FLUIDS and ELECTROLYTES

BODY FLUIDS Functions of Fluids Body fluids:  Facilitate in the transport [nutrients, hormones, proteins, & others]  Aid in removal of cellular metabolic wastes  Provide medium for cellular metabolism  Regulate body temperature  Provide lubrication of musculoskeletal jts.  Component in all body cavities [parietal, pleural fluids]  Water is the principal body fluid & essential for life.

FLUIDS and ELECTROLYTES

BODY FLUIDS Distribution of Body Fluids 50-70% of total body weight;
infant [70-80%], elderly [45-50%] ICF ECF 60-kg man TBW = 0.6 x 60 kg = 3.6 L

IS

ICF = 0.4 x 60 kg = 24 L

ECF = 12 L

3L 9L 40% TBW 20% TBW

FLUIDS and ELECTROLYTES

BODY FLUIDS Factors that Dictate Body Water Requirement 1) Amount needed to give the proper osmotic concentration 2) Amount needed to replace water lost excretion Normal Routes of water gain and loss
INTAKE Fluid intake Food Metabolic water TOTAL ml/day 1,200 1,000 300 2,500 OUTPUT Insensible loss Sweat Feces Urine TOTAL ml/day 700 100 200 1,500 2,500

FLUIDS and ELECTROLYTES

FLUID EXCHANGE BETWEEN BODY FLUID COMPARTMENTS
ICF ECF

Osmotic Pressure Gradient

Oncotic P (Colloid osmotic P) Capillary P (Hydrostatic P)

P ISF

FLUIDS and ELECTROLYTES

Control of Osmotic Pressure, Volume & Electrolyte Concentration OBLIGATORY Reabsorption occurs in the proximal tubules 178 L/day of glomerular filtrate (80% reabsorbed) 2r to solute reabsorption independent of the water requirement FACULTATIVE Reabsorption occurs in the distal & collecting tubules independent of the active solute transport dependent of bodys need of water under the control of ADH

FLUIDS and ELECTROLYTES

DISTURBANCES IN FLUID BALANCE EDEMA (Dropsy)  o in the interstitial fluid volume of about 2 L or more due to increase transudation of fluid from capillaries 2 to: Increased HP [pregnancy, CHF] Decreased OP [malnutrition, end-stage liver dse, nephrotic syndrome]

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DISTURBANCES IN FLUID BALANCE CELL OVERHYDRATION  excess of water in the ECC w/ a normal amount of solute or a deficient amount of solute  occurs in prolonged and excessive diuresis, forcing hypotonic fluids to produce diuresis in the presence of renal impairment  fluid overload from o production of adrenal corticoid hormones [Cushings syndrome]

FLUIDS and ELECTROLYTES

DISTURBANCES IN FLUID BALANCE CELL OVERHYDRATION Symptoms  Weight gain & edema  Cough, moist rales, dyspnea [fluid congestion in lungs]  CVP, bounding pulse,neck vein engorgement [fluid excess in the vascular system]  Bulging fontanelles  q Hg and Hct  Nausea & vomiting

FLUIDS and ELECTROLYTES

DISTURBANCES IN FLUID BALANCE CELL OVERHYDRATION Management  Restrict fluids to lower fluid volume  Diuretics or hypertonic saline  Continuous assessments to prevent skin breakdown  Record daily weight to assess progress of treatment

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DISTURBANCES IN FLUID BALANCE CELL DEHYDRATION (DHN)  loss of body fluids, particularly from the extracellular fluid compartment  water loss > water intake Causes  Fever  Insufficient water intake  Diarrhea, vomiting  Excess urine output [Diabetes insipidus, diuretics]  Excessive perspiration, burns  Hemorrhage, shock, metabolic acidosis

FLUIDS and ELECTROLYTES

DISTURBANCES IN FLUID BALANCE CELL DEHYDRATION (DHN) Symptoms  Thirst, dry mucus membranes, sunken eyeballs  Doughy abdomen, dry skin w/ poor turgor  o temp, weight loss  o HR, o RR, q BP  Restlessness,irritability, disorientation, convulsion, coma [22-30% body H20 loss] Management  Fluid replacement therapy & continued fluid maintenance

