1. 34-1 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Fluid, Electrolyte, and Acid-Base Balance

2. 34-2 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Physiology of Fluid and Acid- Base Balance  The body normally maintains a balance between the amount of fluid taken in and the amount excreted.  Homeostasis is the maintenance of this balance in response to changes in the internal and external environments.

3. 34-3 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Physiology of Fluid and Acid- Base Balance  Fluid Compartments Cells Blood vessels Tissue space (interstitial space) -Space between the cells and blood vessels

4. 34-4 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Fluid Compartments  Two Types of Body Fluids Intracellular fluid (ICF) is fluid within the cell. Extracellar fluid (ECF) -Intravascular fluid (within blood vessels) -Interstitial fluid (between cells; fluid that surrounds cells)

5. 34-5 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Fluid Compartments  Solute: Substance dissolved in a solution.  Solvent: Liquid that contains a substance in solution.  Permeability: Capability of a substance, molecule, or ion to move across a membrane.

6. 34-6 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Fluid Compartments  Cells have semi-permeable membranes that allow fluid and solutes to pass into and out of the cell.  Blood vessels have semi-permeable membranes that bathe and feed the cells.

7. 34-7 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Body Water Distribution  Water represents 45% to 75% of the body’s total weight.  About two-thirds of the body fluid is intracellular.  One-third of body fluid is extracellular. One-fourth of this fluid is intravascular. Three-fourths is interstitial fluid.

8. 34-8 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Body Water Distribution  Bones are made up of nearly one-third water.  Muscles and brain cells contain 70% water.

9. 34-9 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Functions of Body Water  Water acts as a solvent for essential nutrients.  Water transports nutrients and oxygen from the blood to the cells.  Water removes waste material and other substances from the cells and returns it to the blood for excretion by the body.

10. 34-10 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Functions of Body Water  Gives shape and form to cells.  Regulates body temperature.  Acts as a lubricant in joints.  Cushions body organs.

11. 34-11 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. FLUID REQUIREMENTS SourcesLosses Water1500 mlUrine1500 ml Food800 mlStool200 ml Oxidation300 mlSkin500 ml Resp. Tract400 ml Total2600 mlTotal2600 ml

12. 34-12 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Electrolytes  Compounds that, when dissolved in water or another solvent, form or dissociate into ions Sodium (Na+) Potassium (K+) Calcium (Ca2+) Magnesium (Mg2+)

13. 34-13 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. ELECTROLYTES IN BODY FLUID COMPARTMENTS INTRACELLULAREXTRACELLULAR POTASSIUMSODIUM MAGNESIUMCHLORIDE PHOSPHOROUSBICARBONATE

14. 34-14 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Normal Laboratory Values Sodium135-145 meq/L Potassium 3.5-5.0 meq/L Chloride95-105 meq/L Bicarbonate22-28 meq/L Calcium9-11 mg/dL Phosphate3.2-4.3 mg/dL Glucose70-110 mg/dL BUN8-18 mg/dL Creatinine0.6-1.2 mg/dL Osmolality (P)280-295 mOsm/kg Osmolality (U)50-1200 mOsm/kg

15. 34-15 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Electrolytes  Promote normal neuromuscular excitability.  Maintain body fluid osmolarity.  Regulate acid base balance.  Distribute body fluids between fluid compartments.

16. 34-16 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Electrolytes  Extracellular fluid contains the largest quantities of sodium, chloride, and bicarbonate ions, and small quantities of potassium and calcium.  Intracellular fluid contains only small quantities of sodium and chloride, almost no calcium ions, and large quantities of potassium.

17. 34-17 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Movement of Body Fluids  Physiological forces affect the transport of molecules of water, foods, gases, wastes, and ions.  Maintain a balance between extracellular and intracellular fluid compartments.

18. 34-18 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Movement of Body Fluids  Diffusion  Osmosis  Active Transport  Hydrostatic Pressure  Filtration  Colloid Osmotic Pressure

19. 34-19 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Diffusion – movement of particles down a concentration gradient. Osmosis – diffusion of water across a selectively permeable membrane Active transport – movement of particles up a concentration gradient ; requires energy

20. 34-20 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Regulators of Fluid Balance  Fluid and Food Intake and Loss  Skin  Lungs  Gastrointestinal Tract  Kidneys

21. 34-21 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Acid-Base Balance  Acid-base balance refers to the homeostasis of the hydrogen ion concentration in extracellular fluid.  An acid is a substance that donates hydrogen ions.  A base is a substance that accepts hydrogen ions.

