1. FLUIDS AND ELECTROLYTES Southeast Community College

2. 2 Compartments for Body Fluids 0 Intracellular – 40% of total body weight 0 Extracellular – 20% of total body weight 0 Intravascular (in blood vessels) 0 Interstitial (between blood vessels and cells)

3. Body Fluids

4. What is in body fluids? 0 Water 0 Electrolytes (ions capable of carrying an electric current 0 Cations – positive charged ions 0 Anions – negative charged ions Electrolytes are measured in mEq/L

5. How do body fluids move? 0 Diffusion – solute moves from an area of high concentration to an area of low concentration 0 Osmosis – fluid (water) moves across a semipermeable membrane from an area of lower concentration of solute to an area of higher concentration of solute 0 Active Transport – movement of ions against osmotic pressure; requires energy

6. DIFFUSION

7. OSMOSIS

8. ACTIVE TRANSPORT

9. Question?? 0 In what fluid compartment is the majority of our body fluid located?

10. Types of Solutions 0 Hypertonic – solution of higher osmotic pressure pulls fluid from cells 0 Isotonic – solution of same osmotic pressure expands body’s fluid volume without a fluid shift 0 Hypotonic – solution of lower osmotic pressure; solution moves into cells

11. Isotonic Solution

12. Hypotonic Solution

13. Hypertonic Solution

14. Questions?? 0 Which type of solution if given to a patient would cause fluid to move from inside body cells (intracellular)? 0 Where would the fluid move to?

15. Hormonal Regulation of Body Fluids 0 ADH (antidiuretic hormone) – stored in posterior pituitary gland and released in response to changes in blood osmolality – stimulates kidney to reabsorb water 0 Aldosterone – released by adrenal cortex and acts on distal portion of renal tubule to increase reabsorption of Na (also causes loss of potassium)

16. Fluid Output Regulation Kidneys – produces 1200-1500 mL of urine/day; the kidneys are the primary regulators of fluid output

17. Other fluid output regulators

18. Gastrointestinal Tract

19. Question? 0 Which of the following causes sodium reabsorption by the kidneys? 0 Antidiuretic hormone 0 Renin 0 Insulin 0 Aldosterone

20. Terms 0 Osmolarity – used to describe concentration of solutions 0 Sensible fluid loss – fluid loss that is seen 0 Insensible fluid loss – fluid loss that is not perceived

21. Electrolyte Regulation Goal is to maintain electrical neutrality

22. Sodium 0 Most abundant in extracellular fluid 0 Major contributor to water balance 0 Nerve impulse transmission 0 Acid-base balance 0 Cellular chemical reactions 0 Normal level 135-145 mEq/L 0 Level influenced by dietary intake and aldosterone

23. Sodium

24. Potassium 0 Most abundant in intracellular fluid 0 Necessary for glycogen deposits in the liver and skeletal muscle 0 Conduction of nerve impulses 0 Normal cardiac rhythms 0 Skeletal and smooth muscle contraction 0 Normal level 3.5-5.0 mEq/L 0 Body does not conserve potassium well

25. Potassium

26. Foods with potassium

27. Calcium 0 Stored in bone (99%), 1% in ECF 0 Bone and teeth formation 0 Blood clotting 0 Cell membrane integrity 0 Cardiac conduction 0 Transmission of nerve impulses 0 Muscle contraction

28. Foods with Calcium

29. Magnesium 0 Enzyme activities 0 Neurochemical activities 0 Cardiac and skeletal muscle excitability 0 Most found intracellular (along with potassium)

30. Anions – negative charge 0 Chloride – major anion in ECF; dietary intake and kidneys regulate chloride level 0 Bicarbonate – major chemical base buffer in the body; kidneys regulate bicarbonate 0 Phosphate 0 Assist with acid-base balance 0 Helps to develop & maintain bones and teeth 0 Neuromuscular action 0 CHO metabolism

31. Acid/Base Balance Goal is to maintain balance pH 7.35-7.45 Arterial pH is an indirect measurement of hydrogen ions – the greater the concentration of hydrogen ions the more acidic the solution and the lower the pH

32. The pH Scale

33. Acid-base regulators in the body 0 1. Buffer systems in the body (chemical regulators) – first to respond to an acid/base imbalance 0 2. Lungs – regulate CO2 by increasing/decreasing rate & depth of respirations 0 3. Kidneys – regulate excretion/retention of hydrogen ions and bicarbonate – last to respond but a more lasting effect

34. Sodium Imbalances Hyponatremia Causes: increased sweating, GI losses (diarrhea), use of diuretics Data: confusion, abdominal cramping, nausea & vomiting, tachycardia

35. Risk for Hyponatremia

36. Sodium Imbalances Hypernatremia Causes: increased ingestion of concentrated salt solutions, diabetes insipidus, water deprivation Data: thirst, dry flushed skin, dry sticky tongue and mucous membranes, fever, convulsions

37. Hypernatremia

38. Potassium Imbalances Hypokalemia Causes: most common is diuretic use, also diarrhea, vomiting, extreme sweating Data: weakness, fatigue, decreased muscle tone, weak irregular pulse

39. Loss of Potassium

40. Potassium Imbalances Hyperkalemia (big cardiac problem) Causes: primarily renal failure, also burns and trauma of cells (cause release of K+) Data: dysrhythmias, paresthesias, weakness, abdominal cramps, diarrhea

41. Hyperkalemia

42. Calcium Imbalances Hypocalcemia Causes: decreased Ca++ intake, Vitamin D deficiency, hypoalbuminemia (because 50% of Ca++ is bound to protein) Data: numbness and tingling of fingers, tetany, muscle cramps, pathological fractures

