FLUID & ELECTROLYTE BALANCE

Deborah Hoover, RN, MSN

BODY FLUIDS - 60% BODY WEIGHT



WATER IS LARGEST SINGLE COMPONENT Dec. to 45-50 % body weight in elderly Variations occur based on age, gender & amt. of body fat 80% neonate is water*

Major Compartments for Fluids

 

 

INTRACELLULAR FLUID (ICF) Inside cell Most of body fluid here - 40% weight Decreased in elderly

 

EXTRACELLULAR FLUID (ECF) Outside cell Intravascular fluid within blood vessels (5%) Interstitial fluid between cells & blood vessels (15%) Transcellular fluid cerebrospinal, pericardial , synovial

ELECTROLYTES
Substance when dissolved in solution separates into ions & is able to carry an electrical current  CATION - positively charged electrolyte  ANION - negatively charged electrolyte  # Cations must = # Anions for homeostatsis to exist in each fluid compartment  Commonly measured in milliequivalents / liter (mEq/L)


MILLIEQUIVALENT (mEq)
Unit of measure for an electrolyte  Describes electrolytes ability to combine & form other compounds  Equivalent weight is amount of one electrolyte that will react with a given amount of hydrogen  1 mEq of any cation will react with 1 mEq of an anion


DEFINITIONS


SOLUTE - substance dissolved  SOLVENT - solution in which the solute is dissolved  SELECTIVELY PERMEABLE MEMBRANES - found throughout body cell membranes & capillary walls; allow water & some solutes to pass through them freely

METHODS OF FLUID & ELECTROLYTE MOVEMENT

   

Diffusion Osmosis Active Transport Filtration

DIFFUSION
Process by which a solute in solution moves  Involves a gas or substance  Movement of particles in a solution  Molecules move from an area of higher concentration to an area of lower concentration  Evenly distributes the solute in the solution  Passive transport & requires no energy*


FACILITATED DIFFUSION


Involves carrier system that moves substance across a membrane faster than it would with simple diffusion  Substance can only move from area of higher concentration to one of lower concentration  Example is movement of glucose with assistance of insulin across cell membrane into cell

OSMOSIS
Movement of the solvent or water across a membrane  Involves solution or water  Equalizes the concentration of ions on each side of membrane  Movement of solvent molecules across a membrane to an area where there is a higher concentration of solute that cannot pass through the membrane


OSMOTIC PRESSURE
Pull that draws solvent through the membrane to the more concentrated side (or side with solute )  Amt. determined by relative number of particles of solute on side of greater concentration  Proportional to # of particles per unit volume solvent


COLLOID OSMOTIC PRESSURE OR ONCOTIC PRESSURE



Special kind of osmotic pressure Created by substances with a high molecular weight (like albumin)

ISOTONIC
ISO - means alike  TONICITY - refers to osmotic activity of body fluids; tells the extent that fluid will allow movement of water in & out cell  Means that solutions on both sides of selectively permeable membrane have established equilibrium  Any solution put into body with the same osmolality as blood plasma - 0.9% sodium chloride or 5% glucose


HYPOTONIC HYPERTONIC


Solution of lower osmotic pressure Less salt or more water than isotonic If infused into blood, RBCs draw water into cells ( can swell & burst ) Solutions move into cells causing them to enlarge

Solution of higher osmotic pressure 3% sodium chloride is example If infused into blood, water moves out of cells & into solution (cells wrinkle or shrivel) Solutions pull fluid from cells

OSMOLALITY
Measure of solutions ability to create osmotic pressure & thus affect movement of water  Number of osmotically active particles per kilogram of water  Plasma osmolality is 280-300* mOsm/ kg  ECF osmolality is determined by sodium  MEASURE used in clinical practice to evaluate serum & urine


Osmolality In Clinical Practice *

Serum 280-300mOsm/kg; Urine 501400mOsm/kg  Serum osmolality can be estimated by doubling serum sodium  Urine specific gravity measures the kidneys ability to excrete or conserve water  Nl range 1.010 to 1.025 (compared to weight of distilled water with sp g of 1.000)


