ASUHAN KEPERAWATAN PADA GANGGUAN KESEIMBANGAN CAIRAN, ELEKTROLIT & ASAM-BASA

TUTI HERAWATI, MN

Fungsi Air dalam Fisiologi Manusia

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Media semua reaksi kimia tubuh Berperan dalam pengaturan distribusi kimia & biolistrik dalam sel Alat transport hormon & nutrien Membawa O2 dari paru-paru ke sel tubuh Membawa CO2 dari sel ke paru-paru Mengencerkan zat toksik dan waste product serta membawanya ke ginjal dan hati Distribusi panas ke seluruh tubuh

DISTRIBUSI CAIRAN TUBUH

Komponen terbesar dipengaruhi usia, jenis kelamin & jml lemak Neonatus 80 %, Dewasa 60% BB, lansia 45-50 % BB wanita (17-39 th) : 50% BB pria (17-39 th): 60% BB

Elektrolit
Zat yang terlarut dalam cairan yang terpisah dalam ion-ion yg mengandung muatan elektrik CATION ion bermuatan + ANION ion bermuatan Cations = Anions satuan : milliequivalents / liter (mEq/L)

PERPINDAHAN CAIRAN & ELEKTROLIT

Diffusion Active Transport Osmosis Filtration

DIFFUSION
perpindahan molekul dari tekanan/konsentrasi tinggi ke tekanan/konsentrasi rendah Transport Pasif & tdk memerlukan energi

ACTIVE TRANSPORT SYSTEM

perpindahan molekul dari tekanan/ konsentrasi rendah ke konsntrasi tinggi dgn menggunakan energi (ATP) Requires specific carrier molecule as well as specific enzyme (ATPase) Sodium, potassium, calcium, magnesium, plus some sugars, & amino acids use it

OSMOSIS

perpindahan air dari konsentrasi zat terlarut rendah ke konsentrasi zat terlarut tinggi melalui membran osmolaritas: ukuran konsentrasi suatu larutan - isotonus konsentrasi larutan = plasma darah

Pengukuran Osmolality di klinik

Serum 280-300mOsm/kg; Urine 501400mOsm/kg Osmolality = 2 * Na + Glu + BUN mg/dl 18 2.8

Isotonik
Tekanan osmolaritas plasma? 280-300 mosm/kg Osmolaritas ECF ditentukan oleh Na NaCl 0,9 %, RL

HYPOTONIC HYPERTONIC

Rendah Na atau tinggi h2O dari isotonik Jika di infuskan ke darah, cairan akan pindah ke intra sel & menyebabkan edema sel 0,45 % NaCl

Jika diinfuskan ke darah, cairan intra sel ke intravaskular menyebabkan sel mengecil NaCl 3 %, whole blood, Albumin, koloid, dextrose 10 %, dextrose 40 %, Total parenteral Nutrition

Tekanan Cairan
1.

Tekanan osmotik & onkotik

Tekanan osmotik: tekanan untuk mencegah aliran osmotik cairan Tekanan onkotik (osmotik koloid): gaya tarik s/ koloid (albumin)agar air tetap berada dalam plasma darah.

PLASMA PROTEINS (albumin)

mempengaruhi serum osmolarity berupa anion Diseimbangkan dg Na Mempertahankan cairan di dlm vascular dan dppt menarik cairan dari interstitial

Tekanan Hidrostatik

Tekanan cairan melawan dinding vaskuler Tekanan hidrostatik ( filtration force) tekanan yang digunakan oleh air dalam sistem tertutup

FILTRATION
Perpindahan cairan melalui mebran semipermeabel dari area tekanan hidrostatik tinggi ke area yg lebih rendah. Arterial end of capillary has hydrostatic pressure > than osmotic pressure so fluid & diffusible solutes move out of capillary

THIRD SPACING
Large quantities of fluid from the intravascular compartment shift into the interstitial space; is inaccessible to the body May be caused by lowered plasma proteins, increased capillary permeability & lymphatic blockage Can be seen with trauma, inflammation, disease

