Fluids & Electrolytes.pdf

FLUIDS & ELECTROLYTES SULTAN, AUZA, BAUTISTA, SABALA, CALUMBA, RAMIREZ, ZAMORA LECTURE TOPIC DIVIDER and hates water MAIN TOPIC...

FLUIDS & ELECTROLYTES SULTAN, AUZA, BAUTISTA, SABALA, CALUMBA, RAMIREZ, ZAMORA LECTURE TOPIC DIVIDER and hates water MAIN TOPIC Atoms transports electrolytes going into the cell or coming SUBTOPIC out lipids SUBSUB TOPIC carrier through the membrane Cell coat INTRODUCTION STUFF Course Description Long chains of complex carbohydrates make up This course deals with concepts, principles, theories glycoproteins, glycolipids and lectins that form the and techniques of nursing care management of at-risk outside surface of the cell. This intricate coat helps in and sick adult clients in any setting with alterations/ cell-to-cell recognition and adhesion. problems in oxygenation, fluids and electrolytes, BODY FLUID COMPOSITION infectious, inflammatory and immunologic response, - composed of water ad various dissolved substances cellular aberrations, acute and chronic. The learners or solutes are expected to provide nursing care to at risk adult - H20 (primary component) - provides a medium for the clients utilizing the nursing process. transport and exchange of nutrients, and other substances. Objectives: - oxygen O2 Identify the different terminologies related to fluid and - carbon dioxide CO2 electrolyte imbalance; - metabolic wastes describe the anatomy and physiology and functions of - the primary component of body fluids the affected systems; recognise the different causes - regulates body temperature through evaporation and of disorders that affects fluid and electrolyte perspiration identify abnormal findings that may indicate alterations in the given disorders; and Ex; 80 kg (60% water) = 48 appreciate the importance of proper holistic nursing care for client's experiencing such imbalances. - varies with age, gender, and amount of body fat Finals: (BSN 3k) Function of H2O Fluids & Elec - 50% - serves as a temperature regulation through Oxy - 50% perspiration ○ 50% - class standing - transports of materials going to the cell or coming ○ 50% - exam from the cell - aqueous medium for cellular metabolism LESSON 1 - assist in food digestion through hydrolysis - Acts as a solvent and as a solute as available for cell CELL MEMBRANE function cell - smallest autonomous functional unit in the body - eg. blood loss (h20 maintains the blood volume in our cell is undifferentiated sa sulod ni mother body) cell grows differentiated (sex cell, muscle cells, - Maintains blood volume epithelial cells) - Medium for waste excretion - Cushion from the injury CELL WALL - semi-permeable membrane which synthesizes Factors affecting body water: molecules and replicates Age - participates in elect events and will replicate - Infant - 70-80% - adult - 50-60% 3 composition of cell membrane: - Elderly - 45-50% Gender Phospholipids - Male - 60% - Female - 50% because they have more body fats which contains less water Body fats - contains less water - fat cells contains little H20 to maintain normal fluid balance, body water intake and output should be approximately equal - The average fluid intake and output is about 2500mL over a 24-hour period. - Body fluids intake must be equal to output hydrophilic (head) - loves water and absorbs which faces outside and adheres neighboring cells Insensible water loss hydrophobic (tail) - not facing outside; facing inside ○ skin, FLUIDS & ELECTROLYTES SULTAN, AUZA, BAUTISTA, SABALA, CALUMBA, RAMIREZ, ZAMORA LECTURE ○ increase exercise ELECTROLYTE DISTRIBUTION ○ inc environmental temperature ○ during illness vomiting, diarrhea Cation Plasma Interstitial ICF 24 HOURS OF FLUID INTAKE AND OUTPUT Na 142 mg/L 146 mg/L 15 mg/L INPUT: K 5 5 150 H20 - 1L Calcium 5 3 2 Soup H20 in food - 1,300 mL (Ca) Oxidation - 200mL Magnesium 2 1 27 = 2,500 mL OUTPUT: 154 mg/L Urine - 1,500 mL Feces - 200 mL Anions Plasma Interstitial ICF Perspiration - 500 mL Respiration - 300 mL Chloride 102 14 1 = 2,500 mL Bicarbonate 27 30 10 R: Intake must be equal to output in approximation HCO3 ELECTROLYTE Phosphate 2 2 100 - Electrolytes are substances that dissociate in solution (HP042) to form charged particles called ions. - Cations are positively charged (+) Sulfate 1 1 20 - Anion are negatively charged (+) (S042) - meq/L (milliequivalent per liter) organic acid 5 8 0 4 MAJOR FUNCTIONS OF ELECTROLYTES 1. Assisting with regulation of water balance Protinate 16 1 7 2. Regulating and maintain acid-base balance 3. Contributing to enzyme reactions 4. Essential for neuromuscular activity 154 mg/L Why plasma? because serum is extracted from plasma 2 MAJOR ELECTROLYTE PER BODY COMPONENT originated from a vein. EXTRACELLULAR FLUID COMMON ELECTROLYTES CATIONS (+) SODIUM (Na+)- most abundant in extracellular Electrolyte Distribution Basic Dietary compartment Ion in body function source CALCIUM - extracellular fluid fluid MAGNESIUM - both sides meron Na+ -Regulates Table salt ANIONS (-) ECF: 135 - fluid volume cheese CHLORIDE - most abundant 154 meq/L; within ECF milk - isotonic will not shrink nor swell; balance compartmen processed lang siya t meat - eg. blood loss Na is given because it is ICF: 15-20 poultry isotonic it must be abundant si chloride - Regulates seafoods HCO3 vascular foods osmotic preserved INTRACELLULAR FLUID (inside cell) pressure with salt (e.g CATION (+) ham and -controls bacon) POTASSIUM water MAGNESIUM distribution between “Where the sodium goes, water follows” ECF and ICF FLUIDS & ELECTROLYTES SULTAN, AUZA, BAUTISTA, SABALA, CALUMBA, RAMIREZ, ZAMORA LECTURE compartmen associated ts with vit. B Fish - metabolism Participates and the use Nuts in of potassium conduction calcium. and of nerve protein impulses -Promotes regulation of K ECF; - Regulates banana serum osmolality of potato calcium, 3.5-5 ICF. avocado phosphorus and ICF: -Participates potassium in levels. 150-155 transmission - Promotes of nerve neuromuscul impulses. ar activity. - Promotes Notes: contraction of skeletal Sodium: and smooth - if there is a n imbalance dietary sources, we should muscles. know how to replace it - Regulates - sodium is distributed in the ECF, we will always find acid-base sodium in the ECF balance by cellular Potassium exchange of - highest - avocado next is potato hydrogen - banana is more advised because it is readily available ions. compared to potato na need pa i-cook Ca+ ECF; Provides Milk Calcium 4.5-5.5 strength and Sardines - for bones helps in becoming more durable durability to Whole - strengthens the bones ICF: bones and grains - if mababa ang calcium level, mawala ang control 1-2 teeth. Green leafy resulting to hypocalcemia or involuntary muscle - Establishes vegetables movement (+) in Trevulsette sign (involuntary thickness movements in the face) and strength of cell membranes. - Promotes transmission of nerve impulses. - Maintains neuromuscul ar excitability – essential Trousseau Sign for blood - Signs of low calcium levels (hypocalcemia) coagulation. or hypercalcemia - Activates enzyme Chvostek Sign reactions, and - Signs for hyperkalemia or high potassium hormone levels secretions.