Fluids , Electrolytes , and acid- base imbalance

-Objectives: At the end of the lecture you should be able to: 1. 2. 3. 4. 5. 6. Describe the pathophysiology and manifestations of fluid volume or electrolyte imbalance. Identify diagnostic tests used to diagnose fluid, electrolyte, and acid-base disorders. Recognize normal and abnormal values of electrolytes in the blood.Discuss the causes and effects of acid-base imbalances Use arterial blood gas to identify the type of acid-base imbalanceUse the nursing care plan as a framework to provide individualized nursing care to patients with fluid, electrolyte, and acid-base disorders.

Homeostasis: The ability of the body to maintain internal balance. All organs and structure of the body are involved in the maintenance of homeostasis Organs involved in homeostasis include : 1. 2. 3. 4. 5. 6. Balance : Fluid and electrolyte homeostasis is maintained in the body Neutral balance: Positive balance: Negative balance: input = output input > output input < output Kidneys Lungs Heart Adrenal glands Parathyroid glands Pituitary gland.

Intracellular Fluid (ICF): All fluid inside cells Extracellular Fluid (ECF): All fluid outside cells 1. 2. Normal serum osmolality is 275 to 300 mOsm/kg Normal urine osmolality is 250 to 900 mOsm/kg Normal urine specific gravity 1.010 1.025 Pathophysiology of water & electrolytes: Amount and Composition of Body Fluids: Approximately 60% of a typical adults weight consists of fluid (water and electrolytes). Younger people have a higher percentage of body fluid than older people, and men have proportionately more body fluid than women. 3. Obese people have less fluid than thin people because fat cells contain little water.

Composition of Body Fluids and Major Electrolyte Content in Body Fluid A. Water B. Solutes ( dissolved particles) Disturbances in water, electrolyte and acid-base balance occur in a wide variety of diseases and can be associated with a high mortality and require urgent assessment and treatment. The kidneys play an important part in maintaining normal water, electrolyte and acid-base balance . When fluid balance is critical, all routes of gain and all routes of loss must be recorded and all volumes compared. Organs of fluid loss include the kidneys, skin, lungs, and gastrointestinal (GI) tract.

1. 2. 3. 4.

Extracellular Fluid (Plasma) Cations 1. 2. 3. 4. Sodium (Na) Potassium (K) Calcium (Ca++) Magnesium (Mg++) Anions 1. 2. 3. 4. 5. 6. Intracellular Fluid Cations 1. Potassium (K+) 2. Magnesium (Mg++) 3. Sodium (Na+) Anions 1. Phosphates and sulfates 2. Bicarbonate (HCO3) 3. Proteinate Chloride (Cl) Bicarbonate (HCO3) Phosphate (HPO4) Sulfate (SO4) Organic acids Proteinate

Body Fluid Compartments

Average Daily Intake and Output in an Adult INTAKE Oral liquids Water in food 1,300 mL 1,000 mL Urine Stool OUTPUT 1,500 mL 200 mL Insensible Lungs Skin Total loss* 300 mL 600 mL 2,600 mL

Water produced by metabolism 300 mL Total gain* 2,600 mL

Routes of Gains and Losses :

1. Routes of Gains i. Dietary intake of fluid and food ii. Enteral feeding iii. Parenteral fluids 2. Routes of Losses i. Kidney: urine output ii. Skin loss: sensible and insensible losses iii. Lungs : insensible losses iv. GI tract

Fluid Volume Excess (FVE) (Hypervolemia)

Causes : 1. 2. 3. 4. 5. 6. 7. Excess Na intake Rapid administration of hypertonic/isotonic fluids Increased release of ADH Decreased plasma proteins Chronic Kidney Diseases Acute Renal Failure Heart failure

Main clinical features: 1. 2. 3. 4. 5. 6. 7. 8. Fatigue , LOC changes Increased BP, tachycardia SOB; increased RR dyspnea jugular vein distention Edema , Weight gain Crackles over lung bases Increased abdominal girth Decreased Urine output; but polyuria occur with normal kidneys