INTAKE & OUTPUT

INTAKE Oral fluids including ice, gelatin, etc. Parenteral fluids Tube feedings with flushes Catheter irrigants that are not withdrawn

OUTPUT Urine output Liquid feces Vomitus NG drainage Excessive sweating Wound drainage Draining fistula Rapid or labored RR

Normal fluid and electrolyte requirements

Daily water requirements

Weight (kg) x 25-35 mL = mL fluid required daily 25 mL/kg for CHF or renal disease 30 mL/kg for average adults 35 mL/kg for patients with infection or draining wounds

Daily electrolyte requirements

Sodium 2 - 3 mEq/100ml H2O /day Potassium 1 - 2 mEq/100ml H2O /day Chloride 2 - 3 mEq/100ml H2O /day

Examinations to identify fluid/electrolyte problems

Electrolytes This provides information about serum Na+, K+, Cl-, HCO3-

These measures provide an indication of renal perfusion. An elevated BUN and Cr BUN generally reflects intravascular depletion. Creatinine is a useful indicator of acute renal failure. The CBC may provide some indication of hemoconcentration in cases of dehydration. The WBCs and differential cell count are useful indicators of infection. Platelets can elevate as acute phase reactants. The specific gravity of the urine is related to the patient's hydration state. In cases of renal disease, it can help classify the condition. Urine ions can be specifically requested, and are helpful in determining whether sodium is being retained or not.

CBC

Urine Analysis

Serum/Urine Osmolarity

A true measure of serum osmolarity can be compared to the calculated osmolarity. Normally, true osmolarity is about 10 mEq/L higher than calculated due to the presence of particles which are not in the basic osmolarity equation. If there is a greater "osmolar gap" than this, the presence of additional particles should be considered (such as alcohol or mannitol). The osmolarity of serum determines whether a patient is in an isotonic state or if this state has been disturbed. Urine osmolarity is helpful in determining if the kidney is doing its job of concentrating urine.

Total Protein

Total protein, and sometimes albumin levels, are indirect measures of both liver function (where they are produced), dietary protein intake, and renal loss. If serum protein levels fall, the intravascular oncotic pressure falls and fluid migrates to "third spaces". This can be seen in liver disease, nephrotic syndromes, malnutrition and other cases.
In addition to providing information about the patient's blood gases and assisting in classification of acidosis or alkylosis, the ABG yields information about bicarbonate levels. Usually, STAT electrolytes can also be obtained from a blood gas sample, with turn around time better than serum chemistry.

Arterial Blood Gas

Fluid Imbalances

Fluid excess:
CHF Kidney failure

Fluid deficit:
Diarrhea Blood loss

Assessment of Fluid Balance

Health History Daily Weight Intake and Output Vital Signs Skin Turgor Mucous Membranes Hand Vein Filling/Emptying Labs Urine SG; Hb&Ht; Sodium; Total Protein; Albumin; Serum Osmolarity; BUN; Creatinine

Responses to imbalances ?

Regulation of body water loss (dehydration)

Release ADH

Water retention

Aldosterone + Na &Water reabsorbtion in renal tubules

Neuro Endocrine Mechanisms

Central Nervous System Ischemic Response- massive hemorrhage causes dec. in ECF volume & response that constricts afferent arterioles & dec. GFR Baroreceptor Reflex- stretch receptors in large arteries that react to a dec. in ECF & respond with dec. in GFR

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CAUSES OF FVD

Abnormal GI fluid loss such as N&V or drainage of GI tract Abnormal fluid loss from skin such as high temperature or burns Increased water vapor from the lungs such as hyperpnea

Conditions that increase renal excretion of fluids such as diuretics & hypersomolar tube feedings Decrease in fluid intake Third-space shift such as ascites or trauma

SIGNS & SYMPTOMS OF FVD

Dry mucous membranes Weight loss -mild at 2%,moderate at 5%, & severe deficit at 8% Orthostatic hypotension & increase in pulse rate Body temperature usually subnormal Flat neck veins & decrease in CVP Decreased urinary output & altered sensorium

