fluids electrolytes acid-base - lecture 16 FIRST LECTURE FOR EXAM 3

fluid amount

volume

fluid intake:

1100-1400 mL

fluid output:

1200-1500 mL (u/o)

100-200 mL (stool)

intake should equal output

concentration

osmolarity

mOsm/kg H2O:

285-295

# of particles/kg of total body water

solvent - water

solute - electrolytes

composition

electrolyte concentration

sodium 136-145 - brain

potassium 3.5-5.0 - heart

calcium 9.0-10.5

magnesium 1.3-2.1

pH

degree of acidity

blood pH 7.35-7.45

O2 saturation:

95%-100% - relative to comorbidity

PaCO2 35-45 - lungs, works immediately, acidic

HCO3 21-28 - kidneys, Alkalotic

what are the two types of fluid distribution

Intracellular fluid (2/3 of total body water; major electrolyte is potassium)

Extracellular fluid (1/3 total body water; major electrolyte is sodium)

what are the composition of body fluids

Osmolality - number of particles per kg of water (285-295)

Isotonic (285-295)

-- Hypotonic (<285)

-- Hypertonic (>295)

isotonic solution

fluid with the same tonicity as blood (285-295)

dextrose 5% in water (D5W)

0.9% NaCl (NS)

Lactated Ringer (LR)

no shift change

NS + NS = STILL ISOTONIC - DONT GET THIS WRONG

hypotonic + isotonic = HYPERTONIC

hypotonic solution - swell

fluid is more dilute than blood (<285)

0.225% NaCl (1/4 NS)

0.45% NaCl (1/2 NS)

shift to intracellular space = swelling

hypertonic solution - shrink

more concentrated than blood (>295)

dextrose 10% in water (D10W)

dextrose 5% in LR (D5LR)

3% NaCl

5% NaCl

Dextrose 5% in 0.45% NaCl

Dextrose 5% in 0.9% NaCl

shift to extracellular = shrink

osmosis

movement of water from area of lower concentration to area of higher concentration

ex: red blood cells and plasma

active transport

movement of water from area of lower concentration to area of higher concentration with use of energy (ATP)

ex: sodium/potassium pump

diffusion

movement of electrolytes from higher concentration to lower concentration

ex: gas exchange in the lungs

filtration

movement of fluid in and out of the capillaries by way of hydrostatic pressure (pushing force) and oncotic pressure (pulling force)

ex: capillary filtration, glomerular filtration

can a patient with crackles and edema be dehydrated ?

YES

Fluid balance depends upon dynamic interplay, and it's based on fluid intake, absorption, distribution, and output. To maintain homeostasis, ....

fluid intake must equal fluid output.

Average Intake

2200-2700 mL/day

Fluids ingested

Foods (insensible w/solids)

Metabolism (insensible)

Average Output:

2200-2700 mL/day

Skin and sweat (insensible)

Lungs (insensible)

Gastrointestinal (loose stool only)

Urine

oral intake

water, juice, milk, tea, coffee, soup, broth, soft drinks, ensure, boost

ice chips (measured as half the volume of melted liquid ex: 1 cup of ice = 1/2 cup of water)

liquid oral medication

enteral (tube feeding) intake

tube feed formula, water flushes before/after feeding

medications administered via tube (if liquid)

intravenous (IV) fluids

IV maintenance, medication drips, blood transfusion, TPN

IV medication drips (antibiotics, pain meds)

other sources of intake

dialysis fluids (if retained)

irrigation fluids (if absorbed)

enema fluids count !!!!!!

why do we give ice chips?

to decrease fluid intake

urine output

foley catheter, urinal, bed pan, or bedside commode

gastrointestinal (GI) losses

vomitus (emesis), nasogastric (NG) tube drainage

fecal output (especially if diarrhea or from an ostomy bag) - loose stool

surgical drains

jackson-pratt (JP) drain, hemovac drain, chest tube drainage, wound vac output

negative pressure will increase blood flow

other body fluid losses

excessive bleeding (if measurable ex: from a wound or surgical site)

dialysis fluid removal

how do we calculate? what are the conversions we should know?

1kg = 2.2 lbs.

1000 mL = 1L

1L=1kg

Daily weights

an important indicator of fluid status. Fluid gains or losses indicate changes in the amount of total body fluid, usually ECF, but do not indicate shift between body compartments. Weigh patients with heart failure and those who are at high risk for or actually have ECV excess daily.

also useful for patients with clinical dehydration or other causes or risks for ECV deficit.

Have the patient void and weigh the patient at the same time each day with the same scale.

