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FLUIDS

60 %

Intracellular Fluid 40% or 2/3 Extracellular Fluid 20% or 1/3

Arterial Fluid
2%
Intravascular Interstitial
5% or 1/4 15% or 3/4

Venous
Fluid 3% Transcellular fluid 1-2%
ie csf, pericardial, synovial,
pleural,lymph system,
intraocular

FLUIDS - approximately 3L of the average


6L of blood is
•Maintain homeostasis made up of plasma
•Ensure adequate tissue perfusion
•Help maintain body temperature and cell Interstitial space - contains fluids that
shape surround the cell; about 11-12 liters
•Help transport nutrients, gases and wastes
Transcellular space - contains 1 L of fluid
ex. Cerebrospinal, pericardial,
Fluids synovial, intraocular and digestive secretion
•60% of an adult’s body weight Sources of Fluids
* 70 Kg adult male: 60% X 70= 42 Fluid Intake
Liters 1. Exogenous sources
•Infants = more water •Fluid intake
•Elderly = less water oral liquids – 1, 300 ml
•More fat = ↓water water in food – 1, 000 ml
water produced by metabolism – 300 ml
•More muscle = ↑water
•Infants and elderly - prone to fluid •IVF
imbalance •Medications
•Blood products
Factors that influence amount of body
fluids: 2. Endogenous sources
•By products of metabolism
1. age
•secretions
- younger people have higher
percentage of body fluid than older people
Fluid Output
Sensible loss
2. gender
- male > women •Urine - 1, 500 ml
•Fecal losses – 200 ml
3. body fats
- obese people have less fluids than
Insensible loss
thin people
(fat cells contain little water) •skin – 600 ml
•Lungs – 300 ml
Intravascular space - fluid within the blood
vessels , contains plasma
2

Third-space fluid shift/ 2. Usually occurs across capillary


Third “spacing” membranes
- loss of ECF into a space that does
not contribute to equilibrium between ICF D. Active Transport: molecules move
and ECF across cell membranes against concentration
- ie ascites, burns, peritonitis, bowel gradient; requires energy, e.g. Na – K pump
obstruction, massive bleeding
Transport Mechanisms

Mechanisms of Body Fluid Movement (i.e.


•fluids from different compartments move
from one compartment to the other to
movement of solutes, solvents across
maintain fluid balance.
different extracellular locations)
A. Osmosis: water is mover; water •movement is dictated by the transport
moves from lower concentration to higher mechanism principle :
concentration A. PASSIVE
1. Normal Osmolality of ICF and ECF: B. ACTIVE TRANSPORT
275 – 295 mOsm/kg A. Passive Transport Process

