Fluid and electrolyte pp

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SPCADN
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Fluid and electrolyte pp
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2012-04-10 22:58:31
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Fluid electrolyte
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  1. Fluids in the body
    Adults–– 60 % total body weight

    • •Water –
    • largest single constituent of the body

    –Infants -80% total body weight
  2. What two diffrent areas of fluid are in the body?
    •Two basic areas–Intracellular•40% of total body weight - 28 L–Extracellular•Interstitial fluid - 15%•Plasma - 5%•Cerebrospinal, intraocular, etc
  3. How does body lose water?
    • Leaves the body through the kidneys,
    • lungs, skin & GI tract

    Average losses /day through GI = sm

    • Average losses /day through kidneys =
    • 1500 mls

    • Average losses /day through skin &
    • lungs = 100 mls
  4. How does water leave sink and lungs?
    •> Respiratory rate

    •Fever

    •Hot & dry environment

    •Injury to the skin, i.e., burns
  5. Kidney water loss
    •Varies with solute load

    •Varies with ADH

    •10% loss (4L) is serious

    •20% loss (8L) is usually fatal
  6. How do we replace water?
    Ingestion

    • Cellular Metabolism
  7. What is metabolism
    • •Combustion of foodstuffs yields water of
    • oxidation

    • •100 calories releases 14 mls
    • of water
  8. What influences fluid output
    •ADA

    •Aldosterone (regulates Na+ & K+)

    –Excretes K+

    –Reabsorbs Na+

    •Glucocorticoids
  9. What causes Fluid volume deficit (FVD)
    •GI losses

    •Blood loss

    •Burns

    •> perspiration

    •Fever

    •< oral intake

    •Use of diuretics
  10. What are the Physical findings of Fluid volume deficit?
    –Postural hypotension

    –Tachycardia

    –Dry skin & mucous membranes

    –Poor skin turgor

    –Rapid weight loss

    –Collapsed veins

    –Lethargy

    –Oliguria

    –Weak pulse
  11. Labs for Fluid volume deficit?
    –Urine specific gravity > 1.025

    –> hematocrit level > 50%

    • –> blood urea nitrogen (BUN)
    • level > 25mg/100ml
  12. What are causes of fluid volume excess?
    CHF

    –Renal failure

    –Cirrhosis

    • –> serum aldosterone &
    • steroid levels

    –> Na+ intake
  13. The physical findings of fluid volume excess?
    –Rapid weight gain

    • –Edema (especially in dependent
    • areas)

    –>BP

    –Polyuria

    –Neck vein distention

    –> venous pressure

    –Crackles in lungs
  14. Fluid volume excess labs?
    –< hematocrit level < 38 %

    –< BUN level < 10 mg/100ml
  15. What is Third Space Syndrome?
    • Fluid held in the interstitial area,
    • which makes fluid inaccessible to the body
  16. What causes third space syndrome?
    –Burns

    –Sepsis

    –Multisystem organ failure

    –Liver failure

    –Peritonitis

    –Small bowel obstruction
  17. The physical findings of third space syndrome
    •Physical findings

    • –Increased abdominal girth (with
    • ascites) & small bowel obstruction
  18. The lab findings of third space syndrome
    Laboratory findings

    –< serum Na+ < 135 mEq/L

    • –< albumin level < 3.5
    • gl100/ml

  19. Osmolar Imbalances
    Hyperosmolar Imbalance

    • •Hypoosmolar
    • Imbalance
  20. What causes hyperosmolar imbalance?
    Causes

    –Diabetes insipidus

    • –Interruption of neurologically
    • driven thirst drive

    –Diabetic ketoacidosis

    –Osmotic diuresis

    • –Administration of hypertonic
    • fluids
  21. The physical findings of hyperosmolar imbalance?
    Physical findings

    –Weight loss

    –Dry & sticky mucous membranes

    –Flushed & dry skin

    –Thirst

    –> body temperature

    –Irritability

    –Convulsions

    –Coma
  22. THe lab findings of Hyperosmolar imbalance?
    •Laboratory findings

    –> Serum Na+ level > 145 mEq/L

    –> Serum osmolality > 295 mOsm/kg
  23. What causes hypoosmolar imbalance?
    •Causes

    –SIADH

    –Excess water intake
  24. They physical findings of hypoosmolar imbalance?
    •Physical findings

