fluid an dd.ppt
- 1. Figure 24.1 2 Dietary Input Digestive Secretions Water Reabsorption Food and drink 2200 mL The digestive tract sites of water gain through ingestion or secretion, or water reabsorption, and of water loss Small intestine reabsorbs 8000 mL Colon reabsorbs 1250 mL 150 mL lost in feces 1400 mL 1200 mL 9200 mL 5200 mL Colonic mucous secretions 200 mL Intestinal secretions 2000 mL Liver (bile) 1000 mL Pancreas (pancreatic juice) 1000 mL Gastric secretions 1500 mL Saliva 1500 mL
- 2. Fluid Imbalances 2 Water output by the body under varying conditions . Testing for dehydration . From Fritz S: Mosby’s fundamentals of therapeutic massage, ed 5, St Louis, 2013, Mosby . Testing for dehydration .
- 3. Normal Lab Results : - Na 135 145mEq/L → − . - K+ 3.5 5.5mEq/L → − . - Ca++ 8.5 10.5mEq/L → − . - Cl 96 106mEq/L → − . - Mg 1.5 2.5mEq/L → − .
- 4. Homeostasis of electrolytes Electrolyte balance related to “intake” and “output” of specific electrolytes Sodium imbalance Hypernatremia: Blood sodium level >145 mEq/L Hyponatremia: Blood sodium level <136 mEq/L Potassium imbalance Hyperkalemia: Blood potassium level >5.5 mEq/L Hypokalemia: Blood potassium level <3.5 mEq/L Calcium imbalance Hypercalcemia: Blood calcium levels above normal Hypocalcemia: Low blood calcium levels 4 Electrolyte Imbalances
- 5. Fluid Volume Disturbance (FVD) : I-Hypovolemia (fluids volume deficit): − Contributing Factors: * Loss of water and electrolyte. e.g.( vomiting, diarrhea, burns). * Decrease intake. e.g. (anorexia, nausea, inability to gain access to fluids). * Some disease.e.g (D.M, Diabetic Insipidus). − Sings and symptoms: Weight loss, general weakness, dizziness, increase pulse.
- 6. Assessment Diagnostic evaluation History & Physical examination Serum BUN & Creatinine Hematocrit level “great than normal” Urine specific gravity Serum electrolytes level Hypokalemia in case of GI & renal loss Hyperkalemia in case of adrenal insufficiency Hypernatremia in case of insensible losses & ↑ diabetic insepedus
- 8. Management: • Treatment of the causes of FVD should be go with treatment of FVD itself • Factors influence the patient fluid needs should be taken in consideration • In case of sever or acute FVD IV replacement should be started • Isotonic solutions used to treat hypotension resulted from FVD • Renal function & hemodynamic status should be evaluated Nursing Management Monitor I&O as needed “urine” Monitor V/S, skin turgor , mental status & daily weight Extensive Hemodynamic CVP, arterial pressure Mouth care & ↓ irritating fluids
- 9. Fluid Volume Disturbance : II- Hypervolemia (fluid volume excess): − Contributing Factors: * Compromised regulatory mechanism such as renal failure, congestive heart failure, and cirrhosis. * Administration of Na+ containing fluids. * Prolong corticosteroid therapy. * Increase fluid intake. − Sings and Symptoms: Weight gain, increase blood pressure, edema, and shortness of breathing.
- 10. Assessment & Diagnostic Evaluation •Decreased BUN , Creatinine , Serum osmolality & hematocrete because of plasma dilution, &↓protein intake •Urine sodium is increased if kidneys excrete excess fluid •CXR may disclosed pulmonary congestion
- 11. Management Direct cause should be treated Symptomatic treatment consist of : - Diuretics - restrict fluid & Na intake - Maintained electrolytes balance - Hemodialysis in case of renal impairment - K+ supplement & specific nutrition Nursing Management: - Assess breathing , weight ,degree of edema regularly - I & O measurement regularly - Semisitting position in case of shortness of breath - Patient education
- 12. Electrolyte functions Electrolytes are required for many cellular activities, such as nerve conduction and muscle contraction Sodium (Na+ ) Most abundant and important positively charged ion of plasma Normal plasma level: 142 mEq/L Average daily intake (diet): 100 mEq Chief method of regulation: Kidney Aldosterone increases Na+ reabsorption in kidney tubules Sodium-containing internal secretions 12 Importance of Electrolytes in Body Fluids (Cont.)
- 13. Electrolyte imbalance: I- Sodium Deficit (Hyponatremia): • Contributing Factors: • Use of a diuretic. • Loss of GI fluids. • Gain of water. • Sings and Symptoms: Anorexia, nausea and vomiting, headache, lethargy, confusion, seizures.
