Fluid And Electrolytes

Developed by Joanne Beestra, December 1988 Revised by Cindy Hartley & Laurie McLauchlin, September 2008
VCH Acute Medical & Surgical Nursing Fluid & Electrolyte Workshop Pre-reading Revised 2011 1

TABLE of CONTENTS

Learning Outcomes for the Module and the Workshop Introduction........................

3 4

General Principles of Fluid & Electrolyte Imbalance.. 6 Identify Patients at Risk.. 7 Diffusion and Osmosis.......... 9

Assess Volume Status 11 Serum Electrolytes.. 12

Additional Assessments.. 15 Volume Imbalance 16 Volume Deficit 17 Treatment for Volume Deficit.. 20 Volume Excess. 22 Treatment for Volume Excess 23 Appendix A 25 References 27 Answer Key 28

VCH Acute Medical & Surgical Nursing Fluid & Electrolyte Workshop Pre-reading Revised 2011

DIRECTIONS

This module is a pre-requisite activity for the VCH Acute Medical & Surgical Nursing (AMSN) Program AMSN - Level 2 Fluid & Electrolytes Workshop. As you work through this module please complete the exercises to enhance your learning. If you are having difficulty with any section please contact your Nurse Clinician and/or Clinical Educator for assistance. The module will take approximately two hours to complete. Exercises are indicated by the following icon:

LEARNING OBJECTIVES (Learning Module and Workshop) Before you begin this module please review the glossary found in Appendix A on page 25 and ensure you have a solid understanding of the terms used within this module. In addition, please review the anatomy & physiology of the renal system, the gastrointestinal (GI) system, and the neuroendocrine system and their role in fluid and electrolyte balance.

At the end of the learning module and workshop, you will have participated in a review of Fluid and Electrolytes (F & E) allowing you an opportunity to apply your knowledge and skills addressing F & E imbalances commonly seen in an acute medical/surgical setting. Specifically, you will: 1. Accurately interpret lab results in relation to fluid and electrolyte balance. 2. Articulate key electrolytes and symptoms of imbalance. 3. Identify and explain appropriate intravenous solutions related to patient condition. 4. Identify patients who are at risk for disturbance of fluid and electrolytes.
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INTRODUCTION

What are we talking about when we mention fluids and electrolytes? Fluid refers to body fluid which is water and substances dissolved in water such as electrolytes, non-electrolytes, acids, bases, and proteins. The regulation of the bodys water is controlled by hydrostatic pressure, osmotic pressure and hormones.

Electrolytes refer to charged particles found in body fluids that are required for the transmission of electrical impulses for proper nerve, heart and muscle function (Astle 2005).

Every organ system in the body participates in fluid and electrolyte regulation and every organ system relies on fluid and electrolyte balance for normal function. The body works very hard to maintain fluid and electrolyte balance. When

imbalance occurs, a number of compensatory mechanisms are available to restore balance. When a patient becomes acutely ill it becomes increasingly difficult for the body to compensate which means a fluid and electrolyte imbalance can become rapidly life threatening.

VCH Acute Medical & Surgical Nursing Fluid & Electrolyte Workshop Pre-reading Revised 2011

Poor fluid balance management as well as poor documentation of fluid balance records have been recognized as contributing factors in poor patient outcomes (Scales & Pilsworth 2006). The ability to recognize and respond to actual or potential imbalance is a key aspect of your nursing assessment.

The goal of this module and the workshop is to further develop your skills in recognizing normal and abnormal physiology of fluid and electrolytes thereby increasing your ability to respond prior to an imbalance in either fluid balance and/or electrolyte imbalance becoming life threatening.

