Professional Documents
Culture Documents
Help transport
nutrients, gasses
and wastes
Fluid
Isused to indicate that other
substances are also found in
these compartments and that
they influence the water balance
in and between compartments.
Fluids
60% of an adult’s body weight
* 70 Kg adult male: 60% X 70= 42
Liters
Infants = more water
Elderly = less water
More fat = ↓water
More muscle = ↑water
Infants and elderly - prone to fluid
imbalance
60 %
Arterial
Fluid 2%
Intravascular Interstitial
15% or 3/4
5% or 1/4
Venous
Fluid 3% Transcellular fluid 1-2%
ie csf, pericardial,
synovial, intraocular,
sweat
Third-space fluid shift/Third
“spacing”
Diffusion
Regulation of Body Fluid
1. The Kidney
Regulates primarily fluid output by
urine formation 1.5L
Releases RENIN
Regulates sodium and water balance
2. Endocrine regulation
thirst mechanism – thirst
center in hypothalamus
ADH increase water
reabsorption on collecting
duct
Aldosterone increases
Sodium and water retention
retention in the distal
nephron
ANP Promotes Sodium
excretion and inhibits thirst
mechanism
Atrial Natriuretic Peptide: Regulates Na+ & H2O Excretion
ADH Regulation
ADH - produced by the Hypothalamus
- stored and secreted by the posterior
pituitary gland
less water in plasma, ADH secreted to
conserve water by reducing urine output
fluid overload in plasma, ADH secretion
stops to excrete fluid in the kidneys by
increasing urine output
ADH Disorder
IVF
Medications
Blood products
2. Endogenous sources
By products of metabolism
secretions
Fluid Output
Sensible loss
Urine - 1, 500 ml
Fecal losses – 200 ml 2, 600 ml
Insensible loss
skin – 600 ml
Lungs – 300 ml
I&O Imbalance
ICF
cellular dehydration Acidosis
ITF
skin poor skin turgor
IVF
artery ↓BP, pulse (rapid thready)
vein ↓CVP, ↓PAWP
Clinical manifestations
Weight loss
Oliguria
Concentrated urine
Postural hypotension
Flattened neck veins
Increased Temp
Dec CVP
Thirst, anorexia
Muscle weakness and cramps
Laboratory
ITF
skin bipedal pitting edema, periorbital edema and
ANASARCA
IVF
artery ↑BP, pulse (rapid bounding)
vein ↑CVP, ↑PAWP
Clinical Manifestations
Dec BUN
Dec Hct
CRF – serum osmolality and Na level dec
Cxr – pulmonary congestion
Medical Management
Dextran 40 in NS or 5% D5W
- volume/plasma expander
- decrease coagulation
- remains for 6H in circulatory system
Rx: hypovolemia in early shock, improve
microcirculation (dec RBC aggregation)
CI: hemorrhage, thrombocytopenia, renal
disease and severe dehydration
ELECTROLYTES
elements or compounds when dissolved in
water will dissociate into ions and are able
to conduct an electric current.
FUNCTIONS:
1. Regulate fluid balance and osmolality
2. Transmission of nerve impulse
3. Stimulation of muscle activity
ANIONS - negatively
charged ions:
Bicarbonate, chloride,
PO4-, CHON
CATIONS - positively
charged ions:
Sodium, Potassium,
magnesium, calcium
Regulation of Electrolyte Balance
1. Renal regulation
Occurs by the process of glomerular
filtration, tubular reabsorption and tubular
secretion
Urine formation
If there is little water in the body, it is conserved
If there is water excess, it will be eliminated
2. Endocrinal regulation
Aldosterone promotes Sodium retention
and Potassium excretion
ANP promotes Sodium excretion
Parathormone increased bone resorption
of Ca, inc Ca reabsorption from renal tubule
or GI tract
Calcitoninoppose PTH
Insulin and Epinephrine – promotes uptake
of Potassium by cells
The Cations
SODIUM
POTASSIUM
CALCIUM
MAGNESIUM
SODIUM (Na)
FUNCTIONS:
1. assists in nerve transmission and muscle