FLUIDS and ELECTROLYTES

Volume Disorders 2 Alteration in Sodium Balance
Volume Disorder Expansion Isotonic Hypertonic Hypotonic Contraction Isotonic Hypertonic Hypotonic ECF Vol. Inc Inc Inc Dec Dec Dec ICF Vol. N Dec Inc Water Shift No net change ICF p ECF ECF p ICF Conditions

Isotonic fluid ingestion Sea water ingestion Hypotonic IVF

N No net change Diarrhea Dec ICF p ECF Diabetes insipidus Inc ECF p ICF Addisons dse

FLUIDS and ELECTROLYTES

ELECTROLYTES  salts or minerals in extracellular or intracellular body fluids Sodium major cation of ECF Potassium major cation of ICF Chloride - major anion of ICF Protein in ICF > ISF

FLUIDS and ELECTROLYTES

ELECTROLYTE Composition
Electrolyte Conc Sodium, Na+ Potassium, K+ Calcium, Ca++ Magnesium, Mg++ Chloride, ClBicarbonate, HCO3Biphosphate, HPO4Sulfate, SO4-2 Protein Organic foods Plasma (mEq/L) 142 5 5 3 (155) 103 27 2 1 16 6 (155) ISF 141 4.1 4.1 3 115 29 2 1 1 3.4 ICF 10 150 40 15 10 100 20 60 -

FLUIDS and ELECTROLYTES

ELECTROLYTES Functions of Electrolytes Contribute most of the osmotically active particles in body fluids Provide buffer systems for pH regulation Provide the proper ionic environment for normal neuromuscular irritability & tissue function

FLUIDS and ELECTROLYTES

ELECTROLYTES Hyponatremia [Na+ < 135 mEq/L; Normal = 135-145 mEq/L] Causes  q Na+ intake  o Na+ excretion [diaphoresis, GI suctioning]  Adrenal insufficiency Assessment  N & V, abdominal cramps, weight loss  Cold, clammy skin, q skin turgor  Apprehension, HA, convulsions, focal neurologic deficit, coma [cerebral edema]  Fatigue, postural hypotension  Rapid thready pulse

FLUIDS and ELECTROLYTES

ELECTROLYTES Hyponatremia [Na+ < 135 mEq/L; Normal = 135-145 mEq/L] Management  Provide foods high in sodium  Administer NSS IV  Assess blood pressure frequently [measure lying down, sitting & standing]

FLUIDS and ELECTROLYTES

ELECTROLYTES Hypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L] Causes  Excessive, rapid IV admn of NSS  Inadequate water intake  Kidney disease Assessment  Dry, sticky mucus membranes  Flushed skin  Rough dry tongue, firm skin turgor  Intense thirst  Edema, oliguria to anuria  Restlessness, irritability [cerebral DHN]

FLUIDS and ELECTROLYTES

ELECTROLYTES Hypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L] Nursing Intervention  Weigh daily  Assess degree of edema frequently  Measure I & O  Assess skin frequently & institute nursing measures to prevent breakdown  Encourage sodium-restricted diet

FLUIDS and ELECTROLYTES

ELECTROLYTES Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L] Causes  Renal insufficiency  Adrenocortical insufficiency  Cellulose damage [burns]  Infection  Acidotic states  Rapid infusion of IV soln w/ potassiumconserving diuretics

FLUIDS and ELECTROLYTES

ELECTROLYTES Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L] Assessment  Thready, slow pulse  Shallow breathing  N & V, diarrhea, intestinal colic  Irritability  Muscle weakness, flaccid paralysis  Numbness, tingling  Difficulty w/ phonation, respiration

FLUIDS and ELECTROLYTES

ELECTROLYTES Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L] Nursing Interventions  Administer kayexalate as ordered  Administer/monitor IV infusion of glucose & insulin  Control infection  Provide adequate calories & carbohydrates  Discontinue IV or oral sources of K+

FLUIDS and ELECTROLYTES

ELECTROLYTES Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L] Causes  Renal insufficiency  Adrenocortical insufficiency  Cellulose damage [burns]  Infection  Acidotic states  Rapid infusion of IV soln w/ potassiumconserving diuretics