VCH Acute Medical & Surgical Nursing Fluid & Electrolyte Workshop Pre-reading Revised 2011

GENERAL PRINCIPLES OF FLUID & ELECTROLYTE IMBALANCE

There are three basic categories of fluid and electrolyte disturbance:

Volume Imbalance is a loss or gain of isotonic fluid

Concentration Imbalance is a loss or gain of hypotonic fluid

Composition Imbalance is a loss or gain of electrolytes

Although each of these imbalances may be present simultaneously, they are separate entities and must be considered as such when undertaking diagnosis and treatment. For practical purposes, these imbalances occur first in the

extracellular (interstitial and intravascular) compartment. The intracellular compartment may not be affected.

When we talk about fluids we must also consider intravenous (IV) fluids, most hospitalized patients have some form of IV fluid therapy (David, 2007) initiated. There are several different reasons why patients require IV fluid, it may be to maintain a water balance or it may be to replace lost fluids. Whatever the reason you need to know why your patient is receiving therapy to ensure that they are receiving the correct type of fluid.

Assessment

Assessment of fluid and electrolyte balance is based on determining the quantity (volume) of fluid in the patient followed by a determination of the quality (concentration and composition) of the fluid.

VCH Acute Medical & Surgical Nursing Fluid & Electrolyte Workshop Pre-reading Revised 2011

Identify patients at risk

Virtually any disease or injury is capable of producing a disturbance in fluid and electrolyte equilibrium. Imbalance may occur as a primary effect of the disease; as a result of compensation to the disease; or, as a result of therapy for the disease. Because the GI tract, the renal system, and the neuroendocrine system are the major organs of fluid and electrolyte homeostasis, any disease or therapy affecting these organs will have an immediate impact on fluid and electrolyte balance. For example, acid-base status affects both renal excretion and internal distribution of potassium, calcium and chloride; the integrity of the cell membrane influences distribution of electrolytes and water between the intracellular and extracellular compartments; metabolism of glucose impacts on cellular uptake of potassium and phosphate as well as water balance and so forth.

As you review your patients history and current clinical status ask yourself the following questions:

1. Does the patient have any disease that would cause a fluid and electrolyte imbalance? If so, what imbalance is most likely to occur?

2. Is the patient receiving any medication or therapy that would cause a fluid and electrolyte imbalance? Be very suspicious of patients receiving diuretic therapy.

3. Is there an abnormal loss of body fluid? Where are the losses coming from? Does the fluid contain electrolytes and if so, which ones?

4. How does the total intake of fluid compare to the total fluid output?

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Where do we store body fluids?

There are three compartments can you name them?

1. ___________________________________________________________

2. ___________________________________________________________

3. ___________________________________________________________

Intravascular and interstitial are considered Extracellular

Self Check

1. Fluid inside the cell is _________________________________________

2. Fluid outside the cell is ________________________________________

3. Extracelluar fluid is divided into ______________ and ________________

Body fluids are made up of dissolved substances and a good example of this would be sodium chloride. When added to a solution it separates into Sodium (Na+) and Chloride (Cl-). A positive charge is a cation and a negative charge is called an anion, to maintain balance there has to be an equal number of positive and negative ions. The fluid in each compartment contains electrolytes which are measured in milliequivalents (mEq)/L. Each of these compartments has its own unique composition of electrolytes. A specific kind and amount of certain electrolytes must be available for normal cell function (Weldy 1996).

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If potassium is lost from a cell what is the danger?

Each compartment is surrounded by a semipermeable membrane, this allows for mixing of extracellular (EC) fluids and intracellular (IC) fluids. These membranes are considered selectively permeable in the fact that they allow some substance through but not all. For example water moves freely through all fluid compartments but the particles dissolved in the water (solutes) for example sodium or chloride may not be able to pass. DIFFUSION

There are different mechanisms within the body that allow for movement of solutes through the body. This movement is from an area of higher concentration to an area of lower concentration. One such mechanism is diffusion. Diffusion occurs within the fluid compartments and from one compartment to another if the membrane allows. This is also referred to as simple diffusion. Sometimes solutes need help to get across a membrane, or they need a carrier substance, this is known as facilitated diffusion.

OSMOSIS

Osmosis is defined as the movement of water across a membrane. During the process of osmosis the water will move to the higher concentration of solute (a lower concentration of water).

