Chapter 8 Part A - 2024 Fluid, Electrolyte, and Acid–Base Balance (PDF)

Chapter 8 – Part A Disorders of Fluid, Electrolyte, and Acid–Base Balance Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins Fluid Distribution Intracellular fluid (ICF) compartment (inside the cells). 2/3 of body water in healthy adults Extracellular f...

Chapter 8 – Part A Disorders of Fluid, Electrolyte, and Acid–Base Balance Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins Fluid Distribution Intracellular fluid (ICF) compartment (inside the cells). 2/3 of body water in healthy adults Extracellular fluid compartment (outside the cells). 1/3 of body fluid 1. Interstitial (between the cells) ~80% of ECF 2. Intravascular (vascular; plasma) ~20% of ECF 3. Transcellular (~1%). peritoneal, pleural, pericardial cavities; cerebrospinal fluid; joint spaces, lymph system, eyes, and GI tract Copyright © 2015 Wolters Kluwer All Rights Reserved Distribution of Water Intracellular Fluid (ICF) Extracellular Fluid (ECF) Copyright © 2015 Wolters Kluwer All Rights Reserved NEW!! Continuous Glucose Monitoring Systems From what Extracellular fluid? Interstitial Intravascular Copyright © 2015 Wolters Kluwer All Rights Reserved Concentration of ECF and ICF Electrolytes Copyright © 2015 Wolters Kluwer All Rights Reserved Concentration of Electrolytes Minerals in your blood and other body fluids that carry an electric charge. Cations (positively charged ions Anions (negatively charged ions) Expressed as: – mg/dL – mEq/L* – mmol/L Copyright © 2015 Wolters Kluwer All Rights Reserved Osmotic Activity(1) & Tonicity(2) 1. Non-diffusible particles exert in pulling water from one side to the other 2. Tension or effect that a solution with impermeable solutes exerts on cell size because of water movement across the cell membrane ICF ICF Copyright © 2015 Wolters Kluwer All Rights Reserved Copyright © 2015 Wolters Kluwer All Rights Reserved  Isotonic Solutions (e.g., 0.9% saline and lactated Ringer’s solution). Have concentrations of solutes equal to those in the intravascular compartment. Allow fluid to move equally between compartments and do NOT cause notable shifts in fluid. Hypotonic solutions (e.g. 0.45% saline). Have a lower concentration of solutes than those in the intravascular compartment. Cause fluid to shift from the intravascular compartment to the intracellular space. Hypertonic solutions (e.g., 5% in 0.9% saline, 3% saline). Have a higher concentration of solutes than those in the intravascular compartment. Cause fluid to shift from the intracellular compartment to the intravascular space. Copyright © 2015 Wolters Kluwer All Rights Reserved Compartmental Distribution of Fluids ECF: Interstitial Compartment Gel like material Opposes the outflow of water from capillaries, preventing accumulation of water in interstitial spaces Transcellular: cerebrospinal fluid; body spaces – peritoneal, pleural, pericardial cavities; joint spaces. “Third space” Copyright © 2015 Wolters Kluwer All Rights Reserved Forces that Control Movement of Water Between Capillary and Interstitial Space Capillary hydrostatic pressure: PUSHES water out of capillary into interstitial spaces; due to A. Interstitial hydrostatic (fluid) pressure: opposes the movement of water out of capillary; Pushes into capillary B. Interstitial Colloidal Osmotic Pressure: Pulls water out of the capillary into interstitial spaces Capillary Colloidal Osmotic Pressure: PULLS water back into capillary* Results: little excess in interstitial; removed by lymphatic system Copyright © 2015 Wolters Kluwer All Rights Reserved Hydrostatic pressure PUSHing force exerted by a fluid Oncotic pressure: PULLing force created by particles Copyright © 2015 Wolters Kluwer All Rights Reserved Question What forces work to keep blood in the capillary? Capillary COP and tissue hydrostatic pressure Copyright © 2015 Wolters Kluwer All Rights Reserved What is Edema? Watery fluid collecting in body cavities or tissues of the body Copyright © 2015 Wolters Kluwer All Rights Reserved  Palpable edema produced by increased in interstitial fluid volume ? Interstitial space A, B, C, D A B C D Copyright © 2015 Wolters Kluwer All Rights Reserved Chart 8-3 No edema: Balance between of hemodynamic forces along the capillary wall and the function of the lymphatic vessels Common Causes of Edema (one or more) 1. Increase Capillary Pressure 2. Decrease