fluids and electrolytes منتدى تمريض مستشفى غزة الاوروبي

EGH-NSG.ForumPalestine.com

FLUIDS and ELECTROLYTES

Prepared byABED SHAGORA

In-service Education Department

EGH

2011 - 2012

FLUIDS and ELECTROLYTES

BODY FLUIDS

Functions of 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 joints.

– Component in all body cavities [parietal, pleural… fluids]

Water is the principal body fluid & essential for life.

BODY FLUIDS

ICF ECF

40% TBW 20% TBW

P IS

Distribution of Body Fluids – 50-70% of total body weight;

infant [70-80%], elderly [45-50%]

60-kg manTBW = 0.6 x 60 kg = 36 L

ICF = 0.4 x 60 kg = 24 L

ECF = 12 L

3L 9L

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 OUTPUTml/day ml/day

Fluid intake 1,200Food 1,000Metabolic water 300

TOTAL 2,500

Insensible loss 700Sweat 100Feces 200Urine 1,500

TOTAL 2,500

FLUID EXCHANGE BETWEEN BODY FLUID COMPARTMENTS

Osmotic Pressure Gradient

Oncotic P (Colloid osmotic P)

Capillary P (Hydrostatic P)

ICF ECF

P ISF

Control of Osmotic Pressure, Volume & Electrolyte

ConcentrationOBLIGATORY Reabsorption

occurs in the proximal tubules 178 L/day of glomerular filtrate (80%

reabsorbed) 2 to solute reabsorption independent of the water

requirement

FACULTATIVE Reabsorption occurs in the distal & collecting

tubules independent of the active solute

transport dependent of body’s need of water under the control of ADH

DISTURBANCES IN FLUID BALANCE

EDEMA

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 disease, nephrotic syndrome]

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 production of adrenal corticoid hormones [Cushing’s syndrome]

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 Hg and Hct Nausea & vomiting

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

DISTURBANCES IN FLUID BALANCE

CELL DEHYDRATION 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

DISTURBANCES IN FLUID BALANCE

CELL DEHYDRATION

Symptoms Thirst, dry mucus membranes,

sunken eyeballs “Doughy“ abdomen, dry skin w/

poor turgor temp, weight loss HR, RR, BP Restlessness,irritability,

disorientation, convulsion, coma [22-30% body H20 loss]

Management Fluid replacement therapy &

continued fluid maintenance

Volume Disorders 2° Alteration in Sodium Balance

Expansion Isotonic Inc N No net change Isotonic fluid

ingestion Hypertonic Inc Dec ICF ECF Sea water

ingestion Hypotonic Inc Inc ECF ICF Hypotonic IVF

Contraction Isotonic Dec N No net change Diarrhea Hypertonic Dec Dec ICF ECF Diabetes insipidus Hypotonic Dec Inc ECF ICF Addison’s disease

Volume ECF ICF Water Conditions Disorder Vol. Vol. Shift

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

ELECTROLYTE Composition

Electrolyte Conc Plasma (mEq/L) ISF ICF

Sodium, Na+ 142 141 10 Potassium, K+ 5 4.1 150Calcium, Ca++ 5 4.1 -Magnesium, Mg++ 3 3 40

(155)Chloride, Cl- 103 115 15Bicarbonate, HCO3- 27 29 10Biphosphate, HPO4- 2 2 100Sulfate, SO4-2 1 1 20Protein 16 1 60Organic foods 6 3.4 -

(155)

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

Hyponatremia [Na+ < 135 mEq/L; Normal = 135-145 mEq/L]

Causes Na+ intake Na+ excretion [diaphoresis, GI

suctioning] Adrenal insufficiency

Assessment N & V, abdominal cramps, weight

loss Cold, clammy skin, skin turgor Apprehension, HA, convulsions,

focal neurologic deficit, coma [cerebral edema]

Fatigue, postural hypotension Rapid thready pulse

ELECTROLYTES

Hyponatremia

Management Provide foods high in sodium Administer NSS IV Assess blood pressure

frequently [measure lying down, sitting & standing]

ELECTROLYTES

Hypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L]

Causes Excessive, rapid IV adm’n 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]

