Chapter 16 Fluid and Chemical Balance

Body Fluid Body fluid is a mixture of: Water Electrolytes Nonelectrolytes Blood cells WATER --THE VEHICLE FOR TRANSPORTING THE CHEMICALS. WATER IS THE VERY ESSENCE OF LIFE. ISN’T STORED IN ANY GREAT RESERVE, DAILY REPLACEMENT IS THE KEY TO MAINTAINING SURVIVAL. DEPENDING ON AGE AND GENDER BODY IS APPX. 45% -75% WATER ON TEST!!!!!!!!!!!!!! FLUID COMPARTMENTS— INTRACELLULAR—FLUID INSIDE CELLS—REPRESENTS GREATEST PROPORTION OF WATER IN THE BODY. EXTRACELLULAR—FLUID OUTSIDE CELLS—HAS 2 PARTS A. INTERSTITIAL FLUID—FLUID IN THE TISSUE SPACE BETWEEN AND AROUND CELLS B. INTRAVASCULAR FLUID—WATERY PLASMS, OR SERUM, PORTION OF THE BLOOD ELECTROLYTES—CHEMICAL COMPOUNDS SUCH AS SODIUM AND CHLORIDE THAT ARE DISSLOVED, ABSORBED AND DISTRIBUTED IN BODY FLUID AND POSSESS AN ELECTRICAL CHARGE. COLLECTIVELY CALLED IONS (SUBSTANCE THAT CARRY EITHER A POSITIVE OR NEGATVIE ELECTRICAL CHARGE) CATIONS—ELECTROLYTES WITH A POSITIVE CHARGE ANIONS—ELECTROLYTES WITH A NEGATIVE CHARGE EXAMPLE: MORE POTASSIUM IONS ARE INSIDE CELLS THAN OUTSIDE CELLS TABLE 16-2 PAGE 313 NONELECTROLYTES—CHEMICAL COMPUNDS THAT REMAIN BOND TOGETHER WHEN DISSOLVED IN A SOLUTION AND DO NOT CONDUCT ELECTRICITY. THE CHEMICAL END PRODUCTS OF CARBOHHYDRATE PROTEIN ANDFAT METABOLISM NAMELY GLUCOSE, AMINO ACIDS AND FATTY ACIDS PROVIDE A CONTINOUS SUPPLY OF NONELECTROLYTES. KNOW TABLE 16-2 ON PAGE 313 HAVE TO NORMAL RANGES OF THESE ELECTROLYTES!!!!!! BLOOD—CONSISTS OF 3 LITERS OF PLAMSA OR FLUID AND 2 LITERS OF BLOOD CELLS FOR A TOTAL CIRCULATING VOLUME OF 5 LITERS ERYTHROCYTES—RED BLOOD CELLS LUEKOCYTES—WHITE BLOOD CELLS PLATELETS—THROMBOCYTES 500 RBC’S=APPX. 30 PLATELTES AND 1 WBC.

Fluid Transport Mechanisms Osmosis Filtration Passive diffusion Facilitated diffusion Active transport OSMOSIS-Helps regulate the distribution of water by controlling the movement of fluid from one location to another. COLLOIDS—undissolved protein substance such as albumin and blood cells within the body that do not readily pass through membranes FILTRATION—Regulates the movement of water and substances from a compartment where the PRESSURE is higher to one where the PRESSURE is lower. EXAMPLE: COFFEE FILTER PASSIVE DIFFUSION—The physiologic process in which dissolved substances such as electrolytes and gases move from a HIGHER CONCENTRATION to a LOWER CONCENTRATION through a semi-permeable membrane. No energy is required for this process. Keeps electrochemical neutrality. FACILIATED DIFFUSION—The process in which certain dissolved substances require the ASSISTANCE OF A CARRIER MOLECULE to pass from one side of a semi-permeable membrane to the other. It regulates chemical balance. It distributes substances from an area of higher concentration to one that is lower. EXAMPLE: GLUCOSE DISTRIBUTED BY FACILIATED DIFFUSION. INSULIN IS THE CARRIER SUBSTANCE FOR GLUCOSE. ACTIVE TRANSPORT—A process of chemical distribution that requires an energy source. It involves a substance called ATP (ADENOSINE TRIPHOSPHATE). It provides energy to drive dissolved chemicals against the concentration gradient. I.E.—goes from a lower concentration to a higher concentration. Opposite of passive diffusion EXAMPLE: SODIUM-POTASSIUM PUMP