Other Lab Tests*

BUN - blood urea nitrogen; made up of urea an end-product of protein metabolism; Nl 1020 mg/dL; inc. with GI bleeding, dehydration, inc. protein intake, fever, & sepsis; dec. with starvation, end-stage liver dx., low protein diet, expanded fluid vol. (as with pregnancy)  Creatinine - end product of muscle metabolism; better indicator of renal function; nl 0.7-1.5 mg/dL  Hematocrit - vol. % of RBCs in whole blood; m- 44-52%, f- 39-47%


ACTIVE TRANSPORT SYSTEM

Moves molecules or ions uphill against concentration & osmotic pressure  Hydrolysis of adenosine triphosphate (ATP) provides energy needed  Requires specific carrier molecule as well as specific enzyme (ATPase)  Sodium, potassium, calcium, magnesium, plus some sugars, & amino acids use it


FILTRATION
Movement of fluid through a selectively permeable membrane from an area of higher hydrostatic pressure to an area of lower hydrostatic pressure  Arterial end of capillary has hydrostatic pressure > than osmotic pressure so fluid & diffusible solutes move out of capillary


HYDROSTATIC PRESSURE


Force of the fluid pressing outward against vessel wall With blood not only refers to weight of fluid against capillary wall but to force with which blood is propelled with heartbeat Fluid- pushing pressure inside a capillary*

THIRD SPACING
Large quantities of fluid from the intravascular compartment shift into the interstitial space; is inaccessible to the body  May be caused by lowered plasma proteins, increased capillary permeability & lymphatic blockage  Can be seen with trauma, inflammation, disease


PLASMA PROTEINS (Primarily Albumin)

Affect serum osmolarity  Are main negatively charged intravascular fluid anions  Balance the positive charge of sodium in osmolarity  Create colloid osmotic pressure which pulls in & holds water in the vascular bed as well as pulling water from interstitial space into vascular bed - water magnet*


THIRST
Conscious desire for water  Major factor that determines fluid intake  Initiated by the osmoreceptors in hypothalamus that are stimulated by increase in osmotic pressure of body fluids to initiate thirst  Also stimulated by a decrease in the ECF volume


INTAKE
  

FLUIDS OUT
  

Ingested liquids 1500 Water in foods 800* Water from oxidation 300* TOTAL 2600*

  

INSENSIBLE Skin 600* Lungs through expired air 300* Feces 200 Kidneys 1500* TOTAL 2600*

Neuro Endocrine Mechanisms

Central Nervous System Ischemic Response- massive hemorrhage causes dec. in ECF volume & response that constricts afferent arterioles & dec. GFR  Baroreceptor Reflex- stretch receptors in large arteries that react to a dec. in ECF & respond with dec. in GFR


ADH (Antidiuretic Hormone)

Made in hypothalamus; water conservation hormone  Stored in posterior pituitary gland  Acts on renal collecting tubule to regulate reabsorption or elimination of water  If blood volume decreases, then ADH is released & water is reabsorbed by kidney. Urine output will be lower but concentration will be increased.


ALDOSTERONE


Produced by adrenal cortex  Released as part of RAA mechanism  Acts on renal distal convoluted tubule  Regulates water reabsorption by increasing sodium uptake from the tubular fluid into the blood but potassium is excreted  Responsible for reabsorption of sodium & water into the vascular compartment

RENIN
Released by kidneys in response to decreased blood volume  Causes angiotensinogen (plasma protein) to split & produce angiotensin I  Lungs convert angiotensin I to angiotensinII  Angiotensin II stimulates adrenal gland to release aldosterone & causes an increase in peripheral vasoconstriction


Page 207

Page 208

You just ate 4 bags of potato chips so what would you expect?
    

THIRST ? ADH ? OSMOLALITY ? ALDOSTERONE ? URINE OUTPUT ?

You decide to drink 5 gallons of water so what do you expect ?

    

THIRST ? ADH ? OSMOLALITY ? BLOOD VOLUME ? RENAL BLOOD VOLUME ? URINE OUTPUT ?

Quiz ????
1. Who has the highest body % of water? Infant? Adolescent? 50 year old? Elderly?  2. The chief cation of the ICF is Sodium? Chloride? Potassium? Phosphorus  Aldosterone is associated with an increase in - Urine output? Potassium in serum? Sodium in serum? BP?


More Questions ????

