FLUID AND ELECTROLYTE BALANCES

Ms. Ida Anitha Lecturer College of Nursing CMC, Vellore

WHY IS IT IMPORTANT FOR NURSES TO KNOW ABOUT FLUID & ELECTROLYTE BALANCE

INTRODUCTION
Water is found everywhere on earth including human body In an adult 60% of the weight is water Two third of the bodys water is found in the cell

DISTRIBUTION OF BODY FLUIDS

Body fluids are distributed in two distinct compartments: 1.Extracellular fluids[ECF] Which includes interstitial fliud & intravascular fluid 2.Intracellular fluids[ICF]

COMPOSITION OF BODY FLUIDS

The fluids circulating throughout the body in extracellular and intracellular fluid spaces contain 1.Electrolytes 2.Minerals 3.Cells

MOVEMENT OF BODY FLUIDS

Diffusion Osmosis Filtration Active transport

REGULATION OF BODY FLUIDS

Fluid intake Fluid output Hormonal influence Lymphatic influences Neurologic influences Renal influences

ACID-BASE BALANCE
Chemical regulation Biologic regulation Physiological regulation 1.Lungs 2.Kidneys

FLUID ,ELCTROLYTE AND ACID-BASE IMBALANCES

FLIUD IMBALANCES
The five types of fluid imbalances that may occur are: Extracellular fluid imbalances(EVFVD) Extracellular fluid volume excess(ECFVE) Extracellular fluid volume shift Intracellular fluid vloume excess(ICFVE) Intrcellular fluid volume deficit(ICFVD)

EXTRACELULLAR FLUID VOLUME DEFICIT

An ECFVD, commonly called as dehydration , is a decrease in intravascular and interstitial fluids An ECFVD can result in cellular fluid loss if it is sudden or severe

THREE TYPES OF ECFVD

Hyperosmolar fluid volume deficit- water loss is greater than the electrolyte loss Isosmolar fluid volume deficit equal proportion of fluid and electrolyte loss Hypotonic fluid volume deficit electrolyte loss is greater than fluid loss

ETIOLOGY AND RISK FACTORS

Severe vomiting Diaphoresis Traumatic injuries Third space fluid shifts [percardial, pleural, pertonial and joint cavities] Fever Gatrointestinal suction Ileostomy Fistulas Burns
Hyperventilation Decresed ADH secretions Diabetes insipidus Addisons disease or adrenal crisis Diuretic phase of acute renal failure Use of diuretics

ELDERLY ARE HIGH RISK OF ECFVD DUE TO

Decreased thirst response Decreased renal concentration of urine Altered ADH response Increased drug drug interaction Multiple chronic diseases Decreased access to fluids due to financial or transportation barriers Debilitation Chemical or physical restraint Changes in mental status

CLINICAL MANIFESTATION
In Mild ECFVD, 1to 2 L of water or 2% of the body weight is lost In Moderate ECFVD, 3 to 5L of water loss or 5%weight loss IN Severe ECFVD , 5 to 10 L of water loss or 8% of weight loss

CLINICAL MANIFESTATION
Thirst Muscle weakness Dry mucus membrane;dry cracked lips or furrowed tongue Eyeballs soft and sunken (severe deficit) Apprehension , restlessness, headache , confusion, coma in severe deficit Elevated temperature Tachycardia, weak thready pulse Peripheral vein filling> 5 seconds Postural systolic BP falls >25mm Hg and diastolic fall > 20 mm Hg , with pulse increases > 30 Narrowed pulse pressure, decreased CVP&PCWP Flattened neck veins in supine position Weight loss Oliguria(< 30 mlper hour) Decreased number and moisture in stools

LABORATORY FINDINGS
Increased osmolality(> 295 mOsm/ kg) Increased or normal serum sodium level (> 145mEq/ L ) Increase BUN (>25 mg / L ) Hyperglycemia ( >120 mg /dl ) Elevated hematocrit (> 55%) Increased specific gravity ( > 1.030)

MANAGEMENT
Mild fluid volume loss can be corrected with oral fluid replacement -if client tolerates solid foods advice to take 1200 ml to 1500ml of oral fluids -if client takes only fluids, increase the total intake to 2500 ml in 24 hours