- 14. Hyponatremia …… Treatment: correct underlying disorder Fluid restrict, + diuretics Hypertonic saline to increase level 2-3 mEq/L/hr and max rate 100cc of 5% saline/hr
- 15. Electrolyte imbalance: II- Sodium Excess (Hypernatremia): − Contributing Factors: * Water deprivation in patient. * Hypertonic tube feeding. * Diabetes Insipidus. − Sings and Symptoms: Thirst, hallucination, lethargy, restless, pulmonary edema.
- 16. Hypernatremia … Treatment: correct underlying disorder Free water replacement: (0.6 * kg BW) * ((Na/140) – 1). Slow infusion of D5W give ½ over first 8 hrs then rest over next 16-24 hrs to avoid cerebral edema.
- 17. Electrolyte imbalance : III- Potassium Deficit (Hypokalemia): − Contributing factors: * Dirrhea, vomiting, gastric suctions. * Corticosteroid administration. * Diuretics. − Sings and symptoms: Fatigue, anorexia, nausea, vomiting, muscle weakness, change in ECG. ECG: low, flat T-waves, ST depression, and U waves
- 18. Hypokalemia, continued ECG changes in hypokalemia
- 19. Hypokalemia, continued ECG changes in hypokalemia
- 20. Hypokalemia, continued Treatment: Check renal function Treat alkalosis, decrease sodium intake PO (by mouth) with 20-40 mEq doses IV: peripheral 7.5 mEq/hr, central 20 mEq/hr and increase K+ in maintenance fluids.
- 21. Electrolyte imbalance: IV- Potassium Excess (Hyperkalemia): − Contributing Factors: * Renal Failure. * Crush injury, burns. * Blood transfusion. * Administration of IV K+. − Sings and Symptoms: Bradycardia, dysarrythmia, anxiety, irritable. - ECG: peaked T waves then flat P waves, depressed ST segment, widened QRS progressing to sine wave and V fib.
- 22. Hyperkalemia – ECG Changes
- 23. Hyperkalemia – ECG Changes
- 24. Hyperkalemia … Treatment: Remove ( treat) iatrogenic causes Acute: if > 7.5 mEq/L or ECG changes Ca-gluconate – 1 gm over 2 min IV Sodium bicarbonate – 1 amp, may repeat in 15 min D50W (1 ampule = 50 gm) and 10U regular insulin Emergent dialysis Hydration and diuresis, kayexalate 20-50 g, in 100-200cc of 20% sorbitol q 4hrs or enema
- 25. Calcium Hypocalcemia: Seen in hypoalbuminemia. Check ionized Ca Often symptomatic below 8 mEq/dL Check PTH: low may be Mg deficiency High think pancreatitis, hyperphosphatemia, low Vitamin D, pseudohypoparathyroidism, massive blood transfusion, drugs (e.g. gentamicin) renal insufficiency S/Sx: numbness, tingling, circumoral paresthesia, cramps tetany, increased deep tendon reflexes ECG has prolonged QT interval
- 27. ECG Changes in Calcium Abnormalities
- 28. Calcium, continued Hypocalcemia cont. Treatment: Acute: (IV) CaCl 10 cc of 10% solution = 6.5 mmole Ca or CaGluconate 10cc of 10% solution = 2.2 mmole Ca Chronic: (PO – per os) 0.5-1.25 gm CaCO3 = 200- 500 mg Ca. Phosphate binding antacids improve GI absorption of Ca Vit D (calciferol) must have normal serum phosphte (PO4). Start 50,000 – 200,000 units/day
- 30. Calcium, continued Hypercalcemia Usually secondary to hyperparathyroidism or malignancy. Other causes are thiazides, milk-alkali syndrome, granulomatous disease, acute adrenal insufficiency Acute crisis is serum Ca> 12mg/dL. Critical at 16-20mg/dL S/Sx: N/V (nausea & vomiting), anorexia, abdominal pain, confusion, lethargy Mental Status changes= “Bones, stone, abdominal groans and psychic overtones.”
- 31. Calcium, continued Treatment: Hydration with NS then loop diuretic. Steroids for lymphoma, multiple myeloma, adrenal insufficiency, bone MTS, Vit D intoxication. May need Hemodialysis. Mithramycin for malignancy induced hyperCa refractory to other treatment. Give 15-25 mcg/kg IV Calcitonin in malignant PTH syndromes
- 32. Magnesium Hypomagnesemia Malnutrition, burns, pancreatitis, SIADH (syndrom of inappropriate antiduretic hormone secretion), parathyroidectomy, primary hyperaldosteronism S/Sx: weakness, fatigue, MS (mental status) changes, hyperreflexia, seizure, arrhythmia Treatment: IV replacement of 2-4 gm of MgSO4 per day or oral replacement
- 33. Magnesium, continued Hypermagnesemia Renal insufficiency, antacid abuse, adrenal insufficiency, hypothyroidism, iatrogenic S/Sx: Nausea & Vomiting, weakness, MS changes, hyporeflexia, paralysis of voluntary muscles, ECG has AV block and prolonged QT interval. Treatment: Discontinue source, IV Ca Gluconate for acute, Dialysis.
