Fundamentals of Fluid and Electrolyte Balance Parenteral Solutions

ADN136 Fall 09

Fluid Balance
Body fluid is body water in which electrolytes are dissolved Bodywater makes up

60% of Total Body weight in young men 50-55% in women 70-80% in infants

Fluid Balance

Fluid Balance (cont)

Homeostasis- Dependent on fluid and electrolyte intake physiologic factors, disease state factors, external environmental factors and pharmacologic intervention.

Intracellular fluid (ICF) water in the cells = 40% Extractracellular fluid (ECF) fluid out side the cells = 20% 15% in tissue space (interstitial) outside the blood vessel, between cells 5% in plasma (intravascular space)

Percentage of Body Fluid

Fluid Balance

Normal intake 1-3 L/day 200-300 ml produced by oxidation Normal intake and output will balance approximately every 72 hours

Fluid Balance

Elimination of fluids is considered

Sensible (measurable) loss

Skin, Kidneys, Bowels, lungs lose fluid 300-500ml lost through lungs every 24 hrs. 500ml lost with perspiration

Insensible (not measurable) loss

Considered to be 500-1000ml/day

Lost through GI tract only 100-200 ml/day

Fluid Balance (cont)

Loss from Diarrhea or intestinal fistula Significant sweat loss when body temp >101F-38.3C or room temp > 90F When respirations > 20/min Formula to calculate insensible loss

300-400ml/m2/day

Fluid Function
The fluid in the body has the following function: 1. Maintains blood volume 2. Regulates body temperature 3. Transports material to and from cells 4. Serves as an aqueous medium for cellular metabloism 5. Assists digestion of food through hydrolysis 6. Acts as a solvent in which solutes are available for cell function 7. Serves as a medium for the excretion of waste

Fluid Transport

4 transport mechanisms

Passive transport
Passive diffusion Osmosis Filtration

Active transport

Fluid Transport

Passive transport- non carrier mediated transport- Fluid moves through membranes with out the expenditure of energy

Passive diffusion - movement of water and other elements in all directions from high concentration to low concentration Osmosis passage of water from low particle concentration toward one of higher particle concentration Normal osmolarity 280-295 mOsm/L

Osmolarity of ICF and ECF is always equal

Fluid Transport (cont)

Filtration the transfer of water and a dissolved substance from a region of high pressure to a region of low pressure. Force behind it is hydrostatic pressure (the pressure of water at rest)

Pumping heat provides hydrostatic pressure in the movement of water and electrolytes from the arterial capillary bed to the interstitial fluid.

Fluid Transport (cont)

Plasma protein creates and osmotic pressure at the capillary membrane, preventing fluid from plasma leaking into interstitial spaces Osmotic pressure (created within the plasma) keeps water in the vascular system

Fluid Transport (cont)

Starlings law of capillaries

Under normal circumstances fluid filtered out of the arterial end of a capillary bed and reabsorbed at the venous end is exactly the same, creating a state of near equilibrium

Fluid Transport (cont)

Active Transport acts as a concentration gradient

ATP released from the cell to enable substances to acquire the energy needed to pass through the cell membrane Active Transport is vital for maintaining the unique composition of both the intracellular and intracellular compartments

Tonicity of Solution

Isotonic - .9% saline, 5% dextrose

same as body fluids Osmolarity of 250-375mOsm/L Remains within the ECF space Used to expand ECF compartment

Isotonic Solution

Tonicity of Solution

Hypotonic contains less salt than the intracellular space 2.5% DW

Osmolarity below 250mOsm/L Hydrates cells Depletes the circulatory system

Hypotonic Solution

Tonicity of Solution

Hypertonic causes water from within a cell to move to the ECF compartment

Osmolarity of 375mOsm/l or greater Used to replace electrolytes Used to shift EDF from interstitial tissue to plasma D5W, .9 Normal Saline

Hypertonic Solution

Homeostatic Mechanism

Regulation of body water is maintained

Exogenous sources - Intake of food & Fluids (nurses responsibility) Endogenous sources produce with in the body through chemical exidation process (various body systems responsible)

Homeostatic Mechanisms

Renal System Kidneys filter 170L l of plasma/day and excrete 1.5L of urine

Regulation of fluid volume and osmolarity by selective retention and secretion of body fluid Regulation of electrolyte levels by selective retention of needed substances and excretion of unneeded substances Regulation of pH of ECF by excretion or retention of hydrogen ions Excretion of metabolic wastes (primarily acids) and toxic substances