Nursing Assessment for hypervolemia (FVE) : 1. Monitor Vital signs , central venous pressure(CVP) 2. Assess neck and peripheral venous distention
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3. Monitor the degree of edema in the most dependent parts of the body, such as the feet and ankles in ambulatory patients and the sacral region in bedridden patients. 4. The degree of pitting edema is assessed, and the extent of peripheral edema is monitored by measuring the circumference of the extremity with a tape marked in millimeters. 5. Auscultate lungs and heart sounds & assess breath sounds at regular intervals, particularly when parenteral fluids are being administered. 6. Measure intake and output at regular intervals to identify excessive fluid retention. note urine output and fluid balance on 24 hour. 7. Weigh the patient daily and acute weight gain is noted. An acute weight gain of 0.9 kg represents a gain of approximately 1 L of fluid. Nursing Management for hypervolemia (FVE) : 1. PREVENTING FVE a. Sodium restricted diets, and adherence to the prescribed diet is encouraged. b. The patient is instructed to avoid over the-counter medications without first checking with a health care provider because these substances may contain sodium 2. II-DETECTING AND CONTROLLING FVE a. Promoting rest b. Restricting sodium intake c. Monitoring parenteral fluid therapy, and administering appropriate medications (diuretics). d. If dyspnea or orthopnea is present, the patient is placed in a semi-Fowlers position to promote lung expansion. e. The patient is turned and positioned at regular intervals because edematous tissue is more prone to skin breakdown than normal tissue. 3. Give oral fluids with caution 4. Monitor infusion of fluids 5. Encourage deep breathing exercise 6. Provide safety precautions 7. Assist with identification and treatment of underlying cause 8. Monitor lab studies Fluid Volume Deficit ( FVD) (Hypovolemia) Causes: 1. 2. 3. 4. 5. Excessive fluid losses Decreased fluid intake Systemic infections, fever Intestinal obstruction or fistulas Kidney disease

Main clinical features: 1. Decreased BP and postural hypotension (ie, a drop in systolic pressure exceeding 15 mm Hg when the patient moves from a lying to a sitting position).
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2. 3. 4. 5. 6. 7.

Weak , rapid pulse Flattened neck veins Decreased urine volume of less than 30 mL/h in an adult Tingling of extremities Increased RR, rapid shallow breathing Weight loss: a. One liter of fluid weighs approximately 1 kg b. i.e. an acute loss of 0.5 kg represents a fluid loss of approximately 500 mL.

1. 2. 3.

Nursing Assessment for hypovolemia : Monitor vital signs for increase HR, decrease BP or postural BP changes , CVP; and observe for fever. Palpate peripheral pulses; note capillary refill Monitor and measures fluid intake and output at least every 8 hours, and sometimes hourly , and urine output . 4. Monitor skin turgor. Skin turgor is best measured by pinching the skin over the sternum, inner aspects of the thighs, or forehead The skin turgor test is not as valid in elderly people as in younger people because skin elasticity decreases with age; therefore, other assessment parameters must be considered. 5. Evaluating tongue turgor, which is not affected by age, may be more valid than evaluating skin turgor 6. The degree of oral mucous membrane moisture is also assessed; a dry mouth may indicate FVD 7. Daily body weights are monitored and compare with 24 hours fluid balance 8. Evaluate patients ability to swallow 9. Report any sudden sharp chest pain, dyspnea, cyanosis and restlessness 10. Urinary concentration is monitored by measuring the urine specific gravity. 11. In a volume-depleted patient, the urinary specific gravity should be above 1.020, indicating healthy renal conservation of fluid (concentrated urine). Nursing Management for Hypovolemia ( FVD)
I-PREVENTING FVD