Types of solutions according to osmolality – substances transported across the


a. Isotonic: all solutions with membrane w/o energy input from the cell
osmolality same as that of plasma - high to low concentration
Body cells placed in isotonic fluid:
neither shrink nor swell 2 Types of Passive Transport
1. Diffusion – substances/solutes move from
b. Hypertonic: fluid with greater high concentration to low concentration
concentration of solutes than plasma ie exchange of O2 and CO2 b/w pulmonary
Cells in hypertonic solution: water capillaries and alveoli
in cells moves to outside to equalize
concentrations: cells will shrink 2. Filtration – water and solutes forced
through membrane by fluid or hydrostatic
c. Hypotonic: fluid with lower pressure from intravascular to interstitial
concentration of solutes than plasma area
Cells in hypotonic solution: water - solute containing fluid (filtrate)
outside cells moves to inside of cells: cells from higher pressure to lower pressure
will swell and eventually burst (hemolyze) - an example of this process is urine
formation
- increased hydrostatic pressure is
•Different intravenous solutions, used to one mechanism producing edema
correct some abnormal conditions,
categorized according to osmolality:
B. Active Transport Process
a. Hypertonic: 5%glucose, 45% NaCl -Cell moves substances across a membrane
solution through ATP because:
b. Isotonic: 9% NaCl, Lactated -They may be too large
Ringers solution
c. Hypotonic: 45% NaCl -Unable to dissolve in the fat core
-Move uphill against their concentration
B. Diffusion: solute molecules move gradient
from higher concentration to lower
concentration Types of Active Transport
1. Solute, such as electrolytes, is the 1. Active transport – requires protein carriers
mover; not the water using ATP to energize it
2. Types: simple and facilitated ie Amino acids
(movement of large water-soluble Sodium potassium pump – 3Na out, 2K
molecules) in
C. Filtration: water and solutes move 2. Endocytosis – moves substances into the
from area of higher hydrostatic pressure to cell
lower hydrostatic pressure 3. Exocytosis – moves substances out of the
1. Hydrostatic pressure is created by cell
pumping action of heart and gravity against
capillary wall Osmosis
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•Movement of water from low solute to high •10% Dextran 40 in 5% Dextrose isotonic
solute concentration in order to maintain (252 mOsm/L)
balance between compartments. •Lactated Ringer’s Solution isotonic
•Osmotic pressure – amount of hydrostatic - Na 130 mEq/L
pressure needed to stop the flow of water by - K 4 mEq/L
osmosis -Ca 3 mEq/L
•Oncotic pressure – osmotic pressure - Cl 109 mEq/L
exerted by proteins - 273 mOsm/L
Rx:hypovolemia, burns, fluids lost as
Types of Fluid bile/diarrhea, acute blood loss
Tonicity CI: ph>7.5, lactic acidosis, renal
failure(cause HyperK)
•This is the concentration of solutes in a
solution
Hypotonic Fluid
•A solution with high solute concentration is - fluid will enter the cell, the cell
considered as HYPERTONIC will swell
•A solution with low solute concentration is Hypotonic Fluids
considered as HYPOTONIC
•0.45% NaCl (half strength saline)
•A solution having the same tonicity as that - provides Na, Cl and free water
of body fluid or plasma is considered - Na 77 mEq/L
ISOTONIC - Cl 77 mEq/L
- 154 mOsm/L
•In a HYPERTONIC solution, fluid will go Rx: hypertonic dehydration, Na and Cl
out from the cell, the cell will shrink. depletion, gastric fluid loss
CI : 3rd space fluid shifts and inc
•In a HYPOTONIC solution, fluid will enter ICP
the cell, the cell will swell.
•In an ISOTONIC solution, there will be no Hypertonic Fluid
movement of fluid. - fluid will go out from the cell, the
cell will shrink
Isotonic Fluid Hypertonic Fluids
- no movement of fluid.
Isotonic Fluids •3% NaCl (hypertonic saline)
•0.9% NaCl/ Normal Saline/NSS - no calories
-Na=154 - Na 513 mEq/L
-Cl=154 - Cl 513 mEq/L
-308 mOsm/L -1026 mOsm/L
- not desirable as routine maintenance Rx: critical situations to treat HypoNa, assist
solution in removing ICF excess
- only solution administered with blood CI: administered slowly and cautiously (IVF
products overload and pulmonary edema)
Rx: hypovolemia, shock, DKA,
metabolic alkalosis, hypercalcemia, mild NA •5% NaCl
deficit •D10W - 10% Dextrose in water hypertonic
CI: caution in renal failure, heart (505 mOsm/L)
failure and edema •D10W - 20% Dextrose in water hypertonic
(1011 mOsm/L)
•D5W - 5% Dextrose in water •D50W - 50% Dextrose in water hypertonic
- 170 cal and free water (1700 mOsm/L)
- 252 mOsm/L •D5NS - 5% Dextrose & 0.9NaCl
Rx: hypernatremia, fluid loss and hypertonic (559 mOsm/L)
dehydration •D10NS - 10% Dextrose & 0.9NaCl
CI: early post op when ADH inc d/t stress, hypertonic (812 mOsm/L)
sole treatment in FVD (dilutes plasma), head •D5LR - 5% Dextrose in Lactated Ringers
injury (inc ICP), fluid resuscitation hypertonic (524 mOsm/L
(hyperglycemia), caution in renal and
cardiac dse (fluid overload), px with NA Colloid solutions
deficiency (peripheral circulatory collapse
and anuria) •Dextran 40 in NS or 5% D5W
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- volume/plasma expander substance and excretion of unneeded


- decrease coagulation substance
- remains for 6H in circulatory system 3. regulation of pH of the ECF by
Rx: hypovolemia in early shock, improve retention of hydrogen ions
microcirculation (dec RBC aggregation) 4. excretion of metabolic waste and toxic
CI: hemorrhage, thrombocytopenia, renal substances
disease and severe dehydration
B. Heart and blood vessels - pumping action
Mechanisms that Regulate Homeostasis: of the heart to maintain renal perfusion
How the body adapts to fluid and electrolyte C. Lungs - maintain homeostasis through
changes exhalation
A.Thirst: primary regulator of water intake -remove approximately 300 – 400 ml of
(thirst center in brain) water daily
B.Kidneys: regulator of volume and -loss is greater if there is increase in
osmolality by controlling excretion of water respiratory depth or rate or in dry climate
and electrolytes
C.Renin-angiotension-aldosterone D. Pituitary function - hypothalamus
mechanism: response to a drop in blood manufactures ADH
pressure; results from vasoconstriction and - ADH used for water retention or
sodium regulation by aldosterone excretion of water by the kidney and in
D.Antidiuretic hormone: hormone to regulating blood volume
regulate water excretion; responds to
osmolality and blood volume E. Adrenal function - secretes aldosterone,
E.Atrial natriuretic factor: hormone from has effect on fluid regulation
atrial heart muscle in response to fluid - secretes also cortisol – has a fraction effect
excess; causes increased urine output by of aldosterone
blocking aldosterone
F. Parathyroid function - regulates calcium
Organs involved in homeostasis and phosphate
•Kidneys - influences bone resorption , Ca absorption
•Lungs from the intestine, and Ca reabsorption from
•Heart the renal tubules
•Adrenal glands
•Parathyroid glands •Other mechanisms:
•Pituitary glands 1. baroreceptors - are small nerve receptors
•Other mechanisms that detect pressure within blood vessels and
1. baroreceptor transmit information to the CNS
2. renin-angiotensin-aldosterone - responsible for monitoring for circulating
system volume and they regulate sympathetic and
3. ADH and thirst parasympathetic neural activity and
4. osmoreceptor endocrine function
5. release of atrial natriuretic
peptide types: low-pressure
high-pressure
•Organs involved in homeostasis
A. Kidney - vital to regulation of fluid and
•High pressure - are nerve endings in the
electrolytes
aortic arch and in the cardiac sinus
- filters 170 L of plasma everyday
- another is seen in the afferent arteriole of
- urine output in an adult is 1-2
the juxtaglomerular apparatus of nephron
liters / day
- releases RENIN
- regulates sodium and water •Low pressure - are located in cardiac atria,
balance particularly in the left atria

