fluids and electrolytes منتدى تمريض مستشفى غزة الاوروبي
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منتديات تمريض مستشفى غزة الاوروبيTRANSCRIPT
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