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CHAPTER 11 IGGY-PG 148-173 Assessment and Care of Patients with Fluid and Electrolyte Imbalances Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Describe basic concepts of fluid and electrolyte balance Define ways fluids and electrolytes maintain homeostasis Identify nursing interventions to promote fluid, electrolyte balance and how to correct. Describe pathophysiology of selected fluid and electrolyte imbalances Identify key electrolytes and their normal lab values Identify considerations related to the older adult OBJECTIVES 2 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Proper functioning of all body systems; requires fluid and electrolyte balance Extracellular fluid (ECF) Intracellular fluid (ICF) Interstitial fluid Transcellular fluids HOMEOSTASIS 3 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Movement of fluid through cell or blood vessel membrane because of differences in water pressure (hydrostatic pressure) This is related to water volume pressing against confining walls FILTRATION 4 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. “Water-pushing pressure” Force that pushes water outward from a confined space through a membrane Amount of water in any body fluid space determines pressure Example: Blood pressure Moving whole blood from the heart to capillaries where filtration occurs to exchange water, nutrients, and waste products between the blood and tissues HYDROSTATIC PRESSURE 5 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Develops with changes in normal hydrostatic pressure differences CLINICAL SIGNIFICANCE: EDEMA 6 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Free movement of particles (solute) across permeable membrane from area of higher to lower concentration Important in transport of most electrolytes; other particles diffuse through cell membranes Sodium pumps Glucose cannot enter most cell membranes without help of insulin DIFFUSION 7 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Act together at capillary membrane to maintain normal ECF and ICF volumes Thirst mechanism is example of how osmosis helps maintain homeostasis Feeling of thirst caused by activation of brain cells responding to changes in ECF osmolarity OSMOSIS & FILTRATION 8 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Closely linked to/affected by electrolyte concentrations Fluid intake Fluid loss Minimum urine amount needed to excrete toxic waste products = 400 to 600 mL/day Insensible water loss – Through skin, lungs, stool FLUID BALANCE 9 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Aldosterone Antidiuretic hormone Natriuretic peptides https://www.khanacademy.org/science/healthand-medicine/circulatorysystem/blood_pressure_control/v/aldosteroneraises-blood-pressure-and-lowers-potassium HORMONAL REGULATION OF FLUID BALANCE 10 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Blood (plasma) volume and intracellular fluid most important to keep in balance Kidneys are major regulator of water and sodium balance; maintain blood and perfusion pressure to all tissues/organs When the kidneys sense a low parameter, they secrete renin Renin-angiotensin II pathway is greatly stimulated with shock, or when stress response is stimulated SIGNIFICANCE OF FLUID BALANCE: RENIN-ANGIOTENSIN II PATHWAY 11 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Disrupt renin-angiotensin II pathway by reducing amount of ACE produced With less angiotensin II, less vasoconstriction and reduced peripheral resistance Greater excretion of water and sodium in urine By locking angiotensin II receptors, blood pressure lowers Patients with hypertension often take ACEinhibitor medications ACE INHIBITORS 12 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Fluid intake/retention does not meet body’s fluid needs; results in fluid volume deficit Assessment History Physical assessment/clinical manifestations: Cardiovascular Respiratory Skin Neurologic Renal DEHYDRATION: COLLABORATIVE CARE 13 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 1 L of water weighs 2.2 lb, equal to 1 kg Weight change of 1 lb = fluid volume change of about 500 mL FACTS TO REMEMBER... 14 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Assessment Patient safety Pulmonary edema Drug therapy Nutrition therapy Monitoring of intake and output (I&O) FLUID OVERLOAD: COLLABORATIVE CARE 15 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Can occur in healthy people as result of changes in fluid I&O Can be life threatening if severe; can occur in any setting ELECTROLYTE IMBALANCE 16 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Normal level: 136-145 mmol/L “Where sodium goes, water follows” Hyponatremia Hypernatremia SODIUM 17 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Normal level: 3.5-5.0 mEq/L Some control over intracellular osmolarity and volume Hypokalemia Hyperkalemia POTASSIUM 18 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Normal level: 9.0-10.5 mg/dL Absorption requires active form of vitamin D Stored in bones Parathyroid hormone Thyrocalcitonin Hypocalcemia Hypercalcemia CALCIUM 19 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. HYPOCALCEMIA 20 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Normal level: 3.0-4.5 mg/dL Found in bones Activates vitamins and enzymes; assists in cell growth and metabolism Plasma levels of calcium and phosphorus exist in a balanced reciprocal relationship Hypophosphatemia Hyperphosphatemia PHOSPHORUS 21 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Normal level: 1.3 to 2.1 mg/dL Critical for skeletal muscle contraction, carbohydrate metabolism, ATP formation, vitamin activation, cell growth Hypomagnesemia Hypermagnesemia MAGNESIUM 22 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Normal level: 98 to 106 mEq/L Imbalance occurs as a result of other electrolyte imbalances Treat underlying electrolyte imbalance or acidbase problem CHLORIDE 23 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. At risk for most electrolyte imbalances from agerelated organ changes Have less total body water than younger adults; more at risk for fluid imbalances; more likely to be taking drugs affecting fluid or electrolyte balance Extra help/resource: https://quizlet.com/51866323/nursing-fluidelectrolyte-flash-cards CONSIDERATIONS FOR OLDER ADULTS 24 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.