Homeostatic Mechanism

Cardiovascular System

Pumping action of the heart provides circulation of blood through the kidneys under pressure Allow urine to form Renal perfusion makes renal function possible

Homeostatic Mechanism
Lymphatic system

Serves as an adjunct to the cardio vascular system by removing excess interstitial fluid (lymph) and returning it to the circulatory system Prevents fluid overload

Homeostatic Mechanism

Respiratory System

Lungs are vital for maintaining homeostasis and constitute one of the main regulatory orgnas of fluid and acid base balance Functions of the lungs
Regulation of metabolic alkalosis by compensatory hypoventilation Regulation of metabolic acidosis by causing compensatory hyperventilation Removal of 300-500 ml of water daily through exhalation

Homeostatic Mechanism

Nervous system

Master controller in fluid and electrolyte balance through the regulation of sodium and water Responsible for aiding homeostasis through production of various hormones
Antidiuretic hormones (ADH) Parathyroid Hormones Aldosterone Epinephrine

Endocrine system

Physical Assessment

Vital signs, infusion rate of IV fluids, intake and output. Neurological - Changes in orientation, irritability, lethargy, confusion, seizures or coma Cardiovascular

Quality and rate of pulse Peripheral vein filling Orthostatic hypertension Distended or Flat neck veins

Physical Assessment

Physical Assessment

Respiratory

Changes in respiratory rate

Tachypnea > 20/min or dysphnea indicate excess Fluid Volume (FVE) Moist crackles (FVE) Shallow Slow breathing- Metabolic Acidosis Deep rapid Breathing Metabolic Alkalosis

Physical Assessment

Skin Appearance & Temperature

Access skin turgor Appearance of the tongue

Physical Assessment

Body Weight

Weigh Daily better indicator than I&O records Loss or gain of 1 kg indicates a loss or gain of 1 L of body fluid 15% flucation is considered sever

Fluid Volume Imbalance

Fluid Volume Deficit Common Causes of Isotonic Dehydration

Hemorrhage resulting in loss of fluid, electrolytes, proteins and blood cells resulting in inadequate vascular volume Gastrointestinal losses Fever, environmental heat, profuse sweating Burns Diuretics Third spaced fluids

Fluid Volume Imbalance

Causes of Hypertonic Fluid Dehydration

Inadequate fluid intake Decreased water intake results in ECF solute concentration and leads to cellular dehydration

Fluid Volume Imbalance

Fluid Volume Excess

Primary cause Cardiovascular dysfunction secondary to an increase in total body sodium content Renal failure leading to decrease excretion of water and sodium Heart failure leading to stasis of blood Excess fluid intake of isotonic IV solution High corticosteroid levels

Causes of isotonic over hydration

High Aldosterone levels

Fluid Volume Imbalance

Common causes of Hypotonic Over hydration (Water intoxication)

More fluid is gained than solute Serum osmolality falls causing cells to swell Repeated water enemas Overuse of hypotonic IV fluids Ingestion of inappropriately prepared formula SIADH causes kidneys to retain large amounts of water without sodium

Treatment- sodium and fluid restriction, diuretics, treat underlying cause.

Electrolyte Balance

Major electrolytes in body fluid are sodium, potassium, calcium, magnesium, chloride, phosphorus and bicarb Expressed in meq/liter. Measures chemical activity or combining power rather than weight Each water compartment of the body contains electrolytes

Concentration and composition vary from compartment to compartment

Electrolyte Balance (cont)

Physiological role of electrolytes

Maintaining electroneutrality in fluid compartments Mediating enzyme reactions Altering cell membrane permeability Regulating muscle contraction and relaxation Regulating nerve impulse transmission Influencing blood clotting time

Electrolyte Balance (cont)

Sodium- 135 -145 mEq/L Physiologic role of sodium:

Regulation of fluid distribution in body: water follows sodium Maintenance of body fluid osmolarity Promotion of neuromuscular response: Transmission of nerve and muscle impulses depends on sodium, gradient between ECF and ICF Regulation of acid-base balance: Sodium combines with chloride and bicarbonate to alter pH

Electrolyte Balance (cont)

Sodium represents 90% of the extracellular cations Serum plasma levels of electrolytes are important in the assessment and management of patients with electrolyte imbalances Normal daily requirement 100mEq Hyponatermia is a common complication of adrenal insufficiency Hypernatermia Serum Sodium excess great that 145mEq/L can occur with deprivation of water

Electrolyte Balance (cont)

Signs and Symptoms - Marked thirst, elevated body temperature, swollen tongue.