NURSING MANAGEMEMT OF FVD

Monitoring I&O on a regular schedule depending on the patient If urine output is below 30 mL / hr. notify the physician May check urine specific gravity q 8hrs. Weigh patient daily at the same time & recognize that a change of 2.2 lbs. represents a loss of 1000 mL Monitor skin turgor, oral membranes, lab

FLUID VOLUME EXCESS

Hypervolemia or FVE is result of expansion of fluid compartment from an increase in total sodium content Kidney receives signal to save sodium & water to compensate for cirrhosis, CHF, renal failure, excessive Na-containing fluid Labs may show dec.:hematocrit, serum Na, serum osmolality, urine sp. Gr; inc. BUN

SIGNS & SYMPTOMS OF FVE

SOB & orthopnea Edema & weight gain Distended neck veins & tachycardia Increased blood pressure Crackles & wheezes Maybe ascites & pleural effusion Increase in CVP

NURSING MANAGEMENT OF FVE

Monitor I & O plus monitor for physical signs of hypervolemia Check for edema & weigh patient daily Restrict sodium intake as prescribed Limit intake of fluids Watch for signs of potassium imbalance Monitor for signs of pulmonary edema Place patient in semi-Fowlers position

SODIUM (NA)*
Main extracellular fluid (ECF) cation Helps govern normal ECF osmolality Helps maintain acid-base balance Activates nerve & muscle cells Influences water distribution (with chloride) N: 135-145 mEq/L

Hyponatremia: serum Na < 130 mEq/L Sodium deficit calculation: [(normal Na(mEq/L))
(measured Na(mEq/L)] x TBW (L)

Hypernatremia: serum Na > 150 mEq/L

Significant neurological effects usually seen with Na > 160 mEq/L Free water deficit calculation:
measured Na (mEq/L) desired Na (mEq/L) X TBW (L)} - TBW (L)

Use 145mEq/L as desired Na; estimate TBW as 0.6L/kg x body weight (kg)

POTASSIUM (K)*
Dominant cation in intracellular fluid (ICF) Regulates cell excitability Permeates cell membranes, thereby affecting cells electrical status Helps control ICF osmolality & ICF osmotic pressure

POTASSIUM (K+)

MOVEMENT INFLUENCED BY:Changes in pH Insulin Adrenal hormones Changes in serum sodium

IMPORTANT IN: Neuromuscular irritability Intracellular osmotic activity Acid-base balance

Fluid electrolyte management

Estimating the fluid problem 1) Check the weight Rapid changes in weight likely represent changes in TBW. (2) History Ask about losses (diarrhea, vomiting, how much, how often), attempts at replacement (what fluids used, how much given, how successful), urine output. (3) Physical exam findings Mental status, pulse, BP, body weight, mucous membranes, skin turgor, skin color. (4) Laboratory evaluation Serum chemistries, hematocrit, and urine studies can guide therapy and check forcomplications.

HYPERNATREMIA
Collaborative management tries to gradually lower serum sodium by *infusion of 0.45% NaCl *monitoring U/O & serum sodium levels *administering fluids carefully *restricting sodium intake

HYPONATREMIA
Collaborative management seeks to correct cause & give sodium with caution due to possible rebound fluid excess by : *infusing isotonic saline in IV fluids *restricting oral & IV water intake *increasing dietary sodium *monitoring for signs of hypervolemia

HYPERKALEMIA TREATMENT
Watch EKG for fatal dysrthymias or cardiac arrest Collaborative management may include: Calcium to counteract effect on heart Sodium bicarbonate to alkalinize fluids Hemodialysis or peritoneal dialysis Cation exchange resins (Kayexalate) by mouth or enema Small dose of insulin & dextrose Restrict dietary K+

HYPOKALEMIA TX
Correct the cause Oral or IV administration of potassium (dilutes in IV fluids) Salt substitutes containing K+ Foods high in potassium : bananas, pears, dried apricots; fruit juices; tea, cola beverages; milk; meat, fish; baked potato; dried beans (cooked); ANYTHING THAT TASTES GOOD LIKE CHOCOLATE !!