    – < LOC

    –Convulsions

    –Coma
  25. THe lab findings of hypoosmolar imbalance?
    •Laboratory findings

    –< Serum Na+ < 136 mEq/L

    –< Serum osmolality < 280 mOsm/kg
  26. Iv solutions
    •0.9% (normal) saline

    •Tonicity

    –Isotonic

    •Uses

    –Adds saline

    –Expands ECF volume

    •Comments

    –Overuse causes saline excess
  27. IV
    Solutions
    •0.45% (half-normal) saline

    •Tonicity

    –Hypotonic

    •Uses

    –Adds H2O & some Na+

    •Comments

    –Overuse causes hyponatremia
  28. IV
    Solutions
    •5% Dextrose/water (D5W)

    •Tonicity

    • –Isotonic upon infusion; hypotonic
    • after dextrose enters the cells

    •Uses

    –Adds water & calories

    •Comments

    –Overuse causes hyponatremia
  29. IV
    Solutions
    5% dextrose/0.9% saline

    •Tonicity

    • –Hypertonic upon infusion;
    • isotonic after dextrose enters the cells

    •Uses

    • –Adds saline & calories;
    • expands ECF volume

    •Comments

    –Overuse causes saline excess
  30. IV
    Solutions
    •5% dextrose/0.45% saline

    •Tonicity

    • –Hypertonic upon infusion;
    • hypotonic after dextrose enters the cells

    •Uses

    –Adds H2O, some Na=, & calories

    •Comments

    –Overuse causes hyponatremia
  31. IV
    Solutions
    •Lactated Ringer’s

    •Tonicity

    –Isotonic

    •Uses

    • –Fluid & electrolyte
    • replacement

    •Comments

    –Contains Na+, K+, Ca--, & lactase
  32. IV
    Solutions
    •1% saline

    •Tonicity

    –Hypertonic

    •Uses

    –Treatment of severe symptomatic hyponatremia

    •Comments

    –Overuse causes hypernatremia
  33. Fluid
    Solutions
    Isotonic

    –Same concentration of body fluids

    •Hypotonic

    –< concentration of solutes

    –Promotes fluid into cells

    –½ NS

    •Hypertonic

    –> concentration of solutes

    –Promotes fluid out cells

    –D5W
  34. What is the nature of electrolytes?
    • Compounds that dissociate in solution to
    • become ions

    Carry an electrical charge
  35. Cations
    • –Electrolytes that carry a –
    • charge
  36. Anions
    • Electrolytes that carry a +
    • charge
  37. Cations
    •Na+

    •K+

    •Ca++

    •Mg++
  38. Anions
    • Cl-
    • (chloride)

    •HCO3- (bicarbonate)

    •HPO4- (phosphate)

    •SO4 -- (sulfate)
  39. Principle
    ECF Electrolytes
    •Na+

    •Ca++

    •HCO2-
  40. Principle
    Cellular Electrolytes
    •K+

    •Mg++

    •HPO4--

    •Cl-

    •HPO4—

    •SO4--
  41. Sodium
    •Maintains H2O balance

    •Extracellular

    •ADH

    •Intracellular

    –10 mEq./L

    •Excreted in urine

    •Controlled by kidney

    •Average intake

    –6 -15 Gms

    •Acid – Base Balance

    •Transmits nerve impulses – muscles

    •Regulated

    –Intake

    –Aldosterone

    –Output

    –ADH
  42. Hypernatremia
    Causes

    –Intake

    –Hypertonic IV solutions

    –> Aldosterone secretion
  43. What are the Hypernatremia
    S & S
    •Thirst

    •Dry & flushed skin

    •Dry tongue & mucous membranes

    •Fever

    •Agitation

    •Convulsions

    •Restlessness

    •Excitability

    •Oliguria or anuria
  44. Hypernatremia
    Intervention
    • Tx
    • underlying cause

    •Replace with oral fluids

    • •IV fluid replacement –D5W
    • followed by ½ NS

    • •Replace gradually (48) to prevent brain
    • cells swelling

    •Restrict Na+ intake
  45. What causes hyopnatremia?
    • Kidney
    • Disease

    • •Adrenal
    • Insufficiency

    • •GI
    • Fluid Losses

    • •>
    • Sweating

    •Diuretics

    • •<
    • Na+ Diet

    • •Na+
    • - K+ Pump Interruptions

    • •Metabolic
    • Acidosis
  46. Hyponatremia Dx Studies
    •Serum sodium level < 135 mEq./L

    •Serum osmolarity < 280 mOm/K

    •Urine specific gravity < 1.010
  47. what are Hyponatremia S & S
    •Apprehension, Anxiety