contraction
2. Major determinant of ECF osmolality
3. Primary regulator of ECF volume
a. HYPERNATREMIA
Na > 145 mEq/L
Nsg considerations
History – diet, medication
Monitor VS, LOC, I and O, weight, lung sounds
Monitor Na levels
Oral care
initiate gastric feedings slowly
Seizure precaution
b. HYPONATREMIA
s/sx:headache, apprehension,
restlessness, altered LOC,
seizures(<115meq/l),coma, poor skin
turgor, dry mucosa, orthostatic
hypotension, crackles, nausea,
vomiting, abdominal cramping
Mgmt: sodium replacement, water restriction,
isotonic soln for moderate hyponatremia,
hypertonic saline soln for neurologic
manifestations, diuretic for SIADH
Nsg. Consideration
Monitor I and O, LOC, VS, serum Na
Seizure precaution
diet
Hyponatremia
Hypernatremia
Potassium (K)
MOST ABUNDANT cation in the ICF
3.5-5.5 mEq/L
Major electrolyte maintaining ICF balance
maintains ICF Osmolality
Aldosterone promotes renal excretion of K+
Mg accompanies K
FUNCTIONS:
1. nerve conduction and muscle contraction
2. metabolism of carbohydrates, fats and proteins
3. Fosters acid-base balance
a. HYPERKALEMIA
K+ > 5.0 mEq/L
Nsg consideration:
Monitor VS, urine output, lung sounds, Crea, BUN
monitor K levels and ECG
observe for muscle weakness and dysrythmia, paresthesia and GI
symptoms
b. HYPOKALEMIA
Medical Mgmt:
diet ( fruits, fruit juices, vegetables, fish, whole grains,
nuts, milk, meats)
oral or IV replacement
Nsg mgmt:
monitor cardiac function, pulses, renal function
monitor serum potassium concentration
IV K diluted in saline
monitor IV sites for phlebitis
Normal ECG
Hypokalemia
Hyperkalemia
CALCIUM (Ca)
Majority of calcium - bones and teeth
Normal serum range 8.5-10.5 mg/dL
Ca has an inverse relationship with PO4
FUNCTIONS
1. formation and mineralization of bones/teeth
2. muscular contraction and relaxation
3. cardiac function
4. blood coagulation
5. Promotes absorption and utilization of Vit B12
Regulation:
GIT absorbs Ca+ in the intestine with the help
of Vitamin D
Kidney Ca+ is filtered in the glomerulus and
reabsorbed in the tubules
PTH increases Ca+ by bone resorption, inc
intestinal and renal Ca+ reabsorption and
activation of Vitamin D
Calcitonin reduces bone resorption, increase
Ca and Phosphorus deposition in bones and
secretion in urine
a. HYPERCALCEMIA
Serum calcium > 10.5 mg/dL
Etiology: Overuse of calcium supplements and
antacids, excessive Vitamin A and D, malignancy,
hyperparathyroidism, prolonged immobilization, thiazide
diuretic
s/sx: anorexia, nausea, vomiting, polyuria, muscle
weakness, fatigue, lethargy
Nsg Mgmt:
Assess VS, apical pulses and ECG, bowel sounds, renal
function, hydration status
safety precautions in unconscious patients
inc mobility
inc fluid intake
monitor cardiac rate and rhythm
b. HYPOCALCEMIA
Calcium < 8.5 mg/dL
Etiology: removal of parathyroid gland during
thyroid surgery, Vit. D and Mg deficiency,
Furosemide, infusion of citrated blood,
inflammation of pancreas, renal failure, thyroid
CA, low albumin, alkalosis, alcohol abuse,
osteoporosis (total body Ca deficit)
Nsg mgmt
monitor cardiac status, bleeding
monitor IV sites for phlebitis
seizure precautions
reduce smoking
Magnesium Mg
Second to K+ in the ICF
Normal range is 1.3-2.1 mEq/L
FUNCTIONS
1. intracellular production and utilization of
ATP
2. protein and DNA synthesis
3. neuromuscular irritability
4, produce vasodilation of peripheral arteries
a. HYPERMAGNESEMIA
Nsg mgmt:
monitor VS
observe DTR’s and changes in LOC
seizure precautions
b. HYPOMAGNESEMIA
Mgmt:
diet (green leafy vegetables, nuts, legumes,
whole grains, seafood, peanut butter, chocolate)
IV Mg Sulfate via infusion pump
Nsg Mgmt:
seizure precautions
Test ability to swallow, DTR’s
Monitor I and O, VS during Mg administration
The Anions
CHLORIDE
PHOSPHATES
BICARBONATES
Chloride (Cl)
The MAJOR Anion in the ECF
Normal range is 95-108 mEq/L
Inc Na reabsorption causes increased Cl
reabsorption
FUNCTIONS
1. major component of gastric juice aside from H+
2. together with Na+, regulates plasma osmolality
3. participates in the chloride shift – inverse
relationship with Bicarbonate
4. acts as chemical buffer
a. HYPERCHLOREMIA
Mgmt:
Lactated Ringers soln
IV Na Bicarbonate
Diuretics
Nsg mgmt:
monitor VS, ABGs, I and O, neurologic, cardiac
and respiratory changes
b. HYPOCHLOREMIA
Cl < 96 mEq/l
Mgmt:
Normal saline/half strength saline
diet ( tomato juice, salty broth, canned
vegetables, processed meats and fruits
avoid free/bottled water)
Nsg mgmt:
monitor I and O, ABG’s, VS, LOC, muscle
strength and movement
Phosphates (PO4)
The MAJOR Anion in the ICF
Normal range is 2.5-4.5 mg/L
Reciprocal relationship w/ Ca
PTH inc bone resorption, inc PO4 absorption
from GIT, inhibit PO4 excretion from kidney
Calcitonin increases renal excretion of PO4
FUNCTIONS
1. component of bones
2. needed to generate ATP
3. components of DNA and RNA
a. HYPERPHOSPHATEMIA
Mgmt:
diet – limit milk, ice cream, cheese, meat, fish,
carbonated beverages, nuts, dried food, sardines
Dialysis
Nsg mgmt:
dietary restrictions
monitor signs of impending hypocalcemia and changes
in urine output
b. HYPOPHOSPHATEMIA
Serum PO4 < 2.5 mg/dl
Mgmt:
oral or IV Phosphorus correction
diet (milk, organ meat, nuts, fish, poultry, whole
grains)
Nsg mgmt:
introduce TPN solution gradually
prevent infection
Acid Base Balance
Acid
- substance that can donate or release hydrogen
ions
ie Carbonic acid, Hydrochloric acid
TYPES OF BUFFER
1. Bicarbonate (HCO3): carbonic acid
buffer (H2CO3)
2. Phosphate buffer
3. Hemoglobin buffer
Dynamics of Acid Base Balance
1. RESPIRATORY/METABOLIC ACIDOSIS
- kidney excrete H and reabsorbs/generates
Bicarbonate
2. RESPIRATORY/METABOLIC ALKALOSIS
- kidney retains H ion and excrete
Bicarbonate
Lung
1. METABOLIC ACIDOSIS
- increased RR to eliminate CO2
2. METABOLIC ALKALOSIS
- decreased RR to retain CO2
pH - measures degree of acidity and
alkalinity
- indicator of H ion concentration
- Normal ph 7.35-7.45
ACIDOSIS
- decreased pH; < 7.35
- increased Hydrogen
ALKALOSIS
- increased pH-; > 7.45
- decreased Hydrogen
ACUTE AND CHRONIC
METABOLIC ACIDOSIS
- Low pH
- Increased H ion concentration
- Low plasma Bicarbonate
Etiology: diarrhea, fistulas, diuretics, renal
insufficiency, TPN w/o Bicarbonate,
ketoacidosis, lactic acidosis
S/sx: headache, confusion, drowsiness, inc
RR, dec BP, cold clammy skin,
dysrrythmia, shock
Dx: ABG – low Bicarbonate, low pH,
Hyperkalemia, ECG changes
High pH
Decreased H ion concentration
High plasma Bicarbonate
pH > 7.45
PaCO2 < 38 mmHg
pH 7.35 – 7.45
PaCO2 35 – 45 mmHg
HCO3 22-26mEq/L
O2 saturation 93 - 98%
Evaluating ABG’s
1. Note the pH
pH = 7.35 – 7.45 (normal)
pH = < 7.35 (acidosis)
pH = > 7.45 (alkalosis)
compensated – normal pH
uncompensated – abnormal pH
2. Determine primary cause of disturbance
2.1 pH > 7.45
a. PaCo2 < 40 mmHg – respiratory
alkalosis
b. HCO3 > 26 mEq/L – metabolic alkalosis
pH PaCO2 HCO3
7.20 60 24 Uncompensated
mmHg mEq/L Respiratory
acidosis
7.40 60 37 Compensated
mmHg mEq/l Respiratory
acidosis
4. Mixed acid-base pH 7.21 Dec acid
disorders