4. If you dont drink any water or have lost a lot of water, what do you think will happen to: renal blood flow, renal BP, Glomerular filtration rate (GFR), ADH, Urine output  5. Your patients blood volume is low due to hemorrhage. What do you expect to see with: BP ? HR ? Skin hot or cool ? Urine output ?


Methods of Monitoring Fluid Balance !!!!

BP - one of best tools to assess fluid vol  Review technique - ex. Cuff too small  Remember auscultatory gap  Orthostatic hypotension


Pulmonary Artery Catheter !!!!



Measure PAP, PACWP, CO & CVP  Mean PAP = 10- 20 mm Hg  PACWP = nl 6-12 mm Hg  CO = HR X SV = 4-8 L/min  CVP = 5-10 cm H2O or 0-7mm Hg

IV Fluid Tonicity !!!!

   

TONICITY Hypotonic Isotonic Hypertonic

   

OSMOLALITY < 270 mOsm/kg 275-295 mOsm/kg > 300 mOsm/kg

CELL Swelling Nothing Shrinking

Dehydration !!!!
Water isnt replaced in body  Fluid shifts from cells to EC space  Cells lose water  Happens in confused, comatose, bedridden persons along with infants & elderly  May be treated with hypotonic sol (like dextrose 5% in water)


INTAKE & OUTPUT

 

 

INTAKE Oral fluids including ice, gelatin, etc. Parenteral fluids Tube feedings with flushes Catheter irrigants that are not withdrawn

        

OUTPUT Urine output Liquid feces Vomitus NG drainage Excessive sweating Wound drainage Draining fistula Rapid or labored RR

FLUID VOLUME DEFICIT

Hypovolemia or FVD is result of water & electrolyte loss  Compensatory mechanisms include: Increased sympathetic nervous system stimulation with an increase in heart rate & cardiac contraction; thirst; plus release of ADH & aldosterone  Severe case may result in hypovolemic shock or prolonged case may cause renal failure


CAUSES OF FVD


Abnormal GI fluid loss such as N&V or drainage of GI tract Abnormal fluid loss from skin such as high temperature or burns Increased water vapor from the lungs such as hyperpnea

Conditions that increase renal excretion of fluids such as diuretics & hypersomolar tube feedings Decrease in fluid intake Third-space shift such as ascites or trauma

LAB VALUES IN FVD



INCREASE IN: HEMATOCRIT nl 44*-52*% M nl 39*-47% F BUN nl 10*-20 mg/dl URINE SPECIFIC GRAVITY nl 1.010*-1.025*

SIGNS & SYMPTOMS OF FVD

Dry mucous membranes  Weight loss -mild at 2%,moderate at 5%, & severe deficit at 8%  Orthostatic hypotension & increase in pulse rate  Body temperature usually subnormal  Flat neck veins & decrease in CVP  Decreased urinary output & altered sensorium


NURSING MANAGEMEMT OF FVD

Monitoring I&O on a regular schedule depending on the patient  If urine output is below 30 mL / hr. notify the physician  May check urine specific gravity q 8hrs.  Weigh patient daily at the same time & recognize that a change of 2.2 lbs. represents a loss of 1000 mL  Monitor skin turgor, oral membranes, lab


FLUID VOLUME EXCESS

Hypervolemia or FVE is result of expansion of fluid compartment from an increase in total sodium content  Kidney receives signal to save sodium & water to compensate for cirrhosis, CHF, renal failure, excessive Na-containing fluid  Labs may show dec.:hematocrit, serum Na, serum osmolality, urine sp. Gr; inc. BUN


SIGNS & SYMPTOMS OF FVE

SOB & orthopnea  Edema & weight gain  Distended neck veins & tachycardia  Increased blood pressure  Crackles & wheezes  Maybe ascites & pleural effusion  Increase in CVP


NURSING MANAGEMENT OF FVE

Monitor I & O plus monitor for physical signs of hypervolemia  Check for edema & weigh patient daily  Restrict sodium intake as prescribed  Limit intake of fluids  Watch for signs of potassium imbalance  Monitor for signs of pulmonary edema  Place patient in semi-Fowlers position


Water Intoxication !!!!

