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FLUIDS and ELECTROLYTES

Prepared by ABED SHAGORA In-service Education Department EGH

2011 - 2012

FLUIDS and ELECTROLYTES

BODY FLUIDS Functions of Body Fluids Facilitate in the transport [nutrients, hormones, proteins, & others] Aid in removal of cellular metabolic wastes Provide medium for cellular metabolism Regulate body temperature Provide lubrication of musculoskeletal joints. Component in all body cavities [parietal, pleural fluids] Water is the principal body fluid & essential for life.

BODY FLUIDS
Distribution of Body Fluids 50-70% of total body weight; infant [70-80%], elderly [45-50%]
ICF ECF 60-kg man TBW = 0.6 x 60 kg = 36 L
ICF = 0.4 x 60 kg = 24 L ECF = 12 L

IS

3L 9L 40% TBW 20% TBW

Factors that Dictate Body Water Requirement

1) Amount needed to give the proper osmotic concentration 2) Amount needed to replace water lost excretion

Normal Routes of water gain and loss

INTAKE Fluid intake Food Metabolic water TOTAL

ml/day
1,200 1,000 300 2,500

OUTPUT Insensible loss Sweat Feces Urine TOTAL

ml/day 700 100 200 1,500 2,500

FLUID EXCHANGE BETWEEN BODY FLUID COMPARTMENTS

ICF

ECF

Osmotic Pressure Gradient

Oncotic P (Colloid osmotic P) Capillary P (Hydrostatic P)

ISF

Control of Osmotic Pressure, Volume & Electrolyte Concentration

OBLIGATORY Reabsorption occurs in the proximal tubules 178 L/day of glomerular filtrate (80% reabsorbed) 2 to solute reabsorption independent of the water requirement FACULTATIVE Reabsorption occurs in the distal & collecting tubules independent of the active solute transport dependent of bodys need of water under the control of ADH

DISTURBANCES IN FLUID BALANCE

EDEMA in the interstitial fluid volume of about 2 L or more due to increase transudation of fluid from capillaries 2 to: Increased HP [pregnancy, CHF] Decreased OP [malnutrition, endstage liver disease, nephrotic syndrome]

DISTURBANCES IN FLUID BALANCE

CELL OVERHYDRATION excess of water in the ECC w/ a normal amount of solute or a deficient amount of solute occurs in prolonged and excessive diuresis, forcing hypotonic fluids to produce diuresis in the presence of renal impairment fluid overload from production of adrenal corticoid hormones [Cushings syndrome]

DISTURBANCES IN FLUID BALANCE

CELL OVERHYDRATION

Symptoms Weight gain & edema Cough, moist rales, dyspnea [fluid congestion in lungs] CVP, bounding pulse, neck vein engorgement [fluid excess in the vascular system] Bulging fontanelles Hg and Hct Nausea & vomiting

DISTURBANCES IN FLUID BALANCE

CELL OVERHYDRATION

Management Restrict fluids to lower fluid volume Diuretics or hypertonic saline Continuous assessments to prevent skin breakdown Record daily weight to assess progress of treatment

DISTURBANCES IN FLUID BALANCE

CELL DEHYDRATION loss of body fluids, particularly from the extracellular fluid compartment water loss > water intake Causes Fever Insufficient water intake Diarrhea, vomiting Excess urine output [Diabetes insipidus, diuretics] Excessive perspiration, burns Hemorrhage, shock, metabolic acidosis

DISTURBANCES IN FLUID BALANCE

CELL DEHYDRATION Symptoms Thirst, dry mucus membranes, sunken eyeballs Doughy abdomen, dry skin w/ poor turgor temp, weight loss HR, RR, BP Restlessness,irritability, disorientation, convulsion, coma [22-30% body H20 loss] Management Fluid replacement therapy & continued fluid maintenance

