Download Fluids and Electrolytes

Fluids and Electrolytes
Balance and
Disturbances
Amount and Composition of
Body Fluids


Approximately 60% of the weight of a
typical adult consists of fluid (water and
electrolytes).
Factors that influence the amount of body
fluid are:
-age
-gender
-body fat
Amount and Composition of body
fluids (cont.)


In general, younger people have a higher
percentage of body fluid than older
people, and men have proportionately
more body fluid than women.
Obese people have less fluid than those
are thin, because fat cells contain little
water.
Amount and Composition of Body
Fluids (cont)


Both obese and older adults are at risk for
complications of illness from dehydration or
fluid shifts because of less fluid reserve in
their bodies. Loss of 10% is serious, 20% is
fatal.
Very young is also at risk for dehydration
because more than half of an infant’s fluid is
extracellular which is lost from the body more
rapidly than intracellular fluid. Loss of 5% is
serious, 10% is very serious, and 15% is fatal.
Amount and Composition of body
Fluids (cont)


Skeleton has little water.
Muscle, skin and blood vessels have the
highest amount of water.
Body fluid is located in TWO FLUID
COMPARTMENTS separated by a semi
permeable membrane, and are in constant
motion throughout the body to carry out their
functions.
Two Fluid Compartments
1.
2.
Intracellular space (fluid in the cells) –
ICF-2/3 of the body fluid is in the
intracellular fluids compartments, and is
located primarily in the skeletal muscle
mass.
Extracellular space (fluid outside the
cells) –ECF-1/3 in the extracellular fluid
compartment.
Two fluid compartments (cont)



Intravascular space contains plasma.
Approximately 3L of the average 6L of
blood volume is made up of plasma. The
remaining volume is made up plasma. The
remaining 3 is made up of erythrocytes,
leukocytes and thrombocytes.
Interstitial space contains the fluid that
surrounds the cells and totals about 11 to
12 L in adult. Lymph is an interstitial fluid.

Transcellular space is the smallest
division of ECF compartment, contains 1L
EXMAPLE: CSF, Pericardial Fluid
Synovial Intraocular,
Pleural Fluids; sweat
and digestive secretions
Water



Water provides Extracellular transportation
route to deliver nutrients to the cells and
carry waste products from the cells.
Water aids in the maintenance of acid base
balance and assist in the heat regulation by
evaporation.
Body fluid shifts between the two major
compartments or spaces to maintain
equilibrium between the spaces.
Water (cont)


Loss of ECF into a space that does not
contribute to equilibrium between the ICF
and ECF is referred to as a third-space
fluid shift or “third spacing” for short.
Third spacing occurs in ascitis, burns,
peritonitis, bowel obstruction, and
massive bleeding into a joint or body
cavity.
Water (cont)


As water moves through all parts of the
body, it is constantly lost through the
kidney 1-2l/day, skin 600ml/day, lungs
400ml/day, and GI tract 100-200ml/day.
Homeostasis- is the way human body
respond to balance the daily fluid loss by
adaptive responses that promotes healthy
survival.
Water (cont)

Daily water I and O is approximately 2500 ml.

Organs involved in homeostasis are:
– Kidneys
– Lungs
– Heart
– Adrenal glands
– Parathyroid glands
– Pituitary glands
Water (cont)

Liquid output include all fluids leaving the body.
-Urine
-diarrhea
-Nasogastric suction
-Chest tube drainage

Water loss is replenished in two ways:
– Ingestion of liquids and food (TF, parenteral
intake (IV), blood components, TPN)
– Metabolism of both food and body tissue.

Kidney is vital in the regulation of fluid and
electrolyte balance.
-Nephron is the base functional unit of
the kidney. It filters blood at the rate of
125ml/minute, or about 180L/day. This is
called glomerular filtration rate, leads to an
output of 1-2L of urine/day. The distal tubule
of nephron reabsorbs water and
concentrates urine as a result of ADH action.
Kidney (cont)


If the body losses 1-2% of its fluids, the
kidney reacts by conserving fluid by
reabsorbing more water from the renal
filtrate  a more concentrated urine.
Kidney must excrete a minimum of
30ml/hr of urine (720ml/24hrs) to get rid
of body waste products.
Movement of Fluid and Electrolyte

1.
2.
Two transport processes allow the mass
movement of substances into and out of the
cells:
Passive Transport Processes – no cellular
energy is required to move substances from a
high concentration to a low concentration.
Active Transport Processes – cellular energy
is required to move substances from a low
concentration to a high concentration.
Passive Transport
Diffusion – is the movement of particles in all
directions through a solution or gas.
Solutes move from area of higher concentration to
an area of lower concentration which results in
an equal distribution of solutes within the two
areas.
EXAMPLE: The exchange of oxygen and
carbon dioxide between the pulmonary
capillaries and alveoli; the movement of sodium
from ECF compartment where the Na+
concentration is high to he ICF where the
concentration is low.