22. 34-22 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Acid-Base Balance  The pH symbol indicates the hydrogen ion concentration of body fluids.  7.35 to 7.45 is the normal pH range of extracellular fluid.  Acidity increases as the pH decreases.  Alkalinity decreases as the pH increases.

23. 34-23 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Regulators of Acid-Base Balance  Buffer Systems Two or more chemical compounds that prevent marked changes in hydrogen ion concentration when either an acid or a base is added to a solution

24. 34-24 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Regulators of Acid-Base Balance  Respiratory Regulation of Carbon Dioxide in Extracellular Fluid Increased carbon dioxide levels in extracellular fluid increase rate and depth of respirations so that more carbon dioxide is exhaled. Decreased carbon dioxide levels depress respirations to maintain carbon dioxide.

25. 34-25 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Regulators of Acid-Base Balance  Renal Control of Hydrogen Ion Concentration The kidneys control extracellular fluid pH by removing hydrogen or bicarbonate ions from body fluids. -When the kidneys excrete more bicarbonate ions, the urine becomes more alkaline. -When the kidneys excrete more hydrogen ions, the urine becomes more acidic.

26. 34-26 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Factors Affecting Fluid and Electrolyte Balance  Age Adult, 60% water Child, 60% to 77% water Infant, 77% water Embryo, 97% water  In the elderly, body water diminishes because of tissue loss.

27. 34-27 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Factors Affecting Fluid and Electrolyte Balance  Lifestyle Stress Exercise Warm or humid environment Diet

28. 34-28 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Disturbances in Electrolyte and Acid-Base Balance  In illness, one or more of the homeostatic regulating mechanisms may be affected, or the imbalance may become too great for the body to correct without treatment.

29. 34-29 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Electrolyte Disturbances  Sodium is the primary determinant of extracellular fluid concentration.  Alterations in sodium concentration can produce profound effects on the central nervous system and circulating blood volume.

30. 34-30 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Electrolyte Disturbances  Hyponatremia is a deficit in the extracellular level of sodium.  The ratio of water to sodium is too high (a hypo-osmolar state).  Water moves out of the vascular space into the interstitial space, causing edema.

31. 34-31 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Electrolyte Disturbances  Hypernatremia is an excess of sodium in the extracellular fluid.  The ratio of sodium to water is too high (hyperosmolar state).  Extracellular osmotic pressure pulls fluid out of the cells into the extracellular space, causing edema.

32. 34-32 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Electrolyte Disturbances  Potassium The normal range of extracellular potassium is narrow (3.5-5.0 mEq/L). Small deviations cause serious or life- threatening effects on physiologic functions. A reciprocal relationship exists between sodium and potassium.

33. 34-33 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Electrolyte Disturbances  Hypokalemia is a decrease in the extracellular level of potassium.  Gastrointestinal disturbances and the use of potassium wasting diuretics, laxatives, corticosteroids, and antibiotics place the client at risk for hypokalemia.

34. 34-34 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Electrolyte Disturbances  Hyperkalemia is an increase in the extracellular level of potassium.  Three major drug groups may cause hyperkalemia. Potassium-sparing diuretics Central nervous system agents Oral and intravenous replacement potassium salts

35. 34-35 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Electrolyte Disturbances  Calcium Essential for normal bone and teeth formation Critical factor in normal blood clotting Maintenance of normal nerve and muscle excitability

36. 34-36 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Electrolyte Disturbances  Hypocalcemia is a decrease in the extracellular level of calcium.  Hypercalcemia is an increase in the extracellular level of calcium.

37. 34-37 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Electrolyte Disturbances  Magnesium Coenzyme in the metabolism of carbohydrates and proteins Mediator in neuromuscular activity

38. 34-38 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Electrolyte Disturbances  Hypomagnesemia is a decrease in the extracellular level of magnesium and usually occurs with hypokalemia and hypocalcemia.  Hypermagnesemia refers to an increase in the extracellular level of magnesium.

39. 34-39 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Electrolyte Disturbances  Phosphate Main intracellular anion Appears as phosphorus in the serum. Similar to calcium in that Vitamin D is needed for its reabsorption from the renal tubules.

40. 34-40 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Electrolyte Disturbances  Hypophosphatemia is a decreased extracellular level of phosphorus.  Hyperphosphatemia is an increased extracellular level of phosphorus.

41. 34-41 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Electrolyte Disturbances  Chloride and water move in the same direction as sodium ions.  A loss of chloride can be compensated for by an increase in bicarbonate.