Sodium: 135-145

Hypernatremia:

1. decreased LOC

2. Coma

3. Lethargy

4. Confusion

5. Seizures

info:

- hypertonic solution

- water deprivation

- more sodium than water

- diabetes insipidus - - peeing but hold in the sodium

TREAT:

1. DRINK WATER

2. DILAYSIS - ESRD

3. IV hypotonic solution - ICU

Hyponatremia:

1. Decreased LOC

2. Coma

3. Lethargy

4. Confusion

5. Seizures

info:

- too little particles but lots of water

TREAT:

1. oral (salt, crackers)

2. DIALYSIS - ESRD

3. IV hypertonic solution - ICU

Potassium: 3.5-5

Hyperkalemia:

1. muscle weakness

2. abdominal cramps

3. diarrhea

4. cardiac arrest

5. dysrhythmias

info:

- spironolactone causes this

TREAT:

FUROSEMIDE/LASEX - NUMBER 1

ESRD - dialysis

Diabetic Ketoacidosis - insulin

Hypokalemia:

1. muscle weakness

2. abdominal cramps

3. constipation

4. dysrhythmias

info:

- excessive vomiting

-diarrhea

TREAT:

spironolactone

potassium tablets

IV mg sulfate to absorb K+

DISCONTINUE WHAT IS CAUSING THE ISSUE

Magnesium: 1.3-2.1

Hypermagnesemia:

1. Lethary

2. Hypoactive DTRs

3. Bradycardia

4. Hypotension

info:

laxatives/antacids/ESRD cause this

DTR - deep tendon reflexes

TREAT:

furosemide/lasex

IV calcium gluconate to help with Mg go to other cells

Hypomagnesemia:

1. + chvostek sign

2. hyperactive DTRs

3. muscle cramps

4. tetany

5. dysphagia

6. insomnia

calcium: 9-10.5

hypercalcemia:

1. decreased LOC

2. constipation

3. fatigue

4. cardiac arrest

5. personality change

info:

cause: immobility, osteoporosis, ESRD

TREAT:

Loop Diuretic

hypocalcemia:

1. + chovestek sign

2. numbness

3. tingling

4. laryngospasms

5. dysrhythmias

info:

cause: vitamin D deficiency

TREAT:

1. give vitamin D - orange juice

acid base balance

respiratory acidosis - lungs/PaCO2

s/s: light headedness, decreased loc, dysrhythmias

Cause: hypoventilation (COPD, bacterial pneumonia, airway obstruction, respiratory muscle fatigue, drug overdose

Treatment: Encourage deep breathing, oxygen therapy, mechanical ventilation (last resort)

respiratory alkalosis - lungs/PaCO2

s/s: Light headedness, decreased loc, dysrhythmias

Cause: hyperventilation (anxiety, psychological distress, head injury, aspirin overdose, meningitis)

Treatment: Encourage paper-bag breathing, relaxation, oxygen therapy, mechanical ventilation (last resort)

metabolic acidosis - kidneys

s/s: decreased loc, dysrhythmias, abdominal pain

Cause: ketoacidosis, circulatory shock, burns, severe infection, ingestion of acid, ESRD

Treatment: iv fluids, oxygen therapy, oral sodium bicarb, dialysis,

metabolic alkalosis - kidney

s/s: decreased loc, dysrhythmias, abdominal pain

Cause: massive blood transfusion, administration of sodium bicarb

Treatment: iv fluids, IV POTASSIUM, IV ACETALZOLAMIDE, dialysis

what are some lab studies to assess for imbalances

1. Complete blood count (cbc) - RBC, hematocrit

2. Comprehensive Metabolic Panel - Na, K

3. Serum electrolytes, blood urea nitrogen, and creatinine levels - kidneys, GFR <15 = ESRD

4. Urine pH and specific gravity - concentration of solute in urine, how well kidney is filtering urine

5. Arterial blood gas (ABG) - both kidneys and lungs

arterial blood gas

respiratory acidosis: PaCO2/Low pH

respiratory alkalosis: PaCO2/High pH

metabolic acidosis: Kidneys/Low pH/Normal PaCO2

metabolic alkalosis: Kidneys/High pH/Normal PaCO2

A walk through the Nursing process

Ms. Dorothy is a 65 y/o presenting to the ER with complaints of dizziness, fatigue, shortness of breath, and swelling in her lower extremities. She has been experiencing increased urination over the past 48 hours.

Medical History: Hypertension, Type 2 Diabetes, Chronic Kidney Disease (stage 2)Current

Medications: Lisinopril, Metformin, Furosemide (diuretic)

Vital Signs:

- BP: 140/90 mmHg

- Heart Rate: 98 bpm

- Respiratory Rate: 20 breaths/min

- Temperature: 98.7°F

- O2 Saturation: 94% (on room air)

General Appearance: Pale, fatigued, appears dehydrated, and has mild swelling (edema) in both ankles.

Cardiovascular: Tachycardia, no murmurs.

Respiratory: Shortness of breath with exertion, no wheezing or crackles on auscultation.

Musculoskeletal: Mild weakness in the lower extremities, limited range of motion due to edema.

Abdomen: Soft, non-tender, no distension.

Urine Output: Slightly reduced, dark amber in color.