    •Personality Changes

    •Postural Hypotension

    •Postural Dizziness

    •Abdominal Cramping

    •N & V with Diarrhea

    •Tachycardia

    •Convulsions

    •Coma

    • •Fingerprints remain on sternum after
    • palpation

    •Cold, Clammy skin
  48. Hyponatremia Interventions
    Mild

    – Restrict fluid intake

    –Oral Na+ supplements

    –Isotonic IV fluids

    –High Na+ diet

    •Moderate – Severe

    • –Hypertonic IV solution infused
    • slowly

    –Furosemide
  49. Potassium
    Range

    –3.5 – 5.0 mEq./L

    •Controls cellular osmotic pressure

    •Activates enzymatic reactions

    •Acid – Base balance

    •Influences kidney function

    •Neurormuscular excitability
  50. Hyperkalemia
    • •Serum
    • level is > 5.0 mEq/L

    •Causes

    –> ECF K+ concentration

    •Resulting from

    •< K+ excretion

    •> body K+ concentration

    •Abnormal K+ distribution

    • •Metabolic
    • Acidosis

    • •Cell
    • injury

    • •>
    • dietary intake
  51. Hyperkalemia
    Drug induced

    –K+

    –Spironolactone

    –Beta blockers

    –Some antibiotics

    –Chemotherapy

    –Nonsteroidal anti-inflammatory drugs
  52. Hyperkalemia
    S & S
    Paresthesia

    •Muscle weakness

    •Anxiety

    •Irritability

    •Slow or irregular pulse

    •V fib

    •Cardiac Arrest
  53. Hyperkalemia
    Dx Studies
    Serum > 5.5 mEq./L

    •ECG changes

    –Peaked T waves

    –P waves disappear (if persist)

    –QRS widens

    –V fib

    –Asystole
  54. Hyperkalemia
    Dx Studies
    • Serum
    • level < 3.5 mEq/L

    • •Skeletal
    • muscle weakness

    •Paresthesia

    • •Leg
    • cramps

    • •Deep
    • tendon reflexes < or –

    •Paralysis

    • •Anorexia,
    • nausea & vomiting

    •Polyuria
  55. Hyperkalemia
    Dx Studies
    < Bowel sounds

    •Constipation

    •Weak & irregular pulse

    •Orthostatic BP

    •ECG

    – flat T wave

    – depressed ST segment

    –U wave
  56. Hyperkalemia
    Caution
    • A patient taking digitalis and a diuretic
    • should be watched closely for hypokalemia which can potentiate the action of
    • the digitalis and cause toxicity
  57. Hyperkalemia
    Interventions
    High K+ diet

    •Oral K+ supplement

    •IV K+ solutions (Never give IV push, it could be fatal)

    • •Monitor VS, ECG, serum K+ levels, I &
    • O
  58. Hypokalemia
    Causes

    –< intake

    –Severe GI fluid loss

    • •Suction, lavage, prolonged
    • vomiting

    • •Diarrhea, fistulas or laxative
    • abuse

    –Diuresis

    • –High glucose concentration in
    • urine

    –Cushing’s syndrome

    –Periods of high stress
  59. Hypokalemia
    Causes

    –< intake

    –Severe GI fluid loss

    • •Suction, lavage, prolonged
    • vomiting

    • •Diarrhea, fistulas or laxative
    • abuse

    –Diuresis

    • –High glucose concentration in
    • urine

    –Cushing’s syndrome

    –Periods of high stress
  60. Hypokalemia
    • Drug
    • induced

    –Diuretics, esp. thiazide & furosemide

    –Antibiotics

    •Gentamicin

    •Carbenicillin

    –Laxative abuse

    –Corticosteroids

    –Insulin

    –Cisplatin

    • –Adrenergic agents i.e., albuterol &
    • epinephrine
  61. Calcium
    •Influence of serum Ca++

    –Deposition/reabsorption of bone

    –Absorption from GI

    –Excretion from GI & GU

    •Serum range

    –8.8 – 10.5 mg/100ml

  62. Calcium
    Function
    Cell

    –Adherence

    –Maintain shape

    –Affections cell membranes

    •Cofactor

    –Blood coagulation

    •Bones & Teeth

    –Strengthens
  63. Hypercalcemia
    •Occurrence

    –Rate of Ca++ > kidney’s excretion

    •Diseases

    –Hyperparathyroidism

    –Cancer

    –Paget’s Disease

    –Osteoporosis

    –Prolonged Immobilization

    –Pheochromocytoma

    –Acromegaly

    –Vit A intoxication
  64. Hypercalcemia S & S
    •Fatigue

    •Malaise

    •Anorexia

    •N & V

    •Constipation

    •Metallic taste

    •Altered mental status

    •Muscle weakness

    •Depression

    •Hypertension

    •Hyporeflexia

    •Cardiac arrhythmias
  65. Hypercalcemia Dx Studies
    Serum Ca++ level > 10.5 mg/dl