Osmosis – is the movement of water from
an area of lower concentration to an area
of higher concentration. Osmosis
equalizes the concentration of ions or
molecules on each side of the membrane.
EXAMPLE: If ECF is more
concentrated than ICF, the fluid from the
IF moves out to the ECF causing the red
blood cell to shrink.

Filtration – is the transfer of water and
dissolved substances from an area of higher
pressure area to an area of lower pressure.
Filtration allows the kidneys to filter 180 L of
plasma/day.
EXAMPLE: The pumping action of the heart
creates the hydrostatic pressure, responsible
for the passage of water and electrolytes from
the arterial capillary bed to interstitial fluid.
Active Transport


Active transport requires energy to move
solutes from an area of lower
concentration to an area of higher
concentration.
Substances called Adenosine
Triphosphate or ATP makes the active
transport possible. ATP supplies energy
for solute movement in and out of cells.
Electrolytes



Are substances that when in solution,
separate or dissociate into electrically
charged particles called ions.
Ions can either be positive – cations, or
negative- anions.
They are measured by their electrical
activity, chemical activity or combining
power called milliequivalent (mEq)
equivalent to a hydrogen.
Sodium (Na+) 134 to 142 mEq/L



Mostly found in the ECF 90% and 10% in
ICF.
Primary excretion is kidney. But can also
be excreted through GI tract and skin via
sweat.
Minimum daily intake is 0.5 to 2.7g/daily.
Salty American diet contains 6g/day.
Functions of Sodium



It regulates water balance in the body.
It controls the extracellular fluid volume
mainly through osmotic pressure. H2O
follows sodium in the body.
It helps transmit impulses in nerve and
muscle fibers especially the heart and
combines with chloride and bicarbonate
to regulate acid base balance.
Hyponatremia
Means sodium deficiency, a common
electrolyte imbalance.
 Another way to explain
hyponatremia is sodium deficiency
in relation to the amount of water in
the body or sodium loss, water gain.

Hyponatremia (cont)
Causes
 Inadequate intake of sodium
 Loss of GI Fluids
 Vomiting and Diarrhea
 Burns and Ascites
Signs and Syptoms
Headache, Fatigue
Muscle weakness
Postural Hypotension
Severe or Prolonged Deficit
Shock
Altered level of consciousness such Lethargy and confusion
Coma
Nursing Interventions







Monitor I&O of patients receiving diuretic
medications
Monitor and record vital sign, especially blood
pressure and pulse.
Monitor neurological status
Weigh patient daily.
Monitor skin turgor at least every 8 hrs.
Observe for abnormal GI, renal or skin losses
Replace fluid loss with fluids containing
sodium, not plain water.
Hypernatremia
 Refers
to an excess of sodium
relative to the amount of water in
the body.
 The sodium level exceeds 145
mEq/L.
Hypernatremia (cont)
Causes
 Taking too many salt tablets
 IV solution infused too rapidly
 Overuse of table salts
 Dietary products in large amounts
Signs and Symptoms
Dry, tenacious mucous membrane
Low urinary output
Restlessness, flushed skin, agitation, confusion
Severe Prolonged Excess
Manic Excitement
tachycardia
death
Nursing Interventions





Monitor and record vital signs, especially
blood pressure and pulse.
Provide safe environment for confused
and agitated patients.
Monitor I&O.
Weigh patient daily to check for body
fluids loss.
Monitor serum sodium level.
Potassium (K+) 3.5-5 mEq/L




Mostly found in the ICF 98% and 2 % in
ECF.
Primary excretion is Kidney, Feces and
Perspiration.
Minimum daily intake is 60 to 100 mEq.
Food sources leafy vegetables, fruits,
legumes and meat products.
Functions of Potassium