42. 34-42 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Electrolyte Disturbances  Hypochloremia is a decrease in the extracellular level of chloride. Gastrointestinal tract losses because of the acid content of gastric juices (hydrogen chloride), placing the client at risk for metabolic alkalosis  Hyperchloremia usually occurs with dehydration, hypernatremia, and metabolic acidosis.

43. 34-43 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Acid-Base Disturbances  Laboratory Data Arterial blood gases Blood pH Bicarbonate ion concentration Sodium, potassium, chloride levels

44. 34-44 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Acid-Base Disturbances  Respiratory Acidosis (Carbonic Acid Excess)  Respiratory Alkalosis (Carbonic Acid Deficit)  Metabolic Acidosis (Bicarbonate Deficit)  Metabolic Alkalosis (Bicarbonate Excess)

45. 34-45 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Assessment  Health History Clients receiving certain treatments, such as medications and IV therapy Data specific to fluids

46. 34-46 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Assessment  Physical Examination Daily weight Vital signs Intake and output Edema Skin turgor

47. 34-47 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Assessment  Physical Examination Buccal (oral) cavity Eyes Jugular and hand veins Neuromuscular system

48. 34-48 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Assessment  Diagnostic and Laboratory Data Hemoglobin and hematocrit indices -With severe dehydration and hypovolemic shock, the hematocrit is increased. -Overhydration reduces the hematocrit by dilution.

49. 34-49 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Laboratory Data  Osmolality Measurement of the total concentration of dissolved particles (solutes) per kilogram of water -Serum osmolality -Urine osmolality

50. 34-50 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Assessment  Diagnostic and Laboratory Data Urine pH Serum albumin

51. 34-51 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Nursing Diagnosis  Excess Fluid Volume  Deficient Fluid Volume  Risk for Deficient Fluid Volume

52. 34-52 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Other Nursing Diagnoses  Impaired Gas Exchange  Decreased Cardiac Output  Risk for Infection  Impaired Oral Mucous Membrane

53. 34-53 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Deficient Knowledge  Dehydration is one of the most common and most serious fluid balances.  Information obtained from a client’s health history may indicate the client’s level of understanding and perception of alterations in fluid, electrolyte and acid- base balance.

54. 34-54 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Planning and Outcome Identification  Expected outcomes for clients with fluid imbalances include outcomes relative to interventions.  Achievement of the goals and the client’s expected outcomes indicates resolution of the problem.

55. 34-55 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Monitor Daily Weight  Measure Vital Signs  Measure Intake and Output  Provide Oral Hygiene  Initiate Oral Fluid Therapy

56. 34-56 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Nothing by Mouth  Restricted Fluids  Forced Fluids  Maintain Tube Feedings  Monitor Intravenous Therapy

57. 34-57 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Monitor Intravenous Therapy Administration of fluids, electrolytes, nutrients, or medications by the venous route when fluid losses are severe or the client cannot tolerate oral or tube feedings

58. 34-58 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Intravenous Therapy  Parenteral Fluids Hypotonic Isotonic Hypertonic

59. 34-59 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Intravenous Therapy  Equipment Administration Set Health Hazard Intravenous Filters

60. 34-60 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Intravenous Therapy  Equipment Needles and venous peripheral-short catheters -Butterfly needles -Intracath -Angiocatheter Peripheral intravenous (PI) Heparin locks (intermittent venous locks)

61. 34-61 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Intravenous Therapy  Equipment Needle-Free System Vascular Access Devices (VAD) -Various catheters, cannulas, infusion ports that allow for long-term IV therapy or repeated access to the central venous system

62. 34-62 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Intravenous Therapy  Preparing an Intravenous Solution Initiating IV therapy Vein finder  Administering IV Therapy Flushing Regulating IV solution flow rates Calculation of flow rates

63. 34-63 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Intravenous Therapy  Flow Control Devices Manual flow-control devices Electronic infusion devices

64. 34-64 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Intravenous Therapy  Managing IV Therapy Hypervolemia Infiltration Phlebitis Intravenous dressing change

65. 34-65 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Intravenous Therapy  Discontinuation of Intravenous Therapy  Blood Transfusion Whole blood and blood products Initial assessment and preparation Administering whole blood or a blood component Safety measures

66. 34-66 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Complementary Therapy  Herbs and certain foods  Naturopathic health care practitioners  Considerations for using complementary therapies with traditional medications

67. 34-67 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Evaluation  The nurse should focus on the client’s responses when evaluating whether time frames and expected outcomes are realistic.