Management of Hyperosmolar fluid volume deficit

Administration of hypotonic IV solution , such as 5% dextrose in 0.2 %saline If the deficit has existed for more than 24 hours,avoid rapid correction of fluid [sodium solution to be infused at the rate of 0.5 to 0.1m Eq/ L/ hr]

If heamorrhage is the cause for ECFVD

Packed red cells followed by hypotonic IV fluids is administered In situations where the blood loss is less than 1 L normal saline or ringer lactate may be used clients with severe ECFVD accompanied by severe heart , liver, or kidney disease cannot tolerate large volumes of fluid and sodium

EXTRACELLULAR FLUID VOLUME EXCESS

ECFVE is increased fluid retention in the intravasular and interstitial spaces

ETIOLOGY AND RISK FACTORS

Heart failure Renal disorders Cirrhosis of liver Increased ingestion of high sodium foods Excessive amount of IV fluids containing sodium Electrolyte free IV fluids SIADH,Sepsis decreased colloid osmotic pressure lymphatic and venous obstruction Cushings syndrome & glucocorticoids

CLINICAL MANIFESTATION
Constant irritating cough Dyspnea & crackles in lungs Cyanosis, pleural fffusion Neck vein obstruction Bounding pulse &elevated BP S3 gallop Pitting & sacral edema Weight gain Increased CVP& PCWP Change in level of consiousness

LAB INVESTIGATION
serum osmolality <275mOsm/ kg Low , normal or high sodium Decreased hematocrit [ < 45%] Specific gravity below 1.010 Decreased BUN [< 8mg/ dl]

MANAGEMENT
Diuretics [combination of potassium sparing and potassium depleting diuretics] In people with CHF, ACE inhibitors and low dose of beta blockers are used A low sodium diet

VOLUME SHIFT: THIRD SPACING

Fluid that shifts into the interstitial spaces and remain there is called as third space fluid Common sites are abdomen , pleural cavity, peritoneal cavity and pericardial sac

RISK FACTORS
Crushing injuries, major tissue trauma Major surgery Extensive burns Acid base imbalances and sepsis Perforated peptic ulcers Intestinal obstruction Lymphatic obstruction Autoimmune disorders Hypoalbunemia GI tract malabsorption

CLINICAL MANIFESTATION
skin pallor Cold extremities Weak and rapid pulse Hypotension Oliguria
Decreased levels of consiousness

LAB INVESTIGATION
Elevated hematocrit & BUN level

MANAGEMENT
Treat the cause 1. For burns and tissue injuries large volume of isosmolar IV fluid is administered 2. Albumin is administered for protein deficit 3. IV fluid intake is maintained after major surgery to maintain kidney perfusion 4. Pericardiocentesis if pericarditis is the result 5. Paracentesis for ascitis

VOULME EXCESS:WATER INTOXICATION

ICFVE is increase in amount of water inside the cells

ETIOLOGY
Administration of excessive amount of hyposmolar IV fluids[0.45%saline or 5%dextrose in water] Consumption of excessive amount of tap water without adequate nutritional intake SIADH Schizophrenia[compulsive water consumption]

CLINICAL MANIFESTATIONS
Headaches Behavioral changes Apprehension Irritability, disorientation and confusion Increased ICP pupillary changes and decreased motor and sensory function Bradycardia, elevated BP, widened pulse pressure & altered respiratory patterns, Babinskis response flaccidity, projectile vomiting, Papilledema, delirium, convulsions &coma

LABORATORY FINDINGS
High serum sodium level- 125 mEq/L decreased hamatocrit

MANAGEMENT
Early administration of IV fluids containing sodium chloride cam prevent SIADH oral fluids such as juices or soft drinks can be given orally every hour Perform neurologic checks every hour to see if cranial changes are present Monitor fluid intake , IV fluids and fluid output hourly and weight daily Administer antiemetics for food and fluid retention

INTRACELLULAR FLUID VOLUME DEFICIT

Severe hypernatremia and dehydration can cause ICFVD Relatively rare in healthy adults common in elderly people and in those conditions that result in acute water loss Symptoms include confusion, coma, and cerebral hemorrhage