Functions include : 2. renin-angiotensin – aldosterone system:


1. regulation of ECF volume and - renin : an enzyme that convert
osmolality by selective retention and angiotensinogen to
excretion of body fluids angiotensin I, it is released from
2. regulation of electrolytes levels in the juxtaglomerular cells of the kidney to
ECF by selective retention of needed decrease renal perfusion
5

then angiotensin I is converted to 1. The Kidney


angiotensin II by angiotensin converting •Regulates primarily fluid output by urine
enzymes ,w/c is a vasoconstrictor w/c in
formation 1.5L
turn increases arterial perfusion and
stimulates thirst, •Releases RENIN
•Regulates sodium and water balance
aldosterone is released
2. Endocrine regulation
factors that influence aldosterone secretion:
1. increased release of renin
•thirst mechanism – thirst center in
2. increased serum
hypothalamus
potassium
3. decreased Na serum
4. ACTH increase
•ADH increases water reabsorption on
collecting duct
3. ADH and THIRST - have important role
in maintaining sodium concentration and •Aldosterone increases Sodium and water
oral intakes of fluids retention retention in the distal nephron

thirst: oral intake is controlled by thirst •ANP Promotes Sodium excretion and
center located in the hypothalamus : inhibits thirst mechanism
serum
osmolality 3. Gastro-intestinal regulation
or blood - GIT digests food and absorbs water
volume - Only about 200 ml of water is
excreted in the fecal material per day
stimulate thirst
center 4. Heart and Blood Vessel Functions
- pumping action of heart circulates blood
ADH - controls water excretion through kidneys
- determines concentration of urine
5. Lungs – insensible water loss through
4. osmoreceptors - located in the surface of respiration
hypothalamus Other Mechanisms
- sense changes in Na 1. Baroreceptors – carotid sinus and aortic
concentration arch
- causes vasoconstriction and increased
osmotic pressure (neurons become blood pressure
dehydrated)
Dec arterial pressure SNS inc
releases impulses to cardiac rate, contraction, contractility,
posterior pituitary to circulating blood volume, constriction of
renal arterioles and increased aldosterone
release ADH
2. Osmoreceptors – surface of hypothalamus
increases permeability of membrane to senses changes in Na concentration

H2O (kidney, causing Inc osmotic pressure neurons


reabsorption of water and decreased dehydrated release ADH
urine output)

5. Release of atrial natriuretic peptide - KIDNEY


released by cardiac cells in the atria of the •Nephron: glomerulus and tubule
heart in response to increased atrial •Filtration
pressure •Retention/ Reabsorption
•Excretion
- action of this is direct opposite of RAAS •170-180 L/day
and decreases blood pressure and volume
•Filtrate= urine
(1-2 L urine/ day)
- ANP level is 20 to 77 pg /ml (ng/ml)
•Fluid excess excretes dilute urine (rids
Regulation of Body Fluid body of excess fluid while conserving
electrolytes)
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–Urine SG is low
ADH (Antidiuretic hormone) –Hct is high
•Vasopressin RAAS (Renin-Angiotensin-Aldosterone
System)
•Water-retainer •To help maintain a balance of sodium and
•Hypothalamus produces ADH water, a healthy blood volume and blood
•Posterior pituitary gland stores and releases pressure, the juxtaglomerular cells near
ADH each glomerulus secrete RENIN
•Restores blood volume by reducing
•Leads to production of Angiotensin II, a
powerful vasoconstrictor
diuresis and increasing water retention
•Angiotensin II causes peripheral
ADH vasoconstriction, stimulating production of
Low blood volume/ Aldosterone
Pituitary gland •Both increase blood pressure.
Increased serum osmolality
secretes ADH Aldosterone Production
Decreased JG cells
into the bloodstream Renin travels
blood flow to the secrete
ADH causes the Water to the
retention glomerulus Renin
Kidneys to retain water increases liver
blood
volume/ decreases
Renin converts Angiotension 1
serum osmolality Angiotensin 1
ADH Regulation Angiotensin in travels to the
•ADH - produced by the Hypothalamus in the lungs is
the liver to lungs
- stored and secreted by the posterior
converted to
pituitary gland
Angiotensin 1
•less water in plasma,ADH secreted to Angiotensin II
conserve water by reducing urine output
•fluid overload in plasma, ADH secretion
stops to excrete fluid in the kidneys by Angiotensin II Angiotensin II
increasing urine output travels to the stimulates the
ADH Disorder Adrenal glands adrenal glands to
produce
•Abnormally high ADH concentration - Aldosterone
SIADH Aldosterone
reduced urine output (oliguria)
water retention (fluid overload)
Angiotensin II Aldosterone
•Abnormally low ADH – Diabetes Insipidus Sodium and
increased urine output (polyuria) stimulates the causes
water loss (fluid deficit) kidneys water retention
adrenal glands to to
ADH Disorder retain sodium leads to increased
produce Aldosterone and water
•SIADH fluid volume and
–Abnormally high ADH concentration
–urine output is reduced (oliguria)
–water retention (fluid overload) sodium level
–Urine SG is high (normal: 1.005 – 1.030)
–Hct is low (43-48%)
Aldosterone Disorders
•DI •Addison’s Disease
–Abnormally low ADH
–Abnormally low aldosterone
–urine output is increased (polyuria)
–water loss (fluid deficit) –Serum Na is low, serum potassium is high
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–FVD decrease ADH