It maintains cell’s electrical neutrality and
osmolality. (regulates water and
electrolyte content within the cell).
Aids in neuromascular transmission of
nerve impulses.
Assist in skeletal and cardiac muscle
contraction, and electrical conductivity.
Assists in the cellular metabolism of
carbohydrates and protein.
Hypokalemia
 Low
K+ below 3.5 mEq/L.
 A slight decrease has profound
effect in the body.
Hypokalemia (cont)
Causes
 GI Losses (vomiting, diarrhea, and GI suctioning).
 Severe use of diuretics such as thiazides and furosemide (lasix)
 Major cause is RENAL EXCRETION.
Signs and Symptoms
Skeletal muscle weakness esp. in the lower extremities, Leg
cramps
Vomiting, Orthostatic Hypotension, Polyuria
Severe or Prolonged Deficit
Kidney damage
Cardiac arrest/Respiratory arrest
Nursing Interventions






Administer KCI supplement as ordered (oral or
IV).
Encouraged increase intake of foods high in
potassium
Monitor vowel sounds
Monitor serum potassium level
During the treatment of potassium, the patient’s
urinary output must be at least 600 mL/day. If
urinary output is less than 20 mL/hr for 2
consecutive hrs, the nurse should interrupt the
infusion and immediately notify the physician .
Monitor telemetry.
Hyperkalemia



Serum K+ level greater than 5 mEq/L
K+ is gained through intake and loss by
excretion. If either is altered hyperkalemia
can result.
Hyperkalemia is dangerous because it
can cause CARDIAC ARREST.
Hyperkalemia (cont)
Causes
 Use of beta blockers
 Chemotherapy
 NSAIDS
 Angiotensin-converting enzyme inhibitors
 Potassium sparing diuretics
 Renal Failure
Signs and Symptoms
Nausea, Vomiting, Diarrhea, Colic
Cardiac dysrythmias
Severe and Prolonged Excess
Flaccid paralysis
Cardiac Arrest
Nursing Interventions








Decrease intake of foods high in potassium.
Loop diuretics
Medications associated with high potassium level
should be decreased or stopped.
Assess vital signs
Monitor telemetry
Monitor I&O (report an output of less than 30 mL/hr. an
inability to excrete potassium in the urine may lead to
dangerously high potassium level).
Monitor bowel sound and number and character of
bowel movements.
Monitor serum potassium level.
Calcium (Ca+) 4.5 to 5.8 mEq/L or
8.5 mg/dL to 10.5 mg/dL



Mostly found in bones and teeth 99% and 1%
in the soft tissue.
Main excretion is urine and feces.
Minimum daily intake is 200 mg to 2500 mg.
infant 360 mg averages and adults 15 to 18
1200 mg. During pregnancy and lactation
1300 mg. For postmenopausal women taking
estrogen supplement its 1000 mg and with
out estrogen is 1500 mg.
Calcium (cont)


Vitamin D, Calcitonin and parathyroid
hormone is needed for proper
utilization and absorption of calcium.
Sources of foods are milk, and cheese,
other sources are beans, nuts,
cauliflower, lettuce and egg yolk.
Functions of Calcium




Responsible for the formation and structure of
bones and teeth (together with phosphorus).
Helps maintain cellular structure and function
and plays a role in cell membrane permeability
and impulses transmission.
It affects the contraction of cardiac muscle,
smooth muscle, and skeletal muscle.
Plays a role in the blood clothing process and
in the release of certain hormones.
Hypocalcemia


Low calcium level below 4.5 mEq/L
A deficiency may be caused by a variety
of problems.
–
–
–
–
Small bowel disease
Pancreatic disease
Decreased parathyroid function
Inadequate dietary intake of calcium and
vitamin D
Hypocalcemia (cont)
Signs and Symptoms
-Muscle spasm
-Laryngeal spasm
-nausea, vomiting, and diarrhea
-Cardiac dysrythmias and Cardiac
arrest
-Anxiety, confusion, irritability.
Nursing Interventions






Monitor vital signs, monitor respiratory status
Encouraged intake of a diet high in calcium
rich foods and proteins.
Administer calcium and vitamin D as
prescribed.
For acute hypocalcemia, keep a tracheotomy
tray and resuscitation bag at beside incase of
laryngeal spasm.
Monitor serum calcium level, albumin and
magnesium.
Monitor I&O.
Hypercalcemia

Hypercalcemia high calcium level greater
than 5.8 mEq/L
Causes
–
–
–
–
–
Increased Vitamin D
Increased parathyroid hormone
Increased absorption
Loss from the bone
Excess intake of dietary products
Hypercalcemia (cont)
Signs and Symptoms
-Thirst, Polyuria
-Decreased tendon reflexes
-Decreased muscle tone
-Renal calculi
-immobilization
-constipation
Nursing Interventions




Assist in the promotion of excretion of
calcium in the urine.
Administer diuretics as ordered by the
physician.
Encourage drinking 3000 to 4000 L of
fluids per day.
Monitor I&O
Chloride (Cl-) 96 to 105 mEq/L