VCH Acute Medical & Surgical Nursing Fluid & Electrolyte Workshop Pre-reading Revised 2011

When the concentration is equal on both sides it is considered isotonic. Therefore when giving an isotonic IV fluid such as 0.9% Normal Saline (NS) there will be no fluid shift into or out of the cells.

When a solution contains a lower concentration hypotonic. of salt it is called

Two

common

hypotonic

solutions are 0.45% Normal Saline (NS) and Dextrose 5% in Water (D5W). With this type of solution the water will shift out of the vascular bed and into the cells.

Hypertonic fluids which have more solute than the bodys water will pull the water from the cells and interstitial

spaces and back into the circulation. This can shrink cells.

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Diffusion and Osmosis are passive processes; there is a flow from a higher concentration to a lower concentration without any expenditure of energy from the cells. With the active transport system you require energy or adenosine triphosphate (ATP), as you are moving from a lower concentration to a higher concentration. An example would be the sodium potassium pump, where the potassium is greater inside the cell than outside. Sodium, potassium, calcium, and magnesium all require active transport to move across the membrane.

ASSESS VOLUME STATUS

Volume disorders affect the intravascular and interstitial spaces and signs and symptoms of volume imbalance will reflect changes in these:

1. Blood Pressure (BP): Hypotension reflects ____________________; whereas hypertension reflects ____________________. 2. Heart Rate (HR): The HR will ____________________ in response to volume deficit and may ____________________ in response to volume excess 3. Pulse Quality: A full bounding pulse is seen in ____________________ ; and a weak, thready, obliterated pulse occurs with __________________

4. Filling Pressures: Central Venous Pressure (CVP) will be ___________ in response to volume excess and would be ______________ in response to volume deficit. Assess Concentration Status: The concentration of body fluid is determined primarily by _________ although other substances that exert an osmotic force especially serum glucose may

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impact as well. Concentration imbalances affect the intracellular compartment, especially the cerebral cells:

Serum Sodium: Will be ____________in hypertonic states and ____________ in hypotonic states Assess Neuromuscular Status: Cellular edema associated with hypotonicity appears as neuromuscular irritability; cellular dehydration associated with hypertonicity appears as neuromuscular depression.

The acutely ill patient may have a decreased level of consciousness or be irritable for any number of reasons.

Correlate the serum sodium with the clinical presentation. ASSESS THE COMPOSITIONAL STATUS Serum Electrolytes

Serum electrolytes should be monitored as ordered. In general, sodium, potassium, hematocrit, glucose, BUN and creatinine are the most frequently monitored. In the critically ill patient, serum electrolyte monitoring is performed frequently as the patients condition warrants. For the acutely ill patient on the other hand, they may have bloodwork monitored on a daily basis or perhaps as needed (prn). Magnesium, calcium and serum proteins are monitored on a prn basis. The patient should have baseline bloodwork drawn on admission, and post-op day 1 following surgical procedures. Remember to include your patients bloodwork results as part of your physical assessment especially if you have identified the patient as being high risk for imbalance.

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What are the normal values for the following electrolytes and bloodwork?

Sodium ____________________________________________________ Potassium__________________________________________________ Calcium____________________________________________________ Magnesium__________________________________________________ Chloride___________________________________________________ BUN_______________________________________________________ Creatinine___________________________________________________ Hematocrit__________________________________________________ Glucose____________________________________________________ Arterial Blood Gas Analysis pH__________ PaCO__________ PaO__________ HCO__________ SaO__________ SpO__________ What is the difference between these 2 parameters? __________________ ______________________________

What are plasma proteins? __________________________________________

Can you name them and add normal values? ____________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________
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When only one component of fluid and electrolyte balance is disturbed, it is fairly easy to identify the imbalance. However, some acutely ill patients have mixed imbalances. Be aware of the following common patterns as you analyze your patients lab results:

Whats my problem? _________________________________ Na+ 165 K+ 5.0 BiCarb 30 BUN 18 Glucose 5.5 Creatinine 140

Whats my problem? __________________________________ Na+ 135 K+ 7.0 BUN 28 Glucose is 5. 5 Creatinine 900

Compositional disorders primarily affect excitable cells such as the muscle, nerves and cardiac cells. Neuromuscular irritability or depression may be masked or be caused by other clinical conditions. The ECG may reflect some compositional imbalances, especially a potassium imbalance.