ELECTROLYTES

Hypernatremia

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

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 sol’n w/

potassium-conserving diuretics

ELECTROLYTES

Hyperkalemia

Assessment Thready, slow pulse Shallow breathing N & V, diarrhea, intestinal

colic Irritability Muscle weakness, flaccid

paralysis Numbness, tingling Difficulty w/ phonation,

respiration

ELECTROLYTES

Hyperkalemia

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+

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 solution

potassium-conserving diuretics

ELECTROLYTES

Hypokalemia

Assessment Thready, rapid, weak pulse Faint heart sounds BP Skeletal muscle weakness or absent reflexes Shallow respirations Malaise, apathy, lethargy Loss of orientation Anorexia, vomiting, weight loss Gaseous intestinal distention

ELECTROLYTES

Hypokalemia

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

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

ELECTROLYTES

Hypercalcemia

Nursing Interventions

Encourage mobilization Limit vitamin D intake Limit calcium intake Normal saline Administer diuretics Calcitonin

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

ELECTROLYTES

Hypocalcemia

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

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 pulse and respirations

Nursing Intervention Withhold Mg-cont’g drugs/foods;

Ca adm’n fluid intake, unless CI

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

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

Types of Solutions

Isotonic 0.9% sodium chloride (NSS) Lactated Ringer’s solution

Hypotonic 5% dextrose and water (D5W) 0.45% sodium chloride 0.33% sodium chloride

Hypertonic 3% NaCl Protein solution

Colloids Salt pour albumin

Plasmanate, Dextran

• 4/2/1 Rule4 ml/kg/hr for first 10 kg (=40ml/hr)then 2 ml/kg/hr for next 10 kg (=20ml/hr)then 1 ml/kg/hr for any kgs over that

This always gives 60ml/hr for first 20 kgthen you add 1 ml/kg/hr for each kg over 20 kg

This boils down to: Weight in kg + 40 = Maintenance IV rate/hour.For any person weighing more than 20kg

B U R N S

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]

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

B U R N S

STAGES OF BURNS

1st: Shock/Fluid Accumulation Phase

1st 48 hrs IVC ISC Generalized DHN [fluid shifting] Hypovolemia [plasma loss], BP, C.O. Hemoconcentration, Hct [liquid blood

component ISC] Oliguria [ renal perfusion], ADH release &

aldosterone HyperK, hypoNa Metabolic acidosis

B U R N S

STAGES OF BURNS

2nd: Diuretic/Fluid Remobilization Phase

After 48 hrs ISC IVC Hypervolemia, Hemodilution, Hct Diuresis [ renal perfusion], ADH &

aldosterone secretion HypoK, hypoNa [K moves back into the

cells, Na+ still trapped in the edema fluids Metabolic acidosis

B U R N S

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 protein catabolism Protein intake is lesser than the demand

HypoK

B U R N S

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 Berkow’s method – based on client’s age &

changes that occur in proportion of head & legs to the rest of the body as one grows

B U R N S

ASSESSMENT

B U R N S

9%

9% 9%Front=18%Back=18%

18% 18%

1%

Burn Evaluation Chart

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

B U R N S

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

B U R N S

MANAGEMENT

Maintenance of adequate airway

Promoting comfort: relieve pain

Promoting fluid-electrolyte, acid-base balance

Preventing infection

Maintaining adequate nutrition

Wound care

B U R N S

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% sol’n Mafenide acetate (sulfamylon

acetate)

B U R N S

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]

B U R N S

FLUID REPLACEMENT

Types of fluids:

Colloids Blood Plasma & plasma expanders

Electrolytes Lactated Ringers

Non-electrolyte D5W

B U R N S

FLUID REPLACEMENT

EVAN’S Formula:

C – 1ml x % burns x kgBW E - 1ml x % burns x kgBW Glucose 5% for insensible loss – 2,000ml

D5W

Administer sol’n 1st 24 hrs – ½ [1st 8hrs], ½ [16hrs]

BROOKE Formula: [Administer as in Evan’s]

C – 0.5ml x % burn x kgBW E - 1.5ml x % burns x kgBW Water – 1000ml D5W

B U R N S

FLUID REPLACEMENT

MOORES BURN BUDGET:

75 ml of plasma, 75 ml of electrolyte-cont’g 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 30-40 ml/hr

B U R N S