Fluid & Electrolyte Balance Fall 2017-2018 PDF

FLUID AND ELECTROLYTE BALANCE & IMBALANCE By Dr. Manal Mostafa Prof. of Medical Surgical Nursing Cairo University LEARNING OBJECTIVES  Discus, the function, distribution, movement , and regulation of fluid and electrolytes in the body.  D...

FLUID AND ELECTROLYTE BALANCE & IMBALANCE By Dr. Manal Mostafa Prof. of Medical Surgical Nursing Cairo University LEARNING OBJECTIVES  Discus, the function, distribution, movement , and regulation of fluid and electrolytes in the body.  Describe the regulation of acid-base balance in the body, including the role of the lungs, kidneys.  Identify the factors affecting normal body fluid, electrolyte, and acid- base balance.  Collect assessment data related to the client’s fluid, electrolyte, and acid-base balance. INTRODUCTION The human body works best when some conditions are kept within normal. e.g. Body temperature , blood electrolytes values as (sodium, potassium & calcium), blood pH, & blood Volume. To keep the condition as close to normal as possible is called Homeostasis. It is a mechanism responsible for balancing water and molecule movement, from one fluid compartment to another. Water is the most common substance in the body. About 50 % to 60 % of total body weight. VARIATIONS IN FLUID CONTENT  Healthy person — total body water is 50% to 60% of body weight.  An infant has considerably more body fluid and ECF than an adult.  Age, Sex and amount of fat cells affect body water.  Women and obese people have less body water DISTRIBUTION OF BODY FLUIDS  Body fluids are distributed in two distinct compartments:  Extracellular fluids[ECF] is found outside the cells and accounts for about one –third of total body fluid. It is subdivided into intravascular and interstitial.  Intracellular fluids[ICF] is found within the cells of the body and accounts for about two –third of total body fluid.  BODY FLUIDS Extra cellular Intracellular 1/3 of body fluid 2/3 of body fluid ( 15 L.) ( 25 L.) include :  Interstitial fluid  Tran cellular fluid COMPOSITION OF BODY FLUIDS  Body fluids contain Electrolytes  Anions : carry a negative charge  Cl, HCO3,  Cations : carry a positive charge  Na, K, Ca  Electrolytes are measured in mEq  Minerals are ingested as compounds and are constituents of all body tissues and fluids. FUNCTIONS OF WATER  Major solvent of the body.  Present and surrounds every cell.  Regulate and maintain body temperature.  Transport nutrients, electrolytes, and O2 to the cells  Excretion of wastes  Lubricates joints and membranes  Medium for food digestion  Major component of blood plasma  Essential for metabolism  Lubricant in joints and GI tract  Cools the body through perspiration FUNCTIONS OF ELECTROLYTES  Promote neuromuscular reaction  Maintain body fluid volume and osmolarity  Distribute body water between fluid compartments (balance)  Regulate acid-base balance MOVEMENT OF BODY FLUIDS AND ELECTROLYTES  Osmosis : movement across a semi-permeable membrane from area of lesser concentration to area of higher concentration. In other words, water moves toward the higher concentration of solute in an attempt to equalize the concentration.  Osmotic pressure: drawing power of water.  Osmolarity: concentration of solution. OSMOSIS MOVEMENT OF BODY FLUIDS AND ELECTROLYTES  Diffusion: The movement of ions and molecules (solute) across a semi permeable membrane, from an area of higher concentration to an area of lower concentration until equilibrium. MOVEMENT OF BODY FLUIDS AND ELECTROLYTES  Filtration: The movement of fluid and solute together across a semi permeable membrane, from an area of higher pressure to an area of lower pressure. MOVEMENT OF BODY FLUIDS AND ELECTROLYTES  Active Transport: This process is of particular importance in maintaining the difference in sodium and potassium ion concentration concentrations in ECE and ICF REGULATION OF BODY FLUIDS  Homeostasis is maintained