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ADDITIONAL ASSESSMENTS

Renal function

Renal function as reflected by urine output may be a symptom or cause of fluid and electrolyte imbalance. Hypovolemia is the most common cause of decreased urine output but it may also be caused by oliguric renal failure or an excess of anti-diuretic hormone (ADH). A urine output of less than 30 ml/hour should be investigated. A general rule of thumb for a healthy adult is 1mL/kg/hr (Scales, Pilsworth 2008).

High urine output may occur with hypervolemia but it may also be caused by but not limited to hyperglycemia, renal failure in the diuretic phase, or inadequate ADH. Generally speaking, the hourly urine output is a good overall guide to fluid balance. Intake and Output A record of intake versus a record of output is determined for each shift and calculated daily. A cumulative balance of fluid gains and losses determines the response to therapy. Continued gain or loss that is not explained by therapy (i.e. volume change, diuretics) or normalization process (diuresis on 3rd postoperative day) should be investigated. Daily Weights If this is a routine assessment parameter for your patient population it should be done at the same time everyday, using the same scale and the patient should have an empty bladder. Rapid weight gain or loss usually indicates changes in fluid balance. A weight gain may be associated with a fluid shift from the intravascular space to the interstitial space and is, therefore not a reliable indicator of intravascular volume status.
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VOLUME IMBALANCE Volume imbalance is an excess or deficit of water and electrolytes in the extracellular (EC) compartment. Because the chief electrolyte of the EC fluid is sodium, volume imbalance is primarily a loss or gain of sodium

When an isotonic saline solution is lost from or added to body fluid, only the VOLUME of the EC compartment is changed. Intracellular (IC) volume will not be affected because osmolarity or tonicity remains the same between the IC and EC compartment.

Because there are no changes in concentration or composition of the EC fluid, there are no readily available lab tests to aid in the diagnosis of volume imbalance. Therefore, diagnosis is made on the basis of clinical signs and symptoms. Signs and symptoms of volume imbalance usually appear first in the intravascular space and are reflected as changes in blood pressure and hemodynamic values. Symptoms associated with interstitial volume imbalance; for example edema; generally occur later unless the change is rapid and severe.
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VOLUME DEFICIT

Hypovolemia may result from either internal or external loss of isotonic fluid from the extracellular compartment. The most common causes are associated with external volume loss are:

Haemorrhage Loss of GI fluid from vomiting, NG suction or diarrhea

Internal loss occurs when isotonic EC fluid moves into a non-functional compartment such as tissue spaces or body cavities the so-called Third Space phenomena. The term non-functional is used because the fluid remains in the body but cannot participate in the normal functions of the EC compartment. Therefore, initial clinical outcomes are the same as those for external loss. In the critically ill, third spacing is most often associated with conditions that cause permeability changes in the microcirculation such as:

Burn injury Septic Shock Major fractures Major surgery especially abdominal and thoracic

In these conditions, the capillaries become very leaky and allow intravascular volume including water electrolytes, and serum proteins to escape into the interstitium or into potential spaces such as the peritoneum and the pleural and pericardial spaces. For example, a fractured hip is capable of sequestering up to 15 litres of fluid in the adjacent area. In most cases, this fluid will remobilize back into the vascular space within 3 to 5 days as capillary integrity recovers. At this time, if the patient has a limited cardiac reserve or impaired renal function volume overload may occur. The problem with third space losses is that they are invisible. The patient may have all the signs and symptoms of shock with no
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evidence of overt volume loss. Therefore, you have to be aware of conditions associated with third space loss and assess your patient accordingly.