Volume Disorders 2 Alteration in Sodium Balance

Volume Disorder Expansion Isotonic ECF Vol. ICF Vol. Water Shift Conditions

Inc

No net change

Hypertonic
Hypotonic Contraction Isotonic Hypertonic Hypotonic

Inc
Inc Dec Dec Dec

Dec
Inc

ICF ECF
ECF ICF

Isotonic fluid ingestion Sea water ingestion Hypotonic IVF

N No net change Dec ICF ECF Inc ECF ICF

Diarrhea Diabetes insipidus Addisons disease

ELECTROLYTES salts or minerals in extracellular or intracellular body fluids Sodium major cation of ECF Potassium major cation of ICF Chloride - major anion of ICF Protein in ICF > ISF

ELECTROLYTE Composition

Electrolyte Conc Sodium, Na+ Potassium, K+ Calcium, Ca++ Magnesium, Mg++ Chloride, ClBicarbonate, HCO3Biphosphate, HPO4Sulfate, SO4-2 Protein Organic foods

Plasma (mEq/L) 142 5 5 3 (155) 103 27 2 1 16 6 (155)

ISF 141 4.1 4.1 3 115 29 2 1 1 3.4

ICF 10 150 40 15 10 100 20 60 -

ELECTROLYTES

Functions of Electrolytes Contribute most of the osmotically active particles in body fluids

Provide buffer systems for pH regulation

Provide the proper ionic environment for normal neuromuscular irritability & tissue function

ELECTROLYTES

Hyponatremia [Na+ < 135 mEq/L; Normal = 135-145 mEq/L] Causes Na+ intake Na+ excretion [diaphoresis, GI suctioning] Adrenal insufficiency Assessment N & V, abdominal cramps, weight loss Cold, clammy skin, skin turgor Apprehension, HA, convulsions, focal neurologic deficit, coma [cerebral edema] Fatigue, postural hypotension Rapid thready pulse

ELECTROLYTES

Hyponatremia
Management Provide foods high in sodium Administer NSS IV Assess blood pressure frequently [measure lying down, sitting & standing]

ELECTROLYTES

Hypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L] Causes Excessive, rapid IV admn of NSS Inadequate water intake Kidney disease Assessment Dry, sticky mucus membranes Flushed skin Rough dry tongue, firm skin turgor Intense thirst Edema, oliguria to anuria Restlessness, irritability [cerebral DHN]

ELECTROLYTES

Hypernatremia Nursing Intervention Weigh daily Assess degree of edema frequently Measure I & O Assess skin frequently & institute nursing measures to prevent breakdown Encourage sodium-restricted diet

ELECTROLYTES

Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L] Causes Renal insufficiency Adrenocortical insufficiency Cellulose damage [burns] Infection Acidotic states Rapid infusion of IV soln w/ potassium-conserving diuretics

ELECTROLYTES

Hyperkalemia Assessment Thready, slow pulse Shallow breathing N & V, diarrhea, intestinal colic Irritability Muscle weakness, flaccid paralysis Numbness, tingling Difficulty w/ phonation, respiration

ELECTROLYTES

Hyperkalemia Nursing Interventions Administer kayexalate as ordered Administer/monitor IV infusion of glucose & insulin Control infection Provide adequate calories & carbohydrates Discontinue IV or oral sources of K+

ELECTROLYTES

Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L] Causes Renal insufficiency Adrenocortical insufficiency Cellulose damage [burns] Infection Acidotic states Rapid infusion of IV solution potassium-conserving diuretics

ELECTROLYTES

Hypokalemia Assessment Thready, rapid, weak pulse Faint heart sounds BP Skeletal muscle weakness or absent reflexes Shallow respirations Malaise, apathy, lethargy Loss of orientation Anorexia, vomiting, weight loss Gaseous intestinal distention

ELECTROLYTES

Hypokalemia Nursing Interventions Administer K+ supplements to replace losses Be cautious in administering drugs that are not potassiumsparing Monitor acid-base balance Monitor pulse, BP and ECG

