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Objectives
Describe the composition of the major body fluid compartments. Define the processes involved in the regulation of movement of water and electrolytes between the body fluid compartments: diffusion, osmosis, filtration, hydrostatic pressure, oncotic pressure, and osmotic pressure. Describe the etiology, laboratory diagnostic findings, clinical manifestations, and nursing and collaborative management of the following disorders:
Extracellular fluid volume imbalances: fluid volume deficit and fluid volume excess Sodium imbalances Potassium imbalances Magnesium imbalances Calcium imbalances Phosphate imbalances
Identify the processes to maintain acid-base balances. Describe the etiology, laboratory diagnostic findings, clinical manifestations, and nursing and collaborative management of the following disorders:
Homeostasis is a term used to describe stability or equilibrium. Proper fluid and electrolyte balance in the body is regulated by fluid and electrolyte
transport systems and regulatory mechanisms such as hormones and body organs.
Homeostasis
The state of equilibrium in the internal environment of the body Body fluids and electrolytes play an important role in homeostasis Acids are produces in the body during normal metabolism Acids alter internal environment in the body
Starlings Law Equilibrium exists at the capillary membrane when fluid leaving circulation and the amount of fluid returning to circulation are exactly equal.
Water is Vital
Water is necessary as
a medium for metabolic reactions within cells a transporter for nutrients, waste products and other substances a lubricant an insulator and shock absorber a means of regulating and maintaining body temperature a medium for food digestion
Fluid Intake
Factors Affecting Body Fluid
Age Gender and body size Pregnancy (blood volume increase) Ethnic origin Environmental temperature Life style
Infants
percentage of total body water is extracellular Basil metabolic rate Body surface area
(larger volume of fluid loss throught skin)
Elderly
percentage of body fluids intracellular fluid volume thirst Self-limiting of fluids ability to conserve water renal blood flow and glomerular filtration
What effect does obesity have on body water percentage? An obese person would have a lower percentage of total body water.
Muscle contains much more water than body fat which is essentially free of water. Women have more body fat than men.
Anatomy and Physiology
Body Fluids
Most important nutrient Humans can survive only a few days without water
Electrolytes
A solution of a compound that dissociates into ions and can conduct electricity. Electrolytes affect the movement of substances between body fluids and tissues, and are crucial for normal function and metabolism
Water
Major component of the blood - 60% of total body weight of an adult is water 92% of bodys organic and inorganic compounds are dissolved in water Solute the thing being dissolved Solvent does the dissolving Solutions are made up of:
FLUID (solvent) primarily water P ARTICLES DISSOLVED (solute) electrolytes (K, Na, Cl), nonelectrolytes (urea)
Intracellular Extracellular
Distribution of Fluid
Intravascular - within the vascular system (plasma). system Interstitial fluid - surrounds the cells and includes lymph Transcellular - CSF, digestive, pleural, peritoneal and synovial fluids.
If a patient on diuretic therapy loses 6.3 lbs in 24 hours How much fluid has he lost? How much fluid would a person drink in a day? How much fluid would a person loose in a day?
Electrolytes
Substances that split into ions that are electrically charged particles
Catoins (positive charged)
Anions (negatively charged) What are some examples? How are they measured and from where? Measured in the blood plasma
Passive transport
Active transport requires energy as a force to move molecules into the cells against the concentration gradient. Active transport moves fluid and electrolytes from an area of lower concentration to an area of higher concentration The rate of diffusion depends on the size of molecules, the concentration of solution and the temperature.