- - Seizure as side effects - Neurologic sign Mg ECF:4.5-5.5 Activates Green leafy enzyme vegetables Magnesium ICF: 27-29 systems, - regulation of serum calcium and phosphorus mainly those Grains - comes from fish, green leafy vegetable, nuts, and grans FLUIDS & ELECTROLYTES SULTAN, AUZA, BAUTISTA, SABALA, CALUMBA, RAMIREZ, ZAMORA LECTURE SERUM COMPONENT Because we are getting here from the 60% *memorize normal range You have 60% body water from 60% how many are found in ECF and how many fluids are found in ICF Here ICF is 40% in ECF we have 20% VALUES Serum ECF is Further Classified by Location: Component Conventional SI value a. Intravascular - 5% value (mmol/L) - blood vessel compartments called “plasma” is contained with the arteries, veins and (mEq/L) capillaries b. Interstitial - 15% Sodium (Na +) 135 - 145 meq/L 135 - 145 mmol/L - located in the spaces between most cells of the body Chloride (Cl-) 98 – 106 mEq/L 98 - 106 mmol/L - accounts for approximately 15% of body weight Bicarbonate (HCO 22 – 26 mEq/L 22 – 26 mmol/L c. Transcelluar - 1% 3-) - Includes urine; digestive secretions; perspiration; and cerebrospinal, pleural, Calcium (Ca+) 8.5 – 10.0 mEq/L 2.1 – 2.6 mmol/L synovial, intraocular, gonadal, and pericardial fluids Potassium (K+) 3.5 – 5.0 mEq/L 3.5 – 5.0 mmol/L - The transcellular space contributes approximately 1% of the body fluid, and Phosphate/Inorga 1.7 – 2.6 mEq/L 0.8 – 1.5 mmol/L significant gains and losses do not occur on nic Phosphorus (2.5 – 4.5 mg/dl) a daily basis. (P4 +) LESSON 2 Magnesium (Mg+) 1.6 – 2.6 mg/dl 0.8 – 1.3 mmol/L (1.3 – 2.1 mEq/L MECHANISM OF FLUID TRANSPORT Serum Osmolality 275 – 295 275 – 295 mmol/L ACTIVE TRANSPORT mOsm/kg has carrier and it has to be needs carrier (protein) needs electrical charge like sila Adenosine triphosphate High Serum Osmolarity - Dehydrated or concentrated has molecule such as protein that will help move towards the intracellular area which needs energy BODY FLUID COMPARTMENT (DISTRIBUTION) also known as adenosine triphosphate Total Body Water moves from low concentration to high concentration Is the equivalent of the fluids that exist in all the fluid compartments. TYPES OF ACTIVE TRANSPORT: ○ 60 % of the body weight of an average adult Expressed in kilograms, 1 Liter of fluid is equivalent to Primary Active Transport 2.2 lb. (1kg) uses the initial source of energy to carry the substance Body fluid is classified by its location inside or outside the cells. Capillary and cell membranes separate total body fluids into Sodium Potassium Pump two main compartments: PISO- potassium in, sodium out if papasok si sodium, potassium will go out 1. Intracellular Fluid Compartment The sodium-potassium pump moves sodium ions out - Intracellular fluid (ICF) is found within cells. ICF is of and potassium ions into the cell. essential for normal cell function, providing a medium This pump is powered by ATP. For each ATP that is for metabolic processes. broken down, 3 sodium ions move out and 2 - Make up 2/3 of the body’s water or 40% of Body potassium ions move in. weight - Larger of the two compartments Endocytosis (into the cell) - Rich in electrolytes, potassium (occupies ICF compartment), magnesium, inorganic and organic 3 Main Kinds of Endocytosis: phosphates and proteins. Phagocytosis Or Cellular Eating 2. Extracellular Fluid Compartment Occurs when the dissolved materials enter - Extracellular fluid (ECF) is located outside of cells the cell. The plasma membrane engulfs the - Contains all the fluid outside the cells solid material, forming a phagocytic vesicle. - Accounts for 20% of Body weight Rich in electrolytes: (There is fluid inside) sodium, chloride and bicarbonate Side note: The vesicle is a plasma filled Note(s): vesicle. FLUIDS & ELECTROLYTES SULTAN, AUZA, BAUTISTA, SABALA, CALUMBA, RAMIREZ, ZAMORA LECTURE Osmolarity Pinocytosis Or Cellular Drinking the number of solutes per Liter of fluid Occurs when the plasma membrane folds inward to form a channel allowing dissolved Osmotic Pressure substances to enter the cell. When the Power of solution to draw water across the membrane channel is closed, the liquid is encircled the higher the solutes = the higher the osmotic within a pinocytic vesicle. pressure/ the pull of solvent or water Receptor-Mediated Endocytosis(RME) Also called clathrin-mediated endocytosis, Oncotic Pressure is a process by which cells absorb Colloid osmotic pressure metabolites, hormones, proteins – and in osmotic pressure exerted by plasma protein into the some cases viruses – by the inward budding vessel of the plasma membrane. Colloids - Albumin, plasma expanders for Side note: it buds inward or lumubog sya hemorrhages wherein these hormones, proteins will enter Proteins in the bloodstream exert oncotic pressure to the cell. pull fluid out of the interstitial space into the intravascular space to maintain fluid balance and Exocytosis: (release from cell to vesicle pushes outside the osmolality cell) Moves materials out of the cell Tonicity Materials is carried in a membranous vesicle Types of Solutions Vesicle migrates to the plasma membrane 1. Isotonic Solution Vesicle combines with the plasma membrane - has the same concentration of solutes as Materials is emptied to the outside plasma - Cells placed in an isotonic solution will Secondary Active Transport (cotransport): neither harnesses the energy obtained from the primary - Shrink nor swell because there is no net active transport and uses it as a cotransporter of a gain or loss of water within the cell, and no secondary substance change in cell volume. movement of sodium ions papunta intracellular, - D5LR, NaCl, LR nakikisama silang glucose; it can be same way - “iso” = equal (Symporter) -(papasok, papasok) - 270-300 M0sm/L (isoperfect) Antiporter (papasok, palabas) - enough pressure on both sides PASSIVE TRANSPORT 2. Hypertonic Solution - solute is more Osmosis - have greater concentration of solutes than Osmosis is