Clinical Signs of Volume Deficit

Symptoms of volume deficit reflect contraction of the EC compartment. Because there is a loss of isotonic fluid the intravascular and interstitial compartments share the loss and intracellular volume is unchanged.

Symptoms of volume deficit will be quite familiar to you as these patients present with the classic signs of hypovolemic shock. Cardiovascular (CVS) and central nervous system (CNS) changes occur early with acute rapid loss. Changes in tissue turgour may not appear until the deficit has existed for more than 24 hours. CVS symptoms reflect depletion of circulating blood volume as well as the bodys attempt to compensate for the deficit:

Primary

Hypotension (may be postural initially) Decreased CVP Flat hand veins Prolonged capillary refill Weak, thready pulses

Compensatory

Tachycardia to increase cardiac output Peripheral vasoconstriction to shunt volume from non-vital organs such as kidneys, gut and skin to vital organs such as the lung, heart and brain

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Compensatory Contd

Oliguria to preserve body fluid and as a result of decreased renal perfusion Aldosterone secretion to promote renal uptake of salt and water ADH secretion to promote renal uptake of water

CNS symptoms reflect diminished perfusion of cerebral cells:

Initial anxiety and restlessness Confusion Stupor Coma

Other organs suffer from the circulatory shunt that accompanies hypovolemia

Ileus Oliguria progressing to renal failure Cold, clammy extremities

Interstitial depletion is reflected primarily as changes in tissue turgour. These changes are usually not evident until the deficit has existed for more than 24 hours and include:

Decreased turgour Dry tongue and mucous membranes Absence of sweating

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Treatment of Volume Deficit

In the clinical setting, treatment of volume deficit is usually the number one priority because of the stress it imposes on the heart and the systemic impact of inadequate organ perfusion. Treatment of volume deficit is determined by the patients cardiovascular and renal status, the cause of the deficit, and the nature of the fluid that has been lost. Generally speaking, since isotonic fluid has been lost, isotonic fluid should be replaced. Options include:

Red blood Cells

Packed red blood cells (PRBC) or whole blood is the obvious choice when volume deficit is due to acute hemorrhage. You may also need PRBC when the patient is having difficulty oxygenating/ventilating due to an acute loss of haemoglobin. When infusing large amounts of PRBC, be alert for symptoms of hypocalcemia.

Crystalloids

Since sodium is the primary ion of the EC compartment, the replacement solution should contain sodium in relatively isotonic proportions. An isotonic saltcontaining solution will equilibrate with EC water in accordance with normal fluid distribution i.e. 2/3 will pass in the interstitial space and 1/3 will stay in the intravascular (IV) space. For example if 1 litre of NS is infused 750 mL will enter the interstitium and 250 mL will remain in the vessels. Solutions of choice are Normal Saline and Ringers Lactate. These solutions expand the total EC compartment; overload with crystalloid is more likely to result in tissue edema and diuresis than in circulatory overload. 5% DW is not an effective solution treating volume deficit. This solution is hypotonic and will distribute itself throughout the EC and the IC compartment. Youll need a lot more 5% DW to

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achieve the desired result and the patient will end up with a concentration imbalance. Colloids

Colloid infusions consist of a balanced salt solution and protein, usually albumin. Unlike crystalloid, these solutions remain in the intravascular space and produce a greater intravascular expansion than the equivalent amount of crystalloid because they draw the fluid from the interstitial space. For example 100 mL of a 25% albumin solution will increase intravascular volume by 450 mL by drawing 350 mL of fluid out of the interstitium into the vessels. Colloids are a good option when rapid volume expansion is needed or when increased capillary permeability is causing the deficit. Two precautions must be observed when infusing colloid solutions:

Colloids produce a greater degree of intravascular volume expansion than interstitial expansion. Therefore, they are likely to cause circulatory overload in the vulnerable patient

When capillary permeability is at maximum, colloids may leak out of the vessels into the interstitium as an osmotic gradient is established that draws fluid out of the IV space and exacerbates IV volume depletion.

