Chapter 17 Fluid, Electrolytes and Acid-Base Imbalances

Julie S. Brinley, RN, MSN/Ed, CNE

Objectives

Describe the composition of the major body fluid compartments. Define the processes involved in the regulation of movement of water and electrolytes between the body fluid compartments: diffusion, osmosis, filtration, hydrostatic pressure, oncotic pressure, and osmotic pressure. Describe the etiology, laboratory diagnostic findings, clinical manifestations, and nursing and collaborative management of the following disorders:

Extracellular fluid volume imbalances: fluid volume deficit and fluid volume excess Sodium imbalances Potassium imbalances Magnesium imbalances Calcium imbalances Phosphate imbalances

Identify the processes to maintain acid-base balances. Describe the etiology, laboratory diagnostic findings, clinical manifestations, and nursing and collaborative management of the following disorders:

Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Describe the composition and indications of common intravenous fluid solutions.

Homeostasis is a term used to describe stability or equilibrium. Proper fluid and electrolyte balance in the body is regulated by fluid and electrolyte
transport systems and regulatory mechanisms such as hormones and body organs.

Physical and biologic processes work together to maintain a balance or equilibrium.

Homeostasis

The state of equilibrium in the internal environment of the body Body fluids and electrolytes play an important role in homeostasis Acids are produces in the body during normal metabolism Acids alter internal environment in the body

Fluids and electrolytes

Diseases and treatments can alter fluid and electrolyte balance

Starlings Law Equilibrium exists at the capillary membrane when fluid leaving circulation and the amount of fluid returning to circulation are exactly equal.

Water is Vital

Water is necessary as

a medium for metabolic reactions within cells a transporter for nutrients, waste products and other substances a lubricant an insulator and shock absorber a means of regulating and maintaining body temperature a medium for food digestion

Fluid Intake
Factors Affecting Body Fluid

Age Gender and body size Pregnancy (blood volume increase) Ethnic origin Environmental temperature Life style

Exercise Stress Alcohol consumption

Age Newborn (full term) 1 year Puberty to 39 40-60 Over 60

Percentage of fluid 70-80% 64% 52-60% 47-55% 46-52%

Factors Affecting Body Fluid

Infants

percentage of total body water is extracellular Basil metabolic rate Body surface area
(larger volume of fluid loss throught skin)

Fluid requirements Immature kidney function

(inability to concentrate urine)

Elderly
percentage of body fluids intracellular fluid volume thirst Self-limiting of fluids ability to conserve water renal blood flow and glomerular filtration

What effect does obesity have on body water percentage? An obese person would have a lower percentage of total body water.

Muscle contains much more water than body fat which is essentially free of water. Women have more body fat than men.
Anatomy and Physiology

Body Fluids

Most important nutrient Humans can survive only a few days without water

 Electrolytes

A solution of a compound that dissociates into ions and can conduct electricity. Electrolytes affect the movement of substances between body fluids and tissues, and are crucial for normal function and metabolism

Fluid and Electrolyte Movement

Exchange results in fluid balance and homeostasis that is essential to life

Water

Major component of the blood - 60% of total body weight of an adult is water 92% of bodys organic and inorganic compounds are dissolved in water Solute the thing being dissolved Solvent does the dissolving Solutions are made up of:

FLUID (solvent) primarily water P ARTICLES DISSOLVED (solute) electrolytes (K, Na, Cl), nonelectrolytes (urea)

Body Fluid Compartments

Intracellular Extracellular

(ICF) 40 % of body weight (ECF) -20 % of body weight

Interstitial (ISF) 15% of body weight

Lymph Dense connective tissue bone

Intravascular (IVF) 5 % of body weight

Transcellular (TCF) 1 % of body weight

Pleura peritoneum

Distribution of Fluid

Extracellular - outside the cells.

Intravascular - within the vascular system (plasma). system Interstitial fluid - surrounds the cells and includes lymph Transcellular - CSF, digestive, pleural, peritoneal and synovial fluids.

Calculation of Fluid Gain or Loss

1 liter of water = 2.2 Lb (1kg) Example= pg 303

If a patient on diuretic therapy loses 6.3 lbs in 24 hours How much fluid has he lost? How much fluid would a person drink in a day? How much fluid would a person loose in a day?