the process by which water moves across plasma a selectively permeable membrane from an area of - cells will go shrink; fluid is pulled lower solute concentration to an area of higher solute - D5LR, 10 percent concentration. - Greater than 300 m0sm/L Movement from low concentration to high concentration 3. Hypotonic Solution A selectively permeable membrane allows water - Have a lower solute concentration than molecules to cross but is relatively impermeable to plasma (lasaw) dissolved substances (solutes). Osmosis continues - When RBC are placed in a hypotonic until the solute concentration on both sides of the solution, water moves into the cells, causing membrane is equal. (Lemone, 2017) them to swell; rupture (hemolysis) of cells may occur w/ extremely hypotonic solutions Osmolality - osmolarity of less than 300 m0sm/L Osmolality, or concentration of a solution, refers to the - draws fluid from the blood vessel space to number of solutes per kilogram of water (by weight); it the intravascular is reported in milliosmoles per kilogram (mOsm/kg). The osmolality of the ECF depends chiefly on sodium Diffusion concentration. Serum osmolality may be estimated by Solute molecules move from an area of high solute doubling the serum sodium concentration concentration to an area of low concentration (approximately 142 mEq/L). Glucose and urea contribute to the osmolality of ECF, Simple Diffusion although to a lesser extent than sodium. It occurs by the random movement of particles through a solution. Water, carbon dioxide, oxygen, AVERAGE - COP is 28 mmHg and solutes move between plasma and the interstitial space by simple diffusion through the capillary FLUIDS & ELECTROLYTES SULTAN, AUZA, BAUTISTA, SABALA, CALUMBA, RAMIREZ, ZAMORA LECTURE membrane. FLUID VOLUME DEFICIT Water and solutes move into the cell by passing (1) Thirst through protein channels or by dissolving in the lipid Thirst is the primary regulator of water intake. cell membrane Thirst plays an important role in maintaining fluid balance and preventing dehydration. Facilitated Diffusion The thirst centers, located in the hypothalamus, are - carrier mediated stimulated when blood volume drops because of Allows large water-soluble molecules, such as water losses or when serum osmolality increases. glucose and amino acids, to diffuse across cell The Thirst mechanism is highly effective in regulating membranes. extracellular sodium level. Increase sodium in ECF Proteins embedded in the cell membrane function as increases serum osmolality, stimulating the thirst carriers, helping large molecules cross the center. membrane. Fluid intake in turn reduces the sodium concentration of ECF and lowers/reduces the serum osmolality. The rate of diffusion is influenced by a number of Conversely, a drop in serum sodium and low serum factors, such as the concentration of solute and the osmolality inhibit the thirst center. (Lemone, 2017) availability of carrier proteins in the cell membrane. High concentration to low and carried-mediated *A person who respond to the thirst center drinks water *Elderly, Comatose, Infant- thirst mechanism will be Filtration decreasing/declining kaya very prone/vulnerable in dehydration Filtration is the process by which water and dissolved and hyperosmolality (common ang UTI) substances (solute) move from an area of high *Intubated- change in level of consciousness hydrostatic pressure to an area of low hydrostatic *when a person ask for water it is the brain regulating the thirst pressure. This usually occurs across capillary center membranes. *prep cup of water and tongue depressor to hydrate patient for patient na unconscious Hydrostatic Pressure *reduce sodium concentration- when the person drinks Created by the pumping of the heart and gravity water; cause decrease serum concentration in the body against the capillary wall *unconscious patient- depends on the person caring for them Filtration occur in the glomerulus of the kidneys as to maintain good hydration; nurses wet oral mucosa every 2-3 well as the arterial end of capillaries hrs for this type of patient and place lip balm to prevent cracking of the lips FLUID REGULATION - hydrate through IVF Regulatory: eg. if there's continuous dehydration or bleeding, after (2) Kidneys FVD, the patient will develop into shock The kidneys are primarily responsible for regulating Regulatory mechanisms will do their best to fluid volume and electrolytes balance in the body. compensate while waiting for the management They regulate the volume and osmolality of body Hypothalamus will send signals or detect if there is a fluids by controlling the excretion of water and high concentration, therefore, hypothalamus will electrolytes (through urination). activate the feeling of thirst, through drying of the In adults, about 170 liters of plasma are filtered mouth. Antidiuretic hormone will be released resulting through the glomeruli every day. to control of kidney and reabsorbs water that's why By selectively absorbing water and electrolytes, the low ang urine output ng patient kidneys maintain the volume end of molality of body Fluid Volume Overload - (edema, bloated, fluids. About 99% of the glomerular filtrate is pale, SOB, increased RR, reabsorbed, and only about 1,500 ml of urine is Management: High fowler’s position, produced over a 24-hour period. diuretics Besides regulating fluid balance, the kidney also Primary regulator of the water intake is thirst contributes to regulation of electrolytes level. - water plays an important role to maintain Selectively secreting or absorbing electrolytes balance. achieve body balance. Two important electrolytes regulated by the kidneys are hydrogen and HOMEOSTASIS bicarbonate. Regulation of these two ions contribute Require several regulatory mechanisms at processes significantly to the body's overall acid base balance. to maintain the balance between fluid intake and excretion. Major functions of kidneys in maintaining normal fluid This includes first the kidney, the renin angiotensin balance aldosterone mechanisms, antidiuretic hormone, and atrial natriuretic peptide. 1. Regulates ECF volume and osmolality by selective These mechanisms affect the volume, distribution, retention and excretion of body and composition of body fluid. 