Synthetic Volume Expanders

Consist of a balanced salt solution and synthetic substance such as a polymer or polysaccharide. The most common solution of this nature is Pentaspan Like

albumin, this solution remains in the vascular compartment. Pentaspan produces plasma expansion for approximately 18 - 24 hours. An IV infusion of 500 mL of Pentaspan expands plasma volume by up to 750 mL.

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The 2 main goals of therapy in volume deficit are to restore circulating blood volume and maintain organ perfusion. 4 to 6 litres of replacement volume will be required in patients with a moderate deficit and up to 10 litres may be needed in severely depleted patients. All patients require close monitoring until the problem is corrected. Watch for signs of hypervolemia that indicate that the deficit has been overcorrected and decrease IV rate accordingly. Replacement is considered adequate when: Vital signs are within normal limits for that patient Urine output is approximately _________mL/kg body wt. per hour (average adult). Volume Excess

Hypervolemia usually occurs iatrogenically or secondary to renal insufficiency. Iatrogenic volume excess is a frequent event in the acutely ill patient and results from excessive administration of isotonic fluid such as Normal Saline (NS) to a person, especially those with compromised cardiac or renal function. These patients are also vulnerable to volume excess as third space fluid gets remobilized back into the intravascular space. Especially vulnerable are patients with Congestive Heart Failure (CHF) and chronic liver failure. These conditions are characterized by progressive retention of salt and water due to over secretion of aldosterone. Volume equilibrium is very tenuous in these patients and they can easily get into trouble from overaggressive or inappropriate removal of and/or additions of total body fluids.

Clinical signs of hypervolemia reflect overexpansion of the extracellular compartment. Because there is a net gain of isotonic fluid the intravascular and interstitial compartments share the excess therefore intracellular volume is unchanged.

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Signs of Circulatory overload predominate initially and include: Hypertension Increased CVP Distended hand veins

* Full bounding Pulse * Diuresis (if adequate renal function)

With adequate renal function diuresis will occur and the patient will be able to remove the excess fluid.

Signs of interstitial overload appear later unless the excess is severe or the patient has impaired cardiac and/or renal function:

Pulmonary edema Peripheral edema

Overt tissue edema is a relatively late event in hypervolemia. A patient may retain 4 8 litres of fluid before tissue edema is evident.

In the elderly or patients with pre-existing heart disease such as congestive heart failure, pulmonary edema can develop quickly with only a moderate increase in extracellular fluid volume.

Treatment of Volume excess

The goal of therapy is based on removing both fluid and salt from the body:

Simple restriction of sodium and water intake (with adequate renal function)

If pulmonary edema is suspected, you may anticipate that diuretic therapy may be necessary and ordered by the physician. Lasix is a potent loop diuretic,
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which will cause a salt and water diuresis but will also remove other electrolytes from the body in the process. Potassium deficiency is a common complication of loop diuretic therapy.

Supportive measures for treatment of hypervolemia include:

Maintain oxygenation until pulmonary congestion is relieved as the patient is at risk for hypoxia and will require supplemental oxygen. If severely compromised the patient may require intubation. Improve cardiac, renal and hepatic function as indicated by the patients clinical status

Remember high risk patients can experience hypovolemia if treatment is overaggressive

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APPENDIX A
Glossary Define the following terms related to fluid and electrolytes Acid _______________________________________________________ ___________________________________________________________ Acidosis ____________________________________________________ ___________________________________________________________ Active Transport _____________________________________________ ___________________________________________________________ Alkalosis ___________________________________________________ ___________________________________________________________ Base ______________________________________________________ ___________________________________________________________ Buffer ______________________________________________________ ___________________________________________________________ Capillary Hydrostatic pressure __________________________________ ___________________________________________________________ Capillary Osmotic pressure _____________________________________ ___________________________________________________________ Colloid _____________________________________________________ ___________________________________________________________ Concentration Gradient ________________________________________ ___________________________________________________________ Crystalloid __________________________________________________ ___________________________________________________________ Diffusion ___________________________________________________ ___________________________________________________________ Electrolytes _________________________________________________ ___________________________________________________________ Evaporation _________________________________________________