    •ECG Changes

    –Shortened OT interval

    –Slightly widened QRS complex

    –Slightly prolonged PR interval

  66. Hypercalcemia Interventions
    Serum Ca++ > 13 mg/dl

    –Medical emergency

    • –IV isotonic NS, rate 200 – 500
    • ml/hr

    –Loop diuretic

    •I & O

    •Mg + & K+

    • –Replace large amounts lost in
    • urine

    •Drugs

    –Plicamycin, Phosphate, & calcitonin

    IV – Phosphate (extreme emergency
  67. Hypocalcemia
    –Dx Studies

    • •Serum Ca++
    • < 8.8 mg/dl

    •ECG changes

    •Causes

    • –Rapid administration of blood
    • containing nitrate

    –Hypoalbuminemia

    –Hypoparathyroidism

    –Vit D deficiency

    –Neoplastic diseases

    –Pancreatitis
  68. Hypocalcemia S & S
    • Numbness
    • & tingling of finger & circumpolar region

    • •Hyperactive
    • reflexes

    • •+
    • Trousseau’s

    •+ Chvostek’s

    •Tetany

    • •Muscle
    • cramps

    • •Pathological
    • fractures
  69. Hypocalcemia Interventions
    •Correcting the imbalance

    •Oral Ca++

    •IV Ca++ gluconate pr Ca++ Cl-

    • •Vit
    • D supplement

    •Diet

    –Ca++, Vit D, & Protein
  70. Magnesium
    Major intracellular anion

    • –Factor for many enzymatic &
    • metabolic processes

    •Normal Serum level = 1.5 – 2.5 mEq./L

    •Essential to cellular processes

    –Energy storage

    • –CHO, Protein, & Fat
    • metabolism
  71. Hypermagnesmia
    • Dx
    • Studies

    –Serum level > 2.5 mEq./L

    Causes

    • –Prolonged IV therapy with Mg++
    • solutions

    –Severe malabsorption

    –Prolonged NG suctioning

    –Acute pancreatitis

    –Primary aldosteronism

    –Diabetic acidosis

    –Chronic alcoholism

    –Renal failure
  72. Hypermagnesmia
    Signs & Symptoms

    –< Deep tendon reflexes

    –< Depth & rate of R

    –< BP

    –Flushing

    –Generalized weakness

    Serious

    • Respiratory
    • muscle paralysis


    Complete heart block


    Cardiac arrest
  73. Hypermagnesemia Interventions
    IV fluids

    •> Fluid intake

    •Loop diuretic

    • •Ca++
    • gluconate (emergency)

    •hemodialysis
  74. Hypomagnesemia
    • •Dx
    • Studies

    –Serum Mg++ level < 1.05 mEq./L

    –Associated with hypocalcemia & hypokalemia
  75. Hypomagnesemia Causes
    –Inadequate intake

    –Malnutrition

    –Alcoholism

    –Inadequate absorption

    –Vomiting

    –NF drainage

    –Burns

    –Sepsis

    –Thiazide diuretics

    –> Dietary Ca+

    –Diarrhea

    –Fistulas

    –Aldosterone excess

    –Polyuria
  76. Hypomagnesemia
    Signs & symptoms

    –Muscular tremors

    –Hyperactive deep tendon reflexes

    –Confusion & disorientation

    –Dysrhythmias

    –+ Chvostek’s (facial twitching)

    • + Trousseau’s (carpal spasm when the upper arm is
    • compressed
  77. Chloride
    Main ECF anion

    •Maintains normal ECF osmolarity

    •Affects body fluid pH

    •Major role in acid-base balance

    •Produces HCl-

    •Normal serum levels 96 – 106 mEq/L

    •Absorbed in the GI tract
  78. Hypochoremia
    • Dx
    • studies

    –Serum Cl- < 96 mEq/L

    –Serum Na+ < 135 mEq/L

    –Serum pH > 7.45

    –Serum bicarbonate > 26 mEq/L

    •Metabolic alkalosis

  79. Hypochoremia Causes
    • < dietary Cl-
    • intake

    •Prolonged vomiting

    •GI suctioning

    •Diuretic therapy
  80. Hypochoremia Interventions
    •Correct underlying cause

    •Administration of fluids

    •> Dietary intake

    –Tomato juice or salty broth
  81. Hypochoremia S & S
    •R slow & shallow, arrest