- 34. Phosphate • Hyperphosphatemia Renal insufficiency, hypoparathyroidism, may produce metastatic calcification Treat with restriction and phosphate-binding antacid (Amphogel) PO replacement (Neutraphos) or IV KPhos or NaPhos 0.08-0.20 mM/kg over 6 hrs
- 35. Acid-Base Balance Classes of acids Fixed acids Do not leave solution Remain in body fluids until kidney excretion Examples: sulfuric and phosphoric acid Generated during catabolism of amino acids, phospholipids, and nucleic acids Organic acids Part of cellular metabolism Examples: lactic acid and ketones Most metabolized rapidly so no accumulation
- 36. Acid−Base Disturbance : Normal Values: PH 7.35- 7.45. → PCO2 35-45mmHg. → PO2 80-100mmHg. → HCO3 22-26mEq/L. → Respiratory Acidosis: PCO2. → → → → ↑ Respiratory Alkalosis: PCO2. → → → → ↓ Metabolic Acidosis: PH, HCO3. → → → → ↓ ↓ Metabolic Alkalosis: PH, HCO3. → → → → ↑ ↑
- 37. Types of IV solutions : Serum plasma osmalality (280-300 m osmol). I- Isotonic Solutions: A solution with the same osmalality as serum and other body Fluids. e.g. N/S 0.9%, Ringer Lactate, D5W. II- Hypotonic Solutions: A solution with an osmolarity lower than that of serum plasma. e.g. half strength saline (0.45% sodium chloride). III- Hypertonic Solution: A solution with an osmalality higher than that of serum. e.g. D/S >0.9%, D/S 0.18%, D/S 0.45%, D10W, D25W.
- 38. Types of IV solutions: Hypotonic Solutions (0.45% saline) Decreases intravascular osmolarity. Results in intracellular expansion. Used for cellular dehydration. Complications include shock and increased ICP (intracranial pressure). Contraindications include cerebral edema, and hypotension.
- 39. Types of IV solutions: Hypertonic Solutions >(D5% .45% saline, D5% NS, D5%LR.) Increases intravascular osmolarity. Results in intracellular and interstitial dehydration. Used for intravascular expansion by shifting intracellular and interstitial fluids. Complications include circulatory overload. Contraindications include intracellular dehydration and hyperosmolar states.
- 40. Types of IV solutions : Isotonic Solutions (NS, Lactated Ringers, D5%W.) Does not change osmolarity. Results in TBW (total body weight) expansion. Used to increase intravascular space. Complications include circulatory overload. Contraindications include circulatory overload and LR in alkalosis and liver disease.
- 41. Major body buffer systems Three major body buffer systems All can only temporarily affect pH (H+ not eliminated) 1. Phosphate buffer system Buffers pH of ICF and urine 2. Carbonic acid–bicarbonate buffer system Most important in ECF Fully reversible Bicarbonate reserves (from NaHCO3 in ECF) contribute
- 42. Major body buffer systems … 3. Protein buffers systems Contribute to the regulation of pH in the ICF & ECF Hemoglobin buffer system ( rbcs only) Amino acid buffers ( all proteins) Plasma protein buffers
- 43. The body’s three major buffer systems Buffer Systems Intracellular fluid (ICF) Extracellular fluid (ECF) occur in Phosphate Buffer System Protein Buffer Systems Carbonic Acid– Bicarbonate Buffer System Has an important role in buffering the pH of the ICF and of urine Contribute to the regulation of pH in the ECF and ICF; interact extensively with the other two buffer systems Is most important in the ECF Hemoglobin buffer system (RBCs only) Amino acid buffers (All proteins) Plasma protein buffers
- 44. Thank you
Editor's Notes
- #1: Figure 24.1.2 Fluid balance exists when water gains equal water losses
- #2: Figure 19-8 (right) depicts testing for dehydration. Loss of skin elasticity is a clinical sign of dehydration.
- #4: Any disruption in a homeostatic mechanism that controls the level or normal chemical activity of a particular electrolyte in any of the different body fluids produces an electrolyte imbalance. The normal range for potassium in the blood is 3.5 to 5.1 mEq/L. Calcium is the most abundant mineral in the body. The normal range for serum calcium is 8.4 to 10.5 mg/dL. Hypocalcemia may result from dietary calcium deficiency, decreased absorption or availability, and as a result of increased calcium excretion.
- #12: One of the most common areas for swelling to occur is the subcutaneous tissues of the ankle and foot. During a 24-hour period, more than 8 liters of fluid containing 1,000 to 1,300 mEq of sodium are poured into the digestive system.
- #43: Buffer systems can delay but not prevent pH shifts in the ICF and ECF