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___________________________________________________________ External Exchange ___________________________________________ ___________________________________________________________ Facilitated Diffusion ___________________________________________ ___________________________________________________________ Hypertonic __________________________________________________ ___________________________________________________________ Hypotonic __________________________________________________ ___________________________________________________________ Insensible loss _______________________________________________ ___________________________________________________________ Internal Exchange ____________________________________________ ___________________________________________________________ Isotonic ____________________________________________________ ___________________________________________________________ Non-electrolyte ______________________________________________ ___________________________________________________________ Osmolality __________________________________________________ ___________________________________________________________ Osmosis ___________________________________________________ ___________________________________________________________ Permeability ________________________________________________ ___________________________________________________________ pH ________________________________________________________ ___________________________________________________________ Plasma Proteins (name them) ___________________________________ ___________________________________________________________ Specific Gravity (what is normal) _________________________________ ___________________________________________________________ Tonicity ____________________________________________________ ___________________________________________________________
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REFERENCES Astle, S. (2005), Restoring electrolytes. RN May 68(5) pg 34-39 David, K (2007) IV fluids: do you know whats hanging and why? RN October pages 35-40. Day, R., Paul, P., Williams, B., Smeltzer, S., and Bare, B. (2007). Brunner & Suddarths Textbook of Medical Surgical Nursing, First Canadian Edition. Lippincott and Williams Jarvis, C. (2009) Physical Examination & Health Assessment First Canadian Edition; Saunders, Elsevier. Scales, K.;Pilsworth J (2008). The importance of fluid balance in clinical practice. Nursing Standard, 22,(47), 50-57 Weldy, N. (1996) Body fluids and electrolytes a programmed presentation seventh edition. Mosby, St. Louis Missouri. http://vchconnect.vch.ca/policies_manuals/reg_policy_clinical/clinical_care/transf usion_medicine/_docs/binary_44109.pdf

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ANSWER KEY
Page 8

There are three compartments name them: 1. Intracellular 2. Intravascular 3. Interstitial Self Check

1. Fluid inside the cell is intracellular 2. Fluid outside the cell is extracellular 3. Extracelluar fluid is divided into interstitial and intravascular Page 11 BP: Hypotension reflects volume deficit; hypertension volume excess Heart Rate: Will increase in response to volume deficit and may decrease in response to volume excess Pulse Quality: A weak, thready, obliterated pulse occurs with volume deficit; a full bounding pulse is seen in volume excess Assess Concentration Status: The concentration of body fluid is determined primarily by sodium although other substances that exert an osmotic force especially serum glucose may impact as well. Concentration imbalances affect the intracellular compartment, especially the cerebral cells:

Serum Sodium: Will be elevated in hypertonic states and decreased in hypotonic states
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Page 13 Lab Values

Sodium (Na+) 135 145 mEq/L Potassium (K+) 3.5 5.0 mEq/L Calcium (Ca+) Serum 4.5 5.5 mEq/L Ionized 1.12 1.30 mEq/L Magnesium (Mg) 0.70 1.10 mEq/L Chloride (Cl-) 95 107 mEq/L BUN 2.0 8.2 Creatinine 60 115 mmol/L Hematocrit Female 36 46%, Male 41 53% Glucose 3.9 11.0 Arterial Blood Gas pH 7.35 7.45 PaCO 35 45 PaO 80 100 HCO 22 26 mmol/L (mEq/L)

What are plasma proteins?

Albumin 60 80 g/L Globulin 20 35 g/L

Page 14

Whats my problem?

Dehydration Renal failure

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