Facilitated Diffusion
Active Transport
Molecules move against the concentration gradient Energy is required Example:
Fluid and Electrolyte Transport Systems Fluid and Electrolyte Transport Systems
Osmotic Pressure The power of the solution to draw water across a semi permeable membrane
Types of IV Fluids
Isotonic Hypotonic hypertonic
Oncotic
pressure
Fluid Movement
The amount and direction of movement are determined by the interaction of :
Capillary hydrostatic pressure Plasma oncotic pressure
Fluid Spacing
First spacing normal Second spacing edema Third spacing fluid trapped and unavailable for functional use ie
Hypothalamic regulation Pituitary regulation Adrenal cortical regulation Renal regulation Cardiac regulation Gastrointewstional regulation Insensible water loss
Thirst
More sodium and less water in the body make a person thirsty Additional fluids consumed; kidneys conserve water until osmolality returns to
normal
Thrust ADH regulated water retention by the kidneys -causes reabsorption ADH (vasopressin) suppression causes urinary excretion
Corticoids -
Hormones
Renin
Hormone secreted when blood volume or blood pressure falls Causes the release of aldosterone with subsequent sodium and water retention Aldosterone Acts on kidney tubules to increase reabsorption of sodium and decrease reabsorption of potassium Because the retention of sodium causes water retention, aldosterone acts as a volume regulator
Cardiac Regulation
Produced in cardiac cells Respond to increased B/P and high sodium levels Suppress secretion of aldosterone, renin, and ADH Promote excretion of Na+ and water
Hormones
Gastrointestional Regulation
Food metabolism produced water Excretion of water Absorption of water in GI tract Diarrhea or vomiting
electrolyte imbalances
Effects most patients with a major illness or injury Classified as deficits or excess Occurs in the intravascular space
Assessment of Fluid and Electrolyte Balance
Health history
Characteristics
Facial characteristics
Found in the lowest parts of the body such as in the feet and legs and sacrum of the sitting client. Edema can be localized or generalized in the body and can increase weight by at least 10 lb Frequently observed around eyes, and in the feet and hands
Mucous membranes
Tongue turgor Moisture of the oral cavity Veins
Caused by: Abnormal loss through skin, GI or kidneys Bleeding Third spacing
Fluid Imbalances
Less water than normal in the body Isotonic extracellular fluid deficit
Hypovolemia
Decreased intake, abnormal fluid losses, or both Examples: loss of water from excessive bleeding, severe vomiting/diarrhea, severe
burns
Vomiting Diarrhea Suction Drainage of secretions Anorexia Inability to swallow, confusion, Depression
Narrowing pulse pressure Decreased central venous pressure Postural hypotension Flat neck veins urinary output, specific gravity Hemoconcentration ( hematocrit, BUN)
Fluid Imbalances
From renal or cardiac failure with retention of fluid, increased production of antidiuretic hormone or aldosterone, overload with isotonic IV fluids, or administration of dextrose 5% in water (D5W) after surgery or trauma
Excessive IV therapy Excessive ingestions of sodium salts, Alka-Seltzer, hypertonic enemas, CHF, liver failure, renal failure
Body retains both water and sodium Hypervolemia-increased blood volume Caused by excessive intake of Na IV infusions infused to quickly Disease, liver, CHF, renal
Fluid Excess
WEIGHT GAIN 2% gain-mild 5% gain-moderate 8% gain-severe
Monitoring
Daily weights Significant changes in a short period of time are indicative of acute fluid changes Weigh at the same time, same clothes, same scale
Treatment
Loop diuretics act in the loop of Henle. They are the most powerful of diuretics, capable of causing 15-25% of the sodium in the filtrates to be excreted. This can cause serious potassium loss. Can be given orally or IV Patient may be given a loop diuretic such as lasix. Watch for postural hypotension.
Restricted Fluids
May be necessary for pts with fluid volume excess from renal failure, CHF, or other
disease process.