ELECTROLYTES

Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L] Causes Hyperparathyroidism Immobility Increased vitamin D intake Osteoporosis & osteomalacia [early stages] Assessment N & V, anorexia, constipation Headache, confusion Lethargy, stupor Decreased muscle tone Deep bone/flank pain

ELECTROLYTES

Hypercalcemia Nursing Interventions Encourage mobilization Limit vitamin D intake Limit calcium intake Normal saline Administer diuretics Calcitonin

ELECTROLYTES

Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L] Causes Acute pancreatitis Diarrhea Hypoparathyroidism Lack of vitamin D I the diet Long-term steroid therapy Assessment Painful tonic muscle & facial spasms Fatigue, dyspnea Laryngospasm, convulsions

ELECTROLYTES

Hypocalcemia Nursing Interventions Administer oral Ca lactate or IV CaCl2 or gluconate Providing safety by padding side rails Administer dietary sources of calcium Vitamin D Provide quiet environment

ELECTROLYTES

Hyermagnesemia [Mg > 3.0 mEq/L; Normal = 1.5-3.0 mEq/L] Causes Renal insufficiency, dehydration Excessive use of Mg-containing antacids or laxatives Assessment Lethargy, somnolence, confusion N & V Muscle weakness, depressed reflexes pulse and respirations Nursing Intervention Withhold Mg-contg drugs/foods; Ca admn fluid intake, unless CI

ELECTROLYTES

Hypomagnesemia [Mg < 1.50 mEq/L; Normal = 1.5-3.0 mEq/L] Causes Low intake of Mg in the diet Prolonged diarrhea Massive diuresis Hypoparathyroidism Assessment Paresthesias, muscle spasm Confusion, hallucination, convulsions Ataxia, tremors, hyperactive deep reflexes Flushing of the face, diaphoresis Nursing Intervention Provide good dietary sources of Mg

IV FLUID REPLACEMENT THERAPY

Indications Replacement of abnormal fluid & electrolyte losses [surgery, trauma, burns, GI bleeding] Maintenance of daily fluid & electrolyte needs

Correction of fluid disorders

Correction of electrolyte disorders

Types of Solutions

Isotonic 0.9% sodium chloride (NSS) Lactated Ringers solution Hypotonic 5% dextrose and water (D5W) 0.45% sodium chloride 0.33% sodium chloride Hypertonic 3% NaCl Protein solution Colloids Salt pour albumin Plasmanate, Dextran

 4/2/1 Rule 4 ml/kg/hr for first 10 kg (=40ml/hr) then 2 ml/kg/hr for next 10 kg (=20ml/hr) then 1 ml/kg/hr for any kgs over that
This always gives 60ml/hr for first 20 kg then you add 1 ml/kg/hr for each kg over 20 kg

This boils down to: Weight in kg + 40 = Maintenance IV rate/hour. For any person weighing more than 20kg

BURNS
BURNS wounds caused by excessive exposure to the following agents or causes: Causes of Burns: Thermal [moist or dry heat] Electrical Chemical [strong acids and strong alkali Radiation [UV, x-rays, radium, sunburns]

BURNS
CLASSIFICATION OF BURNS

Superficial Partial thickness (1st degree) Outer layer of dermis Erythema, pain up to 48 hrs Healing 1-2 wks [sunburn] Deep Partial thickness (2nd degree) Epidermis & dermis Blisters & edema, frequently quite painful Healing 14-21 days Full thickness (3rd degree) Epidermis, dermis, subcutaneous fat Dry, pearly white or charred in appearance Not painful Eschar must be removed; may need grafting

BURNS
STAGES OF BURNS

1st: Shock/Fluid Accumulation Phase

1st 48 hrs IVC ISC Generalized DHN [fluid shifting] Hypovolemia [plasma loss], BP, C.O. Hemoconcentration, Hct [liquid blood component ISC] Oliguria [ renal perfusion], ADH release & aldosterone HyperK, hypoNa Metabolic acidosis