Sodium imbalances

Definiti on

Risk factors/ etiology

Clinical manifestation

Laboratory findings

management

Kidney diseases Hyponatr -aemia It is defined as a plasma sodium level below 135 mEq/ L Adrenal insufficiency Gastrointestinal losses Use of diuretics (especially with along with low sodium diet) Metabolic acidosis

Weak rapid pulse Hypotension Dizziness Apprehension and anxiety Abdominal cramps Nausea and vomiting Diarrhea Coma and convulsion Cold clammy skin Finger print impression on the sternum after palpation Personality change

Serum sodium less than 135mEq/ L serum osmolality less than 280mOsm/kg urine specific gravity less than 1.010

Identify the cause and treat *Administration of sodium orally, by NG tube or parenterally

*For patients who are able to eat & drink, sodium is easily accomplished through normal diet
*For those unable to eat,Ringers lactate solution or isotonic saline [0.9%Nacl]is given *For very low sodium 0.3%Nacl may be indicated *water restriction in case of hypervolaemia

Sodium imbalan -ce

Definit ion

causes

Clinical manifestation

Lab findings

management

Hypernat -remia

It is defined as plasma sodium level greater than 145mE q/L

*Ingestion of large amount of concentrated salts *Iatrogenic administration of hypertonic saline IV *Excess alderosterone secretion

Low grade fever Postural hypertension Dry tongue & mucous membrane Agitation Convulsions Restlessness Excitability Oliguria or anuria Thirst Dry &flushed skin

*high serum sodium 135mEq/L

*high serum osmolality295m O sm/kg *high urine specificity 1.030

*Administration of hypotonic sodium solution [0.3 or 0.45%]

*Rapid lowering of sodium can cause cerebral edema *Slow administration of IV fluids with the goal of reducing sodium not more than 2 mEq/L for the first 48 hrs decreases this risk *Diuretics are given in case of sodium excess *In case of Diabetes insipidus desmopressin acetate nasal spray is used *Dietary restriction of sodium in high risk clients

Potassium imbalances Hypokalemia

Definition

Causes

Clinical manifestation *weak irregular pulse *shallow respiration *hypotesion *weakness, decreased bowel sounds, heart blocks , paresthesia, fatigue, decreased muscle tone intestinal obstruction

Lab findings

Management

It is defined as plasma potassium level of less than 3.0 mEq/L

*Use of potassium wasting diuretic *diarrhea, vomiting or other GI losses *Alkalosis *Cushings syndrome *Polyuria *Extreme sweating *excessive use of potassium free Ivs

* K less than 3mEq/L results in ST depression , flat T wave, taller U wave * K less than 2mEq/L cause widened QRS, depressed ST, inverted T wave

Mild hypokalemia[3.3to 3.5] can be managed by oral potassium replacement

Moderate hypokalemia *K-3.0to 3.4mEq/L need 100to 200mEq/L of IV potassium for the level to rise to 1mEq/

Severe hypokalemia K- less than 3.0mEq/L need 200to 400 mEq/L for the level to rise to l mEq/L *Dietary replacement of potassium helps in correcting the problem[1875 to 5625 mg/day]

Definition

Causes

Clinical manifestation

Lab findings

Management

Hyperkal emia

It is defined as the elevation of potassium level above 5.0mEq/L

Renal failure ,
Hypertonic dehydration, Burns& trauma

Irregular slow pulse,

hypotension, anxiety,

*High serum potassium 5.3mEq/L results in peaked T wave HR 60 to 110 *serum potassium of 7mEq/L results in low broad Pwave
*serum potassium levels of 8mEq/L results in no arterial activity[no pwave]

*Dietary restriction of potassium for potassium less than 5.5 mEq/L

*Mild hyperkalemia can be corrected by improving output by forcing fluids, giving IV saline or potassium wasting diuretics *Severe hyperkalemia is managed by 1.infusion of calcium gluconate to decrease the antagonistic effect of potassium excess on myocardium 2.infusion of insulin and glucose or sodium bicarbonate to promote potassium uptake 3.sodium polystyrene sulfonate [Kayexalate] given orally or rectally as retention enema