43. Tetany

44. Calcium Imbalances Hypercalcemia Causes: malignant disease, osteoporosis, prolonged immobilization Data: N & V, constipation, weakness, can lead to cardiac arrest, low back pain (from kidney stones)

45. Hypercalcemia

46. Magnesium Imbalances Hypomagnesemia Causes: malnutrition, alcoholism, diarrhea, vomiting, nasogastric drainage Data: muscle tremors, confusion

47. Hypomagnesemia

48. Magnesium Imbalances Hypermagnesemia Causes: renal failure, excessive intake Data: hypotension, decreased rate and depth of respirations

49. Hypermagnesemia

50. Fluid Imbalances Fluid Volume Deficit Causes: losses from GI tract (diarrhea, vomiting), loss of plasma or whole blood (burns, hemorrhage), fever, increased perspiration, decreased oral intake of fluids, diuretic use Data: hypotension, tachycardia, poor skin turgor, thirst, dry mucous membranes, confusion, oliguria, weak pulse, lethargy

51. Fluid Volume Deficit

52. Fluid Imbalances Fluid Volume Excess Causes: congestive heart failure, renal failure, liver disease (cirrhosis), excessive Na intake Data: edema (especially dependent), rapid weight gain, hypertension, neck vein distention, crackles in lungs

53. Edema

54. Jugular Venous Distention

55. Arterial Blood Gases 0 pH – measures H+ ion concentration in body fluids; 7.35-7.45 0 paCO2 – partial pressure of carbon dioxide in arterial blood; 35-45 mm Hg 0 Bicarbonate (HCO3) – major renal component; 22-26 mEq/L 0 (think of CO2 as an acid and HCO3 as a base)

56. Arterial Blood Gases

57. Acid Base Imbalances Respiratory Acidosis Causes: hypoventilation (atelectasis, pneumonia, cystic fibrosis, airway obstruction, chest wall injury), drug overdose, paralysis of respiratory muscles Data: confusion, dizziness, warm/flushed skin, muscular twitching, ventricular dysrhythmias

58. A cause of Respiratory Acidosis

59. Acid Base Imbalances Respiratory Alkalosis Causes: hyperventilation (initial phase of asthma, anxiety, central nervous system infections, salicylate overdose) Data: dizziness, confusion, tachypnea, numbness & tingling of extremities

60. Respiratory Alkalosis

61. Acid Base Imbalances Metabolic Acidosis – high acid content in the blood; loss of sodium bicarbonate Causes: starvation, diabetic ketoacidosis, renal failure, heavy exercise, drug use Data: headache, lethargy, confusion, tachypnea (lungs are trying to compensate), dysrhythmias

62. Metabolic Acidosis

63. Acid Base Imbalances Metabolic Alkalosis Causes: excessive vomiting (most common), prolonged NG suctioning, drug use Data: dizziness, dysrhythmias, numbness and tingling of fingers and toes, muscle cramps

64. Assessment 0 Age – infants, young children and elderly 0 Chronic diseases 0 History of GI problems (vomiting, diarrhea) 0 Any recent surgery or burns 0 Vigorous exercise/temperature extremes? 0 Dietary intake 0 Medication use, smoking, alcohol

65. Assessment – Physical Exam 0 Weight 0 Skin and mucous membranes 0 Body temperature 0 Orientation 0 Distended neck veins 0 Edema (sacrum, legs) 0 Dysrhythmias, pulse rate, blood pressure 0 Lung sounds, rate of respirations 0 Vomiting? Diarrhea? Bowel sounds? 0 Urine output (amount, color, specific gravity) 0 Numbness, tingling, muscle cramps?

66. Assessment – Lab Studies Electrolyte levels, hematocrit, creatinine & BUN, urine specific gravity, ABG’s Hematocrit is an indication of hydration status of the patient; it will elevate when fluid is lost and decrease when fluid is retained Blood creatinine levels measure kidney function

67. Potential Nursing Diagnoses 0 Deficient fluid volume 0 Excess fluid volume 0 Risk for imbalanced fluid volume 0 Impaired gas exchange 0 Ineffective tissue perfusion 0 Decreased cardiac output 0 Ineffective breathing pattern

68. Patient Outcomes Your patient as a fluid volume deficit. What would you write as an outcome? What if your patient had a fluid volume excess?

69. Nursing Interventions 0 Daily weight – single most important indicator of fluid status 0 Intake & output – examine for trends 0 Enteral fluid replacement – oral replacement or nasogastric, gastrostomy or jejunostomy tube feedings 0 Fluid restriction (if fluid volume excess) 0 Parenteral replacement

70. Daily Weights

71. Nasogastric Tubes Purposes of nasogastric tubes: Gastric decompression Gastric feeding Administer medications

72. Types of Nasogastric Tubes

73. Types of nasogastric tubes Levin – single lumen Salem sump – larger lumen to remove gastric secretions and a smaller (usually blue) lumen to vent to air (do not clamp or irrigate the air vent)

74. Insertion of a nasogastric tube

75. 0 Clean technique 0 Place client in high Fowler’s position 0 Lubricate with water soluble lubricant 0 During insertion, if possible, have client take sips of water 0 Always verify placement post insertion and before any feeding or irrigations (pH of stomach contents at 4) 0 Use normal saline for irrigations

76. Nursing Interventions 0 Monitor intake and output (How would you calculate if performing nasogastric irrigations?) 0 Apply water soluble lubricant to nares to prevent irritation 0 Good oral hygiene 0 When removing nasogastric tube instruct client to take a deep breath and hold it while removing the tube smoothly and quickly

77. Keeping it all in balance