Electrolytes
Hyponatremia
Causes:
GI and Renal loss Profuse perspiration, draining skin lesions Fibrocystic disease of the pancreas Diuretics Relative sodium loss in fluid overload (water toxicity) Post surgery when pt losses blood and other fluids
Assessment
Postural blood pressure change Poor skin turgor Flat neck veins Hypotension with rapid thready pulse, cooled clammy skin Headache, faintness, mental confusion, muscle cramps
Hypernatremia
Causes: Inadequate water intake or excessive water loss Diminished thirst response especially in elderly and infants TPN and tube feeding may deplete the cells of water
Assessment: Changes in neuromuscular and cardiac activity Changes in personality: agitation and confusion, later seizures and death Skeletal muscle weakness Decreased myocardial contractibility resulting in decreased cardiac output Death may occur as a result of excessive rise in osmotic pressure and respiratory arrest
Maintains osmotic
Causes:
Hypokalemia GI disturbances, diuretic therapy. Needs KCl replacement. Hypokalemia potentiates digitoxicity. Hyperkalemia renal disease, action of digitalis with major cardiac effects excessive trauma, inhibits the (Cardiac arrest)
Hypokalemia
Increased renal loss by using excessively diuretic therapy GI loss through N&V Insufficient potassium intake Potassium cannot be stored it should be ingested daily
Assessment: Early signs as fatigue, lack of strength Muscular weakness: paralysis, ventilation problems, Bradycardia, atrial dysrhythmias Late signs: tetany and loss of deep tendon reflexes Depression Death is caused by anoxia from paralysis of the respiratory muscles and cardiac arrest
Hyperkalemia
Causes:
Renal disease K cannot be excreted adequately Addisons disease Crushing injuries with muscular destruction Metabolic acidosis (shift potassium from ICF to ECF)
Assessment Neuromuscular irritability (similar to hypokalemia) Vague muscle weakness leading to paralysis Pt. remains alert and conscious until cardiac arrest occur Death results in the toxic state from cardiac dysrhythmias (VF or atrial standstill)
Beef (4oz) Avocado (medium) Bananas (1 medium) Mushrooms (10 small) Spinach raw (3oz) Tomato (1medium)
Education
Do not substitute one potassium supplement for another Do not crush potassium tablets such as Slow-K or K-tab Do not use salt substitute that contained KCl Take Potassium supplements with meals
Calcium (Ca++)
Essential role in bone structure blood clotting, muscle contraction and nerve impulse transmission. Positive for Chvosteks sign & Trousseaus Sign sign of metastatic bone tumor, Pagets disease, hyperparathyroidism
Hypocalcemia Hypercalcemia
Chvosteks signs
Signs of Hypocalcemia
Tapping on the face at a point just anterior to the ear and just below the zygomatic bone Positive response: Twitching of the ipsilateral facial muscles, suggestive of neuromuscular excitability caused by Hypocalcemia
Trousseau's sign
Inflating a sphygmomanometer cuff above systolic blood pressure for several minutes Positive response: Muscular contraction including flex-ion of the wrist and metacarpophalangeal joints, hyperextension of the fingers, and flexion of the thumb on the palm, suggestive of neuromuscular excitability caused by hypocalcemia
Phosphorus is a primary anion in the ICF and is essential to the function of muscle, RBCs, and the nervous system. It is deposited with calcium for bone and tooth structure. Phosphorus is also involved in the acid base buffering system, the mitochondrial energy production of ATP, cellular uptake and use of glucose, and the metabolism of carbohydrates, proteins, and fats. Maintenance of normal phosphate balance requires adequate renal functioning because the kidneys are the major route of phosphate excretion. A reciprocal relationship exists between phosphorus and calcium in that a high serum phosphate level tends to cause a low calcium concentration in the serum. Hyperphosphatemia is caused by acute or chronic renal failure that results in an altered ability of the kidneys to excrete phosphate. Other causes include;
Chemotherapy for certain malignancies (lymphomas) Excessive ingestion of milk or phosphate containing laxatives. Large intake of vitamin D that increase GI absorption of phosphorus.
Clinical manifestations primarily relate to metastatic calcium and phosphate precipitates. Ordinarily, calcium and phosphate are deposited only in bone. An increased serum phosphate concentration along with calcium precipitates readily, and calcified deposits can occur in soft tissue such as joints, arteries, skin, kidneys, and corneas. Clinical manifestations also include; neuromuscular irritability and tetany, which are related to low serum calcium levels. Management includes;
Identifying cause Restrict foods and fluids high in phosphorus (dairy products) Adequate hydration Correct hypocalcemia (as calcium levels increase phosphorus is excreted thru the kidneys.
