Download Fluids, Electrolyte, and Acid-Base Balance

Fluids, Electrolyte, and AcidBase Balance
Susan L. Maiocco, RN, APN, C
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Fluid Balance
– Body Fluid
• Water and dissolved
substances
• Electrolytes
• Gases
• Non-electrolytes
– Homeostasis
• Establishes and
maintain equilibrium
in the exchange of
water among the
internal fluid
compartments of the
body and between
the body and the
external environment
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Body Fluids
• Water
– Most essential nutrient of life
• Provides medium for transporting nutrients to and from
cells
• Transports substances such as hormones, enzymes,
blood platelets, and red and white blood cells
• Facilitates metabolism and proper cellular chemical
functioning
• Acts a s a solvent for electrolytes and non-electrolytes
• Maintains normal body temperature
• Facilitates digestion and promotes elimination
• Acts as a tissue lubricant
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Body Water and Fluid
Compartments
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Fluid and Electrolyte Movement
• Cell membranes
– Semipermeable
• Allows some particles to pass through while
other solutes are not able to be transported
• Osmolarity
– Concentration of particles in a solution
(pulling power)
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Osmosis
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Isotonic
• Has the same
concentration of
particles as plasma
(osmolarity)
•If the concentration of
solute (salt) is equal on
both sides, the water will
move back in forth but it
won't have any result on
the overall amount of
water on either side.
"ISO" means the same
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Hypertonic
•Has greater osmolarity
than plasma
•The word "HYPER"
means more, in this case
there are more solute
(salt) molecules outside
the cell, which causes
the water to be sucked in
that direction.
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Hypotonic
•Has less osmolarity than
plasma
•The word "HYPO" means
less, in this case there are
less solute (salt)
molecules outside the
cell, since salt sucks,
water will move into the
cell.
•The cell will gain water
and grow larger.
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Diffusion
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Active Transport
• Process that requires energy for the
movement of substances through a
cell membrane from an area of lesser
solute concentration to an area of
higher solute concentration
• Adenosine triphosphate or ATP, stored
in all cells, is released from a cell and
supplies energy for solute movement in
and out of the cell.
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Filtration
• The passage of fluid
through a
permeable
membrane.
• Passage is from an
area of high
pressure to one of
lower pressure.
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Fluid Balance
• Adult intake and loss
– 1500-3500 ml each 24 hours
– Average
• 2500-2600 ml/per day
• Fluid Sources
– Ingested liquids
– Water contained in food
– Metabolism
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Gains and Losses
•Kidneys
•Skin
•Lungs
•GI tract
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Fluid Loss
• Kidneys
– Urine
• Intestinal Tract
– Feces
• Skin
– Perspiration
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Acid-Base Balance
• pH
– Unit of measure to describe acid-base balance
– Expression of H+ ion concentration and the
resulting acidity or alkalinity of a substance
– Acid
• Substance containing H+ ions that can be liberated or
released (e.g. carbonic acid)
– Base
• Substance that can accept or trap H+ ions (e.g.
bicarbonate)
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An acid releases H+, as follows
A base traps H+, as follows:
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H+ Balance Control
• Respiratory
– Lungs are the primary controller of body’s
carbonic supply
• Renal
– Kidneys regulate concentration of
bicarbonate in the plasma
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Disturbances in Fluid , Electrolyte,
and Acid-Base Balance
• Fluid volume deficit
(hypovolemia or
isotonic fluid loss)
• Caused by a loss
of both water and
solutes in the
same proportion
from the ECF
space
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Risk Factors
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Vomiting, diarrhea, suction, fistulas
Hemorrhage
Excessive sweating
Skin trauma, burns, draining wounds
Third-space fluid shifts
Excessive laxative or diuretic use
Polyuria from renal disease or diuretics
Hyperglycemia
Change in mental status
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Assessment
• Thirst
• Weight loss over
short period
• Weakness, fatigue,
anorexia
• Dry mucous
membranes
• Postural
hypotension
• Weak, rapid pulse
• Poor skin and
tongue turgor
• Sunken eyes
• Flat neck veins
• Urine output <30
mL/hr
• ↑ Urine specific
gravity
• ↑Hematocrit
• ↑BUN
• ↑Serum sodium
• Altered sensorium
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Nursing Interventions
• Assess for presence or worsening of FVD.