Assessing a Client’s Fluid Status Signs of deficit or excess Physical assessment Measurement of intake Output volumes Intake and output (I&O) tool Loss over 24-hour period Fluid intake generally averages appx. 2,500 ml per day, but it can range from 1,800 to 3,000 ml per day with a similar volume of fluid loss. INSENSIBLE LOSSES (UNNOTICABLE AND UNMEASURABLE)—Normal ways we loose fluids—urination, bowels, sweating, breathing and through the skin (glands) AS FLUID VOLUME EXPANDS, THE KIDNEYS EXCRETE A PROPORTIONATE VOLUME OF WATER TO MAINTAIN OR RESTORE PROPER BALANCE. LOOK AT PAGE 314 TABLE 16-3 INTAKE AND OUTPUT AREAS GO OVER DIFFERENT TYPES OF INTAKE AND OUTPUT!!!!!!!!!!!!

Common Fluid Imbalances Hypovolemia: low volume in extracellular fluid compartments Hypervolemia: excess water in intravascular fluid compartment Third-spacing: movement of intravascular fluid to nonvascular fluid compartments Hypovolemia can lead to dehydration if untreated. Evident by decreased skin tugor. TENTING ON CHEST IS BEST PLACE TO CHECK. WHY?--- HYPERVOLEMIA—higher than normal concentration of volume of water in the intravascular fluid compartment. EDEMA THIRD-SPACING—MOVEMENT OF INTRAVASCULAR FLUID TO NONVASCULAR FLUID COMPARTMENTS WHERE IT BECOMES TRAPPED AND USELESS. MANIFESTED BY TISSUE SWELLING OR FLUID THAT ACCUMULATES IN A BODY CAVITY SUCH AS THE PERITONEUM. ASSOCIATED WITH HYPOALBUMINEMIA.

Restoring Fluid Volume Treating the cause of hypovolemia Increasing oral intake Administering IV fluid replacements Controlling fluid losses Using a combination of these measures SO, HOW DO WE FIX IT? SEE ABOVE FOR ANSWERS.

Reducing Fluid Volume Treating the disorder contributing to the increased fluid volume Restricting or limiting oral fluids Reducing salt consumption Discontinuing IV fluid infusions or reducing the infusing volume Administering drugs that promote urine elimination Using a combination of the above interventions SO, HOW DO WE FIX IT CONTINUED!!!!!!!!!!!!

Administering Intravenous Fluids Maintain or restore fluid balance when oral replacement is inadequate or impossible Maintain or replace electrolytes Administer water-soluble vitamins Provide a source of calories Administer drugs Replace blood and blood products RN HAS TO START BLOOD TRANSFUSION AND MONITOR FOR 1ST 15 MINUTE AND THEN LVN CAN CONTINUE TO MONITOR AFTER THAT.

Question Is the following statement true or false? Reducing salt consumption helps restore fluid volume. ANSWER IS FALSE

Answer False. Reducing salt consumption helps reduce fluid volume.

Crystalloid and Colloid Solutions Crystalloid solutions are made of water and other uniformly dissolved crystals such as salt and sugar Colloid solutions are made of water and molecules of suspended substances such as blood cells and blood products (such as albumin) KNOW THE DIFFERENCE!!!!!!

Types of Intravenous Solutions Isotonic: contains the same concentration of dissolved substances as normally found in plasma Hypotonic: contains fewer dissolved substances than normally found in plasma Hypertonic: more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment YOU HAVE TO KNOW THESE!!!!!!!!!!!!!

IV Solutions A=ISOTONIC SOLUTION B=HYPOTONIC SOLUTION—RE-HYDRATE PATIENTS WITH THIS ONE (VOMITING AND DIARRHEA) C=HYPERTONIC SOLUTION—RARELY USED

Question Is the following statement true or false? Blood is an example of crystalloid solution. ANSWER IS FALSE

Answer False. Blood is an example of colloid solution.