It is the chief anion in the interstitial and
intravascular fluid.
It has the ability to diffuse quickly
between the intercellular and extracellular
compartment and combines easily with
sodium to form sodium chloride or with
potassium to form potassium chloride.
It is more often linked with sodium.
Chloride (cont)



Daily intake is 3.65 to 10.85 g/day.
Main excretion is kidney.
It is necessary for the formation of
hydrochloric acid in the gastric juice.
Hypochloremia


It is a deficiency in chloride
Losses may occur through the skin (it is found in sweat),
vomiting, diarrhea, NG suctioning, and other GI tube drainage
(fistula).
Signs and Symptoms
-tetany
-muscle twitching
-weakness, agitation
Severe or Prolonged Deficit
-seizure
-coma
-arrythmias
-respiratory arrest
Hyperchloremia


Rarely occurs but may be seen when
bicarbonate level falls.
The chloride anions attempts to
compensate to maintain equal
numbers with cations the body fluids.
Phosphorus (HPO-4) 4 mEq/L




Mainly found in bones and teeth combine
with calcium 70 to 80%, in muscle 10%
and in nerve tissue of the body 10%
Main excretion is the kidney and the
remainder is the feces.
Daily minimum intake is 800 to 1500 mg.
Food sources are beef, pork, fish, poultry,
milk products and legumes.
Functions of Phosphorus



It promotes effectiveness of many of
the B vitamins.
Assist in the normal nerve and muscle
activity.
Participates in carbohydrates
metabolism.
Hypophosphatemia

Can occur in dietary insufficiency,
impaired kidney function, and
maldistributions of phosphate.
Signs and Symptoms
-muscle weakness
Especially affecting the respiratory muscle,
may occur
Hyperphosphatemia


Most commonly occurs as a result of renal
insufficiency.
Another cause is increased intake of
phosphate and vitamin D.
Signs and Symptoms
-tetany
-numbness
-tingling around the mouth
-muscle spasm
Magnesium (Mg++) 1.5 to 2.4
mEq/L




Mainly found in bones 60%, in muscle and soft
tissue 39%, and 1% in the ECF most of which is
in the CSF.
Main excretion is kidney and GI tract.
Daily minimum intake 200 to 400 mg. The
average is 250 mg, for infant 150 mg, for
pregnant and lactating women is 400 mg.
Food sources are whole grains, fruits, vegetable,
meat, fish, legumes and dairy products.
Hypomagnesemia

A decrease in magnesium often parallels
decreased potassium. If the magnesium
level is low, the kidney tends to excrete
more potassium. (and retain magnesium).
Signs and Symptoms
–
Neuromacular irritability similar to those
observed in hypocalcemia.
Nursing Interventions





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Monitor Vital signs.
Assess neuromuscular status
Assess dysphagia
Increase intake of magnesium-rich foods
Monitor I&O
Monitor respiratory status
Hypermagnesemia


Serum level greater than 2.4 mEq/L
Three major causes:
Impaired renal function
– Excess administration of magnesium
– Diabetic ketoaciosis
Signs and Symptoms
– Hypotension
– Vasodilation
– Heat
– thirst
–
Nursing Interventions




Promote urine excretion
Administer diuretics as prescribed by the
physician
Decrease intake of foods or medications
high in magnesium
Monitor I&O
Bicarbonate (HCO-3) 22 to 24
mEq/L


It is a main anion of the ECF, whose major
function is the regulation of acid base
balance and acid alkaline balance.
Bicarbonate acts as a buffer to neutralize
acids in the body and maintain 20:1
bicarbonate/carbonic acid ratio to keep
body in homeostasis.
Bicarbonate (cont)



It indicates how the metabolic system
is functioning.
22 mEq/L acidosis
24 mEq/L alkalosis
Acid –Base balance


The hydrogen ion concentration
determined by the ratio of carbonic acid
to bicarbonate in the ECF, 1:20
pH is the symbol used to indicate
hydrogen ion balance. Keep in mind that
when pH is measured, it is the hydrogen
ion concentration in the patient’s body
that is measured.
Acid –Base balance (cont)




