ANP

Loss of subcutaneous tissue Decrease in thirst mechanism Musculoskeletal changes Mental status changes

FLUID VOLUME DEFICIT

What

causes it?

What

can you do?

FLUID VOLUME EXCESS

What

causes it?

What

can you do?

NURSING INTERVENTIONS

Strict I/O
Intake oral, IV, tube feedings, retained irrigants Output urine, excess sweating, wound/tube drainage, vomitus, diarrhea

Urine specific gravity Assessment 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)

SERUM ELECTROLYTES

Sodium (Na) 135 - 145

Primarily

Potassium (K) 3.5 5.0

responsible for maintaining osmotic pressure (intracellular and extracellular fluids) Increased with fluid deficit Decreased with fluid excess
Major component of cardiac function Increased with poor kidney function Decreased with excessive urination, diarrhea or vomiting Works with Na to maintain osmotic pressure Increased with poor kidney function Decreased with excessive vomiting or diarrhea Transmission of nerve impulses, heart and muscle contractions, blood clotting, formation of teeth and bone Function of muscle, RBCs, and the nervous system

Chloride (Cl) 96 106

Calcium (Ca) 8.6 10.2

Phosphate (PO4) 2.4 4.4

THE MAGIC FOURS

Electrolyte Potassium Chloride Sodium pH CO2 HCO3 24 Range 3.5 - 5.0 96 - 106 135 - 145 7.35 - 7.45 35 - 45 22 - 26 Magic 4 4 104 140 7.4 40

SODIUM (135 - 145)

Major cation of ECF Primary determinant of osmolality GI tract absorbs sodium from food Regulated by kidneys, ADH, aldosterone Sodium level reflects the ratio of sodium to water Imbalances are typically associated with fluid volume problems

HYPERNATREMIA (HIGH SODIUM)

What

causes it?

What can you do?

HYPONATREMIA (LOW SODIUM)

What

causes it?

What

can you do?

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

HYPERKALEMIA (HIGH POTASSIUM)

What

causes it?

What

can you do?

HYPOKALEMIA (LOW POTASSIUM)

What

causes it?

What

can you do?

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

HYPERCALCEMIA (HIGH CALCIUM)

What

causes it?

What

are the symptoms?

What

can you do?

HYP0CALCEMIA (LOW CALCIUM)

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
Cause malnutrition, malabsorption syndrome, alcohol withdrawal S/S CNS depression, confusion, muscle weakness, dysrhythmias Tx oral supplements (Neutra-Phos), lots of dairy products, IV phosphate (but this can cause sudden hypocalcemia)

Hypophosphatemia

MAGNESIUM IMBALANCES

Hypermagnesemia

Cause increased intake (ie. MOM, Maalox) with chronic kidney disease S/S lethargy, n/v, loss of DTRs, can have respiratory and cardiac arrest Tx avoid magnesium-containing drugs, IV calcium, increased fluid intake, may need dialysis Cause prolonged fasting or starvation, chronic alcoholism, diuretics S/S confusion, hyperactive DTRs, tremors, seizures, cardiac dysrhythmias Tx oral supplements, increase green veggies, nuts, bananas, oranges, peanut butter, chocolate; IV or IM magnesium (if given too rapidly can cause cardiac or respiratory arrest)

Hypomagnesemia

MEDICATIONS

Loop diuretics Thiazide diuretics Potassium sparing diuretics Electrolytes

Kayexolate

ACID BASE BALANCE

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 HCO3

Renal system (2-3 days to max respond)

Reabsorbs

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

DETERMINING ACIDBASE BALANCE

1.
2. 3.

4.
5.

Is pH acid, base or normal? Is CO2 acid, base or normal? Is HCO3 acid, base or normal? Which of the components match? Is there compensation?
Is non-matching reading abnormal? partial compensation Is non-matching reading normal? no compensation

RESPIRATORY ALKALOSIS

RESPIRATORY ALKALOSIS

Causes

Treatment

Hyperventilation Pulmonary disease High altitudes Hyperventilation Feels light-headed Arrhythmias Anxiety

Signs/symptoms

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

RESPIRATORY ACIDOSIS

RESPIRATORY ACIDOSIS

Causes

Treatment

CNS depression Loss of lung surface Neuromuscular disease Immobility Mechanical ventilation Dyspnea Hypoxia Drowsiness Tachycardia Seizures Diaphoresis

Signs/symptoms

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

METABOLIC ALKALOSIS

METABOLIC ALKALOSIS

Causes

Treatment

NG suctioning Prolonged vomiting Diuretic use Multiple blood transfusions CPR (given bicarb)
Dizziness Dysrhythmias Convulsions Confusion Muscle cramps (late sign)

Signs/symptoms

Identify and treat the cause! IV fluids Stop giving bicarbonate Give antiemetics Give Diamox Assess:

Resp rate/depth HR & BP Serum K levels (usually low) Hydration status (tend to be dehydrated) Check for digitalis toxicity Parasthesias

METABOLIC ACIDOSIS

METABOLIC ACIDOSIS

Causes

Treatment

Diabetic ketoacidosis Renal or liver failure Severe diarrhea Vomiting Starvation

Kussmaul respirations Hypotension Arrythmias Warm to hot ,flushed skin Confusion

Signs/symptoms

Identify and treat the cause! Administer insulin (if due to ketoacidosis) Give antiemetics IV fluids IV bicarbonate Assess:

Renal function (BUN, creatinine) Serum K levels (tends to go up but down once insulin given) Hydration status

IV FLUIDS

Isotonic

NS D5W LR
3% NS D51/2NS D10W 1/2NS

Hypertonic

Hypotonic

Plasma Expanders

CENTRAL VENOUS ACCESS DEVICES

Centrally inserted catheters (CVCs)

Peripherally inserted central catheters (PICCs)

Implanted infusion ports

NURSING CARE OF CVADS

Inspect site for redness, edema, warmth, drainage, pain Dressing change/cleaning with sterile technique using chlorhexidine (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 during cleaning and cap change Have patient Valsalva during cap change if unable to clamp Use push-pause method to flush (creates turbulence) Removal of non-tunneled CVCs and PICCs may be done by a trained nurse (have pt Valsalva as last of