1. Fluid and Electrolytes Presented by Joanna Shedd, MS, CNS, RN

2. Physiology of Fluid Balance Intracellular Fluid (ICF) – inside cells Interstitial fluid – tissue spaces Plasma volume – intravascular fluid

3. Physiology of Fluid Balance Extracellular fluid (ECF)  Interstitial fluid  Plasma volume

4. Osmolality # dissolved particles or solutes in 1kg (1L) of water Sodium – greatest contributor, most common Glucose Urea

5. Tonicity Ability of a solution to cause a change in water movement cross a membrane Relative concentration of IV fluids

6. Tonicity Normal plasma considered isotonic Hypertonic – greater concentration of solutes than plasma Hypotonic – lesser concentration of solutes than plasma

7. Osmosis Water movement form area of low solute concentration to area of high solute concentration

8. Osmosis Hypertonic IV – plasma gains more solutes than interstitial fluid  water from interstitial fluid and cells to plasma Hypotonic IV – water moves from interstitial fluid and plasma to cells Isotonic IV – no net fluid shift

9. Fluid balance Water essential to maintain fluid balance Can go without food longer than water Water travels from less concentration to higher concentration (osmosis)

10. Intake Drinking fluids Ingesting foods with moisture Absorbing water during metabolic processes

11. Output Kidneys as urine Perspiration/ sweat Expired air (vapor) Feces/ stool Tears/ saliva

12. Thirst Mechanism Osmoreceptors in hypothalamus Hypertonic ECF Saliva secretion decreased, feeling of thirst Once water absorbed, thirst center no longer stimulated

13. Fluid output regulation Renin-angiotensin system (RAAS) – aldosterone Antidiuretic hormone (ADH) – acts on distal renal tubule to increase water resorption

14. Excess Fluid Deficit Dehydration Hypovolemic shock Treatment: IV fluid replacement Correct cause of disorder

15. Overhydration Volume excess Hypervolemia Correct cause of disorder

16. Colloids Proteins/ large molecules that remain in blood for a long time Draw water from cells into plasma Increase plasma osmolality and osmotic pressure

17. Colloids: uses Hypovolemic shock due to burns Hemorrhage Surgery loss of fluid

18. Crystalloids Electrolytes used to replace lost fluids Promote urine output Quick diffusion across membranes Leave plasma and enter interstitital fluid

19. Crystalloids: uses Replace electrolytes Increase total fluid volume in body Compartment which is most expanded dependent on solute

20. Parenteral Solutions – Isotonic Equal concentration of solutes Replace extracellular fluid loss No movement into or out of ICF

21. Isotonic - uses Before and after blood transfusion (NS) Treat metabolic alkalosis Intravascular dehydration

22. Isotonic – precautions Circulatory overload Dilute concentration of Hgb and Hct

23. Hyper- vs. Hypotonic http://youtu.be/SSS3EtKAzYc YouTube explanation of hypertonicity and hypotonicity

24. Hypertonic Solutions Water moves from within cell to extracellular compartment Cells will shrink/ become smaller in size Fluid shifts out of ICF and into intravascular

25. Hypertonic – uses Intravascular dehydration/ interstitial overload Decreases cellular edema  raise BP and increase UO Draw fluid out of edematous cells to plasma Replace electrolytes Fluid shifted to plasma to be excreted by kidneys

26. Hypertonic – precautions Circulatory overload Irritation to vein walls Careful with elderly as water retained as a response to stress

27. Hypotonic Solutions Concentrated salt in intracellular (in cell) spaces - dehydrated Water moves into cell Cause cells to swell, possibly burst Fluid shifts out of intravascular spaces into ICF

28. Hypotonic – uses Cellular dehydration Hydrate cells and lower serum sodium levels Replace electrolytes depleted by diuretics Assists with renal function Provides free water, Na, and Cl Assists with daily body fluid needs

29. Hypotonic – precautions Depletion of circulatory system

30. Nursing Management Assess Infiltration – solution enters tissue Thrombosis – blood clot Thrombophlebitis – formation of blood clot with inflammation Pain at administration site

31. Nursing Management Necrosis – tissue death, sloughing of tissue Pulmonary edema – overload of fluids Air emboli – air into the circulatory system

32. Nursing Interventions Maintain even flow at rate ordered Connections secure Solution bag higher than site Avoid areas of flexion Prevent thrombophlebitis