Chronic Hyponatremia: impaired sensation of taste, anorexia, muscle cramps, feeling of exhaustion, apprehension, feeling of impending doom and focal weakness.

Treatment: Gradually lower seum sodium level by infusion of hypotonic electrolyte solution .45 Normal Saline or D5W. Level lowered no more than 15 mEq/L in 8 hr.

Electrolyte Balance (cont)

Potassium: Physiological role

Regulation of fluid volume within the cell Promotion of nerve impulse transmission Contraction of skeletal smooth and cardiac muscle Control of hydrogen ion concentration, acidbase balance Role of enzyme action for cellular energy production.

Electrolyte Balance (cont)

Potassium is an intracellular electrolyte with 98% in ICF and 2% in the ECF Acquired thru diet and must be ingested daily Daily requirement is 40 mEq Involved in muscle activity and transmission of nerve impulses.

Electrolyte Balance (cont)

Hypokalemia (cont) Can cause alkalosis

S&S fatigue, muscle weakness, anorexia, nausea and vomiting, irregularity Treatment at level less than 3.5mEq/L replacement must be slow to prevent hyperkalemia

Electrolyte Balance (cont)

Hyperkalemia- Serum plasma level greater than 5.5mEq/L

Signs & Symptoms

Increased intake of potassium Decreased urinary excretion Movement out of cells into extra cellular space.

Changes shown on ECG Vague muscle weakness Flaccid paralysis Anxiety Nausea and vomiting Cramping and diaherrea

Electrolyte Balance (cont)

Calcium: Physiological role

Maintaining skeletal elements; calcium is needed for strong bones and teeth Regulating neuromuscular activity Influencing enzyme activity Converting prothrombin to thrombin, a necessary part of clotting.

99% resides in bones and teeth

Electrolyte Balance (cont)

Hypocalcemia: reduction in total body calcium levels

Because of increase calcium loss, reduced intake secondary to altered intestinal absorption, altered regulation hypoparathyroidism Numbness of fingers, muscle cramps, hyperactive deep tendon reflexes, positive Trousseauss sign and Chevosteks sign

S & S:

Treatment with Calcium Gluconate oral or IV

Electrolyte Balance (cont)

Hyperclacemia: Excessive release of calcium from bone S & S Neuromuscular symptoms, lethargy, bone pain, flank pain, pathological fractures, constipation, anorexia, N & V, Stone formation.

Electrolyte Balance (cont)

Magnesium: Physiological role

Enzyme action Regulation of neuromuscular activity Regulation of electrolyte balance, including facilitating transport of sodium and potassium across cell membranes, influencing the utilization of calcium, potassium, and protein.

A major intracellular electrolyte

Electrolyte Balance (cont)

Hypomagnesemia: often overlooked in critically ill patients Results from:

Chronic alcoholism Malabsorption syndrome Prolonged malnutrition or starvation Prolonged diarrhea Acute pancreatitis Administration of magnesium-free solutions for more than one week Prolonged NG tube suctioning

Electrolyte Balance (cont)

S&S

Neuromuscular symptoms
Hyperactive reflexes, Coarse tremors Muscle cramps Positive Chvosteks and Trousseaus signs Seizures Paresthesia of the feet and legs Painfully cold hands and feet Disorientation dysrhythmias tachycardia and indreased potential for digitalis toxicity

Electrolyte Balance (cont)

Hypermagnesemia: renal failure, addisons disease, and inadequate excretion of magnesium by kidneys S & S:

Neuromuscular symptoms Flushing and sense of skin warmth Lethargy Sedation Hypoactive deep tendon reflexes, Depressed respiration Weak or absent new born cry

Electrolyte Balance (cont)

Phosphorus: physiologic role:

Essential to all cells Role in metabolism of proteins, carbohydrates and fats Essential to energy, necessary in the formation of high energy compounds adenosine triphosphate (ATP) and adenosine diphosphate (ADP) As a cellular building block, it is the backbone of nucleic acids and is essential to cell membrane formation Delivery of oxygen; functions information of red blood cell enzyme.

Electrolyte Balance (cont)

Approximately 80% is contained in the bones and teeth 20% is abundant in the ICF Plays and important role in delivery of oxygen to tissues by regulating the level of 2,3-DPG Hyphphosphatemia: results from

Overzealous refeeding, TPN administered without adequate phosphorus Malabsorption Alcohol withdrawal Vomiting, chronic diarrhea, and malabsorption syndromes

Electrolyte Balance (cont)

Other Electrolyte imbalance:

Hyperphosphatemia Hypochloremia Hyperchloremia