2. Regulation of electrolytes level in the ECF by selective Retention of needed substances and excretion of unneeded substances FLUIDS & ELECTROLYTES SULTAN, AUZA, BAUTISTA, SABALA, CALUMBA, RAMIREZ, ZAMORA LECTURE 3. Regulates ph ECF through retention of hydrogen ions. II is a potent vasoconstrictor; it raises the blood 4. Excretion of metabolic waste and toxic substances. pressure. It also stimulates the thirst mechanism to promote fluid intake and acts directly on the kidneys, (3) Respiratory System causing them to retain sodium and water. The lungs participate in the maintenance of fluid balance by excreting moisture during exhalation. Angiotensin II stimulates the adrenal cortex to (insensible water loss) around 200 ml or 300 ml per release aldosterone. Aldosterone promotes sodium 24 hrs ang water na nilalabas and water retention in the distal nephron of the kidney, increase rr during fever and pneumonia restoring blood volume. Under normal conditions, this contributes about 300ml There is a compensation if there are changes in the per 24 hours to the fluid output of the body. vital signs such as increase of BP, RR; these However, in cases of increased respiratory rate, as compensatory mechanism are temporary only; if may occur with fever or respiratory problems, such as failure, still there is deficit or bleeding and wala na pneumonia, the amount of fluid lost during respiration control, it will lead to hypovolemic shock and can increase significantly, potentially leading to fluid cardiovascular prolapse leading to death deficits. The lungs also play a role in acid-base balance by regulating excretion of carbon dioxide (CO2) na sobra from the body. (Daniels, 2007) Another function of respiratory, evaporating/releasing water to insensible loss Maintains acid-base balance by excreting the acid content of the metabolism of the body through carbon dioxide (4) Renin-Angiotensin-Aldosterone System (RAAS) - maintain IV fluid balance and BP Aldosterone – secreted by adrenal carta in response to low sodium (e.g. patient is suffering from a decrease in sodium levels) and It follows increased water loss. When aldosterone is released it will prevent sodium and water loss Aldosterone will work on the nephron(kidney) and will try to reabsorb sodium water back into the circulation Renin-Angiotensin-Aldosterone System and will increase blood volume & blood osmolarity but it decreases your calcium because you have excreted (5) Antidiuretic Hormone (ADH) (Vasopressin) potassium. Antidiuretic hormone (ADH), released by the posterior Hypernatremia & hypokalemia – a disease when pituitary gland, regulates water excretion from the there is an increase of aldosterone secretion (patient kidneys. Osmoreceptors(the specific receptor) in the will have problems in adrenal gland, trauma in adrenal hypothalamus respond to increases in serum cortex, tumor) osmolality (if high concentration ang solute) and Addison's disease will have an effect on aldosterone decreases in blood volume, stimulating ADH plus an effect because a decrease of cortisol levels production and release. ADH acts on the distal tubules of the kidney, making them more permeable Renin-Angiotensin-Aldosterone System (RAAS) to water and thus increasing water reabsorption. The renin-angiotensin-aldosterone system helps to If more water is reabsorbed, less is secreted. Thus, maintain intravascular fluid balance and blood there is conservation and reabsorption of water back pressure. into the circulation, hence, eliminating the problem of decreased fluid in the body.(expect low volume of A decrease in blood flow or blood pressure to the urine) kidneys stimulates specialized receptors in the There are other circumstances wherein this hormone juxtaglomerular cells of the nephrons to produce is a problem: Excessive increase of ADH and renin, an enzyme. decreased levels of ADH. Excessive increase of ADH - “SIADH” Syndrome of Renin (enzyme) converts angiotensinogen (a plasma Inappropriate Antidiuretic Hormone - retention of too protein) (located in intravascular circulation in blood) much water - “nagarelease ng ADH na hindi into angiotensin I. kailangan” - causes circulatory overload Lack of ADH - “DI” Diabetes Insipidus (not related to Angiotensin I travel through the bloodstream to the DM but also has polyuria) - excessively excreting lungs where it is converted to angiotensin II by water (polyuria) angiotensin-converting enzyme (ACE). Angiotensin ADH will be inhibited- when there is presence of FLUIDS & ELECTROLYTES SULTAN, AUZA, BAUTISTA, SABALA, CALUMBA, RAMIREZ, ZAMORA LECTURE alcohol and phenytoin(anticonvulsant); inhibits the affect the body including abdomen, eyes, release of antidiuretic hormone resulting to inc urine face, and lungs. output (sigeg ihi) We have to press using our index finder, if you press it, if there is a pit or lumubog. If nonpitting, it is the FLUID VOLUME EXCESS opposite. If it is pitting edema, we have to scale and grade the edema. Measure the indention in (6) Atrial Natriuretic Peptide millimeters. Grade 1,2,and 3. is a hormone released by atrial muscle cells in *2-3 seconds - time given to assess if it is pitting or non pitting response to distention from fluid overload. ANP edema affects several body systems, including the cardiovascular, renal, neural, GI, and endocrine How Many Millimeters Deep? systems, but it primarily opposes the Grade 1: 1-2 mm deep, few seconds return to renin–angiotensin–aldosterone system by inhibiting normal. renin secretion and blocking the secretion and Grade 2: 3-4mm deep, 15-30 seconds return to sodium-retaining effects of aldosterone. As a result, normal. ANP promotes sodium wasting and increased urine Grade 3: 6mm deep, after 1 minute, it goes back to output. as a regulatory mechanism normal. primarily oppose the RAAS by inhibiting the renin secretions and blocks the secretion and sodium Incomplete if ilagay mo lang na positive pitting edema. retaining effects of aldosterone. The mechanism causing this edema can cause fluid shift to (7) Cortisol other vulnerable areas of the body. It’s not only confined to one Increases glomerular filtration rate extremity or one part of the body. Fluid shifts are sometimes Renal plasma flow from the kidneys, increasing called third-space shift or third-space sequestration. sodium and water retention and potassium excretion in high amounts acting as aldosterone (in Face: unilateral or bilateral high amounts cortisol is converted to cortisone which Eyes: puffy acts on mineralocorticoid receptors mimicking the effect of aldosterone). INFILTRATION: Depends on the solution that enters the body tissue. If IV solution is non- irritating, it is non-vesicant. If (8) Parathyroid Hormone irritating, vesicant solution sya. It is the most important endocrine regulator of calcium EXTRAVASATION: Nagkakaroon ng swelling, pain, and is cool and phosphorus concentration in extracellular fluid. to touch. Painful swelling extravasation. It is a complication of It is secreted from parathyroid gland cells and finds its IV therapy. There’s redness and necrosis. Nagkakaroon na ng major target cells in bone and kidney. cell death to the part where the medication extravasate. There are other hormones that regulate fluid balance. Aldosterone: a mineralocorticoid. Cortisol: ABDOMEN: Ascites glucocorticoid. Cortisol is also released by the adrenal cortex. Also has the same effect as aldosterone but There are many reasons why there is shifting of plasma into more potent effect when it comes to regulating water interstitial. Either medication or protein deficits or due to and sodium reabsorption. pregnancy. If pregnancy, it is because of a gravid uterus. There Parathyroid hormone - It also balances your fluid is pulling of fluid, kaya nagkakaroon ng edema sa lower status, these hormones is secreted by the cells of the extremities. parathyroid gland, and finds major targets in the bone and specifically for the kidney. They contribute little We have to know what is the main reason of edema. That will only in hormonal balance and only temporary. now be the focus of the nsg management and intervention. FLUID SHIFTING THIRD SPACING PLASMA TO INTERSTITIAL (ECF) Shift of fluid from the vascular space into an area where it is not available to support normal physiologic EDEMA processes (Why is this fluid going to this one wherein it should not go. There are membranes that do not There are a lot of processes wherein fluid will shift allow fluid to pass through this compartment. from compartment to another. This is just in between Fluid may be sequestered in the abdomen or bowel, the ecf. If fluid shifts from intravascular into the or in other actual or potential spaces as the pleural or interstitial space. It will cause edema. peritoneal space. There is fluid sequestration. It could ○ Edema: palpable swelling produced by also be in the abdomen, not only in the skin. If in expansion of the interstitial fluid volume. lungs: causes difficulty in breathing. Peritoneal space: Usually comes from intravascular. increases abdominal girth. ○ It may be localized (usually as lower Fluid may also become trapped within soft tissues extremities or night involve upper following trauma or burns. The trapped fluid extremities), pitting, non pitting. represents a volume loss and is unavailable for ○ Or generalized edema (ANASARCA), it will FLUIDS & ELECTROLYTES SULTAN, AUZA, BAUTISTA, SABALA, CALUMBA, RAMIREZ, ZAMORA LECTURE normal physiologic processes. In many cases, fluid is 4. Albumin drip IV (Albumin: Volume expander, one of sequestered in interstitial tissues and is unavailable to the managements of edema) support cardiovascular function. in a 50mL vial to be given for 3 hours to run When there is sprain, contusion, concussion because not fast drip; after giving albumin they will of this trauma, fluid will be trapped into tissues. give furosemide; q 12 hrs (3-4 gtts/min) It has to go back. Kailangan mawala sya doon. Stabilizes the oncotic pressure to prevent leakage of fluid to other compartments 4 MAJOR CAUSES OF EDEMATOUS STATE Bakit kaya nagkakaroon ng edematous state?... INTERSTITIAL TO PLASMA Movement back of edema to circulatory volume e.g. 1. Decreased colloid osmotic pressure excessive administration of hypertonic solution. E.g. Burns, liver failure, cirrhosis, hypoproteinemia FLUID VOLUME IMBALANCE / IMPAIRMENT (There is lack of albumin in the ECF kaya nagkakaroon ng FLUID VOLUME DEFICIT colloid osmotic pressure) Is a decrease in intravascular, interstitial and/or intracellular fluid in the body 2. Increased capillary hydrostatic pressure There is a loss of fluid in this component. E.g. Congestive Heart Failure usual causes: fluid/GI suctioning (Right-sided heart failure: Backward flow of fluid, the heart fails to pump. Nagkakaroon ng edema and 3 Types of FVD swelling. Left-sided: Forward flow, has problems with ISO-OSMOLAR FLUID VOLUME DEFICIT the lungs. Pulmonary edema.) ○ Occurs when sodium and water are lost in equal amounts 3. Increased capillary permeability ○ Losing both water and sodium E.g. Burns, allergic reactions (Hindi na siya semi-permeable, the fluid can just HYPEROSMOLAR FLUID VOLUME DEFICIT freely flow from one compartment to another like ○ Occurs when more fluid is lost than sodium, burns. The potassium will now go to your ecf, allergic resulting in higher serum osmolality than reactions also.) normal (>295 mosm/kg) ○ Water loss is high and sodium is retained as 4. Lymphatic obstruction or increased interstitial normal colloid osmotic pressure HYPOOSMOLAR FLUID VOLUME DEFICIT E.g. Surgical removal of lymph structures ○ Occurs when electrolyte loss is greater than (Pulling of fluid into the interstitial space). These are fluid (rare) the common problems why there is an edematous ○ Electrolytes are lost and much more fluid is state and we have to identify the reason for the retained edema and give the interventions adequate for this ○ Very rare because electrolytes are always problem. together with the fluids Management of Edema Side note: Dehydration is different from Hypovolemia 1. Diuretic therapy Give Diuretic therapy to patient if they have Example: fluid volume excess or to those patients who When jogging or exercising fluids are lost but sodium are hypertensive is retained then that is dehydration. Their Furosemide, Spironolactone managements are different as well as their manifestations. 