through:  Fluid intake regulation  Hormonal regulation  Fluid output regulation  Normally fluid intake and fluid loss are balanced. Illness can upset this balance so that the body has too little or too much fluid BALANCE  Fluid and electrolyte homeostasis is maintained in the body  Neutral balance: input = output  Positive balance: input > output  Negative balance: input < output DAILY BODY FLUID INTAKE AND LOSSES Intake Output Oral fluid: 1200-1500ml Urine: 1400-1500ml Water in Food: 1000ml Feces: 100-200 ml Metabolism: 200ml Insensible losses: Lungs: 350-40 ml Skin: 350-400 ml Sweat: 100 ml Total: 2400-2700ml Total: 2300-2600ml FLUID OUTPUT REGULATION  Organs of water loss  Kidneys  Lungs  Skin  GI tract ELECTROLYTES IN BODY FLUIDS  Normal Values  Sodium (Na+) 135 – 145 mEq/L  Potassium (K+) 3.5 – 5.0 mEq/L  Ionized Calcium (Ca++) 4.5 – 5.5 mg/dL  Calcium (Ca++) 8.5 – 10.5 mg/dL  Bicarbonate (HCO3) 24 – 30 mEq/L  Chloride (Cl--) 95 – 105 mEq/L  Magnesium (Mg++) 1.5 – 2.5 mEq/L  Phosphate (PO4---) 2.8 – 4.5 mg/dL REGULATION OF ELECTROLYTES  Major Cations in body fluids  Sodium (Na+)  Potassium (K+)  Calcium (Ca++)  Magnesium (Mg++) HYPOKALEMIA  Decrease Potassium(K+)level in the blood below 3.5 mEq  Causes:  Excessive potassium loss:  Excessive use of drugs as ; diuretics, digitals; corticosteroid.  Increase secretion of aldosterone as in Cushing's syndrome.  Diarrhea , vomiting,  Gastrointestinal wound drainage,  Heat induced excessive diaphoresis,  Renal disease. POTASSIUM EXCESS (HYPERKALEMIA)  serum potassium concentration greater-than5.0 mEq/L. it is seldom occurs in patients with normal renal function.  Hyperkalemia is usually more dangerous because cardiac arrest is more frequently associated with high serum potassium levels. CAUSES OF HYPERKALEMIA  Excessive potassium intake:  over ingestion of potassium-containing foods or medications (potassium chloride).  Rapid infusion of potassium chloride  Transfusion of whole blood or packed cells.  Decrease potassium excretion:  In renal failure.  Movement of potassium:  from intracellular fluid to extra cellular fluid as in tissue damage. SODIUM IMBALANCE (HYPONATREMIA)  Sodium (Na+)is the most cation of the blood and interstitial fluid.  Hyponatremia: Decrease the sodium level in the blood below 135 mEq/L. CAUSES OF HYPONATREMIA  Increase sodium excretion:  Excessive diaphoresis.  Diuretics.  GIT. wound drainage.  Inadequate sodium intake:  Nothing by Mouth (NPO)  low salt diet  Dilution of sodium  Excessive ingestion of hypotonic fluids  Hyperglycemia  Irrigation with hypotonic fluids. SODIUM IMBALANCE (HYPERNATREMIA)  Increase serum sodium level over 145mEq/L.  As serum sodium level rises, a large difference in sodium levels occurs between the extracellular fluid (ECF) & the intracellular fluid (ICF). CALCIUM REGULATION  Stored in the bone, plasma and body cells  99% of calcium is in the bones and teeth  1% is in ECF  50% of calcium in the ECF is bound to protein (albumin)  40% is free ionized calcium  Is necessary for  Bone and teeth formation  Blood clotting  Hormone secretion  Cell membrane integrity  Cardiac conduction  Transmission of nerve impulses  Muscle contraction HYPOCALCEMIA  Hypocalcemia occurs when the body’s serum calcium level falls below 4.5 mg/dl.  causes and pathophysiology:  Inadequate calcium intake.  Impaired calcium absorption:  From increased intestinal motility from sever diarrhea, laxative abuse, lake of Vit. D in the diet.  Excessive calcium loss: related to pancreatic insufficiency that cause malabsorption of calcium, and subsequent loss of calcium in stool.  Drugs as diuretics, Calcitonin,.  