increase GFR w/c increases
•Cushing’s Disease urinary excretion of Na and
–Abnormally high aldosterone Decrease blood pressure
–Serum Na is high, serum potassium is low water
–FVE
Suppression of serum renin
ANP (Atrial Natriuretic Peptide)
•Cardiac hormone decrease vascular
•Stored in the cells of the atria volume
decrease BP,
•Released when atrial pressure increases decrease preload and afterload
•Counteracts the effects of the RAAS by
decreasing blood pressure and reducing Thirst mechanism
intravascular blood volume •Regulated by the hypothalamus
•When blood volume and BP rise and •Stimulated by an increase in ECF and
stretch the atria, ANP shuts off RAAS drying of mucous membrane
•Causes a person to drink fluids, which is
ANP absorbed by the intestines, moved to the
•Suppresses serum renin levels bloodstream and distributed between the
compartments
•Decreases aldosterone release from the
adrenal glands •Leads to increased amount of fluid in the
body and a decrease in concentration of
•Increases glomerular filtration, which solutes
increases urine excretion of sodium and
Decreased Blood Volume
water
•Decreases ADH release from the posterior THIRST mechanism
pituitary gland
•ADH secretion is increased
•Reduces vascular resistance by causing
vasodilation •ANP secretion is decreased
•RENIN secretion is increased
Examples of causes of atrial stretching
(which result to increased release of ANP) •BARORECEPTOR vasoconstricton
•Orthostatic changes •ALDOSTERONE secretion is increased
•Atrial tachycardia Increased Blood Volume
•High sodium intake •NO THIRST mechanism
•Sodium chloride infusions •ADH secretion is decreased
•Use of drugs that cause vasoconstriction •ANP secretion is increased
•RENIN secretion is increased
•BARORECEPTOR vasodilation
•Physiology/pathophysiology
•ALDOSTERONE decreased
increased blood
volume Fluid status can be assessed through:
increased blood
pressure •Mucus membrane
•Skin integrity
increased stretch of •Body weight
atria •Jugular vein
•BP, PAWP 6-12 mm Hg
•CVP (most accurate) 0-7 mm Hg or 5-10
increased cm of H2O
ANP release •I&O
•Pulse
•Temperature
vascular resistance
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•Lung sound and heart sound •byproduct of muscle metabolism &


•Urine output excreted
•Urine SG 1.005-1.030 by kidneys regardless of fluid
•Hematocrit 48% intake, diet, etc.
•Plasma osmolality •measures kidney function; 50% renal
•LOC function lost BEFORE ↑ in serum
creatinine level
Evaluation of fluid status
Osmolality – concentration of fluid that •better indicator of renal function
affects movement of water between fluid • .7 to 1.5 mg/dl
compartments by osmosis
- measures the solute concentration
per kg in blood and urine Hematocrit - indication of hydration status
- measure of solution’s ability to - measures the volume percentage of
create osmotic pressure and affect the red blood
movement of sodium cells in whole blood and normally
ranges from
- reported as mOsm/kg
- normal value= 280-300 mOsm/kg 44% to 52% for male
39% - 47% in females
Osmolarity – concentration of solutions
- measures the solute concentration hematocrit due to: 1. dehydration
per L in blood and urine 2. polycythemia
- mOsm/L
hematocrit due to: 1. overhydration
2. anemia
urine specific gravity - measures the kidneys
ability to excrete or conserve water

urine specific gravity: 1.010 - 1.025 •Urine sodium values: change with sodium
intake and status of fluid volume
Blood urea nitrogen - made up of urea, end
product of metabolism of protein - normal level ranges from 50 -
220mEq/24h
10-20mg/dl (3.5-7mmol/l) - used to assess volume status and
in the diagnosis of hyponatremia and acute
BUN: not most reliable indicator of renal renal failure
disease BUN:creatinine ratio better indicator
Normal 10:1. Fluid volume disturbances
•I and O must be equal
increased BUN due to:
•2.5 L per day
1. renal function •Fluid volume deficit (hypovolemia)
2. GI bleeding
3. dehydration
•Fluid volume excess (hypervolemia)
4. increased protein
intake
I&O Imbalance
5. fever and sepsis
Fluid Volume Deficit
decreased BUN due to : •↑output, normal intake
1. end-stage liver •Normal output, ↓ intake
disease •No intake
2. low protein
intake
3. starvation Fluid Volume Excess
4.condition that
expands fluid volume •↑ intake, normal output
ex. •Normal intake, ↓ output
pregnancy •No output

Creatinine
9

1. Fluid volume deficit •Isotonic fluids ie LR lactated ringers or


- occurs when loss of ECF volume
.9% NaCl for hypotensive patients to expand
exceeds the intake of fluid
plasma volume
Nursing Management
causes:
1. abnormal fluid losses •measure I and O accurately
vomiting, diarrhea, GI •monitoring of body weight
suctioning and sweating - loss of .5 kg means a loss of 500ml
Diabetes Insipidus
Adrenal insufficiency •monitoring of V/S
Osmotic diuresis •skin turgor assessment
Hemorrhage
3rd space fluid shift •Assess CVP, LOC, breath sounds and skin
color
2. decreased intake •Monitor urinary concentration
•Monitor mental function

signs and symptoms :