• Administer oral fluids if indicated.
• If patient unable to eat and drink,
anticipate TPN or tube feedings to be
ordered.
• Monitor patient's response to fluid intake,
either oral or parenteral.
• Be alert for signs of fluid overload.
• Provide appropriate skin care.
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Fluid Volume Excess
– Fluid volume excess
(hypervolemia or excess
of isotonic fluid)
• Excessive retention of
water and sodium in
ECF in near equal
proportions
• May accumulate in
intravascular
compartments or
interstitial spaces
• Accumulation of fluid
in interstitial space is
known as edema
– Eyes, fingers,
ankle, sacral area
– >5% weight gain
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Risk factors
– Compromised regulatory mechanisms:
renal failure, CHF, cirrhosis of liver,
– Cushing's syndrome
– GI irrigation with hypotonic fluid
– Excess IV fluids with sodium
– Corticosteroid therapy
– Excessive ingestion of sodium-containing
substances in diet or sodium-containing
medications
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Assessment
• Weight gain over short
period
• Peripheral edema
(may be pitting)
• Increased BP
• Shortness of breath
• Crackles and wheezes
in lungs
• Full, bounding pulse
• Neck vein distention
• Polyuria if renal function
is normal
•
•
•
•
Ascites,
Pleural effusion
Pulmonary edema
↓BUN (due to plasma
dilution)
• ↓Hematocrit
• ↓Serum sodium
• ↓Urine specific gravity
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Nursing Interventions
• Assess for presence or worsening of FVE
• Encourage adherence to sodium-restricted
and fluid-restricted diet, if ordered.
• Avoid OTC drugs or check with physician or
pharmacist about sodium content.
• Encourage rest periods.
• Monitor patient's response to diuretics.
• Teach self-monitoring of weight and intake
and output.
• Attentive skin care.
• Monitor respiratory status.
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Major Electrolytes
Electrolyte
Normal Value
Na+
135 -145 mEq/
K+
3.5 - 5 mEq/L
Ca +
8.4 -10.5mg/dL
Mg +
1.5 - 2.5 mEq/L
Cl-
98-106 mEq/L
HCO3-
22 - 26 mEq/L
PO4-
2.7-4.5 mEq/L
2
2
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Electrolyte Imbalances
• Deficit or excess of an electrolyte
• Indicates dysfunction
– Fluid or acid-base imbalance
– Neuromuscular
– Cardiac
– Renal
– Endocrine
– Skeletal
• Venous sampling
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Hyponatremia
• Sodium deficit in ECF < 135 mEq/L
– Caused by loss of sodium or gain of water
• Fluid moves from less concentrated
ECF to ICF space
• Leads to swelling of cells and cerebral
edema
• Watch for seizures
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Hypernatremia
• Surplus of sodium in ECF > 145 mEq/L
– Results from excess water loss or excess of
sodium
• Fluids move from the cells causing
them to shrink
• CNS are especially affected
– Neurological impairment
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Hypokalemia
• Potassium deficit in ECF < 3.5 mEq/L
• K+ moves from the cell creating
intracellular K+ deficiency
• Skeletal muscles are first to
demonstrate K+ deficiency
– Muscle weakness
– Leg cramps
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Hyperkalemia
• Excess K+ in ECF > 5.0 mEq/L
• Affects nerve conduction, muscle
contractility
• Cardiac irregularities, cardiac arrest
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Hypocalcemia
• Calcium deficit in ECF, < 8.4 mg/dL
– Inadequate calcium intake
– Impaired calcium absorption
– Excessive calcium loss
• Sx
– Numbness/tingling of fingers
– Muscle cramps
– Tetany
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Chvostek’s Sign
• Elicitation: Tapping on the face at a
point just anterior to the ear and just
below the zygomatic bone
• Postitive response: Twitching of the
ipsilateral facial muscles, suggestive of
neuromuscular excitability
• Caused by hypocalcemia
Trousseau’s Sign
• Elicitation: Inflating a sphygmomanometer
cuff above systolic blood pressure for several