Excess fluid moves from EC space to IC space  Happens with SIADH, rapid infusion of hypotonic IV sol or tap water as NG irrigant or enemas; can happen with psychogenic polydipsia ( may drink 12-18 L/day )  Findings Serum NA < 125 mEq/L Serum Osmolality < 280 mOsm/kg


ISOTONIC SOLUTIONS p.211



 

0.9% Sodium Chloride Solution Ringers Solution Lactated Ringers Solution

HYPOTONIC SOLUTIONS


5% DEXTROSE & WATER 0.45% SODIUM CHLORIDE 0.33% SODIUM CHLORIDE

HYPERTONIC SOLUTIONS
    

 

3% SODIUM CHLORIDE 5% SODIUM CHLORIDE WHOLE BLOOD ALBUMIN TOTAL PARENTERAL NUTRITION TUBE FEEDINGS CONCENTRATED DEXTROSE (>10%)

SODIUM

+) (NA
DOMINANT EXTRACELLULAR ELECTROLYTE CHIEF BASE OF BLOOD NL SERUM LEVEL 135-145 mEq/L

SODIUM (NA)*
Main extracellular fluid (ECF) cation  Helps govern normal ECF osmolality  Helps maintain acid-base balance  Activates nerve & muscle cells  Influences water distribution (with chloride)


SODIUM


+) (NA
IS REGULATED BY: Aldosterone Renal blood flow Renin secretion Antidiuretic hormone (ADH) due to its effect on water Estrogen Carbonic anhydrase enzyme

SODIUM AFFECTS FLUID VOLUME & CONCENTRATION IN ECF

HYPERNATREMIA


Serum Na + level > 148 mEq/L serum osmolality > 295 mOsm/kg & urine sp gr > 1.030 with nl kidneys  Collaborative management tries to gradually lower serum sodium by *infusion of 0.45% NaCl *monitoring U/O & serum sodium levels *administering fluids carefully *restricting sodium intake  The thirsty person will not get this !!!!

HYPONATREMIA
Serum Na+ < 135 mEq/L (patient may be asymptomatic until level drops below 125)  Collaborative management seeks to correct cause & give sodium with caution due to possible rebound fluid excess by : *infusing isotonic saline in IV fluids *restricting oral & IV water intake *increasing dietary sodium *monitoring for signs of hypervolemia


POTASSIUM


+) (K

DOMINANT INTRACELLULAR ELECTROLYTE PRIMARY BUFFER IN CELL NL SERUM LEVEL 3.5-5.5 *mEq/L

POTASSIUM (K)*
Dominant cation in intracellular fluid (ICF)  Regulates cell excitability  Permeates cell membranes, thereby affecting cells electrical status  Helps control ICF osmolality & ICF osmotic pressure


POTASSIUM


+) (K
IMPORTANT IN: Neuromuscular irritability Intracellular osmotic activity Acid-base balance

MOVEMENT INFLUENCED BY:Changes in pH Insulin Adrenal hormones Changes in serum sodium

HYPERKALEMIA
K+ > 5.5 mEq/L  Dangerous due to potential for fatal dysrhythmias, cardiac arrest  Major cause is renal disease  EKG shows tall, peaked T waves & dysrthythmias  Beware of pseudohyperkalemia due to prolonged tourniquet, hemolysis of blood, sampling above KCl infusion


HYPERKALEMIA TX


Watch EKG for fatal dysrthymias or cardiac arrest  Collaborative management may include: Calcium to counteract effect on heart Sodium bicarbonate to alkalinize fluids Hemodialysis or peritoneal dialysis Cation exchange resins (Kayexalate) by mouth or enema Small dose of insulin & dextrose Restrict dietary K+

HYPOKALEMIA


K+ < 3.5mEq/L  Most common type of electrolyte imbalance  Major cause is increase renal loss most often associated with diuretics  EKG shows dysrhythmias, flattened T wave  Can increase the action of digitalis  NEVER GIVE K+ IV PUSH & ALWAYS DILUTE IN IV FLUIDS

HYPOKALEMIA TX
Correct the cause  Oral or IV administration of potassium  Salt substitutes containing K+  Foods high in potassium : bananas, pears, dried apricots; fruit juices; tea, cola beverages; milk; meat, fish; baked potato; dried beans (cooked); ANYTHING THAT TASTES GOOD LIKE CHOCOLATE !!