1. acute weight loss 2. fluid volume excess
2. decreased skin turgor (hypervolemia)
3. oliguria - refers to an isotonic expansion of
4. concentrated urine the ECF caused by the abnormal retention
5. postural hypotension, of water and Na in approx. same proportion
weak and rapid heart rate - usually 2nd to increase in total
6. flattened neck veins, body Na content
decreased CVP, cool clammy skin
7. Thirst, anorexia Pathophysiology:
8. Muscle weakness and 1. related to simple fluid
cramps overload
2. diminished function of
the homeostatic
Assessment of FVD mechanism responsible for
•ICF regulating fluid balance
cellular dehydration
Causes of FVE
•ITF
skin poor skin turgor •Heart failure
•IVF •renal failure
artery ↓BP, pulse (rapid thready) •cirrhosis of the liver
vein ↓CVP
•consumption of excessive amount of salt
assessment : •Excessive administration of Na containing
1. elevated BUN fluids in a patient w/ impaired regulatory
2. elevated Hct. mechanism
3. serum electrolyte changes
may also exist
•SIADH
1. hypokalemia- GI
and renal losses Clinical Manifestations
2. hyperkalemia- •Distended neck veins
adrenal insufficiency •Tachycardia
3. hyponatremia- •Inc weight
increased thirst and ADH release
4. hypernatremia- •Increased urine output
increased insensible losses and •Shortness of breath and wheezing/ crackles
diabetes •Inc CVP
insipidus
Medical Management
•Edema
•increased BP
•Oral intake when mild
•increased pulse pressure
•IV route, acute or severe
10

Assessment of FVE •Assess breath sounds


•Monitor degree of edema
•ICF ie ambulatory – feet and ankles
cellular edema - ↓LOC
bedridden – sacral area
pulmonary edema - crackles (bibasilar),
wheezing, •Promote rest – favors diuresis/inc venous
shortness of breath, Inc RR return
•Administer appropriate medication
•ITF
skin - bipedal pitting edema, periorbital
edema and ANASARCA
Electrolytes
•IVF •elements or compounds when dissolved in
artery - ↑BP, pulse (rapid bounding) water will dissociate into ions and are able
vein - ↑CVP to conduct an electric current.

Edema FUNCTIONS:
•common manifestation of FVE 1. Regulate fluid balance and osmolality
2. Transmission of nerve impulse
•d/t inc capillary fluid pressure, decreased 3. Stimulation of muscle activity
capillary oncotic pressure, increased
interstitial oncotic pressure
•Localized or generalized
•ANIONS - negatively charged ions:
•Etiology: obstruction to lymph flow, Bicarbonate, chloride, PO4-, CHON
plasma albumin level < 1.5-2 g/dl, burns and
infection, Na retention in ECF, drugs
•CATIONS - positively charged ions:
Sodium, Potassium, magnesium, calcium
•Labs: Dec Hct, respiratory alkalosis and
hypoxemia, dec serum Na and osmolality,
inc BUN Crea, Dec Urine SG, dec urine Na Cations
level Sodium , Potassium , Calcium , Magnesium
, hydrogen ions
•Mgmt: diuretics, fluid restriction, elevation Anions
of extremities, elastic compression
Chloride, bicarbonate , phosphate, sulfate,
stockings, paracentesis, dialysis
proteinate ions
Laboratory (FVE)
•Dec BUN •Sodium - positively charged ions , major
•Dec Hct cation in the ECF
-important in regulating the volume
•CRF – serum osmolality and Na level dec of body fluids
•chest x-ray may reveal pulmonary -retention of Na- associated with
congestion fluid retention
Medical Management -loss of Na- decreased volume of
•Discontinue administration of Na solution body fluids
•Diuretics •Potassium - major cation in the ICF
ie Thiazide – block Na reabsorption
in
•Chloride - major anion in the ECF
distal tubule
Loop diuretics – block Na reabsorption
•Phosphate - major anion in the ICF
in ascending loop of Henle
•Restrict fluid and salt intake Regulation of Electrolyte Balance
•Dialysis 1. Renal regulation
•Occurs by the process of glomerular
Nursing Management filtration, tubular reabsorption and tubular
•Measure intake and output secretion
•Weigh patient daily •Urine formation
2 lb wt gain = 1 L fluid
11

–If there is little water in the body, it is Dx: inc serum sodium and Cl level, inc
conserved serum osmolality, inc urine sp.gravity, inc
–If there is water excess, it will be urine osmolality
eliminated