33. Nursing Interventions Restart any infiltrated IVs Hospital protocol for extravasation Never try to “move” a blood clot Monitor I&Os Monitor labwork

34. Nursing Education Need for IV therapy Inform MD of labwork Educate family re: pain, infiltration, do not play with IV machinery Care of IV line with ambulation, getting out of bed Assessment of patient qshift and prn

35. Electrolytes – Sodium Major electrolyte in extracellular fluid Regulated by sodium consumption in diet Excretion via kidneys Controls body water

36. Sodium Electrophysiology of nerves, muscles, gland cells Regulates pH and isotonicity Combines readily with Cl and HCO3 to promote acid-base balance

37. Hyponatremia Induced by excessive sweating, only water is replaced Examples: adrenal insufficiency, GI suctioning, potent diuretics, surgery

38. Hyponatremia - Signs/symptoms (s/s) Lethargy Hypotension Stomach cramps Vomiting Diarrhea Possible seizures

39. Hyponatremia – Treatment (Tx) Normal saline infusion (0.9% NS) Ringer’s Lactate

40. Hypernatremia Excessive use of saline infusions Inadequate water consumption Examples: taking drugs such as cortisone preps and cough medications Excess fluid loss without a loss of sodium

41. Hypernatremia – s/s Edema Hypertonicity Red, flushed skin Dry, sticky membranes Increased thirst Elevated temp Decrease/ absence of urine

42. Hypernatremia – Tx Reduce salt intake D5W to promote diuresis by increasing excretion of both salt and water from blood

43. Potassium Major electrolyte in intracellular fluid

44. Potassium Roles  Muscle contraction  Conduction of nerve impulses  Enzyme actions – CHO to energy  Enzyme actions – amino acids to proteins  Cell membrane function

45. Hypokalemia Potassium poorly stored in body Chronic administration of IV fluids without K+ Diuretic therapy Reduced dietary intake

46. Hypokalemia Poor absorption – steatorrhea Vomiting/ diarrhea GI suctioning or drainage Extensive burns

47. Hypokalemia – s/s N/V Dysrhythmias Abdominal distention Soft, flabby muscles

48. Hypokalemia – Tx Replace orally or parenterally Watch for s/s hyperkalemia Labwork

49. Hyperkalemia Acute/ chronic renal failure Overtreatment with K+ salts Metabolic acidosis (diabetes)

50. Hyperkalemia – s/s Tachycardia followed by bradycardia Can lead to cardiac arrest – v. fib Numbness/ tingling to extremities Oliguria Abdominal cramps Weakness – decr. neuromuscular function

51. Hyperkalemia – Tx Stop K-sparing drugs or supplements Hypertonic dextrose with insulin (shift K into the cells temporarily) Kayexalate Diuretic therapy

52. Body pH pH: degree of acidity or alkalinity -7.0 less than 7.0 – acidic greater than 7.0 – alkaline

53. Buffers Chemicals that help maintain normal body pH Bicarbonate Phosphate

54. Removal of Acids Lungs via exhalation Kidneys via excretion

55. Acidosis – pH < 7.35 Range: 7.35-7.45 Can be respiratory or metabolic Sleepiness/ coma Disorientation Dizziness/ headache Seizures

56. Nursing Correct cause Re-assess diagnostic testing after intervention Watch for s/s of alkalosis

57. Contraindications to HCO3 Excess vomiting Continuous GI suctioning Diuretic therapy causing hypochloremia Hypocalcemia Patients on low sodium diet – sodium mixed with bicarbonate

58. Benefits of NaHCO 3 Tx overdosing of acidic meds (ASA and phenobarbital) Alkalinization of urine  less acid reabsorbed  increased excretion in urine Neutralizes gastric acid (baking soda) May lead to systemic alkalosis with prolonged use

59. Alkalosis – pH>7.45 Range: 7.35-7.45 Irritability Confusion Cyanosis Slow respirations Irregular pulse Muscle twitching

60. Treatment NS with potassium – mild Ammonium chloride - severe Increases excretion of bicarbonate ion

61. Nursing Correct underlying cause Monitor chemistry labs Assess for s/s acidosis

62. Ammonium chloride Given to prevent life- threatening alkalosis s/s toxicity: pallor, sweating, irregular breathing, bradycardia, twitching, convulsions Drug irritating to vein – assess site