Types of Tubing Primary or secondary tubing Vented or unvented tubing Microdrip or macrodrip chamber Unfiltered or filtered tubing Needle or needleless access ports MICRO DRIP= 10 DROP SET MACRO DRIP= 60 DROP SET

Unvented and Vented Tubing GREEN = NONVENTED IV SOLUTIONS WHITE = VENTED NITROGLYCERIN DRIP

Techniques for Infusing Intravenous Solutions Gravity infusion Electronic infusion devices Infusion pumps Volumetric controllers

Vein Selection Venipuncture device is inserted in veins of: Hand in adults Scalp in child Forearm in adults HAVE TO BE IV CERTIFIED AFTER YOU GET YOUR LVN LICENSE.

Complications With IV Administration Circulatory overload Infiltration Phlebitis Thrombus formation Pulmonary embolus Infection Air embolism INFILTRATION-Escape of IV fluid into the tissue—KNOW S/S OF COMPLICATIONS PHLEBITIS—Inflammation of a vein—KNOW S/S OF COMPLICATIONS THROMBUS FORMATION—Stationary blood clot PULMONARY EMBOLUS—Blood clot that travels to the lung AIR EMBOLISM—Bubble of air traveling within the vascular system.

Inserting an Intermittent Venous Access Device When client no longer needs continuous infusions of fluid When client needs intermittent IV medication When client needs emergency IV fluid or medications

Intermittent Venous Access Device

Blood Administration Blood collection and storage Blood safety Blood compatibility Blood transfusion Blood transfusion equipment Catheter or needle gauge Blood transfusion tubing BLOOD TYPE O = UNIVERSAL DONOR—GIVE TO ANYBODY BLOOD TYPE AB = UNIVERSAL RECIPIENTS—CAN GET BLOOD FROM ANYBODY BLOOD TYPE A&O ARE COMPATIBLE BLOOD TYPE B&O ARE COMPATIBLE RH NEGATIVE PERSON SHOULD NEVER RECEIVE RH POSITIVE BLOOD NEEDLE SIZE FOR BLOOD TRANSFUSION = 16 TO 20 GAUGE, PERFERABLY 18 GUAGE THIS ALLOWS BLOOD TO BE GIVEN IN THE REQUIRED 4 HOUR PEROID GIVE BY Y TUBING

Transfusion Reactions Febrile nonhemolytic transfusion reaction Viral infection Bacterial infection Acute hemolytic reaction Anaphylactic reaction INCOMPATIBILITY—S/S HYPOTENSION, RAPID HEART RATE, S.O.B., BACK PAIN, FLUSHING STOP BLOOD TRANSFUSION CALL FOR HELP GIVE O2 TRENDELBURG FOR HYPOTENSION ER DRUGS IF NEEDED. OVERLOAD –CALL MD ALLERGIC REACTION—STOP BLOOD, ASSESS PT., REPORT FINDINGS, GIVE MEDS PRN.

Parenteral Nutrition Intravenous administration of nutrients such as protein, carbohydrate, fat, vitamins, minerals, and trace elements Peripheral parenteral nutrition Total parenteral nutrition Lipid emulsions LOOKS MILKY WHITE IS HYPERTONIC GIVEN IN CENTRAL VEIN-SUBCLAVIAN AREA PR PICC LINE IN ARM.

Question Is the following statement true or false? The venipuncture device is inserted in hand veins in infants or small children. ANSWER IS FALSE

Answer False. The venipuncture device is inserted in scalp veins in infants or small children.

General Gerontologic Considerations Older adults at risk for fluid and electrolyte imbalances due to cardiac meds and chronic conditions Encourage fluid intake to keep oral mucosa moist and provides hydration Offer noncaffeinated beverages; offer fluids at non-meal times When fasting before procedures, ensure prior increased oral fluid intake

General Gerontologic Considerations (cont’d) Indicators of dehydration Test skin turgor over sternum Mental status changes Increased pulse and respiration rates Decreased blood pressure Dark, concentrated urine with high specific gravity

General Gerontologic Considerations (cont’d) Indicators of dehydration (cont’d) Dry mucous membranes Warm skin, furrowed tongue Low urine output Hardened stools