Electrolytes

Substances that split into ions that are electrically charged particles
Catoins (positive charged)

Anions (negatively charged) What are some examples? How are they measured and from where? Measured in the blood plasma

Mechanisms Controlling Fluid and Electrolyte Movement

Diffusion Facilitated diffusion Active transport Osmosis

Osmosis Osmotic pressure osmolality

Hydrostatic Pressure Oncotic pressure

Fluid and Electrolyte Transport Systems

Movement of fluid & electrolytes

Passive transport

Diffusion Osmosis Filtration

Active transport requires energy as a force to move molecules into the cells against the concentration gradient. Active transport moves fluid and electrolytes from an area of lower concentration to an area of higher concentration The rate of diffusion depends on the size of molecules, the concentration of solution and the temperature.

Facilitated Diffusion

A carrier molecule facilitates the rate of diffusion Example:

glucose requires insulin to be transported or facilitated into cells

Active Transport
Molecules move against the concentration gradient Energy is required Example:

Solium / potassium pump

Fluid and Electrolyte Transport Systems Fluid and Electrolyte Transport Systems
Osmotic Pressure The power of the solution to draw water across a semi permeable membrane

Types of IV Fluids
Isotonic Hypotonic hypertonic

Pressures That Affect Fluid Movement

Hydrostatic pressure

The force within a fluid compartment

Oncotic

pressure

(colloidal osmotic pressure) is osmotic pressure exerted by colloids in a solution

Fluid Movement
The amount and direction of movement are determined by the interaction of :
Capillary hydrostatic pressure Plasma oncotic pressure

Interstitial hydorstatic pressure Interstitial oncotic pressure

Fluid Spacing

Term used to describe the distribution of body water

First spacing normal Second spacing edema Third spacing fluid trapped and unavailable for functional use ie

Peritonitis Burn trauma edema sepsis

How is Water Balance Regulated?

Hypothalamic regulation Pituitary regulation Adrenal cortical regulation Renal regulation Cardiac regulation Gastrointewstional regulation Insensible water loss

Thirst

Regulates fluid intake

Increased plasma osmolality stimulates osmoreceptors in the hypothalamus to

trigger the sensation of thirst

More sodium and less water in the body make a person thirsty Additional fluids consumed; kidneys conserve water until osmolality returns to
normal

Hypothalamic, Pituitary, and Adrenal Cortical Regulation

Thrust ADH regulated water retention by the kidneys -causes reabsorption ADH (vasopressin) suppression causes urinary excretion

Corticoids -

enhance sodium retention and water follows sodium

Aldosterone is potent sodium retaining capabilities

Is stimulated by decreased renal perfusion

Hormones

Renin

Hormone secreted when blood volume or blood pressure falls Causes the release of aldosterone with subsequent sodium and water retention Aldosterone Acts on kidney tubules to increase reabsorption of sodium and decrease reabsorption of potassium Because the retention of sodium causes water retention, aldosterone acts as a volume regulator

Cardiac Regulation

ANP atrial natriuretic peptide BNP b-type natriuretic peptide

Produced in cardiac cells Respond to increased B/P and high sodium levels Suppress secretion of aldosterone, renin, and ADH Promote excretion of Na+ and water

Hormones

Antidiuretic hormone (ADH)

Causes capillaries to reabsorb more water, so urine is more concentrated and less volume is excreted

Atrial natriuretic factor (ANF)

Hormone released by the atria in response to stretching of the atria by increased blood volume Stimulates excretion of sodium and water by the kidneys, decreased synthesis of renin, decreased release of aldosterone, and vasodilation Reduces blood volume and lowers blood pressure

Gastrointestional Regulation

Food metabolism produced water Excretion of water Absorption of water in GI tract Diarrhea or vomiting

Leads to significant fluid and

electrolyte imbalances

Regulators of Fluids & Electrolyte Balance

Skin estimated water loss 300-400 cc/day called Insensible Loss Lungs Insensible water loss due to expired air saturated with water vapor is 300-400 cc/day GI System 8,000 cc /day is secreted into GI tract and about 200cc is lost through feces. Severe diarrhea can cause fluid and electrolytes imbalance Kidneys 1,200-1,500 cc water per day as urine Fluid and food intake water consumption and obtained from food

Thirst water consumption is in response to the sensation of thirst

Intake & Output Fluid and Electrolyte Imbalances

Effects most patients with a major illness or injury Classified as deficits or excess Occurs in the intravascular space
Assessment of Fluid and Electrolyte Balance

Health history

Determines if patient has conditions that contribute to fluid or

electrolyte imbalances Like What???