BURNS
STAGES OF BURNS

2nd: Diuretic/Fluid Remobilization Phase

After 48 hrs ISC IVC Hypervolemia, Hemodilution, Hct Diuresis [ renal perfusion], ADH & aldosterone secretion HypoK, hypoNa [K moves back into the cells, Na+ still trapped in the edema fluids Metabolic acidosis

BURNS
STAGES OF BURNS

3rd: Recovery Phase

5th day onwards Hypocalcemia Ca is lost on the exudates Ca is utilized in the granulation tissue formation Negative nitrogen balance Due to stress response protein catabolism Protein intake is lesser than the demand HypoK

BURNS
ASSESSMENT

1. Assess extent of body surface burned Greater morbidity & mortality for burns affecting face, hands & perineum Assess for dyspnea, stridor, hoarseness
2. Assess extent of burn injury Rule of nine immediate appraisal Lund-Browder chart more accurate Berkows method based on clients age & changes that occur in proportion of head & legs to the rest of the body as one grows

BURNS
ASSESSMENT 9%

9%

Front=18% Back=18%

9%

1% 18% 18%

Burn Evaluation Chart

BURNS
ASSESSMENT

3. Assess depth of burn Major burns 2nd degree over 30% of body Hospitalization - eyes, face, neck, hands, perineum, genitalia
4. Assess unique contributing factors Age of client Health history Diabetes, preexisting ulcers Tetanus immunization

BURNS
EMERGENCY MANAGEMENT

Stop the burning process Remove patient from source of injury Advise client to roll on the ground if clothing is in flame [STOP-DROP-ROLL] Throw a blanket over the client to smother the flame Remove clothing only if hot or for scald burn Immerse affected part in cold water [10 min] Irrigate copiuosly w/ large amount of running water w/ chemical burns [except w/ phosphorus] Interrupt power source w/ electrical burn

BURNS
MANAGEMENT

Maintenance of adequate airway

Promoting comfort: relieve pain Promoting fluid-electrolyte, acid-base balance Preventing infection Maintaining adequate nutrition Wound care

BURNS
METHODS OF TREATING BURNS

Open method or Exposure method Face, neck, perineum, trunk Allowing exudate to dry in 3 days
Occlusive Less pain, absorption of secretion, comfort, transportability, accelerated debridement Aesthetic considerations Semi-open method Covering of wound w/ topical antimicrobials: Silver sulfadiazine 1% (Flamazine) Silver nitrate 0.5% soln Mafenide acetate (sulfamylon acetate)

BURNS
BIOLOGIC DRESSING (Skin Graft)

Allograft Skin taken from other person [cadaver]

Autograft Same person Heterograft Different species Xenograft [segment of skin from animal such as pig or dog]

BURNS
FLUID REPLACEMENT

Types of fluids:
Colloids Blood Plasma & plasma expanders Electrolytes Lactated Ringers Non-electrolyte D5W

BURNS
FLUID REPLACEMENT

EVANS Formula:
C 1ml x % burns x kgBW E - 1ml x % burns x kgBW Glucose 5% for insensible loss 2,000ml D5W Administer soln 1st 24 hrs [1st 8hrs], [16hrs] BROOKE Formula: [Administer as in Evans] C 0.5ml x % burn x kgBW E - 1.5ml x % burns x kgBW Water 1000ml D5W

BURNS
FLUID REPLACEMENT

MOORES BURN BUDGET:

75 ml of plasma, 75 ml of electrolyte-contg fluid for q 1%TBSA plus 2000 D5W HYPERTONIC RESUSCITATION Formula: Hypertonic salt containing 300mEq of Na+, 100mEq of Cl-, 200mEq lactate Administered to maintain urinary output of 3040 ml/hr