minutes
• Postitive response: Muscular contraction
including flexion of the wrist and
metacarpophalangeal joints,
hyperextension of the fingers, and flexion of
the thumb on the palm, suggestive of
neuromuscular excitability
• Caused by hypocalcemia
Hypercalcemia
• Excess of calcium in ECF > 10.5 mg/dL
– Cancer
– Hyperparathyroidism
• Emergency –can lead to cardiac
arrest
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Hypomagnesemia
• Magnesium deficit in ECF < 1.5 mEq/L
– Chronic alcoholism
– Intestinal malabsorption
• Sx
– Heart block
– AMS
– Hyperactive deep tendon reflexes
– Respiratory paralysis
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Hypermagnesemia
• Magnesium excess in ECF
– early sign
• 3-5 mEq/L
– End-stage renal failure
• Kidneys fail to excrete magnesium
– Excessive magnesium intake
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Hypophosphatemia
• Below normal serum concentration of
phosphorous in the ECF < 2.7mg/dL
– Hyperventilation
– Insulin release
– Absorption problems
– Diuretic use
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Hyperphosphatemia
• Above normal serum concentrations of
phosphorous in the ECF > 4.5 mg/dL
– Impaired kidney excretion
– Hypoparathyroidism
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Grading Edema
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What Do We Assess for re: Fluid,
Electrolyte, and Acid-Base
Balance………
VS
Intake and Output
Urine volume/concentration
Body weight
Skin Turgor
Tongue turgor
– Multiple longitudinal
furrows
Moisture and oral cavity
Tearing and salivation
– Absent
Facial appearance
– Pinched and drawn
– Sunken eyes
Neck veins
• Appearance of skin and skin
temperature
– Warm, flushed skin
(Peripheral vasodilation)
• Edema
– Clinical edema is usually
not apparent in the adult
until the retention of 5-10
lbs. of excess fluid occurs
• Body temperature
• Neuromuscular irritability
– DTR
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Laboratory Studies
• CBC
– The complete blood count, the basic screening test,
determines the total number of red blood cells and values
for hemoglobin and hematocrit. Significant values include
the following:
– Increased hematocrit values: found in severe fluid volume
deficit and shock (when hemoconcentration rises
considerably)
– Decreased hematocrit values: found with acute, massive
blood loss, and with hemolytic reaction after transfusion of
incompatible blood or with fluid overload
– Increased levels of hemoglobin: found in
hemoconcentration of the blood
– Decreased levels of hemoglobin: found with anemia states,
severe hemorrhage, and after a hemolytic reaction
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Laboratory Studies
• Serum Electrolytes, BUN, and
Creatinine Levels
– Determines plasma levels
• Sodium
• Potassium,
• Chloride,
• Bicarbonate ions
• BUN and creatinine levels
– Provide information related to the fluid status and
the renal function of the patient.
– BUN-10-20 mg/100mL
– Creatinine-0.7-1.4 mg/100mL
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Laboratory Studies
• Urine pH and Specific Gravity
–
–
–
–
dipstick measurement
fresh voided specimen
laboratory analysis.
pH of urine
• 4.5 and 8.2
– Specific gravity
• measure of the urine's concentration
• Range depends on the patient's state of hydration and
varies with urine volume and the load of solutes to be
excreted
• Normal values range from 1.003 to 1.035 (concentrated
urine: 1.020–1.030 or more; dilute urine: 1.001–1.010).
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Laboratory Studies
• ABG’s determine the
adequacy of oxygenation and
ventilation and to assess acid–
base status.
• Partial pressure of oxygen
(PaO2) and oxygen saturation
(SaO2) results directly reflects
the adequacy of oxygenation
and ventilation.
• When interpreting ABGs, follow
these necessary steps:
– Determine whether the pH
is alkalotic or acidotic.
– Check for the cause of the
change in pH. Is it
respiratory (PaCO2) or
metabolic (HCO3-)?