 Complaints of fatigue, palpitations, dizziness, edema, muscle

weakness or cramps, dyspnea, and confusion may be associated with fluid imbalances

Vital signs Intake and output Skin

Characteristics

Facial characteristics

Skin turgor Edema

Dependent Edema

Found in the lowest parts of the body such as in the feet and legs and sacrum of the sitting client. Edema can be localized or generalized in the body and can increase weight by at least 10 lb Frequently observed around eyes, and in the feet and hands

Mucous membranes

Tongue turgor Moisture of the oral cavity Veins

Fluid Volume Deficit AKA Dehydration

Hypovolemia

Caused by: Abnormal loss through skin, GI or kidneys Bleeding Third spacing
Fluid Imbalances

Deficient fluid volume

Less water than normal in the body Isotonic extracellular fluid deficit

Hypovolemia

Hypertonic extracellular fluid deficit

Dehydration

Decreased intake, abnormal fluid losses, or both Examples: loss of water from excessive bleeding, severe vomiting/diarrhea, severe
burns

Risk For Fluid Volume Deficit

Vomiting Diarrhea Suction Drainage of secretions Anorexia Inability to swallow, confusion, Depression

Fluid Volume Deficit (Hypovolemia)

Signs and Symptoms

Poor skin turgor Dry mucous membranes, dry furrowed tongue Tachycardia

Narrowing pulse pressure Decreased central venous pressure Postural hypotension Flat neck veins urinary output, specific gravity Hemoconcentration ( hematocrit, BUN)

Fluid Imbalances

Excess fluid volume

An increase in body water

Extracellular fluid excess

Isotonic fluid excess

Intracellular water excess

Hypotonic fluid excess

From renal or cardiac failure with retention of fluid, increased production of antidiuretic hormone or aldosterone, overload with isotonic IV fluids, or administration of dextrose 5% in water (D5W) after surgery or trauma

Fluid Volume Excess

Excessive IV therapy Excessive ingestions of sodium salts, Alka-Seltzer, hypertonic enemas, CHF, liver failure, renal failure

Body retains both water and sodium Hypervolemia-increased blood volume Caused by excessive intake of Na IV infusions infused to quickly Disease, liver, CHF, renal

Fluid Volume Overload (Hypervolemia)

Signs and Symptoms

Bounding pulses Distended neck veins Increased BP Increased CVP Dyspnea Edema Weight gain Decreased hematocrit and hemoglobin

Fluid Excess
WEIGHT GAIN 2% gain-mild 5% gain-moderate 8% gain-severe

Monitoring

Daily weights Significant changes in a short period of time are indicative of acute fluid changes Weigh at the same time, same clothes, same scale
Treatment

Loop diuretics act in the loop of Henle. They are the most powerful of diuretics, capable of causing 15-25% of the sodium in the filtrates to be excreted. This can cause serious potassium loss. Can be given orally or IV Patient may be given a loop diuretic such as lasix. Watch for postural hypotension.

Restricted Fluids

May be necessary for pts with fluid volume excess from renal failure, CHF, or other
disease process.

You might want to give the patient hard candy.

Electrolytes
Hyponatremia
Causes:

GI and Renal loss Profuse perspiration, draining skin lesions Fibrocystic disease of the pancreas Diuretics Relative sodium loss in fluid overload (water toxicity) Post surgery when pt losses blood and other fluids

Assessment
Postural blood pressure change Poor skin turgor Flat neck veins Hypotension with rapid thready pulse, cooled clammy skin Headache, faintness, mental confusion, muscle cramps

Hypernatremia
Causes: Inadequate water intake or excessive water loss Diminished thirst response especially in elderly and infants TPN and tube feeding may deplete the cells of water

Assessment: Changes in neuromuscular and cardiac activity Changes in personality: agitation and confusion, later seizures and death Skeletal muscle weakness Decreased myocardial contractibility resulting in decreased cardiac output Death may occur as a result of excessive rise in osmotic pressure and respiratory arrest

Potassium (K+) - 3.5 5.0 mEq/L

Major intracellular electrolyte

Maintains normal nerve and muscle activity (especially cardiac).

Maintains osmotic

pressure in the cell.

Causes:

Hypokalemia GI disturbances, diuretic therapy. Needs KCl replacement. Hypokalemia potentiates digitoxicity. Hyperkalemia renal disease, action of digitalis with major cardiac effects excessive trauma, inhibits the (Cardiac arrest)

Hypokalemia

Increased renal loss by using excessively diuretic therapy GI loss through N&V Insufficient potassium intake Potassium cannot be stored it should be ingested daily

Assessment: Early signs as fatigue, lack of strength Muscular weakness: paralysis, ventilation problems, Bradycardia, atrial dysrhythmias Late signs: tetany and loss of deep tendon reflexes Depression Death is caused by anoxia from paralysis of the respiratory muscles and cardiac arrest

Hyperkalemia
Causes:

Renal disease K cannot be excreted adequately Addisons disease Crushing injuries with muscular destruction Metabolic acidosis (shift potassium from ICF to ECF)