Colloidal Osmotic Pressure 3. Increased Capillary Permeability 4. Obstruction of Lymphatic Flow Copyright © 2015 Wolters Kluwer All Rights Reserved  Increased Capillary Filtration Pressure (hydrostatic pressure) Edema Increase in vascular volume Increased capillary pressure common cause of dependent edema Fluid accumulation in lower parts of body; effects of gravity Copyright © 2015 Wolters Kluwer All Rights Reserved Increase Hydrostatic Pressure (see Chart 8-3) 1. Heart failure (HF), often referred to as congestive heart failure (CHF), heart is unable to pump sufficiently to maintain blood flow to meet body’s needs; overload & backup Pushing fluid into interstitial spaces S/S: SOB, dyspnea, generalized edema 2. Kidney disease Renal failure (sodium and water retention) causes plasma volume overload and edema S/S: fluid overload, generalized edema Copyright © 2015 Wolters Kluwer All Rights Reserved (cont) Cause of Edema: Increase Hydrostatic Pressure 3. Venous obstruction – Increase pressure behind the obstruction pushing fluid from capillaries into the interstitial spaces a) Thrombophlebitis & Deep vein thrombosis (DVT) (thrombus-inflammation of veins) Manifestations: local pain, erythema, edema, increase circumference Copyright © 2015 Wolters Kluwer All Rights Reserved  DVT S&S - Redness - Pain - Unilateral circumference increased Copyright © 2015 Wolters Kluwer All Rights Reserved (cont) Cause of Edema: Increase Hydrostatic Pressure b. Hepatic obstruction / Liver disease with obstruction Manifestations: local and systemic Copyright © 2015 Wolters Kluwer All Rights Reserved (cont) Cause of Edema: Increase Hydrostatic Pressure 4. Acute (flash) pulmonary edema Emergency situation! increase pulmonary edema; pushing fluid into the lungs  alveoli Other: Life threatening! (edema of brain (limited cranial space), larynx, lungs) Copyright © 2015 Wolters Kluwer All Rights Reserved 5. Varicose veins (superficial): incompetence valves – Prolong standing in ONE spot – Increased hydrostatic pressure – Clinical manifestations? Copyright © 2015 Wolters Kluwer All Rights Reserved (cont.) Cause of Edema: Increase Hydrostatic Pressure Prolong standing in one spot; prolong bed rest Veins: low-pressure system; how do we keep the blood moving? Legs: Keep the blood moving => “calf pump” or “peripheral heart” skeletal muscle pressure Tight clothing around extremity(ies) local findings ‘pushing’ fluids into ? Copyright © 2015 Wolters Kluwer All Rights Reserved  Decreased Colloidal Osmotic Pressure: Cause of Edema 1. Increase loss of plasma proteins (albumin) 1. Extensive burns (via injury to skin; early stages of a burn) 2. Decrease production of plasma proteins - Kidney disease (loss of albumin via urine) - Liver disease, malnutrition - Manifestations: - Generalized edema (face, legs, feet, etc) Copyright © 2015 Wolters Kluwer All Rights Reserved  Increase Capillary Permeability: Cause of Edema 1. Inflammation Leakage into interstitial space Inflammation Allergic reactions Malignancy (ascites, pleural effusion) Tissue injury Copyright © 2015 Wolters Kluwer All Rights Reserved Increase Capillary Permeability Burns Copyright © 2015 Wolters Kluwer All Rights Reserved Cause of Edema: Obstruction of Lymphatic Flow Lymphatic System – Absorbs interstitial fluid and a small amount of proteins – When channels are blocked (tumors) or surgical removed proteins and fluid accumulate in interstitial space causing lymphedema – Tumors may obstruct, leading to edema; impede drainage of lymph. – Surgical removal (breast, pelvic) or injury to lymph nodes Copyright © 2015 Wolters Kluwer All Rights Reserved  Unilateral lymphedema Right mastectomy (secondary lymphedema) Always ask what arm the pt. prefers to have BP taken Protein-rich lymph builds up in interstitial space; raises local colloid oncotic pressure and promotes more fluid leakage: Leads to infection, delayed wound healing, chronic inflammation, fibrosis of tissue Copyright © 2015 Wolters Kluwer All Rights Reserved Bilateral Lymphedema: Hallmark Non-pitting edema (lipedema) Accumulation of excess fluid (lymphatic fluid) in soft tissues Stemmer sign: inability to tent the skin at base of the digits- Copyright © 2015 Wolters Kluwer All Rights Reserved  (cont.) Cutaneous and subcutaneous thickening (with long term lymphedema) Copyright © 2015 Wolters Kluwer All Rights Reserved  Elastic support stockings (TEDs) –Nurses, bus