In respiratory acid–base
imbalances, the pH and
PaCO2 values are
inversely abnormal
(move in opposite
directions):
– Respiratory acidosis:
• ↓ pH < 7.35 ↑ PaCO
Normal HCO3-
– Respiratory alkalosis:
• ↑ pH > 7.45 ↓ PaCO2
Normal HCO3-
In metabolic acid–base
imbalances, the pH and
HCO3-values are both
high or both low:
– Metabolic acidosis:
• ↓ pH < 7.35 ↓ HCO3Normal PaCO2
– Metabolic alkalosis:
• ↑ pH > 7.45 ↑ HCO3Normal PaCO2
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How do you know if the patient is in
some type of compensated
process……..
• Anytime PaCO2 and HCO3- are going the
same direction (either both high or both
low), it is a compensated process - such as
partially compensated respiratory acidosis
(both PaCO2 and HCO3- are high)
– Respiratory
• Renal system ↑ or ↓ HCO3-
– Metabolic
• Respiratory system regulates CO2 levels
• The focus of compensation efforts is to return
the pH to normal range
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Sum
It
All
Up
Look at pH and determine if it is high or low (alkalosis or acidosis)
•
• Examine the PaCO2 and determine if it indicates acidosis or alkalosis
– If pH is low it is some type of acidosis
• If PaCO2 is high, it’s respiratory acidosis
• If HCO3 is low it’s metabolic acidosis
– If pH is high it is some type of alkalosis
• If PaCO2 is low, its respiratory alkalosis
• If HCO3 is high, its metabolic alkalosis
• Identify the origin of the acid-base disturbance as respiratory or
metabolic
– Circle the acidosis or alkalosis that matches the pH
• Determine whether the patient is in compensation
– If the pH is normal, and values for respiratory and metabolic
components outside their normal ranges but in opposite
directions, the patient is fully compensated
– If the pH is not normal, look at the value not circled. If within
normal limits, the patient is uncompensated; if outside the normal
limits, patient is compensated
– Anytime PaCO2 and HCO3 are going the same direction (either
both high or both low), it is a compensated process - such as
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partially compensated respiratory acidosis (both PaCO2 and
HCO3 are high)
Nursing Process
• Identifying patients at high risk for fluid, electrolyte,
and acid–base imbalance
• Determining that a specific imbalance is present
and identifying the nature of the imbalance along
with its severity, etiology, and defining
characteristics or assessment findings
• Determining the plan of care, including the
appropriate nursing diagnosis/es or collaborative
problem/s, followed by the identification of specific
outcomes, associated interventions, and the
evaluation of the effectiveness of the plan of care
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Nursing Diagnosis
1. Excess Fluid Volume
2. Deficient Fluid Volume
3. Risk for Imbalanced Fluid Volume
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•
Intravenous
Therapy
Maintain strict aseptic
technique
Examine the solution for
type, amount, expiration
date, character of the
solution, and lack of
damage to container
Select and prepare an IV
infusion pump, as indicated
Monitor for IV patency
before administration of IV
medication
Perform IV site checks
according to agency policy
Maintain occlusive dressing
Flush IV lines between
administration of
incompatible solutions
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IV Administration
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Vascular Access Devices
• Peripheral Venous Catheters
• Central Venous Access Devices
– Peripherally inserted central catheters (PICCs)
– Nontunneled percutaneous central venous catheters
• Shorter dwell time
• Introduced through skin into jugular, subclavian,
femoral veins and sutured in place
– Tunneled central venous catheters
• Long term use
• Implanted into internal jugular subclavian or femoral
vein
• Tunneled in subclavian tissue under skin and sutured in
place
– Implanted ports
– Requires aseptic technique with mask R/T dressing,
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tubing, cap changes
CVAD
• Provides access for IV fluids, medications,
blood products, and TPN solutions
• Means for hemodynamic monitoring and
blood sampling
• CVAD is usually introduced into the
subclavian or internal jugular vein and
passed to the superior vena cava just above
the right atrium
• All CVADs require radiographic confirmation
of position.
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PICC
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Triple Lumen CVC
(nontunneled)
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Implanted Port
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Peripheral IV Sites
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Infusion Site Care
• Maintain patency
• Observe site for complications
• Regular dressing changes (aseptic technique) and tubing
replacements are important means of preventing infection.