Assessment Neuromuscular irritability (similar to hypokalemia) Vague muscle weakness leading to paralysis Pt. remains alert and conscious until cardiac arrest occur Death results in the toxic state from cardiac dysrhythmias (VF or atrial standstill)

Food sources for Potassium:

Beef (4oz) Avocado (medium) Bananas (1 medium) Mushrooms (10 small) Spinach raw (3oz) Tomato (1medium)
Education

400 1000 451 410 470 366

Do not substitute one potassium supplement for another Do not crush potassium tablets such as Slow-K or K-tab Do not use salt substitute that contained KCl Take Potassium supplements with meals

Calcium (Ca++)
Essential role in bone structure blood clotting, muscle contraction and nerve impulse transmission. Positive for Chvosteks sign & Trousseaus Sign sign of metastatic bone tumor, Pagets disease, hyperparathyroidism

Hypocalcemia Hypercalcemia
Chvosteks signs

Signs of Hypocalcemia

Tapping on the face at a point just anterior to the ear and just below the zygomatic bone Positive response: Twitching of the ipsilateral facial muscles, suggestive of neuromuscular excitability caused by Hypocalcemia

Trousseau's sign
Inflating a sphygmomanometer cuff above systolic blood pressure for several minutes Positive response: Muscular contraction including flex-ion of the wrist and metacarpophalangeal joints, hyperextension of the fingers, and flexion of the thumb on the palm, suggestive of neuromuscular excitability caused by hypocalcemia

Phosphate (PO4) 2.8mg/dl4.5mg/dl

Phosphorus is a primary anion in the ICF and is essential to the function of muscle, RBCs, and the nervous system. It is deposited with calcium for bone and tooth structure. Phosphorus is also involved in the acid base buffering system, the mitochondrial energy production of ATP, cellular uptake and use of glucose, and the metabolism of carbohydrates, proteins, and fats. Maintenance of normal phosphate balance requires adequate renal functioning because the kidneys are the major route of phosphate excretion. A reciprocal relationship exists between phosphorus and calcium in that a high serum phosphate level tends to cause a low calcium concentration in the serum. Hyperphosphatemia is caused by acute or chronic renal failure that results in an altered ability of the kidneys to excrete phosphate. Other causes include;

Chemotherapy for certain malignancies (lymphomas) Excessive ingestion of milk or phosphate containing laxatives. Large intake of vitamin D that increase GI absorption of phosphorus.

Wound of a 55 yr old with Hx of Hyperphosphatemia

Clinical manifestations primarily relate to metastatic calcium and phosphate precipitates. Ordinarily, calcium and phosphate are deposited only in bone. An increased serum phosphate concentration along with calcium precipitates readily, and calcified deposits can occur in soft tissue such as joints, arteries, skin, kidneys, and corneas. Clinical manifestations also include; neuromuscular irritability and tetany, which are related to low serum calcium levels. Management includes;

Identifying cause Restrict foods and fluids high in phosphorus (dairy products) Adequate hydration Correct hypocalcemia (as calcium levels increase phosphorus is excreted thru the kidneys.

Lung of patient with lymphoma and Hyperphosphatemia

Hypophosphatemia is seen in patients with malnourishment or has malabsorption syndrome.

Other causes are alcohol withdrawal and use of phosphate binding antacids. Because phosphorus is needed for formation of ATP and 2,3, DPG, its deficit results in impaired cellular energy and oxygen delivery. Other clinical manifestations include muscle weakness and pain dysrhythmias, and cardiomyopathy. Management includes oral supplementation (Nutra-Phos) and ingestion of foods high in phosphorus (dairy products).

Magnesium (1.3-2.1 mg/dl)

Magnesium is the second most abundant intracellular cation. Approximately 50% to 60% of the bodys magnesium is contained in bone. If functions as a co-enzyme in the metabolism of carbohydrates and protein. It is also involved in metabolism of cellular nucleic acids and proteins. Magnesium is regulated by GI absorption and renal excretion. The kidneys are able to conserve magnesium in times of need and excrete excesses. Factors that regulate calcium balance (PTH) appear to similarly influence magnesium balance. Because magnesium balance is related to calcium and potassium balance. All three cations should be assessed together. Magnesium acts directly on the myoneural junction, and neuromuscular excitability is profoundly affected by alterations in serum magnesium levels. Hypomagnesaemia produces neuromuscular and CNS hyperirritability. Hypermagnesemia depresses neuromuscular and CNS functions. Magnesium is important for normal cardiac function. There is an association between hypomagnesaemia and cardiac dysrhythmias. Hypermagnesemia usually occurs only with an increase in magnesium intake accompanied by renal insufficiency or failure. Clinical manifestations;

Lethargy, drowsiness, and nausea and vomiting As the levels increase, deep tendon reflexes are lost, followed by somnolence, and then

respiratory and ultimately, cardiac arrest.