1. Identify patients at risk and take measures to minimize fluid losses. 2. For example, if the patient has diarrhea, diarrhea control measures should be implemented and replacement fluids administered. 3. These measures may include administering antidiarrheal medications and small volumes of oral fluids at frequent intervals. II-CORRECTING FVD 1. Oral fluids are administered to help correct FVD, and select fluids most likely to replace the lost electrolytes 2. If the patient is reluctant to drink because of oral discomfort, the nurse assists with frequent mouth care and provides nonirritating fluids.
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3. If the patient cannot eat and drink, the nurse may need to administer fluid by an alternative route (enteral or parenteral) prescribed to prevent renal damage related to prolonged FVD. 4. Assist with identification & treatment of cause 5. Monitor laboratory studies 6. Administer IV solutions as indicated 7. Administer sodium bicarbonate, if indicated 8. Provide tube feedings, including free water 9. Turn frequently, massage skin and protect bony prominences 10. Provide skin and mouth care 11. Apply lotion as indicated 12. Provide safety precautions

Electrolytes Balance and imbalance Sodium

1. 2. 3. 4. NV = 135-145 mEq/L Is the major cation of ECF Important for Neuromuscular conduction/transmission of impulses Maintains acid-base balance Hyponatremia o Level less than 135 mEq/L Causes: 1. 2. 3. 4. Diuretics , chronic vomiting Chronic diarrhea Decreased aldosterone Decreased Na+ intake

Clinical manifestations of Hyponatremia 1. Neurological: a. Lethargy, headache, confusion, apprehension, depressed reflexes, seizures and coma 2. Muscle: a. Cramps, weakness, fatigue 3. Gastrointestinal: a. Nausea, vomiting, abdominal cramps, and diarrhea Tx : limit water intake or discontinue meds , Treat underlying causes Hypernatremia o Level more than 145 mEq / L. Causes of Hypernatremia: 1. Hypertonic IV soln. 2. Oversecretion of aldosterone 3. Loss of pure water: a. Long term sweating with chronic fever
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b. Respiratory infection water vapor loss c. Diabetes polyuria 4. Insufficient intake of water (hypodipsia) Clinical manifestations of Hypernatremia 1. 2. 3. 4. Thirst Lethargy Neurological dysfunction due to dehydration of brain cells Decreased vascular volume

Tx : Lower serum Na+ 1. Isotonic salt-free IV fluid i.e. Dextrose 2. Oral solutions preferable

Potassium
1. NV = 3.5-5.3 mEq/L 2. Mainly intracellular 3. Regulates neuromuscular excitability Hypokalemia Serum K+ less than 3.5 mEq /L Causes : 1. Decreased intake of K+ 2. Increased K+ loss a. Chronic diuretics b. Acid/base imbalance c. Trauma and stress d. Increased aldosterone e. Redistribution between ICF and ECF Clinical manifestations of Hypokalemia 1. 2. 3. 4. Weakness, flaccid paralysis, respiratory arrest, constipation Dysrhythmias, appearance of U wave Postural hypotension , Cardiac arrest Hyperkalemia Serum K+ more than 5.3 mEq / L Causes: 1. 2. 3. 4. 5. 6. Renal disease Massive cellular trauma Insulin deficiency Addisons disease Potassium sparing diuretics Decreased blood pH
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7. Exercise causes K+ to move out of cells Clinical manifestations of Hyperkalemia 1. 2. 3. 4. 5. Early : Hyperactive muscles , paresthesia Late : Muscle weakness, flaccid paralysis Change in ECG pattern Dysrhythmias Bradycardia , heart block, cardiac arrest

Calcium
2.1 2.6 mEq/L (ionized calcium) Essential for: 1. 2. 3. 4. Bone formation/reabsorption Neural transmission/muscle contraction Coenzyme in blood coagulation Ionized Ca is the active form Hypocalcemia Serum level < 2.1 mEq / L Caused by: 1. 2. 3. 4. 5. 6. 7. Renal failure Lack of vitamin D Suppression of parathyroid function ( PTH) Hypersecretion of calcitonin Malabsorption states Abnormal intestinal acidity and acid/ base bal. Widespread infection or peritoneal inflammation

Manifestations: 1. 2. 3. 4. Numbness and tingling of fingers and circumoral region Muscle cramps , tetany Severe : seizures Chvosteks and Trousseaus signs. Hypercalcemia Serum level > 2.6 mEq / L Causes: 1. 2. 3. 4. 5. Hyperparathyroidism ( PTH ) Hypothyroid states Renal disease Excessive intake of vitamin D Milk-alkali syndrome
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6. 7.

