FLUID AND ELECTROLYTES

Anatomy and Physiology

TOTAL BODY WATER (TBW)
60% Body Weight

• INTRACELLULAR FLUID (ICF) 40%

• EXTRACELLULAR FLUID (ECF)20%
Interstitial
Intravascular
Trancellular
• THIRD SPACE FLUID
Disease; injury
 Electrolytes

 Na Extracellular CATION
 Cl Extracellular ANION
K Intracellular CATION
 PO4 Intracellular ANION
Body Fluid Transport
• DIFFUSION
Higher to lower concentration
• OSMOSIS
Lower to higher concentration
Semi permeable membrane
• FILTRATION
Particles
• ACTIVE TRANSPORT
Na-K Pump
Requires ATP
 Fluids

• BODY INPUT • BODY OUTPUT

Fluids 1500mL Urine 1500mL
Food 500mL Feces 200-400mL
Digestion 500mL Respiration200-400mL
Total >2500mL Skin 200-400mL
Total >2500mL
 Intravenous Fluids

 ISOTONIC:
Equal in concentration
• 0.9% NaCl or NSS
• D5 Water, Lactated Ringer’s
 Intravenous Fluids
 HYPOTONIC:
↓ Salt or solute
Cellular swelling
• 0.45% NaCl, Distilled water

 HYPERTONIC:
↑ Solute
Cellular shrinkage
• D5 NSS, D10 Water
• D5 0.45 % NaCl, D5 LRS
FLUID VOLUME DEFICIT

DEHYDRATION
Inadequate Intake
Excessive Loss

Types:
• ISOTONIC Dehydration
• HYPERTONIC Dehydration
• HYPOTONIC Dehydration
FLUID VOLUME DEFICIT
Assessment:
↓ BP; ↑ PR
Weak and thready pulses
Flat neck veins
Lethargic to coma
Dry skin; poor skin turgor
Oliguria (↓ UO)
↑ Urine specific gravity
Thirst
 FLUID VOLUME DEFICIT
Management:
Monitor VS; BP and PR
Mild: Oral Rehydrating Solution (ORS)
Severe: IV fluid
Administer prescribed meds
• Antibiotics
• Antiemetics
• Antipyretics
Monitor/ correct electrolyte imbalances
FLUID VOLUME EXCESS
FLUID OVERLOAD

Types:
• ISOTONIC
• HYPOTONIC
• HYPERTONIC
FLUID VOLUME EXCESS
Assessment:
↑ BP and CVP
Bounding pulse
↑ RR, Dyspnea
Crackles
Distended neck vein
Altered level of consciousness
Weight gain
Ascites; pedal edema
Polyuria
FLUID VOLUME EXCESS
Management:
Monitor VS: BP and RR
Monitor I and O
Restrict fluid and Na intake
Weight and AC OD pre-breakfast
Administer prescribed diuretics
Monitor/treat electrolyte imbalances
HYPOKALEMIA
Normal K 3.5-5.0 meq/L
K ↓ 3.5 meq/L

Causes:
Diuretics, digitalis, and steroids
Cushing’s syndrome
Metabolic Alkalosis
Diarrhea, NPO
↑ Insulin
HYPOKALEMIA
Assessment:
Weak irregular pulses
ECG:
• U wave
• Inverted T waves
Altered LOC
Shallow respiration
Weakness; hyporeflexia
Ileus; constipation
 HYPOKALEMIA
Management:
Monitor VS; PR
Monitor serum K values
Bed rest
Encourage K-rich foods:
• Banana, avocado, raisins,
orange, potatoes
Diet: High fiber foods
K- sparing diuretics
• Spirinolactone (Aldactone)
HYPOKALEMIA
Management:
• Oral Potassium
Kalium Durule (PC)
K-Lor
• IV Potassium
NEVER given by IV push, IM nor SC
5-10 meq/hr
Use of cardiac monitor
Assess IV site
HYPERKALEMIA
K ↑ 5.5 meq/L