The more hydrogen ions (H+) in a
solution, the more acidic the solution.
The fewer hydrogen ions (H+) in a
solution the more alkaline the solution.
Normal blood pH is between 7.35 (venous)
7:45 (arterial).
A blood pH 6.8 to 7.8 is usually fatal.
When pH rises or falls, three regulatory
system come into play to void
potentially serious consequences;
1. Chemical buffer or Blood buffers – they act like
sponges. They neutralizes excess acids or bases by
contributing or accepting hydrogen ions. They work
within a FRACTION of SECOND to prevent change in
hydrogen ion concentration. Three chemical buffers:
a) Phosphate buffers – renal tubules
b) Protein buffers – the most plentiful
buffers in the body, work inside and outside the cells.
c) Bicarbonate buffers – is the body’s
primary buffer system. The main responsibility is to
buffer blood and interstitial fluid.
2. Lungs – respiratory system uses hypoventilation
or hyperventilation as needed to regulate
excretion or retention of acids within MINUTES of
a change in pH such as increase or decrease the
amount of carbon dioxide in the blood.
3. Kidneys – kick in by excreting or retaining acids
and bases as needed. Renal regulation can
restore normal hydrogen ion concentration
within HOURS or DAYS. It is the slowest of the
systems, but they are efficient enough to return
the pH exactly normal.
Four Primary types of acid –base
imbalance
Respiratory Acidosis – any condition that impairs
three essential parts of breathing – ventilation,
perfusion, or diffusion – causes respiratory
acidosis.
-The acid-base balance is characterized by alveolar
hypoventilation, meaning the pulmonary system is
unable to rid the body of enough CO2 to maintain a
healthy pH balance, and therefore causes
inadequate gas exchange.
- When a patients hypoventilates, CO2 builds up in the
blood stream and pH drops below normal results is
respiratory acidosis.
1.
Respiratory Acidosis (cont)
Signs and Symptoms
Central Nervous System
-Lethargy, dizziness, Disorientation
-Decreased level of consciousness
- Occipital headache
Cardiopulmonary System
-Dyspnea
-Tachycardia
-Hypertension
-Cardiac dysrythmias
Treatment

Treatment for respiratory acidosis is aimed at
improving ventilation such as;
-IPPB to assist in exhaling carbon dioxide
-Antibiotic to treat any respiratory infection
-Adequate hydration to keep the mucous
membranes moist and aid in removal
secretions.
-Bronchodilators to help reduce bronchial
spasm.
Respiratory Alkalosis
2. Respiratory alkalosis is opposite of
respiratory acidosis.
 Caused by hyperventilation and
hypocapnia (low carbon dioxide), there is
an increase in rate, depth, or both can
result in the loss of excessive amounts of
carbon dioxide. Resulting to low carbonic
acid in the blood being blown off with
each exhalation, pH level rises.
Respiratory Alkalosis (cont)
Signs and Symptoms
Central Nervous System
-Irritability
-Anxious Appearance
-Tingling of the extremities
-Fainting and Dizziness
Cardiopulmonary System
-Cardia arrythmias
-Tachypnea
Treatment
The common treatment for respiratory alkalosis is:
-Sedation
-Reassurance
-If the cause is Anxiety, the patient should be
made aware of the abnormal breathing pattern.
-Instruct the patient to breath slowly to retain
and accumulate carbon dioxide in the body or
breath into a paper bag to get back the exhaled
carbon dioxide.
Metabolic Acidosis
3. Metabolic acidosis increase in acids (H+)
characterized by a pH below 7.35 and a HCO3level below 22 mEq/L
 The disorder depresses the CNS if left untreated
may lead to ventricular arrythmias, coma and
cardiac arrest
Signs and Symptoms
-Lethargy, Headache, and decrease level of
consciousness
-Kausmaul’s respirations and Cardiac
arrythmias
Treatment





Monitor the patient’s neurological status
closely, changes may occur rapidly.
Insert IV line as ordered.
Position the patient to promote chest
expansion and facilitate breathing.
Monitor ABG results to check for
overcorrection.
Orient patient as needed.
Metabolic Alkalosis
4. Metabolic Alkalosis is caused by a decrease in
(H+) production.
 Characterized by a blood pH >7.45 and
accompanied by an HCO3- level above 26 mEq/L.
Early diagnosis and prompt treatment, the
prognosis is good. Left untreated can result in
coma, arrythmias, and death.
 The most common cause of metabolic alkalosis
is vomiting gastric content, normally high in
acid.
Treatment and Nursing Care





For treatment, IV administration of ammonium
chloride rarely done.
DC NG suctioning and use of thiazide diuretics.
Administer antiemetic to treat nausea
For nursing care, irrigate an NG tube with normal
saline solution instead of tap water to prevent
loss of gastric electrolytes.
Watch for signs of muscle weakness, tetany and
decreased activity.