FLUIDS and ELECTROLYTES

ELECTROLYTES Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L] Assessment  Thready, rapid, weak pulse  Faint heart sounds  q BP  Skeletal muscle weakness  q or absent reflexes  Shallow respirations  Malaise, apathy, lethargy  Loss of orientation  Anorexia, vomiting, weight loss  Gaseous intestinal distention

FLUIDS and ELECTROLYTES

ELECTROLYTES Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L] Nursing Interventions  Administer K+ supplements to replace losses  Be cautious in administering drugs that are not potassium-sparing  Monitor acid-base balance  Monitor pulse, BP and ECG

FLUIDS and ELECTROLYTES

ELECTROLYTES Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L] Causes  Hyperparathyroidism  Immobility  Increased vitamin D intake  Osteoporosis & osteomalacia [early stages] Assessment  N & V, anorexia, constipation  Headache, confusion  Lethargy, stupor  Decreased muscle tone  Deep bone/flank pain

FLUIDS and ELECTROLYTES

ELECTROLYTES Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L] Nursing Interventions  Encourage mobilization  Limit vitamin D intake  Limit calcium intake  Normal saline  Administer diuretics  Calcitonin

FLUIDS and ELECTROLYTES

ELECTROLYTES Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L] Causes  Acute pancreatitis  Diarrhea  Hypoparathyroidism  Lack of vitamin D I the diet  Long-term steroid therapy Assessment  Painful tonic muscle & facial spasms  Fatigue, dyspnea  Laryngospasm, convulsions  (+) Trousseaus and Chvosteks signs

FLUIDS and ELECTROLYTES

ELECTROLYTES Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L] Nursing Interventions  Administer oral Ca lactate or IV CaCl2 or gluconate  Providing safety by padding side rails  Administer dietary sources of calcium  Vitamin D  Provide quiet environment

FLUIDS and ELECTROLYTES

ELECTROLYTES Hyermagnesemia [Mg > 3.0 mEq/L; Normal = 1.5-3.0 mEq/L] Causes  Renal insufficiency, dehydration  Excessive use of Mg-containing antacids or laxatives Assessment  Lethargy, somnolence, confusion  N&V  Muscle weakness, depressed reflexes  q pulse and respirations Nursing Intervention  Withhold Mg-contg drugs/foods; Ca admn  o fluid intake, unless CI

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ELECTROLYTES Hypomagnesemia [Mg < 1.50 mEq/L; Normal = 1.5-3.0 mEq/L] Causes  Low intake of Mg in the diet  Prolonged diarrhea  Massive diuresis  Hypoparathyroidism Assessment  Paresthesias, muscle spasm  Confusion, hallucination, convulsions  Ataxia, tremors, hyperactive deep reflexes  Flushing of the face, diaphoresis Nursing Intervention  Provide good dietary sources of Mg

FLUIDS and ELECTROLYTES

IV FLUID REPLACEMENT THERAPY Indications Replacement of abnormal fluid & electrolyte losses [surgery, trauma, burns, GI bleeding] Maintenance of daily fluid & electrolyte needs Correction of fluid disorders Correction of electrolyte disorders

FLUIDS and ELECTROLYTES

IV FLUID REPLACEMENT THERAPY Types of Solutions Isotonic  0.9% sodium chloride (NSS)  Lactated Ringers soln Hypotonic  5% dextrose and water (D5W)  0.45% sodium chloride  0.33% sodium chloride Hypertonic  3% NaCl  Protein solns Colloids  Salt pour albumin Plasmanate, Dextran

BURNS
BURNS  wounds caused by excessive exposure to the following agents or causes: Causes of Burns: Thermal [moist or dry heat] Electrical Chemical [strong acids and strong alkali Radiation [UV, x-rays, radium, sunburns]

BURNS
CLASSIFICATION OF BURNS Superficial Partial thickness (1st degree)  Outer layer of dermis  Erythema, pain up to 48 hrs  Healing 1-2 wks [sunburn] Deep Partial thickness (2nd degree)  Epidermis & dermis  Blisters & edema, frequently quite painful  Healing 14-21 days Full thickness (3rd degree)  Epidermis, dermis, subcutaneous fat  Dry, pearly white or charred in appearance  Not painful  Eschar must be removed; may need grafting