Mgmt: sodium restriction, water restriction,


2. Endocrinal regulation diuretics, isotonic non saline soln. (D5W) or
•Aldosterone promotes Sodium retention hypotonic soln, Desmopressin Acetate for
and Potassium excretion Diabetes Insipidus
•ANP promotes Sodium excretion Nsg considerations
•Parathormone increased bone resorption History – diet, medication
of Ca, inc Ca reabsorption from renal tubule Monitor VS, LOC, I and O, weight, lung
or GI tract sounds
•Calcitoninoppose PTH Monitor Na levels
•Insulin and Epinephrine – promotes uptake Oral care
initiate gastric feedings slowly
of Potassium by cells
Seizure precaution
The Cations
•SODIUM b. HYPONATREMIA
•POTASSIUM •Na < 135 mEq/L
•CALCIUM
•MAGNESIUM •Etiology: diuretics, excessive sweating,
SODIUM (Na) vomiting, diarrhea, SIADH, aldosterone
deficiency, cardiac, renal, liver disease
•MOST ABUNDANT cation in the ECF
•135-145 mEq/L •Dx: dec serum and urine sodium and
•Aldosterone increases sodium osmolality, dec Cl
reabsorption
•ANP increases sodium excretion
•Cl accompanies Na •s/sx: headache, apprehension, restlessness,
altered LOC, seizures(<115meq/l),coma,
FUNCTIONS: poor skin turgor, dry mucosa, orthostatic
1. assists in nerve transmission and muscle hypotension, crackles, nausea, vomiting,
contraction abdominal cramping
2. Major determinant of ECF osmolality
3. Primary regulator of ECF volume
Mgmt: sodium replacement, water
a. HYPERNATREMIA restriction, isotonic soln for moderate
hyponatremia, hypertonic saline soln for
•Na > 145 mEq/L neurologic manifestations, diuretic for
SIADH
•Assoc w/ water loss or sodium gain
Nsg. Consideration
Monitor I and O, LOC, VS, serum
•Etiology: inadequate water intake, Na
excessive salt ingestion /hypertonic feedings Seizure precaution
w/o water supplements, near drowning in diet
sea water, diuretics, Diabetes mellitus/
Diabetes Insipidus Potassium (K)
•MOST ABUNDANT cation in the ICF
•3.5-5.5 mEq/L
S/SX: polyuria, anorexia, nausea, vomiting, •Major electrolyte maintaining ICF balance
thirst, dry and swollen tongue, fever, dry and
flushed skin, restlessness, agitation,
•maintains ICF Osmolality
seizures, coma, muscle weakness, crackles, •Aldosterone promotes renal excretion of
dyspnea, cardiac manifestations dependent K+
on type of hypernatremia •Mg accompanies K
FUNCTIONS:
12

1. nerve conduction and muscle contraction ECG - flattened , depressed T waves,


2. metabolism of carbohydrates, fats and presence of “U” waves
proteins ABGs - metabolic alkalosis
3. Fosters acid-base balance
Medical Mgmt:
a. HYPERKALEMIA diet ( fruits, fruit juices, vegetables, fish,
whole grains, nuts, milk, meats)
•K+ > 5.0 mEq/L oral or IV replacement

•Etiology: IVF with K+, acidosis, hyper- Nsg mgmt:


alimentation and excess K+ replacement, monitor cardiac function, pulses, renal
decreased renal excretion, diuretics, Cancer function
monitor serum potassium concentration
•s/sx: nerve and muscle irritability, IV K diluted in saline
tachycardia, colic, diarrhea, ECG changes, monitor IV sites for phlebitis
ventricular dysrythmia and cardiac arrest,
skeletal muscle weakness, paralysis Normal ECG

•Dx: inc serum K level


Hypokalemia
ECG: peaked T waves and wide QRS
ABGs – metabolic acidosis
Hyperkalemia

Mgmt:
Regulation:
K restriction (coffee, cocoa, tea, dried fruits,
beans, whole grain breads, milk, eggs) •GIT absorbs Ca+ in the intestine with the
diuretics help of Vitamin D
Polystyrene Sulfonate (Kayexalate) •Kidney Ca+ is filtered in the glomerulus
IV insulin and reabsorbed in the tubules
Beta 2 agonist •PTH increases Ca+ by bone resorption,
IV Calcium gluconate – WOF Hypotension inc intestinal and renal Ca+ reabsorption and
IV NaHCo3 – alkalinize plasma activation of Vitamin D
Dialysis
•Calcitonin reduces bone resorption,
Nsg consideration: increase Ca and Phosphorus deposition in
Monitor VS, urine output, lung bones and secretion in urine
sounds, Crea, BUN a. HYPERCALCEMIA
monitor K levels and ECG
observe for muscle weakness and •Serum calcium > 10.5 mg/dL
dysrythmia, paresthesia and GI symptoms
•Etiology: Overuse of calcium supplements
b. HYPOKALEMIA and antacids, excessive Vitamin A and D,
malignancy, hyperparathyroidism, prolonged
•K+ < 3.5 mEq/L immobilization, thiazide diuretic

•Etiology: use of diuretic, corticosteroids •s/sx: anorexia, nausea, vomiting, polyuria,


and penicillin, vomiting and diarrhea, muscle weakness, fatigue, lethargy
ileostomy, villous adenoma, alkalosis,
hyperinsulinism, hyperaldosteronism •Dx: inc serum Ca
ECG: Shortened QT interval, ST segments
•s/sx: anorexia, nausea, vomiting, decreased inc PTH levels
bowel motility, fatigue, muscle weakness, xrays - osteoporosis
leg cramps, paresthesias, shallow
respiration, shortness of breath,
dysrhythmias and increased sensitivity to •Mgmt:
digitalis, hypotension, weak pulse, dilute 0.9% NaCl
urine, glucose intolerance IV Phosphate
Diuretics – Furosemide
IM Calcitonin
Dx: dec serum K level corticosteroids
13

