1. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. N246 Renal Fluid and Electrolytes created by S. Buckley, RN, MS copyright:2012 all rights reserved

2. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Homeostasis State of equilibrium in body Naturally maintained by adaptive responses Body fluids and electrolytes are maintained within narrow limits

3. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Why nurses need to understand fluid and electrolytes? Important to anticipate the potential for alterations in fluid and electrolyte balance associated with certain disorders and medical therapies, to recognize the signs and symptoms of imbalances, and to intervene with the appropriate action.

4. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Enhanced understanding and management of fluids and electrolytes Composition of body fluids Fluid compartments/Extracellular fluid osmolality Factors that affect movement of water and solutes Regulation of vascular volume Facilitated by clinical condition understanding, nursing assessment, lab analysis

5. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Composition of body fluids (water content of body) 60% of body weight in adult 45% to 55% in older adults 70% to 80% in infants –Varies with gender, body mass, and age

6. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Changes in Water Content with Age Fig. 17-1

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9. Composition of body fluids In addition to water, the body contains solutes; substances the separate in solution and conduct electrical current. Concentration of solutes in solution=osmolality or osmolarity. May by electrolytes or non-electrolytes: Cations(+), Na, K Anions (-), CL, HCO-3 (bicarbonate), PO Non-electrolytes (glucose, urea, creatinine, bilirubin)

10. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Compartments Intracellular fluid (ICF): Located within cells 42% of body weight Extracellular fluid (ECF)-found outside cell –Intravascular (plasma) –Interstitial –lymph –Transcellular 30% of body weight

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12. Fluid Compartments of the Body Fig. 17-2

13. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Transcellular Fluid Part of ECF Small but important/Approximately 1 Includes fluid in –Cerebrospinal fluid –Pericardial fluid –Pleural spaces –Synovial spaces –Intraocular fluid –Digestive secretions

14. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Factors that affect Fluid and Electrolyte Movement Membranes Osmosis Diffusion Facilitated diffusion Active transport Hydrostatic pressure Oncotic pressure

15. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Membrane physiology

16. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Transport process Osmosis Diffusion Active transport filtration

17. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Osmosis Movement of water between two compartments by a membrane permeable to water but not to solute Moves from low solute to high solute concentration Requires no energy

18. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Terms associated with osmosis Osmotic Pressure: amount of pressure required to stop osmotic flow of water. Determined by concentration of solutes in solution Oncotic pressure: pressure exerted by colloids (proteins, such as albumin) Osmotic diuresis: increased urine output (caused by substances such as mannitol, glucose or contrast medium)

19. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Osmotic movement of fluids Cells affected by osmolality of the fluid that surrounds them. Isotonic -fluid with same osmolality as cell interior Hypotonic (hypoosmolar)-solutes are less concentrated than cells. hypertonic (hyperosmolar)-solutes more concentrated than cells.

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21. Diffusion Random movement of particles in all directions from an area of high concentration to low concentration.

22. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Active transport Relies on availability of carrier substances, utilizes energy (ATP), to transport solutes in and out of cells. Na, K, hydrogen, glucose, amino-acids,

23. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Filtration Movement of water and solutes from area of high hydrostatic pressure to area of low hydrostatic pressure that is created by “weight” of fluid. Kidney is example; (filters 180L/day plasma)

24. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hydrostatic Pressure Force within a fluid compartment Major force that pushes water out of vascular system at capillary level

25. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Movement in Capillaries Amount and direction of movement determined by –Capillary hydrostatic pressure –Plasma oncotic pressure –Interstitial hydrostatic pressure –Interstitial oncotic pressure

26. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Exchange Between Capillary and Tissue Fig. 17-8

27. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Shifts Plasma to interstitial fluid shift results in edema –Elevation of hydrostatic pressure –Decrease in plasma oncotic pressure –Elevation of interstitial oncotic pressure

28. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Shifts (Cont’d) Interstitial fluid to plasma –Fluid drawn into plasma space with increase in plasma osmotic or oncotic pressure –Compression stockings decrease peripheral edema

29. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Movement between ECF and ICF Water deficit (increased ECF) –Associated with symptoms that result from cell shrinkage as water is pulled into vascular system

30. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Movement between ECF and ICF (Cont’d) Water excess (decreased ECF) –Develops from gain or retention of excess water

31. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Spacing First spacing –Normal distribution of fluid in ICF and ECF Second spacing –Abnormal accumulation of interstitial fluid (edema)

32. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid Spacing (Cont’d) Third spacing –Fluid accumulation in part of body where it is not easily exchanged with ECF; fluid trapped and unavailable for functional use (ascites)

33. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 3 rd spacing, fluid shift from intravascular to interstitial space; edema

34. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Regulation of Water Balance Hypothalamic regulation Pituitary regulation Adrenal cortical regulation Renal regulation Cardiac regulation Gastrointestinal regulation Insensible water loss

35. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Normal fluid balance Intake: fluids, food, oxidation=~2500ml Output : skin and lungs (insensible loss)-900ml, feces-100ml, urine-1500ml=~2500ml/day

36. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hypothalamic Regulation Osmoreceptors in hypothalamus sense fluid deficit or increase –Stimulates thirst and antidiuretic hormone (ADH) release –Result in increased free water and decreased plasma osmolarity

37. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pituitary Regulation Under control of hypothalamus, posterior pituitary releases ADH Stress, nausea, nicotine, and morphine also stimulate ADH release

38. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Adrenal Cortical Regulation Releases hormones to regulate water and electrolytes –Glucocorticoids Cortisol –Mineralocorticoids Aldosterone

39. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Factors Affecting Aldosterone Secretion Fig. 17-9

40. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Renal Regulation Primary organs for regulating fluid and electrolyte balance –Adjusting urine volume Selective reabsorption of water and electrolytes Renal tubules are sites of action of ADH and aldosterone

41. Effects of Stress on F&E Balance Fig. 17-10

42. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Cardiac Regulation Natriuretic peptides are antagonists to the RAAS –Produced by cardiomyocytes in response to increased atrial pressure –Suppress secretion of aldosterone, renin, and ADH to decrease blood volume and pressure

43. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Gastrointestinal Regulation Oral intake accounts for most water Small amounts of water are eliminated by gastrointestinal tract in feces Diarrhea and vomiting can lead to significant fluid and electrolyte loss

44. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Insensible Water Loss Invisible vaporization from lungs and skin to regulate body temperature –Approximately 600 to 900 ml/day is lost –No electrolytes are lost

45. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Gerontologic Considerations Structural changes in kidneys decrease ability to conserve water Hormonal changes lead to decrease in ADH and ANP Loss of subcutaneous tissue leads to increased loss of moisture

46. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Gerontologic Considerations (Cont’d) Reduced thirst mechanism results in decreased fluid intake Nurse must assess for these changes and implement treatment accordingly

47. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fluid and Electrolyte Imbalances Common in most patients with illness –Directly caused by illness or disease (burns or heart failure) –Result of therapeutic measures (IV fluid replacement or diuretics)

48. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Extracellular Fluid Volume Imbalances ECF volume deficit (hypovolemia) –Abnormal loss of normal body fluids (diarrhea, fistula drainage, hemorrhage), inadequate intake, or plasma-to-interstitial fluid shift –Treatment: replace water and electrolytes with balanced IV solutions

49. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Extracellular Fluid Volume Imbalances (Cont’d) Fluid volume excess (hypervolemia) –Excessive intake of fluids, abnormal retention of fluids (CHF), or interstitial-to-plasma fluid shift –Treatment: remove fluid without changing electrolyte composition or osmolality of ECF

50. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses Hypovolemia –Deficient fluid volume –Decreased cardiac output –Potential complication: hypovolemic shock

51. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation (Cont’d) Neurologic function –LOC –PERLA –Voluntary movement of extremities –Muscle strength –Reflexes

52. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Diagnoses (Cont’d) Hypervolemia –Excess fluid volume –Ineffective airway clearance –Risk for impaired skin integrity –Disturbed body image –Potential complications: pulmonary edema, ascites

53. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Nursing Implementation I&O Monitor cardiovascular changes Assess respiratory status and monitor changes Daily weights Skin assessment

54. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Electrolytes Substances whose molecules dissociate into ions (charged particles) when placed into water –Cations: positively charged (Na, K, Ca 2, Mg 2 ) –Anions: negatively charged (HCO 3, CL, PO 4 3 ) –Measurement; International standard is millimoles per liter (mmol/L), U.S. uses milliequivalent (mEq) –Ions combine mEq for mEq

55. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Electrolyte Composition ICF –Prevalent cation is K + –Prevalent anion is PO 4 3  ECF –Prevalent cation is Na + –Prevalent anion is Cl 

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57. Sodium Serum levels; 135-145mEq/L Responsible for water balance and determination of plasma osmolality Cation+,plays a major role in –ECF volume and concentration ( movement of Cl- closely associated with Na+) Imbalances can exist in different volume states : euvolemia (normal volume), hypovolemia (low volume), hypervolemia (increased volume)

58. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Na+ (continued) –Generation and transmission of nerve impulses –Acid–base balance ( combining HCO3 and CL to alter pH) –Impacted by hormonal control ( aldosterone, ADH ) Dietary level : current recommendation 500mg-2300mg/day, Western diet; 4000-6000mg/day!!! Primary source; table salt (NaCL)

59. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Differential Assessment of ECF Volume Fig. 17-12

60. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Potassium Major cation of ICF Serum level: 3.5-5.0mEq/L Necessary for –Transmission and conduction of nerve and muscle impulses –Control via sodium-potassium pump (contained within cell membrane of all cells/utilizes ATP) –Inverse relationship between Na+ and K+reabsorption in the kidney; factors that cause Na+ retention cause K+ loss in the urine.

61. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. K+ (continued) Kidneys eliminate 90% of K+, thus if renal function impaired, toxic levels may be retained. Dietary level: 40-60mEq/day, Western diet inclusive of K+ salt substitutes may contain K+ Maintenance of cardiac rhythms/function Acid–base balance

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63. Calcium (Ca 2 +) Function: transmission of nerve impulses, muscle/myocardial contraction, blood clotting, formation of teeth and bones Balance controlled by PTH, calcitonin, vitamin D Obtained from diet, daily need: 1-1.5G/d More than 99% combined with phosphorus and concentrated in skeletal system Inverse relationship with phosphorus Serum Level:8.5-10.5 mg/dl

64. Tests for Hypocalcemia Fig. 17-15

65. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Phosphate /phosphorus (PO 4 -/ P+) Serum Level: 2.5-4.5mg/dL Primary anion in ICF Essential to function of muscle, red blood cells, nervous system and Ca+levels Deposited with calcium for bone and tooth structure, Ca+ and P+ exist in a reciprocal balance Required for release of O 2 from hemoglobin

66. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. PO 4 - (continued) Involved in acid–base buffering system (phosphate buffer), ATP production, and cellular uptake of glucose 90% excreted by Kidneys; requires adequate renal functioning Dietary level; intake via balanced diet, daily need: 800-1600mg/dl

67. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Magnesium 2 nd most abundant cation in ICF Serum level: 1.4-2.1 mEq/L Daily need: 300-350mg (average Western diet contains 170-720mg/day) Coenzyme in metabolism of protein, carbohydrate and Ca+ absorption and utilization (Factors that regulate calcium balance appear to influence magnesium balance)

68. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Mg + (continued) Acts directly on myoneural junction to transmit electrical impulses (relaxes lung muscles that open airways) Important for normal cardiac function Powers Na+/K+ pump Plays essential role in secretion and action of insulin (impacts BG)

69. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chloride Major ECF anion Serum level: 95-108 mEq/L Function; circulates with Na + and H 2 O to help maintain cellular integrity, fluid balance and osmotic pressure Affects acid/base balance (enzyme activator, serves as buffer in exchange of O 2 and CO 2 in RBC’s)

70. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. CL- (continued) In conjunction with Ca+, Mg+, helps maintain nerve transmission/muscle function Vital role in production of HCL Obtained primarily from foods (processed) and table salt, daily need: ~750mg. 90% excreted by kidney

71. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. IV Fluids Purposes 1.Maintenance When oral intake is not adequate 2.Replacement When losses have occurred

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74. IV Fluids (Cont’d) Hypotonic –More water than electrolytes Pure water lyses RBCs –Water moves from ECF to ICF by osmosis –Usually maintenance fluids Isotonic –Expands only ECF –No net loss or gain from ICF

75. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. IV Fluids (Cont’d) Hypertonic –Initially expands and raises the osmolality of ECF –Require frequent monitoring of Blood pressure Lung sounds Serum sodium levels

76. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. D5W Isotonic Provides 170 cal/L Free water –Moves into ICF –Increases renal solute excretion Used to replace water losses and treat hyponatremia Does not provide electrolytes

77. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Normal Saline (NS) Isotonic No calories Expands IV volume –Preferred fluid for immediate response Does not change ICF volume Compatible with most medications/blood administration

78. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Lactated Ringer’s Isotonic More similar to plasma than NS –Has less NaCl –Has K, Ca, PO 4 3 , lactate (metabolized to HCO 3 ) Expands ECF

79. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. D5 ½ NS Hypertonic Common maintenance fluid KCl added for maintenance or replacement

80. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. D10W Hypertonic Provides 340 kcal/L Free water Limit of dextrose concentration may be infused peripherally

81. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Plasma Expanders Stay in vascular space and increase osmotic pressure Colloids (protein solutions) –Packed RBCs –Albumin –Plasma

82. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diuretics Act by increasing volume of urine production in tx of hypertension, heart failure, and kidney disorders. Electrolyte depletion common (hypokalemia)

83. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing interventions I&O, loc, nutritional status, monitor liver and kidney function, observe for hypersensitivity, monitor hearing and vision (loop/lasix are ototoxic, thiazide may impact vision), monitor alcohol and caffeine (diuretic), safety (oh), monitor light exposure (photosensitivity), monitor edema, labs, admin in am.

84. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. References *Copyright@ by S. Buckley, 2012 (all rights reserved) Medical-Surgical Nursing Lewis, Heitkemper, Kirksen, Obrien, Bucher, Taber’s cyclopedic Medical Dictionary Venes, 19 th edition Pharmacology, A nursing approach Kee, Hayes, 3 rd edition Fluid and Electrolytes Innerarity, Stark, 3 rd edition

85. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. References (continued) Fluid, Electrolyte, and Acid-base Balance Heitz, Horne-Mosby, 4 th edition IV Therapy made incredibly Easy! McCann, Lippincott, 3 rd edition Acute Renal Failure Hudson, Rn, MSN Electronic source; dynamicnursingeducation.com Fluid & Electrolytes Chernecky, Macklin, Murphy-ende, Saunders 2002 Fluids, Electrolytes & Acid-Base Balance Hogan, Wane, Prentice Hall nursing