Large amount of IV administration of potassium,

Adrenal insufficiency Use of potassium retaining diuretics & rapid infusion of stored blood

irritability,
paresthesia, weakness

Calcium imbalanc es

Definitio n

Causes

Clinical manifestation

Lab findings

Management

hypocalc emia

It is a plasma calcium level below 8.5 mg/dl

Rapid administration of blood containing citrate, hypoalbuminemia, Hypothyroidism , Vitamin deficiency, neoplastic diseases, pancreatitis

Numbness and tingling sensation of fingers, hyperactive reflexes, Positve Trousseaus sign, positive chvosteks sign , muscle cramps, pathological fractures, prolonged bleeding time

Serum calcium less than 4.3 mEq/L and ECG changes

1.Asymtomatic hypocalcemia is treated with oral calcium chloride, calcium gluconate or calcium lactate 2.Tetany from acute hypocalcemia needs IV calcium chloride or calcium gluconate to avoid hypotension bradycardia and other dysrythmias 3.Chronic or mild hypocalcemia can be treated by consumption of food high in calcium

Calcium imbalance

Definition

Causes

Clinical manifestation

Lab findings

Management

Hypercalc emia

It is calcium plasma level over 5.5 mEq/l or 11mg/dl

Hyperthyro idism,
Metastatic bone tumors, pagets disease, osteoporosis , prolonged immobalisation

Decreased muscle tone,

anorexia, nausea, vomiting, weakness , lethargy, low back pain from kidney stones, decreased level of consciousness & cardiac arrest

High serum calcium level 5.5mEq/L,

x- ray showing generalized osteoporosis, widened bone cavitation, urinary stones, elevated BUN 25mg/100ml, elevated creatinine1.5mg /100ml

1.IV normal saline, given rapidly with Lasix promotes urinary excretion of calcium
2.Plicamycin an antitumor antibiotics decrease the plasma calcium level 3.Calcitonin decreases serum calcium level 4.Corticosteroid drugs compete with vitamin D and decreases intestinal absorption of calcium 5. If cause is excessive use of calcium or vitamin D supplements reduce or avoid the same

Acid-Base imbalance

Definition

Causes

Clinical manifestation

Lab findings

Management

Respiratory acidosis Hypoventilation & excessive CO2 production

It is a clinical disorder in which the pH is less than 7.35 and the paCO2 is greater than 42mmHg

COPD, neuromuscular disorder, GuillianBarre syndrome, Myssthenia gravis, Respiratory center depression, Drugs, late ARDS,

Dyspnea ,
disorientation, coma

PH lesser than 7.35, Paco2 greater than 45mmHg, Hyperkalemia, Hypoxemia

1.Treat underlying cause 2.Support ventilation 3.Correct electrolyte imbalance 4.Intravenous NaHCO3

Respiratory Alkalosis
Hyperventilation

It is a clinical condition in which the arterial Ph is greater than7.45 and the paCO2 is less than 38mmHg

Hypoxemia, impaired lung expansion, thickened alveolar capillary membrane, Chemical stimulation of respiratory center, traumatic stimulation of respiratory center

Tachypnea, giddiness, dizziness, syncope, convulsions, coma, weakness, paresthesia, tetany

PH greater than 7.35 PaCO2 lesser than 35 mmHg, Hypokalemia, Hypocalcemia

Increase CO2 retention through CO2 rebreathing & sedation and mechanical hypoventilation

Definition

causes

Clinical manifestation

Lab findings

Management

Metabolic Acidosis

It is a clinical condition in which the HCO3 & pH is decreased

Renal failure, Diabetic ketoacidosis, Lactic acidosis, ingested toxins, renal tubular acidosis

Hyperventilation confusion, drowsiness, coma, headache

PH< 7.35, HCO3< 22mEq/L

1.Treat the underlying cause 2.Intravenous NaHCO3 3.correct electrolyte imbalance

Metabolic Alkalosis

It is a clinical condition in which PH is raised

Hypokalemia, gatric fluid loss, massive correction of whole blood, Overcorrection of acidosis with NaCO3

Hypoventilation Dysrythmias

PH >7.45 Hypokalemia Hypocalcemia PaCO2 normal or increased

1.Treat the underlying cause 2.Administer KCL 3.intravenous acidifying salts[NH4CL] 4.Administer acetazolamide

CONCLUSION