dietary restriction (cheese, ice cream, milk, DKA, adrenocortical insufficiency


yogurt, oatmeal, tofu)
•s/sx: hypotension, nausea, vomiting,
Nsg Mgmt: flushing, lethargy, difficulty speaking,
Assess VS, apical pulses and ECG, bowel drowsiness, dec LOC, coma, muscle
sounds, renal function, hydration status weakness, paralysis, depressed tendon
safety precautions in unconscious reflexes, oliguria, ↓RR
patients
inc mobility
inc fluid intake
monitor cardiac rate and rhythm
b. HYPOCALCEMIA •Mgmt: discontinue Mg supplements
Loop diuretics
•Calcium < 8.5 mg/dL IV Ca gluconate
Hemodialysis
•Etiology: removal of parathyroid gland
during thyroid surgery, Vit. D and Mg Nsg mgmt:
deficiency, Furosemide, infusion of citrated monitor VS
blood, inflammation of pancreas, renal observe DTR’s and changes in LOC
failure, thyroid CA, low albumin, alkalosis, seizure precautions
alcohol abuse, osteoporosis (total body Ca
deficit) b. HYPOMAGNESEMIA
•Mg < 1.5 mEq/l
• s/sx: Tetany, (+) Chovstek’s (+)
Trousseaus’s, seizures, depression, impaired •Etiology: alcohol w/drawal, tube feedings,
memory, confusion, delirium, hallucinations, diarrhea, fistula, GIT suctioning, drugs ie
hypotension, dysrythmia antacid, aminoglycosides, insulin therapy,
sepsis, burns, hypothermia

•Dx: •s/sx: hyperexcitability w/ muscle weakness,


dec Ca level tremors, tetany, seizures, stridor, Chvostek
ECG: prolonged QT interval and Trousseau’s signs, ECG changes, mood
changes
•Mgmt:
Calcium salts •Dx: serum Mg level
Vit D ECG – prolonged PR and QT interval, ST
diet (milk, cheese, yogurt, green depression, Widened QRS, flat T waves
leafy vegetables) low albumin level

•Nsg mgmt •Mgmt:


monitor cardiac status, bleeding diet (green leafy vegetables, nuts, legumes,
monitor IV sites for phlebitis whole grains, seafood, peanut butter,
seizure precautions chocolate)
reduce smoking IV Mg Sulfate via infusion pump
Magnesium Mg
•Second to K+ in the ICF •Nsg Mgmt:
•Normal range is 1.3-2.1 mEq/L seizure precautions
Test ability to swallow, DTR’s
FUNCTIONS Monitor I and O, VS during Mg
1. intracellular production and utilization of administration
ATP The Anions
2. protein and DNA synthesis •CHLORIDE
3. neuromuscular irritability
4, produce vasodilation of peripheral arteries
•PHOSPHATES
•BICARBONATES
a. HYPERMAGNESEMIA
Chloride (Cl)
•M > 2.1 mEq/L •The MAJOR Anion in the ECF
•Normal range is 95-108 mEq/L
•Etiology: use of Mg antacids, K sparing
diuretics, Renal failure, Mg medications,
14

•Inc Na reabsorption causes increased Cl •PTH inc bone resorption, inc PO4
reabsorption absorption from GIT, inhibit PO4 excretion
FUNCTIONS from kidney
1. major component of gastric juice aside •Calcitonin increases renal excretion of
from H+ PO4
2. together with Na+, regulates plasma
osmolality FUNCTIONS
3. participates in the chloride shift – inverse 1. component of bones
relationship with Bicarbonate 2. needed to generate ATP
4. acts as chemical buffer 3. components of DNA and RNA
a. HYPERCHLOREMIA
a. HYPERPHOSPHATEMIA
•Serum Cl > 108 mEq/L
•Serum PO4 > 4.5 mg/dL
•Etiology: sodium excess, loss of
bicarbonate ions •Etiology: excess vit D, renal failure, tissue
trauma, chemotherapy, PO4 containing
•s/sx: tachypnea, weakness, lethargy, deep medications, hypoparathyroidism
rapid respirations, diminished cognitive
ability and hypertension, dysrhytmia, coma •s/sx: tetany, tachycardia, palpitations,
anorexia, vomiting, muscle weakness,
hyperreflexia, tachycardia, soft tissue
•Dx: inc serum Cl calcification
dec serum bicarbonate
•Dx: inc serum phosphorus level
Mgmt: dec Ca level
Lactated Ringers soln xray – skeletal changes
IV Na Bicarbonate
Diuretics Mgmt:
diet – limit milk, ice cream, cheese,
Nsg mgmt: meat, fish, carbonated beverages, nuts, dried
monitor VS, ABGs, I and O, neurologic, food, sardines
cardiac and respiratory changes Dialysis
b. HYPOCHLOREMIA
Nsg mgmt:
•Cl < 96 mEq/l dietary restrictions
monitor signs of impending
•Etiology: Cl deficient formula, salt hypocalcemia and changes in urine output
restricted diets, severe vomiting and diarrhea
b. HYPOPHOSPHATEMIA
•s/sx: hyperexcitability of muscles, tetany, •Serum PO4 < 2.5 mg/dl
hyperactive DTR’s, weakness, twitching,
muscle cramps, dysrhytmias, seizures, coma •Etiology: administration of calories in
severe CHON-Calorie malnutrition
•Dx: dec serum Cl level (iatrogenic), chronic alcoholism, prolonged
ABG’s – metabolic alkalosis hyperventilation, poor dietary intake, DKA,
thermal burns, respiratory alkalosis, antacids
Mgmt: w/c bind with PO4, Vit D deficiency
Normal saline/half strength saline
diet ( tomato juice, salty broth, canned •s/sx: irritability, fatigue, apprehension,
vegetables, processed meats and fruits weakness, hyperglycemia, numbness,
avoid free/bottled water) paresthesias, confusion, seizure, coma
Nsg mgmt:
monitor I and O, ABG’s, VS, LOC, •Dx: dec serum PO4 level
muscle strength and movement
Phosphates (PO4) Mgmt:
oral or IV Phosphorus correction
•The MAJOR Anion in the ICF diet (milk, organ meat, nuts, fish,
•Normal range is 2.5-4.5 mg/L poultry, whole grains)
•Reciprocal relationship w/ Ca
15