Certain drugs Hypercalcemia of malignancy

Clinical manifestations: 1. 2. 3. 4. 5. 6. Many nonspecific fatigue, weakness, lethargy Increases formation of kidney stones and pancreatic stones Muscle cramps Bradycardia, cardiac arrest Pain GI activity also common a. Nausea, abdominal cramps b. Diarrhea / constipation 7. Metastatic calcification

Nursing Assessment for Electrolyte Imbalance 1. Monitor VS , volume status, CVS/ECG , LOC 2. Monitor for abnormal serum / urine electrolytes & osmolality 3. Monitor for manifestations of electrolyte imbalance 4. Monitor for loss of electrolyte-rich fluids (e.g., nasogastric suction, ileostomy drainage, diarrhea, wound drainage, and diaphoresis) 5. Obtain ordered specimens for laboratory analysis of electrolyte levels (e.g., ABG, urine, and serum levels), as appropriate 6. Monitor patient's response to prescribed electrolyte therapy 7. Monitor for side effects of prescribed supplemental electrolytes (e.g., GI irritation) 8. Monitor closely the serum potassium levels of patients taking digitalis and diuretics 9. Place on cardiac monitor , especially during therapy

Nursing management for Electrolyte Imbalance

1. 2. 3. 4. 5. 6. 7. Maintain patent IV access Administer fluids, as prescribed Maintain accurate intake and output record Maintain intravenous solution containing electrolyte(s) at constant flow rate, as appropriate Administer supplemental electrolytes (e.g., oral, NG, and IV) as prescribed Consult physician if signs and symptoms of fluid and/or electrolyte imbalance persist or worsen Provide appropriate diet for patient's electrolyte imbalance (e.g., potassium-rich, low-sodium, and lowcarbohydrate foods) 8. Instruct the patient and/or family on specific dietary modifications, as appropriate 9. Provide a safe environment for the patient with neurological and/or neuromuscular manifestations of electrolyte imbalance 10. Teach patient and family about the type, cause, and treatments for electrolyte imbalance, as appropriate 11. Prepare patient for dialysis (e.g., assist with catheter placement for dialysis), as appropriate

Acid-Base Balances
Normal PH = 7.35 - 7.45 (slightly alkaline) Alkalosis PH > 7.45 Acidosis PH < 7.35 PH measured in arterial blood gases test (ABG) PaCO2: 35 to 45 mm Hg HCO3-: 22 to 26 mEq/L Acid Base Regulatory Mechanisms 1. Chemical Acid-Base Control Bicarbonate (HCO3) and phosphate (P) [ Body buffers ] 2. Respiratory Acid Base Control Carbon dioxide (CO2 ) 3. Renal Acid Base Control Bicarbonate (HCO3) , acids, ammonium

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 Nursing Assessment & intervention for acid-base imbalance: The previously mentioned in fluid/electrolyte imbalance , + 1. Clinical assessment for history and physical examination. 2. ABG values provide important information about patients condition. 3. Identify patients at risk for acid-base disturbances, including those who have or are at risk for: Significant electrolyte imbalances Ventilation abnormalities Abnormal kidney function. 4. Assess patients carefully to identify early clues of acid-base disturbances. 5. Consider what your patients vital signs are telling you. 6. Count your patients respirations for a full minute. What are the rate and the depth? 7. What is your patients level of consciousness? Confusion can be an early sign of an acid-base disturbance 8. Correlate your patients fluid balance and creatinine levels with kidney function. 9. Always correlate your assessment findings with your patients diagnosis. 10. Be sure to double-check the implications and adverse effects of all drugs you administer.

Good luck DR. Abeer ALi

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