Causes:
Excessive K intake
K sparing diuretics
Addison’s disease
Chronic renal failure (CRF)
Metabolic Acidosis
Tissue damage; injury
HYPERKALEMIA
Assessment:
Irregular weak pulses, ↓ BP
ECG:
• Tall T wave
• Flat P wave
Muscular weakness
Paresthesia
Diarrhea
HYPERKALEMIA
Management:
Monitor VS
Restrict K rich foods
Discontinue K supplements PO/ IV
If no renal disease; Diuretics
Na polystyrene sulfonate (KAYEXALATE)
→ K excretion
Prepare for dialysis
Administer NaHCO3
Glucose with insulin
 HYPONATREMIA
Serum Na 135-145meq/L
Na ↓ 135 meq/L

Causes:
Diuretics
Diaphoresis
Addison’s Disease
SIADH
NPO, ↓ Salt diet
Freshwater drowning
HYPONATREMIA
Assessment:
↑ Pulse rate
Shallow respiration
Headache; altered LOC
Seizures
Weakness
Polyuria (↑ UO)
HYPONATREMIA
Management:
Monitor VS
Monitor LOC
Intake of Na rich foods:
→Table salt, soy sauce, cured pork,
canned and processed foods
Hypovolemia: IVF NSS (ISOTONIC)
Fluid excess: Osmotic diuretics
SIADH: Lithium and Demeclocycline
→ Antagonize ADH
Seizure precautions
HYPERNATREMIA
Na ↑145 meq/L

Causes:
Steroids
↑ Na intake
↓ Water intake
Cushing’s syndrome
Chronic renal failure (CRF)
HYPERNATREMIA
Assessment:
↓ PR
Shallow respiration
Weakness
Dry flaky skin
Altered LOC
Oliguria (↓ UO)
HYPERNATREMIA
Management:
Monitor VS
Restrict Na and fluid
Diuretics
Hypovolemia: D5W and HYPOTONIC IVF
 HYPOCALCEMIA
Serum Ca 8-10.5 mg/dL
4.5-5.5 meq/L
Ca ↓ 8 mg/dL

Causes:
↓ Intake of Ca and vitamin D
Lactose intolerance
Parathyroidectomy
CRF
Diuretics
HYPOCALCEMIA
Assessment:
Irregular pulses
ECG Prolonged ST interval
Prolonged QT interval
Paresthesia; numbness
Weakness
Tetany; carpopedal spasm
(+) Trosseau’s sign
(+) Chvostek’s sign
HYPOCALCEMIA
Management:
Monitor VS; PR/ CR
Monitor serum Ca and Mg
Encourage Ca-rich foods:
Milk and poultry, cheese, eggs
Oral Ca supplement:
• CaCO3 (Calci-Aid)
1-2 hrs PC or HS
HYPOCALCEMIA
Management:
IV Ca:
• Calcium Gluconate
Given very SLOWLY
Never thru IV push, IM or SQ
Use of cardiac monitor
Assess PR/ CR
HYPERCALCEMIA
Ca ↑10.5mg/dL

Causes:
Excessive intake of Ca or Vitamin D
Use of Thiazides; Lithium
Hyperparathyroidism
Malignancy
Immobility; Fracture
HYPERCALCEMIA
Assessment:
Irregular CR cardiac arrest
ECG:
• Shortened ST interval
Altered LOC
Muscle weakness
Colic pain → Renal stones
Constipation
 HYPERCALCEMIA

Management:
Monitor VS; CR
Restrict Ca rich foods
Discontinue PO and IV Ca
Give prescribed Diuretics
↑ Fluid intake
• Calcitonin; Biphosphanates
• ASA and NSAIDS
→Inhibit Ca resorption from bones
Prepare for dialysis
ACID BASE BALANCE
Hydrogen ions (H) → pH

 ACIDS → Hydrogen donors

 BASES → Hydrogen acceptors
CARBONIC ACID/ BICARBONATE
SYSTEM
Maintains pH of 7.4
Bicarbonate to Carbonic Acid Ratio 20:1