Other causes are alcohol withdrawal and use of phosphate binding antacids. Because phosphorus is needed for formation of ATP and 2,3, DPG, its deficit results in impaired cellular energy and oxygen delivery. Other clinical manifestations include muscle weakness and pain dysrhythmias, and cardiomyopathy. Management includes oral supplementation (Nutra-Phos) and ingestion of foods high in phosphorus (dairy products).
Lethargy, drowsiness, and nausea and vomiting As the levels increase, deep tendon reflexes are lost, followed by somnolence, and then
Emergency treatment for Hypermagnesemia is IV administration of calcium chloride or calcium gluconate to physiologically oppose the effects of the magnesium on cardiac muscle.
The major cause of hypomagnesaemia is prolonged fasting or starvation. Chronic alcoholism commonly causes hypomagnesaemia as a result of insufficient food intake. Fluid loss from the GI tract interferes with magnesium absorption. Another cause is prolonged TPN without magnesium supplementation. Osmotic diuresis caused by high glucose levels in uncontrolled DM increases renal excretion of magnesium. Clinical manifestations include;
Confusion, hyperactive deep tendon reflexes, tremors, and seizures. It also predisposes to dysrhythmias.
Hemoglobin System
For each Cl- that leaves a RBC a HCO3- enters For each Cl- that enters a RBC a HCO3- leaves
Plasma protein system
Functions along with the liver to vary the amount of H- in the chemical structure of plasma proteins Plasma proteins have the ability to attract or release H- ions
Primary buffer system in the body Is controlled by the lunges by the excretion of CO2 The kidneys control the bicarbonate concentration and selectively retain
or excrete bicarbonate in response to body needs
Acid-Base Control
Respiratory Acidosis
Caused by pneumonia, drug overdose, head injury, chest wall injury, obesity,
asphyxiation, drowning, or acute respiratory failure
Medical treatment
Improve ventilation, which restores partial pressure of carbon dioxide in arterial blood (Paco 2) to normal
Nursing care
Assess Paco2 levels in the arterial blood Observe for signs of respiratory distress: restlessness, anxiety, confusion, tachycardia
Intervention
Encourage fluid intake Position patients with head elevated 30 degrees
Respiratory Alkalosis
Major goal of therapy: treat underlying cause of condition; sedation may be ordered for the anxious patient
Nursing care
Intervention
In addition to giving sedatives as ordered, reassure the patient to relieve anxiety Encourage patient to breathe slowly, which will retain carbon dioxide in the body
Metabolic Acidosis
Body retains too many hydrogen ions or loses too many bicarbonate ions; with too
much acid and too little base, blood pH falls
Causes are starvation, dehydration, diarrhea, shock, renal failure, and diabetic
ketoacidosis
Nursing care
Assessment of the patient in metabolic acidosis should focus on vital signs, mental status, and neurologic status Emergency measures to restore acid-base balance. Administer drugs and intravenous fluids as prescribed. Reassure and orient confused patients
Metabolic Alkalosis
Increase in bicarbonate levels or a loss of hydrogen ions Loss of hydrogen ions may be from prolonged nasogastric suctioning, excessive
vomiting, diuretics, and electrolyte disturbances
Medical treatment
Nursing care
Assessment
Take vital signs and daily weight; monitor heart rate, respirations, and fluid gains and losses Keep accurate intake and output records, including the amount of fluid removed by suction Assess motor function and sensation in the extremities; monitor laboratory values, especially pH and serum bicarbonate levels
Intervention
To prevent metabolic alkalosis, use isotonic saline solutions rather than water for irrigating nasogastric tubes because the use of water for irrigation can result in a loss of electrolytes Provide reassurance and comfort measures to promote safety and well-being
Respiratory
Opposite
Metabolic
Equivalent