BURNS
STAGES OF BURNS 1st: Shock/Fluid Accumulation Phase 1st 48 hrs IVC p ISC Generalized DHN [fluid shifting] Hypovolemia [plasma loss], q BP, q C.O. Hemoconcentration, o Hct [liquid blood component p ISC] Oliguria [q renal perfusion], ADH release & aldosterone HyperK, hypoNa Metabolic acidosis

BURNS
STAGES OF BURNS 2nd: Diuretic/Fluid Remobilization Phase After 48 hrs ISC p IVC Hypervolemia, Hemodilution, q Hct Diuresis [o renal perfusion], q ADH & aldosterone secretion HypoK, hypoNa [K moves back into the cells, Na+ still trapped in the edema fluids Metabolic acidosis

BURNS
STAGES OF BURNS 3rd: Recovery Phase 5th day onwards Hypocalcemia  Ca is lost on the exudates  Ca is utilized in the granulation tissue formation Negative nitrogen balance  Due to stress response  o protein catabolism  Protein intake is lesser than the demand HypoK

BURNS
ASSESSMENT 1. Assess extent of body surface burned Greater morbidity & mortality for burns affecting face, hands & perineum Assess for dyspnea, stridor, hoarseness 2. Assess extent of burn injury Rule of nine immediate appraisal Lund-Browder chart more accurate Berkows method based on clients age & changes that occur in proportion of head & legs to the rest of the body as one grows

BURNS
ASSESSMENT 9%

9%

Front=18% Back=18%

9%

1% 18% 18%

Burn Evaluation Chart

BURNS
ASSESSMENT 3. Assess depth of burn Major burns 2nd degree over 30% of body Hospitalization - eyes, face, neck, hands, perineum, genitalia 4. Assess unique contributing factors Age of client Health history  Diabetes, preexisting ulcers  Tetanus immunization

BURNS
EMERGENCY MANAGEMENT Stop the burning process Remove patient from source of injury Advise client to roll on the ground if clothing is in flame [STOP-DROP-ROLL] Throw a blanket over the client to smother the flame Remove clothing only if hot or for scald burn Immerse affected part in cold water [10 min] Irrigate copiuosly w/ large amount of running water w/ chemical burns [except w/ phosphorus] Interrupt power source w/ electrical burn

BURNS
MANAGEMENT Maintenance of adequate airway Promoting comfort: relieve pain Promoting fluid-electrolyte, acid-base balance Preventing infection Maintaining adequate nutrition Wound care

BURNS
METHODS OF TREATING BURNS Open method or Exposure method  Face, neck, perineum, trunk  Allowing exudate to dry in 3 days Occlusive  Less pain, absorption of secretion, comfort, transportability, accelerated debridement  Aesthetic considerations Semi-open method  Covering of wound w/ topical antimicrobials:  Silver sulfadiazine 1% (Flamazine)  Silver nitrate 0.5% soln  Mafenide acetate (sulfamylon acetate)

BURNS
BIOLOGIC DRESSING (Skin Graft) Allograft  Skin taken from other person [cadaver] Autograft  Same person Heterograft  Different species  Xenograft [segment of skin from animal such as pig or dog]

BURNS
FLUID REPLACEMENT Types of fluids: Colloids  Blood  Plasma & plasma expanders Electrolytes  Lactated Ringers Non-electrolyte  D5W

BURNS
FLUID REPLACEMENT EVANS Formula: C 1ml x % burns x kgBW E - 1ml x % burns x kgBW Glucose 5% for insensible loss 2,000ml D5W  Administer soln 1st 24 hrs [1st 8hrs], [16hrs] BROOKE Formula: [Administer as in Evans] C 0.5ml x % burn x kgBW E - 1.5ml x % burns x kgBW Water 1000ml D5W

BURNS
FLUID REPLACEMENT MOORES BURN BUDGET: 75 ml of plasma, 75 ml of electrolyte-contg fluid for q 1%TBSA plus 2000 D5W HYPERTONIC RESUSCITATION Formula: Hypertonic salt containing 300mEq of Na+, 100mEq of Cl-, 200mEq lactate Administered to maintain urinary output of 3040 ml/hr