2. Elevating the affected extremity (30 mins) When a patient cannot take fluids orally then a normal This will reduce venous flow or blood flow saline solution must be administered. into the affected part therefore decreasing the edema and patients who are Etiology: Post-trauma and Post-surgery to reduce Due to excessive GI losses such as vomiting, edema elevate with at least 1 pillow unless diarrhea contraindicated (However, do not elevate too GI suctioning much) Intestinal drainage (e.g. colostomy) ○ eg. postoperatively hindi pa form ang fecal 3. Elastic support stockings in the morning material kaya due to laxatives , mag excrete It controls swelling, reduce blood flow thus ng maraming fluids si patient resulting to reducing possible build-up of fluids in a FVD specific area ○ cleansing enema is done before operating It squeezes the legs to reduce flow of fluid in Renal disorders the tissue Hot environment Hemorrhage e.g postpartum nag relax ang uterus FLUIDS & ELECTROLYTES SULTAN, AUZA, BAUTISTA, SABALA, CALUMBA, RAMIREZ, ZAMORA LECTURE Excessive exercise due to hyperperspiration muna ipatayo. This is dangerous. We are not Fluid loss due to trauma going to ambulate the patient. RISK FOR FALL ang patient kay nahihilo man and Most Vulnerable at risk for fluid volume deficit: decrease blood flow sa brain. Bawal Elderly magtayo or maglakad. Dapat COMPLETE infants BED REST w/o bathroom privileges. If may ○ because of poor thirst mechanism confusion na kay affected na mental state. ○ caused by drop of >15mmHg systolic blood Fluid volume deficits may be the result of: pressure 1. Excessive fluid losses Diarrhea (take note of the frequency and the 4. Flat neck veins D/T falling of venous pressure volume), vomiting, Gl suctioning, ○ Flat neck veins due to falling of venous Hemorrhage pressure. Naka supine ang patient, dapat sitting siya kasi magkaroon ng decrease in Side note: How do we drain fluid from the Gl?: insertion of the venous pressure. nasogastric or orogastric tube into the nose going to the stomach to drain fluids to rest the bowels or if the patient has 5. Tachycardiac undergone abdominal surgery that warrants the need to rest ○ Tachycardia ang patient kasi HEART will the bowels. compensate. The heart will increase pumping in an attempt to maintain blood 2. Insufficient fluid intake pressure with less blood volume. When we When patient is unable to take oral fluids palpate for the pulse, weak and thready siya. might be because of unavailability of water or fluid, difficulty in swallowing obstructions 6. Pale, cool skin Try to check the skin turgor. Poor skin turgor ○ caused by vasoconstriction due to loss in the interstitial fluid. ○ a sign that the body is compensating Difference of TURGOR and MOBILITY. SKIN MOBILITY is the rise of the skin, and turgor 7. Decreased urine output is the return or elasticity of the skin. So ○ NORMAL URINE OUTPUT IS 30-60ml per kapag gi pinch natin ang skin, irelease mun hour. Pag mababa kay oliguric. Pag mababa so that we will be able to tell to the CI that pa sa 10ml Anuria. patient has a good ○ So if we have a patient with FVD, we always need to check and get the intake and output 3. Failure of regulatory mechanisms to compare if the patient is having worsening fluid volume deficit. 4. Fluid shifts within the body fluid shifts within the body especially from Multi System Effects plasma to the interstitium FVD is a relatively Mucous membranes common problem that may exist alone or in ○ Dry; may be sticky combination with other electrolyte or acid-base imbalances (Lemone, 2017) Decrease tongue size, longitudinal furrows increase You can also accumulate FVD when you ○ Because decreased nga yung fluid kaya nag have electrolyte imbalances or an acid crack ang lips base-imbalance ○ Iba din yung naga crack pag exposed ka sa Manifestation cold environment 1. Rapid weight loss - good indicator for fluid volume deficit Urinary ○ 1kg of lost is equivalent of 1L ○ Decrease urine output ○ Mild FVD- loss of 2% of the body weight ○ Oliguria (severe PVD) ○ Moderate FVD- 5% loss ○ Increase in urine specific gravity ○ Severe FVD- loss of 8-10% Neurologic 2. Skin turgor to diminish D/T loss in interstitial fluid ○ Altered mental status - because of ○ caused poor skin turgor because of loss in decreased blood flow interstitial fluid ○ Anxiety, restlessness in severe cases ○ Diminished alertness/condition in moderate 3. Postural or orthostatic hypotension cases ○ This is where pag nakahiga tas bigla mag ○ Possible coma (severe FVD) in very severe tayo then mahilo, there is a loss of cases intravascular fluids. So check the BP first while in the supine position and also kapag Integumentary nag sit na ang patient kay icheck din, wag ○ Diminished skin turgor FLUIDS & ELECTROLYTES SULTAN, AUZA, BAUTISTA, SABALA, CALUMBA, RAMIREZ, ZAMORA LECTURE ○ Dry skin (glucose) ○ Pale, cool extremities This test is done on a blood sample taken from a vein Helps to differentiate isotonic fluid loss from water Cardiovascular loss ○ Tachycardia ○ Orthostatic hypotension (moderate PVD) 3. Hemoglobin and hematocrit (CBC) ○ Falling systolic/diastolic pressure (severe The hematocrit often is elevated due to loss of FVD/fluid volume deficit) intravascular volume and hemoconcentration ○ Flat neck veins There is an elevated result of hematocrit because of a ○ Decrease venous filling decrease in the circulating fluid volume in the ECF. ○ Decrease capillary refill - less than 3 seconds Hemoglobin ○ Increase hematocrit When the hemoglobin level is low, the patient has Hematocrit - it is because of lower anemia. An erythrocytosis is the consequence of too plasma. Because of the loss of fluid many red cells; this results in hemoglobin levels volume nag increase ang above normal. concentration of hematocrit. So It may not be because of anemia, walay anemia. It’s anong mangyari dito? We have to just because of the increased loss of your fluid dilute, increase volume in the ECF. including hematocrit. So you will not give blood We have to replenish it kaya nga transfusion to your client here. This is just an effect magkaroon tayo ng IV hydration or because of a decrease of your plasma because of oral hydration. fluid loss. normal in children because they So anong gagawin? Give IV rehydration don't usually drink water Elevated hematocrit loss of intravascular volume Potential complication Hematocrit (Hct) ○ Hypovolemic shock Measures the volume of red blood cells compared to ○ Cardiac prolapse and death - if lala najud the total blood volume (red blood cells and plasma) kaayo Both the hemoglobin and the hematocrit are based on whole blood and are therefore dependent on plasma Musculoskeletal volume. If a patient is severely dehydrated, the ○ Fatigue hemoglobin and hematocrit will appear higher than if the patient were normovolemic. If the patient is fluid Metabolic processes overloaded, they will be lower than their actual level. ○ Decrease body temperature (isotonic FVD) Pag bumaba ang plasma volume, hematocrit and ○ Increase body temperature (dehydration) hemoglobin levels will go higher. ○ Thirst If fluid volume deficit is high ang concentration of ○ Weight loss hematocrit and it is fluid volume excess, mababa and 2-5% mild FVD hematocrit concentration. 