drivers….. –Decreases diameter of distended veins increases venous blood flow velocity & valve effectiveness Elastic sleeves & wraps –Lymphedema; Mastectomy Compression massage; …to increase lymph flow Lymphedema clinics Copyright © 2015 Wolters Kluwer All Rights Reserved Before compression After compress Copyright © 2015 Wolters Kluwer All Rights Reserved Third-Spacing: Accumulation Transcellular Compartment Movement of ECF in a trans- compartmental spaces (serous cavities) – Peritoneal cavity (ascites; chronic) – Pleural cavity (life threatening) – Pericardial (life threatening) – Joints Distributional loss of ECF that is sequestered in a non-ECF, non-ICF compartment (e.g., ascites) Copyright © 2015 Wolters Kluwer All Rights Reserved Pericardium sac Pericardial effusion is the accumulation of excess fluid around the heart often related to inflammation of the pericardium that's caused by disease or injury. Pleural effusion Pericardial effusion Inflammation: pneumonia Emergency – Cardiac Arrest (AMI, cardiac surgery) Emergency : pericardiocenteses Copyright © 2015 Wolters Kluwer All Rights Reserved Summary: Edema #1 Life threatening – Acute edema of the brain, larynx and lungs Non-life threatening – Movement/function Edematous tissue is more susceptible to injury. Why? Increases distance for diffusion of oxygen, nutrients, and waste Tourniquet-like Copyright © 2015 Wolters Kluwer All Rights Reserved Summary: Edema #2 Localized edema – Typically limited to the site of trauma – Particular organ system (cerebral edema, peritoneal ascites, pleural effusion, pulmonary edema, pericardial) Generalized edema – More uniform distribution of fluid in interstitial spaces – Interstitial volume increased by 2.5 to 3 L Dependent edema: gravity dependent areas (legs and feet); could signal more generalized edema Peripheral edema Pedal edema Copyright © 2015 Wolters Kluwer All Rights Reserved  Finger pressure Pitting edema 5 seconds – tissue fluid can be displaced - dependent areas - lower extremities, - over sacrum (bed rest) Nonpitting edema – edema without pitting – ? lymphatic or hypothyroidism Some long term inflammatory can become firm & discolored (pitting and non-pitting) Copyright © 2015 Wolters Kluwer All Rights Reserved  Edema (dependent) Assessment Manifestations – Swelling of part or all of your arm or leg, including fingers or toes; local / generalized – Patients: A feeling of “heaviness or tightness”; restricted range of motion “”Aching or discomfort; tight shoe, clothing; ‘tight’ Puffiness (eyes, generalized), weight gain Copyright © 2015 Wolters Kluwer All Rights Reserved Management 1)Daily weight (general edema as in HF, renal disease) – most reliable measure for measuring body fluid volume increase. 2) Visual assessment (comparison of extremities) – Hardening and thickening of the skin (fibrosis) – Recurring infections ? 3) Measure (circumference of both legs, especially with thrombophlebitis, DVT) Copyright © 2015 Wolters Kluwer All Rights Reserved Management Correct underlying cause (i.e., HF) Elevate extremities, range of motion (ROM), ambulation Control intravascular volume – Diuretics ‘water pills’; dialysis Decreased albumin? (hypoalbuminemia) – IV albumin Skin care!! Meticulous skin care to prevent infection Copyright © 2015 Wolters Kluwer All Rights Reserved Case Study Sandra is a 56 year-old bus driver. She comes into the clinic because of ‘puffy’, ‘achy’ & ‘red’ leg, which has gotten worse over the last week. She has a past history of “having clots in her legs”. She is diagnosed with DVT. 1) What would place Sandra at risk for DVT? 2) What findings would the nurse expect with DVT? Copyright © 2015 Wolters Kluwer All Rights Reserved Scenario An athlete ran a marathon even though he felt ill. After the race, he collapsed. He was pale with a low blood pressure (98/60 mm Hg). One knee and ankle were badly swollen; his abdomen was distended with fluid. The doctor diagnosed appendicitis and dehydration. Questions: What has happened to his: – Transcellular compartment volume? – Vascular compartment volume? Copyright © 2015 Wolters Kluwer All Rights Reserved  Edematous areas are more susceptible to injury, development ischemic tissue damage. Wounds heal more slowly with prolonged edema. Why? Copyright © 2015 Wolters Kluwer All Rights Reserved This End the Presentation Copyright © 2015 Wolters Kluwer All Rights Reserved