    • –S & S of acid – base &
    • electrolyte imbalance

    –Tetany, muscle cramps

    –Hyperactive deep tendon reflexes

    –^pH – alkalosis

    –Agitation, irritability

    –Seizures & coma
  82. Hyperchoremia
    • Dx
    • Studies

    –Serum Cl- > 106 mEq/L

    –Serum Na+ > 145 mEq/L

    –Serum pH < 7.35

    –Serum bicarbonate < 22 mEq/L

    –Metabolic acidosis
  83. Hyperchoremia
    Causes

    –Water loss

    –> absorption by bowel with anastomoses

    –Dehydration

    –Metabolic acidosis

    –Renal failure

    –Respiratory failure

    –Hyperparathyroidism

    –Hypernatremia

    –Hyperaldosteronism

  84. Hyperchoremia
    Drug induced

    –Acetazolamide

    –Ammonium chloride

    –Phenylbutazone

    –Kayexalate

    –Salicylates (overdose)

  85. Hyperchoremia S & S



    Tachypnea

    •Tachycardia

    •Lethargy

    •Weakness

    • •Diminished
    • cognitive ability

    •Kussmaul’s respiration

    • •Decreased
    • cardiac output

    •Coma
  86. Hyperchoremia Interventions
    •Correct underlying cause

    •Diuretics

    •Fluids to dilute the Cl-

    • •Restrict Na+ & Cl-
    • intake

    •IV lactated Ringer’s solution

    •IV Na+bicarbonate
  87. Phosphate
    •Major intracellular anion

    •Essential to cellular process

    –Energy storage

    –CHO, protein & fat metabolism

    • H+ major intracellular buffer

    –Maintains acid-base balance

    •Paired with Ca+

    • –Forms essential bone & tooth
    • component

    – Approximately 85%M
  88. Phosphorus
    Serum level – 2.5 – 4.5 mg/dl (1.8 – 2.6 mEq/L

    •Controlled by parathyroid
  89. Hypophosphatemia
    •Serum < 2.5 mg/dl (1.8 mEq/L)

    •Causes

    –Respiratory alkalosis

    –Hyperventilation

    –Sepsis

    –Alcohol withdrawal

    –Hyperthyroidism

    –Extensive Burns
  90. Hypophosphatemia
    •Diuretics – most common cause

    –Thiazides

    –Loop Diuretics

    –Acetazolamide

    •Second most common cause

    –Diabetic ketoacidosis

    •High glucose levels
  91. Hypophosphatemia
    S & S
    Weakness

    •Malaise

    •Anorexia

    •Weakened hand grasp

    •Slurred speech or dysphagia

    • •Myalgia (tenderness or pain in the
    • muscles

    •Confusion, apprehension, irritability

    •< BP
  92. Hypophosphatemia
    Intervention
    Diet high in phosphorus

    • –Eggs, nuts, whole grains, meat,
    • fish, poultry, & milk

    •Oral phosphorus supplements

    •IV phosphorus

    –Potassium phosphorus

    –Sodium phosphorus
  93. Hyperphosphatemia
    • Serum
    • phosphorus level > 4.5 ml/dl (2.6 mEq/L)

    • •Severe
    • at 6.0 mg/dl

    •Causes

    –Kidney’s inability to excrete

    –Hypoparathyroidism

    –Respiratory acidosis

    –Diabetic ketoacidosis

    –Cellular destruction

    –Excessive intake & > Vitamin D
  94. Hyperphosphatemia S & S
    • Inverse
    • relationship with Ca++ , therefore may be life threatening

    •Paresthesia (fingertips & mouth)

    • •Muscle
    • spasm

    •Cramps

    •Pain

    •Weakness

    •+ Chvostek’s & Trousseau’s signs

    •Hyperreflexia

    • •Prolonged
    • QT interval & ST segment

    • •Anorexia,
    • nausea, & vomiting
  95. Hyperphosphatemia Intervention
    Low – phosphorus diet

    •Decrease absorption with drug therapy

    –Aluminum, magnesium, or calcium

    •Treat underlying cause

    •IV solution of saline

    –Must have functional kidneys

    –Hemodialysis

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