6-9% moderate FVD >10% severe FVD 4. Urine Specific Gravity and Osmolality (through urinalysis) DIAGNOSTICS As the kidneys conserve water, both specific gravity and osmolality of urine increase 1. Serum Electrolytes Concentration of the urine Test measures the levels of electrolytes such as What will happen if you are fluid volume deficit? It is sodium, potassium, and chloride high because urine output is decreased therefore, it is Isotonic fluid deficit - serum sodium levels are concentrated. Tataas/Increased ang urine specific within normal limits gravity. Iso Osmolar-serum sodium (Na) levels is normal Normal urine specific gravity: 1.010-1.025 hyperosmolar- ang nawala lang is ang water If mababa naman yung urine specific gravity, polyuria Water loss - sodium levels are high ka. Because you are excreting a lot of urine. So the Decreases in potassium level are common expected outcome of urine specific gravity is Always check your electrolytes in order to know what deceased. type of fluid volume deficit is this 5. Central Venous Pressure (CVP) 2. Serum Osmolality The CVP measures the mean pressure in the Measures the amount of particles of chemicals superior vena cava or right atrium, providing an dissolved in the liquid (part) serum of the blood - the accurate assessment of fluid volume status sample is the blood. Pag mataas ang solutes, of It is not our job to insert CVP catheter course there is an increase in osmolality Central veins: subclavian. Chemicals that affect serum osmolality include Sa subclavian gina insert yung central venous sodium, chloride, bicarbonate, proteins, and sugar catheter until superior vena cava, malapit sa atrium. FLUIDS & ELECTROLYTES SULTAN, AUZA, BAUTISTA, SABALA, CALUMBA, RAMIREZ, ZAMORA LECTURE That is one way of assessing yung fluid volume 1. FLUID RESTORATION status. If the patient is capable, go for oral dehydration. In Normal CVP: 8-12 mmHg severe cases, a combination of oral rehydration and 2-6 mmHg (other references) IV rehydration. CVP is elevated by: In most cases, when we do IV rehydration, usually ○ Overhydration which increases venous hindi pwede maka-inom ang patient. If the patient can return tolerate drinking, they already need IV infusion ○ Heart Failure or PA stenosis which limit because you’re going to administer medications venous outflow and lead to venous intravenously, for faster effect of the drugs congestion ○ Positive pressure breathing, straining Oral Rehydration CVP decreases with: safest and most effective treatment for fluid volume ○ Hypovolemic shock from hemorrhage, fluid deficit shift, dehydration Fluids are replaced gradually, particularly in older ○ Negative pressure breathing which occurs adults, to prevent rapid rehydration of the cells when the patient demonstrates retractions or Take note of the word GRADUAL. That is why it is mechanical negative pressure which is important to monitor because there is a big chance na sometimes used for high spinal cord injuries pagmagkamali ng regulate, management, and pag-compute, magkakaroon ang patient ng fluid volume excess. 1,500 ml of fluids per day (normal) Note: Any patient manifesting vomiting must be in NPO for 2 hours Solving: multiply 30 by IBW Ex: IBW of patient is 54 kg ○ 30 x 54 kg = 1,620 ml IV Rehydration When the fluid deficit is severe or the patient is unable to ingest fluids, the IV route is used to administer replacement fluids. Types of Volume Deficit 1. Isotonic FVD Caused by losing fluids and solutes about equally; solute concentration in the remaining extracellular fluid then remains relatively unchanged Treatment: Isotonic Solution 2. Hypertonic FVD Caused by losing more fluids than solutes, leading to increased solute concentration in the remaining fluid. Treatment Hypotonic Solution 3. Hypotonic FVD Caused by losing more solutes than fluid leading to decreased solute concentration in remaining fluid. This is the rarest type. There is a manometer that we are going to Treatment: Hypertonic Solution manipulate. This is where we will connect that IV fluid, the port going to the manometer and the port going to 2. MONITORING COMPLICATIONS OF FLUID the patient. RESTORATION Usually, pagnabibigla ang fluid restoration, there are MEDICAL MANAGEMENT times wherein, nacocorrect nga natin yung deficit pero Correction of fluid loss depends on the acuteness and meron namang fluid volume excess. Nabibigla yung severity of the fluid deficit. Goals are to replace F/E patient and the cells. (Na primarily) that have been loss That is why its very important for the doctor to know the rate of how much we are going to give to the patient. FLUIDS & ELECTROLYTES SULTAN, AUZA, BAUTISTA, SABALA, CALUMBA, RAMIREZ, ZAMORA LECTURE Client with severe ECFVD (extracellular fluid volume 10. Keep fluids easily accessible deficit) accompanied by severe heart, liver, and 11. Administer and monitor intake of oral fluids as kidney disease can’t tolerate large volumes of fluid or prescribed sodium without the risk of development of heart 12. Administer IV fluids as prescribed using an infusion failure. pump. Monitor for indicators of fluid overload if rapid ○ For example, may liver problems, fluid replacement is ordered; dyspnea, tachycardia, magkakaroon ka ng ascites, and the flow of increased CVP, jugular vein distention, and edema blood going to your liver will be slower than S&S of Fluid Overload: dyspnea, normal that means mas tatambay yung dugo tachycardia, increased CVP, jugular vein and it would add up pressure in your blood distention, and edema vessels resulting in leaky capillaries causing CONGESTION. ○ Congestion - refers to the blood volume in your blood vessels. If may congestion sa blood vessels, meaning daghan kaayog didto. Unstable clients needs to be monitored to detect increase pressure from fluids. Monitor 3. CORRECTION OF THE UNDERLYING PROBLEM Underlying problem = root cause/etiology of the fluid volume deficit. Then they will treat that root cause to bring back the homeostasis of our patient. M Medications: Antiemetics - if patient is experiencing hyperemesis (severe vomiting) / Nausea and vomiting Antidiarrhea - for patients with acute gastroenteritis / Diarrhea Antibiotics Antidiuretics to reduce body temperature NURSING MANAGEMENT Nurses are responsible for: Identify if the patient is at risk for fluid volume deficit. Green - PNSS Initiating and carrying out interventions to prevent and Pink - D5LR treat fluid volume deficit Blue - PNLR Monitoring the effects of therapy ISOTONIC Monitor: normal saline PNSS 1. I&O every 4 hrs, every shift, or hourly (record all lactated ringer output accurately) normosol- plain nss 2. VS every 2-4hrs, report changes from baseline VS; d5w assess CVP every 4hrs (if patient has CVP access) PLR 3. Weigh patients daily and record - The weight should increase, so if for