Other causes as: hypomagnesemia, hypoalbuminemia, hyperphosphatemia HYPERCALCEMIA  It occurs when the serum calcium level rises above 10.5mg/dl, the ionized serum calcium level rises above 5.1 mg/dl.  causes and pathophysiology:  Hyperparathyroidism: is the most common cause of hypercalcemia  Cancer: is the second cause hypercalcemia the malignant cell invade the bones , leading to an increase in serum calcium levels and bone destruction.and subsequently the kidney can’t excrete the excess level. HYPERCALCEMIA  other causes: as  Excessive use of antacids that contain calcium  Excessive amount of Vit. D.  An over dose of calcium drug.  Vitamin A overdose , leading to increased bone reabsorption of calcium.  Hyperthyroidism.  Multiple fractures or prolonged immobilization.  Hypophosphatemia or acidosis. MAGNESIUM REGULATION  Essential for enzyme activities  Neurochemical activities  Cardiac and skeletal muscle excitability  Regulation  Dietary  Renal mechanisms  Parathyroid hormone action  50 – 60% of magnesium contained in bones  1% in ECF  Minimal amount in cell REGULATION OF ELECTROLYTES CONT’D.  Major Anions in body fluids:  Chloride (Cl-)  Major anion in ECF  Follows sodium  Bicarbonate (HCO3-)  Is the major chemical base buffer  Is found in ECF and ICF  Regulated by kidneys REGULATION OF ELECTROLYTES CONT’D.  Phosphate (PO4---)  Buffer ion found in ICF  Assists in acid-base regulation  Helps to develop and maintain bones and teeth  Calcium and phosphate are inversely proportional  Promotes normal neuromuscular action and participates in carbohydrate metabolism  Absorbed through GI tract  Regulated by diet, renal excretion, intestinal absorption and PTH CAUSES OF ELECTROLYTE IMBALANCES  Excessive sweating  Fluid loss leading to dehydration  Excessive vomiting  Diuretics like Lasix (K+ depletion)  Massive blood loss  Dehydration may go unnoticed in hot, dry climates  Renal failure ASSESSMENT  Nursing history  Age  Prior Medical History  Acute illness  Surgery  Burns increase fluid loss  Resp. disorder predisposes to resp. acidosis  Head Injury can alter ADH secretion  Chronic illness  Cancer  CVD  Renal disorders  GI disturbances ASSESSMENT CONT’D.  Environmental factors affecting fluid/electrolyte alterations  Diet  Lifestyle – smoking,….  Medications  Physical Assessment  Daily weights  I&O  Vital signs LABORATORY STUDIES  Osmolality “concentration per kilogram in blood and urine”.  Blood osmolarity : 280 – 300 mOsm/kg  Urine osmolality : 50 – 1400 mOsm/kg  BUN: (10-20 mg/dL)made up of urea, an end product of protein metabolism by the liver.  Creatinine (0.7 to 1.5 mg/dL)- end product of muscle metabolism  Serum electrolytes: N, K, C. NURSING DIAGNOSIS  Decreased cardiac output  Acute confusion  Deficient fluid volume  Excess fluid volume  Impaired gas exchange  Deficient knowledge regarding disease management  Impaired oral mucous membrane  Impaired skin integrity  Ineffective tissue perfusion PLANNING  Determine goals and outcomes  Set priorities  Collaborative care  Medical Doctor.  Dietician  Pharmacy IMPLEMENTATION  Health promotion  Education  Acute care  Enteral replacement of fluids  Restriction of fluids  Parenteral replacement of fluids and electrolytes  Total parenteral nutrition (TPN)  IV fluids and electrolyte therapy (crystalloids)  Blood and blood components (colloids)  Blood groups and types  Autologous transfusion  Transfusion reactions  ABGs RESTORATIVE CARE  Home IV therapy  Nutritional support  Medication safety  Patient education EVALUATION  Have goals been met?  Have changes in assessment occurred?  Progress determines need to continue or revise plan of care FLUID VOLUME DEFICIT (HYPOVOLEMIA) Dehydration: fluid intake is less than what is needed to meet the body’s fluid needs, resulting in a fluid volume deficit. ASSESSMENT OF FLUID DEFICIT  Hypotension  Weak rapid pulse  Temperature decreased if hypovolemic, and increased in dehydration  Weight loss  Skin turgor poor in dehydration and possible edema in hypovolemic  Concentrated urine and blood CAUSES OF DEHYDRATION  Hemorrhage,  Vomiting  Diarrhea  Profuse salivation  Fistulas  Abscesses  Burns  Severe wounds  Diuretic therapy  GIT suctioning FLUID VOLUME OVERLOAD (HYPERVOLEMIA) Causes:  Excess intake of fluids  Excess intake of sodium  Congestive Heart Failure  Cirrhosis  Renal failure  Normal post-operative response CLINICAL MANIFESTATIONS OF FLUID OVERLOAD  Weight gain  Balance intake more than output (I>O)  Bounding pulse.  