ACID-BASE BALANCE


Governed by the regulation of hydrgen ion (H+) concentration in the body  pH = negative logarithm of the H+ concentration  Acids - proton donors & give up H+  Bases - H+ acceptors  Acidic - inc. in concentration of H+  Basic - dec. in concentration of H+

HENDERSON HASSELBALCH EQUATION



Expresses that the ratio of base to acid or HCO3- to H2CO2 * ( 20: 1) determines the pH pH < 7.35 ACIDOSIS pH > 7.45 ALKALOSIS

ACID-BASE REGULATORY MECHANISMS

CHEMICAL BUFFER SYSTEMS bicarbonate, phosphate, protein, hemoglobin  LUNGS - carbonic acid broken down into CO2 & H2O  KIDNEYS - increasing or decreasing bicarbonate ions


Arterial Blood Gases (ABGs)

    

pH 7.35-7.45 PaCO2 35-45 mm Hg Pa O2 80-100 mm Hg O2 sat. 95-99% HCO3- 22-26mEq/L

ACID-BASE PARAMETERS
   

ACID pH <7.35 PaCO2 >45 HCO3 <22

   

BASE pH >7.45 PaCO2 <35 HCO3 >26

Which way will the scale tip???*



Acidosis vs. Alkalosis

Respiratory Acidosis*


pH < 7.35  PaCO2 > 45mm Hg  Due to inadequate alveolar ventilation  Tx aimed at improving ventilation  Respiratory Opposite

Respiratory Alkalosis*


pH > 7.45  PaCO2 < 35mm Hg  Due to alveolar hyperventilation & hypocapnia  Tx depends on underlying cause

Metabolic Acidosis*


pH < 7.35  HCO3 < 22mEq/L  Due to gain of acids or loss of base (like excessive GI loss from diarrhea)  May have associated hyperkalemia  Tx aimed at correcting metabolic defect  Metabolic Even

Metabolic Alkalosis*


pH > 7.45  HCO3 > 26 mEq/L  Due to loss of acid or gain of base (most common is vomiting or gastric suction)  Hypokalemia may produce alkalosis  Tx aimed at underlying disorder

EVALUATING ABGs*
1. List pH, PaCO2, & HCO3 2. Compare to normals & rate as ACID, BASE OR NORMAL. Write A (acid), B (base), or N (normal) or think ROME  3. Circle any two letters that are the SAME to tell IMBALANCE.  pH 7.10 PaCO2 80mmHg HCO325mEq/l ???? IMBALANCE ????  Look at PaO2 & SaO2 for oxygenation


ABG ASSESSMENT*


     

36 yo pt. complains of acute SOB, R sided pleuritic pain pH 7.50 PaCO2 29 mmHg PaO2 60 mmHg HCO3- 24 mEq/l SaO2 78% ? Meaning ?

     

32 yo pt. with drug OD & breathing 5 times / minute pH 7.25 PaCO2 61 mmHg PaO2 74 mmHg HCO3- 26 mEq/l SaO2 89% ? Meaning ?

ABGs*


   

70 year old diabetic with hx of not taking insulin pH 7.26 PaCO2 42 HCO3 17 ????

   

58 year old pt. With CHF for 6 mos. & placed on digoxin & Lasix pH 7.48 PaCO2 45 HCO3 26 ????

FASTING BLOOD GLUCOSE 70-110mg/dl



GLUCOSE levels are controlled by insulin & glucagon  While fasting glucose levels are low & glucagon is secreted Glucagon breaks glycagon to glucose in liver & blood  glucose rises

Glucose goes up after eating & insulin is secreted Insulin attaches to insulin receptors in cells which drive glucose into these target cells to be metabolized Blood glucose levels go down

HYPER


HYPOGLYCEMIA


CAUSED BY: DIABETES MELLITUS; Acute stress response; Cushings syndrome; Pheochromocytoma; Chronic renal failure;Diuretic therapy; Corticosteroid therapy

CAUSED BY: INSULIN OVERDOSE; Insulinoma; Hypothyroidism; Hypopituitarism; Addisons dx; Extensive liver dx; Starvation