Rx should focus on prevention.

Emergency treatment for Hypermagnesemia is IV administration of calcium chloride or calcium gluconate to physiologically oppose the effects of the magnesium on cardiac muscle.

The major cause of hypomagnesaemia is prolonged fasting or starvation. Chronic alcoholism commonly causes hypomagnesaemia as a result of insufficient food intake. Fluid loss from the GI tract interferes with magnesium absorption. Another cause is prolonged TPN without magnesium supplementation. Osmotic diuresis caused by high glucose levels in uncontrolled DM increases renal excretion of magnesium. Clinical manifestations include;

Confusion, hyperactive deep tendon reflexes, tremors, and seizures. It also predisposes to dysrhythmias.

Acid - Base Imbalances

Acids Bases Buffers Buffer systems

Hemoglobin system Plasma protein system Carbonic acid-bicarbonate system

Hemoglobin System

RBSs contain hemoglobin Chloride shift

 Chloride shifts in and out of cells in response to the level of O2 in the

blood

For each Cl- that leaves a RBC a HCO3- enters For each Cl- that enters a RBC a HCO3- leaves
Plasma protein system

Carbonic acid-bicarbonate system

Functions along with the liver to vary the amount of H- in the chemical structure of plasma proteins Plasma proteins have the ability to attract or release H- ions

Primary buffer system in the body Is controlled by the lunges by the excretion of CO2 The kidneys control the bicarbonate concentration and selectively retain
or excrete bicarbonate in response to body needs

Acid-Base Control

Lungs Kidneys Potassium

Respiratory Acidosis

Respiratory system fails to eliminate the appropriate amount of carbon dioxide to

maintain the normal acid-base balance

Caused by pneumonia, drug overdose, head injury, chest wall injury, obesity,
asphyxiation, drowning, or acute respiratory failure

Medical treatment

Improve ventilation, which restores partial pressure of carbon dioxide in arterial blood (Paco 2) to normal

Nursing care
Assess Paco2 levels in the arterial blood Observe for signs of respiratory distress: restlessness, anxiety, confusion, tachycardia

Intervention
Encourage fluid intake Position patients with head elevated 30 degrees

Respiratory Alkalosis

Low Paco2 with a resultant rise in pH

Most common cause of respiratory alkalosis is hyperventilation Medical treatment

Major goal of therapy: treat underlying cause of condition; sedation may be ordered for the anxious patient

Nursing care
Intervention

In addition to giving sedatives as ordered, reassure the patient to relieve anxiety Encourage patient to breathe slowly, which will retain carbon dioxide in the body

Metabolic Acidosis

Body retains too many hydrogen ions or loses too many bicarbonate ions; with too
much acid and too little base, blood pH falls

Causes are starvation, dehydration, diarrhea, shock, renal failure, and diabetic
ketoacidosis

Signs and symptoms: changing levels of consciousness, headache, vomiting and

diarrhea, anorexia, muscle weakness, cardiac dysrhythmias

Medical treatment: treat the underlying disorder

Nursing care

Assessment of the patient in metabolic acidosis should focus on vital signs, mental status, and neurologic status Emergency measures to restore acid-base balance. Administer drugs and intravenous fluids as prescribed. Reassure and orient confused patients

Metabolic Alkalosis

Increase in bicarbonate levels or a loss of hydrogen ions Loss of hydrogen ions may be from prolonged nasogastric suctioning, excessive
vomiting, diuretics, and electrolyte disturbances

Signs and symptoms: headache; irritability; lethargy; changes in level of

consciousness; confusion; changes in heart rate; slow, shallow respirations with periods of apnea; nausea and vomiting; hyperactive reflexes; and numbness of the extremities

Medical treatment

Depends on the underlying cause and severity of the condition

Nursing care
Assessment

Take vital signs and daily weight; monitor heart rate, respirations, and fluid gains and losses Keep accurate intake and output records, including the amount of fluid removed by suction Assess motor function and sensation in the extremities; monitor laboratory values, especially pH and serum bicarbonate levels

Intervention

To prevent metabolic alkalosis, use isotonic saline solutions rather than water for irrigating nasogastric tubes because the use of water for irrigation can result in a loss of electrolytes Provide reassurance and comfort measures to promote safety and well-being

ROME for Acid-Base

Respiratory

Opposite

Metabolic
Equivalent