example, the patient weighs 35kg HYPERTONIC ata ni bhiee then pagka ugma, naging 33kg, the next day naging D5W 32, definitely, the medication is not working. (best time D5LR is early in the morning kay wala pa naka breakfast si D5NSS or D50.9 NaCl patient) HYPOTONIC 4. Peripheral vein filling (capillary refill 3-5sec) 0.45% 5. Renal client/relatives to report urine output < 30m/L x 0.25 % saline 2 consecutive hrs or < 240 ml x 80 period D5W 6. Assess for dryness or mucous membrane and skin turgor (check should be done) Nursing Diagnosis 7. Oral care to decrease discomfort related to mucous 1. Fluid Volume Deficit membrane dryness ○ Patients with a fluid volume deficit due to 8. Monitor plasma sodium, BUN, glucose, HCT to abnormal losses, inadequate intake, or determine osmolality - Dapat day by day, naga impaired fluid regulation require close decrease ang value ng osmolality. monitoring as well as immediate and 9. Assess the patient for confusion or any indication of ongoing fluid replacement ICF involvement FLUIDS & ELECTROLYTES SULTAN, AUZA, BAUTISTA, SABALA, CALUMBA, RAMIREZ, ZAMORA LECTURE 2. Ineffective tissue perfusion can be injected ○ A fluid volume deficit can lead to decreased Ito yung mga IVTT drugs, dapat slow lang sya pag perfusion or renal, cerebral, and peripheral flow (calcium gluconate) and needs cardiac tissues. Inadequate renal perfusion can lead monitoring to acute renal failure. Decreased cerebral perfusion leads changes in mental status Needleless - I screw lang nila or twist and cognitive function, causing restlessness, anxiety, agitation, excitability, confusion, 4. Piggyback/Secondary Infusion vertigo, fainting, and weakness Some IV medications, such as antibiotics, need to be infused over a short period of time 3. Risk for injury In order for the piggyback medication to infuse, it ○ The patient with fluid volume deficit is at risk must hung higher than the primary infusion for injury because of dizziness and loss of Ang other term nya is side drip balance resulting from decreased cerebral do not give side drip if D5LR perfusion secondary to hypovolemia. Methods of Infusion: IV THERAPY 1. Gravity Drip- mano mano Indications for IV therapy: ○ with the use of IV stand -position 3 ft. above Unable to eat or drink adequate amounts height ○ patient can receive for life-sustaining fluids, ○ the lower the position, the slower the drip electrolytes, and nutrition ○ the higher the position, the faster the drip of Rapid delivery of medication in an emergency the fluids ○ IV route that allows rapid delivery of meds 2. Electronic Control Devices (e.g infusion pump) (emergency situations) Patients with anemia or blood loss can receive life Factors Affecting Flow Rates: saving IV (blood) transfusions Change in catheter position ○ anemia, severe, acute blood loss ○ most of the time para dili sya (hemorrhage) madislodge/para patent sya always, labi na ○ Colloids sa mga bata (lihokan) - IV board para dili large particles hindi dadaan sa mulihok2 semi-permeable membrane Height of the solution blood products Patency of the catheter Unable to eat for an extended period can have their ○ how to check for patency nutritional needs met with total parenteral nutrition ○ inaog ang iv bag, check for backflow of blood (TPN) sa IV insertion site. Pag walang backflow ○ Kabiven yawa mahal daw kayni ba tas meaning barado/problem with the vein, delikado if mabutas maybe complication ○ stop kaagad and refer accordingly. Types of Infusion: Types of IV Solution: 1. Continuous Infusion Infusion is kept running constantly until discontinued Colloids (albumin, proteins) by the physician. Fluids that expand the circulatory volume due to Ma discontinue sa pag merong physician's order. particles that cannot cross a semipermeable Naka kabit talaga sya sa veins and depending on the membrane. They pull fluid from the interstitial space site into the intravascular space, increasing fluid volume Advantage: is beneficial to large losses of fluid 2. Intermittent Infusion Disadvantage: costly and the risk of volume overload, Intermittent IV lines are “capped off” with an injection including pulmonary edema port and used only periodically ginagamit sa rule of osmosis IVTT lang talaga sya and there are times na may merong Heplock and hindi sya continuous Crystalloids (does not contain proteins) When the use of Heplock, mas makikita sya pag nasa usual na ginagamit o nakikita sa hospital home tapos nag PTN lang. I coconnect lang ang - Work much like colloids but do not stay in the needle doon sa Heplock ug I turn on ang IV infusion intravascular circulation as well as colloids do, so hypotonicmore of them need to be used 3. Bolus (IV push or IVP Drug) Advantage: cheaper and more convenient to use; Bolus drug (sometimes called an IV push or IVP drug) provide hydration and calories to patients and include is injected slowly via a syringe into the IV site or dextrose, normal saline, and Ringers and lactated tubing port Ringer’s solution Can be dangerous if they are given incorrectly, and a Disadvantage: lacks large molecules If you’re going to drug reference should always be checked to choose between the two to increase the oncotic determine the safe amount of time over which drug pressure, para mapull talaga yung fluids from the FLUIDS & ELECTROLYTES SULTAN, AUZA, BAUTISTA, SABALA, CALUMBA, RAMIREZ, ZAMORA LECTURE interstitial going back to the intravascular you have the albumin yung mga colloid products natin. meron siyang percentage of the Classification of IVF according to TONICITY saline so hindi enough if 1. Isotonic FVD hyponatremic ang patient NS, Plain LR Do not administer to patients at risk 2. Hypertonic FVD for increased More Solute intracranial NPO pressure (e.g head ○ D5 0.9 NaCl / D5NSS trauma, stroke, ○ D5LR - NPO neurosurgery) Do not administer 3. Hypotonic FVD to patients at risk less solute for third- space 0.45% or 0.25% Saline shifts (burns, D5W trauma, liver disease, malnutrition) SOLUTION NSG. RESPONSIBILITIES HYPERTONIC SOLUTIONS Monitor for ISOTONIC SOLUTIONS Monitor for fluid Hypertonic fluids inflammation and PNSS overload; have a tonicity infiltration at IV 0.9% Saline discontinue fluids >350 mEq/L and insertion site as Lactated Ringer’s and notify the include the ff: hypertonic solution healthcare provider Fluids containing solutions cause Do not administer medications cells to shrink, lactated ringer’s D5W sodium exposing the solution to patients chloride basement with severe liver D5W in lactated membrane of the disease as the liver ringer’s solution