 CARBONIC ACID Lungs

 BICARBONATE Kidneys
ACID BASE BALANCE

 ACIDOSIS → Hyperkalemia (↑ K)
 ALKALOSIS → Hypokalemia (↓ K)
ARTERIAL BLOOD GAS

PH 7.35- 7.45
PCO2 35- 45 mmHg
HCO3 22- 26 meq/L
PO2 80- 100 mmHg
ARTERIAL BLOOD GAS
 ROME
• Respiratory Acidosis ↓pH ↑pCO2
• Respiratory Alkalosis ↑pH ↓pCO2
• Metabolic Acidosis ↓pH ↓HCO3
• Metabolic Alkalosis ↑pH ↑HCO3
ARTERIAL BLOOD GAS
Pre-op care:
 ALLEN’S Test

Rest x 30 min
 NO SUCTION
 Note O2 therapy

Room air: → No O2
 Prepare heparinized syringe
ARTERIAL BLOOD GAS
Post-op care:
Container with ice
Client’s temperature
 O2 and respirator set up
 Pressure dressing x 5-10 min
RESPIRATORY ACIDOSIS
 ↓pH ↑pCO2

Causes:
 Pulmonary Diseases:
• PTB, Pneumonia
• COPD, B. Asthma
 Brain Injury
 Medications:
• Sedatives, Narcotics, Anesthetics
RESPIRATORY ACIDOSIS

Assessment:
 HYPOVENTILATION

(Rapid, shallow breathing)

↑ PR
Headache
 Blurring of vision
 Restlessness

 Cyanosis
RESPIRATORY ACIDOSIS
Management:
 Semi to high fowlers

 Monitor VS; RR

 Administer O2

 Coughing and deep breathing exercises

Turning from side to side

Encourage hydration
Suction secretion PRN
Appropriate treatment as prescribed
• Bronchodilators, Antibiotics
• Respirator; CTT/ Thoracentesis
RESPIRATORY ALKALOSIS
 ↑pH ↓pCO2

Causes:
 Hysteria

 Anxious; panic states

 Severe pain; fever

 Over- use of respirator

RESPIRATORY ALKALOSIS
Assessment:
 HYPERVENTILATION

(Rapid, deep breathing)

Headache; dizziness
Mental status changes
 Paresthesia
 Weakness

 Tetany; carpopedal spasm

RESPIRATORY ALKALOSIS
Management:
 Monitor VS; RR

 Emotional support and reassurance

 Appropriate breathing patterns: → ↑pCO2

• Brown bag
• Voluntary holding of breath
Monitor electrolytes
 Cautious care with clients on respirator
Administer prescribed medication
 METABOLIC ACIDOSIS
 ↓pH ↓HCO3

Causes:
 DM/DKA
 CRF

Starvation; malnutrition
Lactic acidosis
 ASA and ethanol intoxication
 Severe diarrhea
METABOLIC ACIDOSIS
Assessment:
 KUSSMAUL BREATHING

(Rapid, deep breathing)

Irregular pulses
Headache
 Altered LOC
 Fruity or ketone breath

 ↑ Serum K
 METABOLIC ACIDOSIS
Management:
 Monitor VS; RR and PR
 Assess LOC

Monitor I and O
 Assess and correct serum K
Safety and seizure precaution
 Administer NaHCO3
 Administer Kayexalate

DM: Give prescribed insulin

CRF: Prepare for dialysis
METABOLIC ALKALOSIS
 ↑pH ↑HCO3

Causes:
 Excessive NaHCO3 intake

 Chronic use of diuretics

 Excessive vomiting/GI suctioning

Several BT with FWB (Citrate)

METABOLIC ALKALOSIS
Assessment:
 Nausea and vomiting
 Irregular pulses

Restlessness
Paresthesia
 ↓ Serum K
METABOLIC ALKALOSIS
Management:
 Monitor VS; PR

Assess and correct serum K

Safety precautions
 Discontinue HCO3
 Administer prescribed anti-emetics