– 2% chlorhexidine-based solution is recommended for skin
antisepsis for central venous catheter site care (CDC,
2002).
– For peripheral catheter site care, chlorhexidine is preferred.
– Iodine, iodophor, and 70% alcohol are considered
acceptable alternatives (Hadaway, 2003).
– Transparent membrane dressings are used most
commonly to protect the insertion site.
– Transparent dressings (eg, Tegaderm or OpSite IV) allow
easy inspection of the IV site, permit evaporation of
moisture that accumulates under the dressing, and help to
secure the catheter.
• Agency policy generally determines the type of dressing and
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the intervals for dressing change.
Complications
• Infiltration: the escape of
fluid into the subcutaneous
tissue
– Dislodged needle
Penetrated vessel wall
– Swelling, pallor, coldness, or
pain around the infusion
site; significant decrease in
the flow rate
• Sepsis: microorganisms
invade the bloodstream
through the catheter
insertion site
– Poor insertion technique
– Red and tender insertion
site Fever, malaise, other
vital sign changes
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Complications
• Phlebitis: an inflammation of
a vein
– Mechanical trauma from
needle or catheter
– Chemical trauma from
solution
– Septic (due to
contamination)
– Local, acute tenderness;
redness, warmth, and
slight edema of the vein
above the insertion site
• Thrombus: a blood clot
– Symptoms similar to
phlebitis
– IV fluid flow may cease if
clot obstructs needle
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Complications
• Speed shock: the body's reaction to a substance
that is injected into the circulatory system too
rapidly
– Too rapid a rate of fluid infusion into circulation
– Pounding headache, fainting, rapid pulse rate,
apprehension, chills, back pains, and dyspnea
• Fluid overload: the condition caused when too
large a volume of fluid infuses into the circulatory
system
– Too large a volume of fluid infused into circulation
– Engorged neck veins, increased blood pressure, and
difficulty in breathing (dyspnea)
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Complications
• Air embolus: air in the circulatory system
– Break in the IV system above the heart level allowing air in
the circulatory system as a bolus
– Respiratory distress
– Increased heart rate
– Cyanosis
– Decreased blood pressure
– Change in level of consciousness
– Pinch off catheter or secure system to prevent entry of air.
Place patient on left side in Trendelenburg position.
Call for immediate assistance.
Monitor vital signs and pulse oximetry.
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Blood Products
• Typing and Cross-Matching
• Blood Types
– A, B, AB, and O
• Rh Factor
• Donate their own blood for transfusion (autologous
transfusion)
• Group AB
– Universal Recipient
• Have no agglutinins for A or B antigens
• Group-O
– Universal Donor
• Have neither A or B antigens
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Blood Components
• Packed red blood cells
– Patient with anemia (a reduction in red blood cells or
hemoglobin)
– Patient with cardiovascular failure, with a need to increase
blood volume and red blood cells while avoiding
cardiovascular overload
– Patient with GI bleeding, with a need to maintain
adequate hemoglobin levels without increasing blood
pressure, which would likely lead to more bleeding
• Fresh-frozen plasma
– When only plasma is required, such as when plasma
protein or the blood's clotting factor is low.
• Platelet infusion
– is indicated for the treatment or prevention of bleeding
associated with deficiencies in the number or function of a
patient's platelets
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Transfusion Reactions
• Allergic reaction: allergy to transfused blood
• Febrile reaction: fever develops during
infusion
• Hemolytic transfusion reaction:
incompatibility of blood product
• Circulatory overload: too much blood
administered
• Bacterial reaction: bacteria present in blood
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TPN
• Total parenteral nutrition (TPN)
– Highly concentrated nutrient solution consisting of
dextrose, amino acids, and select electrolytes, vitamins,
minerals, and trace elements that must be infused through
a central vein because of its hypertonic nature
• Hypertonic
• Monitor glucose levels/lytes
• Should infuse by itself-designated lumen
– Given to patients who are unable to meet their nutritional
needs through the oral or enteral routes.
– Complication
• Catheter related infection
• Electrolyte imbalances
– Must not be stopped suddenly causes hypoglycemic
reaction
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