Nsg mgmt: - kidney excrete H and


introduce TPN solution gradually reabsorbs/generates Bicarbonate
prevent infection 2. RESPIRATORY/METABOLIC
ALKALOSIS
- kidney retains H ion and excrete
•Fluids D1 Bicarbonate

•Electrolytes D2 Lung
•Acid-Base D3 -Control CO2 and Carbonic acid content of
ECF
•Burns D3
•Shock D4 1. METABOLIC ACIDOSIS
•GUT D5 - increased RR to eliminate CO2

•MASTERY D6 2. METABOLIC ALKALOSIS


- decreased RR to retain CO2

Acid Base Balance


•Acid •pH - measures degree of acidity and
- substance that can donate or release alkalinity
hydrogen ions - indicator of H ion concentration
ie Carbonic acid, Hydrochloric acid - Normal ph 7.35-7.45

** Carbon dioxide – combines with water to


form carbonic acid •ACIDOSIS
- decreased pH; < 7.35
- increased Hydrogen
•Base
- substance that can accept hydrogen ions
Ie Bicarbonate
•ALKALOSIS
- increased pH-; > 7.45
•BUFFER- substance that can - decreased Hydrogen
accept or donate hydrogen
- prevent excessive changes in pH ACUTE AND CHRONIC
METABOLIC ACIDOSIS
TYPES OF BUFFER -Low pH
1. Bicarbonate (HCO3): carbonic acid buffer
(H2CO3) -Increased H ion concentration
2. Phosphate buffer -Low plasma Bicarbonate
3. Hemoglobin buffer Etiology: diarrhea, fistulas, diuretics, renal
insufficiency, TPN w/o Bicarbonate,
Dynamics of Acid Base Balance ketoacidosis, lactic acidosis
•Acids and bases are constantly produced in S/sx: headache, confusion, drowsiness, inc
the body RR, dec BP, cold clammy skin, dysrrythmia,
•They must be constantly regulated shock
•CO2 and HCO3 are crucial in the balance
•A HCO3:H2CO3 ratio of 20:1 should be
maintained •Dx: ABG – low Bicarbonate, low pH,
Hyperkalemia, ECG changes
•Respiratory and renal system are active in
regulation
•Rx: Bicarbonate for pH < 7.1 and
Bicarbonate level < 10
Kidney monitor serum K
- Regulate bicarbonate level in ECF dialysis
ACUTE AND CHRONIC
1. RESPIRATORY/METABOLIC METABOLIC ALKALOSIS
ACIDOSIS •High pH
•Decreased H ion concentration
16

•High plasma Bicarbonate ARTERIAL BLOOD GAS ANALYSIS

Etiology: vomiting, diuretic, Evaluating ABG’s


hyperaldosteronism, hypokalemia, excesive Note the pH
alkali ingestion pH = 7.35 – 7.45 (normal)
pH = < 7.35 (acidosis)
s/sx: tingling of toes, dizziness, dec RR, inc pH = > 7.45 (alkalosis)
PR, ventricular disturbances
compensated – normal pH
•Dx:ABG – pH > 7.45, serum Bicarbonate > uncompensated – abnormal pH
26 mEq/L, inc PaCO2

2. Determine primary cause of disturbance


2.1 pH > 7.45
•Rx: restore normal fluid balance a. PaCo2 < 40 mmHg – respiratory
correct hypokalemia alkalosis
Carbonic anhydrase inhibitors b. HCO3 > 26 mEq/L – metabolic alkalosis
ACUTE AND CHRONIC
RESPIRATORY ACIDOSIS 2.2 pH < 7.35
•Ph < 7.35 a. PaCo2 > 40 mmHg – respiratory acidosis
PaCO2 > 42 mmHg b. HCO3 < 26 mEq/L – metabolic acidosis

Etiology: pulmonary edema, aspiration, 3. Determine compensation by looking at


atelectasis, pneumothorax, overdose of the value other than the primary disturbance
seatives, sleep apnea syndrome, pneeumonia

s/sx: sudden hypercapnia produces inc PR,


RR, inc BP, mental cloudinesss, feeling of 4. Mixed acid-base disorders
fullness in head, papiledema and dilated
conjunctival blood vessels

•Dx: ABG – pH < 7.35


PaCO2 - > 42 mmHg
Thank You!
•Rx: improve ventilation
pulmonary hygiene
mechanical ventilation

ACUTE AND CHRONIC


RESPIRATORY ALKALOSIS
•pH > 7.45
•PaCO2 < 38 mmHg
Etiology: extreme anxiety, hypoxemia

s/sx: lightheadednes, inability to


concentrate, numbness, tingling, loss of
consciousness

•Dx: ABG – pH > 7.45


PaCO2 < 35
dec K
dec Ca

Rx: breathe slowly


sedative