Dyspnea  Cough  Crackles  Jugular vein distention  Edema  Increased BP NURSING MANAGEMENT OF FLUID OVERLOAD  Daily weights  Strict I&O - Reduce fluid intake  Reduce sodium intake  Diuretics  Monitor electrolytes  Elevate legs, encourage movement ACID - BASE BALANCE  Acid: releasing H ions in solution  Bases : or alkalis have low hydrogen ions and accept hydrogen ions in solutions.  PH: reflects the H ions concentration of the solution  Higher H ion concentration the lower the PH.  The body fluid are normally slightly alkaline. ACID - BASE BALANCE An important part of regulating the chemical balance or homeostasis of body fluids is regulating their acidity or alkalinity.  Blood pH - 7.35 - 7.45  paCO2 - 35 – 45 mm/Hg  Bicarbonate (HCO3) - 22-26 mEq/L ACID BASE REGULATION  Body fluids are slightly alkaline  7.35-7.45, narrow range, necessary for optimal body function  pH range compatible with life is 6.8 - 8.0  Three body systems maintain the balance  Buffer  Kidney  lung BUFFERS  Buffers prevent excessive changes in pH by removing or releasing hydrogen ions.  If excess hydrogen ion is present in body fluids, buffers bind with the hydrogen ion, minimize the change in pH. RESPIRATORY REGULATIONS  The lungs help control acid-base balance by eliminating or retaining CO2 (acid).  Changing the rate and depth of respiration  Respiratory system is so sensitive acid base changes and reacts within minutes RESPIRATORY REGULATIONS  When breathing is increased, the blood carbon dioxide level decreases and the blood becomes more Base  When breathing is decreased, the blood carbon dioxide level increases and the blood becomes more Acidic  By adjusting the speed and depth of breathing, the respiratory control centers and lungs are able to regulate the blood pH minute by minute RESPIRATORY REGULATIONS  Carbon dioxide levels in the blood are measured as the:  PCO2: Refer to Partial pressure of CO2 in venous blood,  PaCO2: Refer to Partial pressure of CO2 in rterial blood, normal PaCO2 35-45 mm hg  Increase: leads to acidosis  Decrease: leads to alkalosis RENAL REGULATION  The kidneys are the ultimate long- term regulator of acid-base balance. They are slower to respond to changes, requiring hours to days to correct imbalance.  Their response is more permanent.  The kidneys help regulate acid-base balance by excreting or retaining HCO3, hydrogen ions.  pH falls (acidosis) kidneys reabsorb and regenerate bicarbonate and excrete hydrogen.  In case of alkalosis and high pH, excess bicarbonate is execrated and hydrogen ion is retained. ACID BASE BALANCE  RESPIRATORY ACIDOSIS.  RESPIRATORY ALKALOSIS.  METABOLIC ACIDOSIS.  METABOLIC ALKALOSIS  MIXED PATTERN OF ACID-BASE IMBALANCE RESPIRATORY ACIDOSIS  Causes: hypoventilation, COPD, asthma  Arterial blood gases: PH below 7.35, CO2 above 45  Compensation: kidney takes hours to days to restore PH by retaining HCO3 to restore the normal carbonic acid  Treatment: if not self compensated. RESPIRATORY ALKALOSIS  Causes: hyperventilation, anxiety, fever,  CO2 wash, carbonic acid fall,  ABGs: pH above 7.45, CO2 bellow 35  Compensation: kidney excrete bicarbonate METABOLIC ACIDOSIS  Causes: PH below 7.35, renal failure, inability to excrete H+ or retain HCO3, diabetic ketoacidosis, too much acid is produced  Blood Gases: PH below 7.35, CO2 above 45, HCO3 below 22 mEq/L  Respiratory compensation: rate and depth of respiration increase to eliminate CO2 and decrease carbonic acid METABOLIC ALKALOSIS  Causes: PH above 7.45, prolonged vomiting,  ABGs: PH above 7.45, CO2 below 35, HCO3 above 26 mEq/L  Respiratory compensation: hypoventilation slow shallow respiration to retain CO2 and increase carbonic acid TANK YOU