NORMAL

HIPERKALEMIA

HIPOKALEMIA

Oral therapy
Oral rehydration with electrolyte solutions is safe, efficacious and convenient. Can be used as first line therapy in nearly all fluid and electrolyte aberrations except severe circulatory compromise.

IV therapy reestablish effective circulating volume a) What IV fluid should be used? Initial IV therapy should be with isotonic fluid to improve effective circulating volume.

b) How much IV fluid should I give initially? Use clinical findings to determine if patient is responding (mental status, vital signs, urine output). Repeat this infusion if necessary.

c) How should continue IV fluids? do not require continued IV fluids after effective circulation has been restored. Continue IV fluids in situations where oral rehydration will be difficult, such as high ongoing losses, severe electrolyte abnormalities, poor mental status or inability to tolerate enteral fluids.

Continuing IV therapy considers:

(a) Estimate remaining deficits Volume: Check current weight and compare to desired baseline. If using preresuscitationweight, consider the amount of volume given in resuscitation. (b) Estimate daily needs Estimate daily needs for water and electrolytes, as for any patient. Adjust based on the clinical situation (e.g., fever, coma, ventilator, etc.) (c) Consider ongoing losses Monitor for losses such as stool, drains, etc. Consider replacing these as needed. (d) Provide therapy Add up water and electrolyte needs from deficits and daily requirements.

ACID-BASE BALANCE
Governed by the regulation of hydrgen ion (H+) concentration in the body pH = negative logarithm of the H+ concentration Acids - proton donors & give up H+ Bases - H+ acceptors Acidic - inc. in concentration of H+ Basic - dec. in concentration of H+

HENDERSON HASSELBALCH EQUATION

Expresses that the ratio of base to acid or HCO3- to H2CO2 * ( 20: 1) determines the pH pH < 7.35 ACIDOSIS pH > 7.45 ALKALOSIS

ACID-BASE REGULATORY MECHANISMS

CHEMICAL BUFFER SYSTEMS bicarbonate, phosphate, protein, hemoglobin LUNGS - carbonic acid broken down into CO2 & H2O KIDNEYS - increasing or decreasing bicarbonate ions

Arterial Blood Gases (ABGs)

pH 7.35-7.45 PaCO2 35-45 mm Hg Pa O2 80-100 mm Hg O2 sat. 95-99% HCO3- 22-26mEq/L

ACID-BASE PARAMETERS

ACID pH <7.35 PaCO2 >45 HCO3 <22

BASE pH >7.45 PaCO2 <35 HCO3 >26

Respiratory Acidosis*
pH < 7.35 PaCO2 > 45mm Hg Due to inadequate alveolar ventilation Tx aimed at improving ventilation Respiratory Opposite

Respiratory Alkalosis*
pH > 7.45 PaCO2 < 35mm Hg Due to alveolar hyperventilation & hypocapnia Tx depends on underlying cause

Metabolic Acidosis*
pH < 7.35 HCO3 < 22mEq/L Due to gain of acids or loss of base (like excessive GI loss from diarrhea) May have associated hyperkalemia Tx aimed at correcting metabolic defect Metabolic Even

Metabolic Alkalosis*
pH > 7.45 HCO3 > 26 mEq/L Due to loss of acid or gain of base (most common is vomiting or gastric suction) Hypokalemia may produce alkalosis Tx aimed at underlying disorder

ABG ASSESSMENT*

36 yo pt. complains of acute SOB, R sided pleuritic pain pH 7.50 PaCO2 29 mmHg PaO2 60 mmHg HCO3- 24 mEq/l SaO2 78% ? Meaning ?

32 yo pt. with drug OD & breathing 5 times / minute pH 7.25 PaCO2 61 mmHg PaO2 74 mmHg HCO3- 26 mEq/l SaO2 89% ? Meaning ?

ABGs*

70 year old diabetic with hx of not taking insulin pH 7.26 PaCO2 42 HCO3 17 ????

58 year old pt. With CHF for 6 mos. & placed on digoxin & Lasix pH 7.48 PaCO2 45 HCO3 26 ????

NUHUN KASIH TERIMA

HATUR