CBC:

- Hemoglobin: 12.5 g/dL (low-normal)

- Hematocrit: 37% (normal)

Electrolytes:

- Sodium (Na): 132 mEq/L (low)

- Potassium (K): 5.2 mEq/L (elevated)

- Chloride (Cl): 98 mEq/L (normal)

- Bicarbonate (HCO₃): 22 mEq/L (normal)

Renal Function:

- Blood Urea Nitrogen (BUN): 25 mg/dL (elevated)

- Creatinine: 1.5 mg/dL (elevated)

- Glomerular Filtration Rate (GFR): 50 mL/min (stage 2 kidney disease)

Arterial Blood Gases (ABGs):

- pH: 7.25

- PaCO₂: 58 mmHg

- HCO₃: 22 mEq/L

- Capillary blood sugar 320 DG/l

what are the nursing diagnosis?

- Fluid Imbalance

- Dehydration

- Electrolyte imbalance

- Acid Base Imbalance

- Lack of Knowledge of Fluid Regimen

Ms. Dorothy is a 65 y/o presenting to the ER with complaints of dizziness, fatigue, shortness of breath, and swelling in her lower extremities. She has been experiencing increased urination over the past 48 hours.

Medical History: Hypertension, Type 2 Diabetes, Chronic Kidney Disease (stage 2)Current

Medications: Lisinopril, Metformin, Furosemide (diuretic)

Vital Signs:

- BP: 140/90 mmHg

- Heart Rate: 98 bpm

- Respiratory Rate: 20 breaths/min

- Temperature: 98.7°F

- O2 Saturation: 94% (on room air)

General Appearance: Pale, fatigued, appears dehydrated, and has mild swelling (edema) in both ankles.

Cardiovascular: Tachycardia, no murmurs.

Respiratory: Shortness of breath with exertion, no wheezing or crackles on auscultation.

Musculoskeletal: Mild weakness in the lower extremities, limited range of motion due to edema.

Abdomen: Soft, non-tender, no distension.

Urine Output: Slightly reduced, dark amber in color.

CBC:

- Hemoglobin: 12.5 g/dL (low-normal)

- Hematocrit: 37% (normal)

Electrolytes:

- Sodium (Na): 132 mEq/L (low)

- Potassium (K): 5.2 mEq/L (elevated)

- Chloride (Cl): 98 mEq/L (normal)

- Bicarbonate (HCO₃): 22 mEq/L (normal)

Renal Function:

- Blood Urea Nitrogen (BUN): 25 mg/dL (elevated)

- Creatinine: 1.5 mg/dL (elevated)

- Glomerular Filtration Rate (GFR): 50 mL/min (stage 2 kidney disease)

Arterial Blood Gases (ABGs):

- pH: 7.25

- PaCO₂: 58 mmHg

- HCO₃: 22 mEq/L

- Capillary blood sugar 320 DG/l

what are the interventions

- Monitor vital signs frequently, especially blood pressure, heart rate, and respiratory rate.

- Assess urine output and characteristics to monitor for changes in fluid balance.

- Administer fluids as prescribed, considering electrolyte balance and kidney function.

- Monitor serum electrolytes and renal function to assess treatment efficacy and adjust medications as needed.

- Administer medications as ordered (e.g., diuretics, antihypertensives), ensuring proper dosage and patient tolerance.

- Provide education on diet, emphasizing the importance of low-sodium and balanced potassium intake to prevent further electrolyte imbalances.

Ms. Dorothy is a 65 y/o presenting to the ER with complaints of dizziness, fatigue, shortness of breath, and swelling in her lower extremities. She has been experiencing increased urination over the past 48 hours.

Medical History: Hypertension, Type 2 Diabetes, Chronic Kidney Disease (stage 2)Current

Medications: Lisinopril, Metformin, Furosemide (diuretic)

Vital Signs:

- BP: 140/90 mmHg

- Heart Rate: 98 bpm

- Respiratory Rate: 20 breaths/min

- Temperature: 98.7°F

- O2 Saturation: 94% (on room air)

General Appearance: Pale, fatigued, appears dehydrated, and has mild swelling (edema) in both ankles.

Cardiovascular: Tachycardia, no murmurs.

Respiratory: Shortness of breath with exertion, no wheezing or crackles on auscultation.

Musculoskeletal: Mild weakness in the lower extremities, limited range of motion due to edema.

Abdomen: Soft, non-tender, no distension.

Urine Output: Slightly reduced, dark amber in color.

CBC:

- Hemoglobin: 12.5 g/dL (low-normal)

- Hematocrit: 37% (normal)

Electrolytes:

- Sodium (Na): 132 mEq/L (low)

- Potassium (K): 5.2 mEq/L (elevated)

- Chloride (Cl): 98 mEq/L (normal)

- Bicarbonate (HCO₃): 22 mEq/L (normal)

Renal Function:

- Blood Urea Nitrogen (BUN): 25 mg/dL (elevated)

- Creatinine: 1.5 mg/dL (elevated)

- Glomerular Filtration Rate (GFR): 50 mL/min (stage 2 kidney disease)

Arterial Blood Gases (ABGs):

- pH: 7.25

- PaCO₂: 58 mmHg

- HCO₃: 22 mEq/L

- Capillary blood sugar 320 DG/l

what are the evaluations

- Fluid Volume Status: dizziness and fatigue improved with IV fluid administration, and she showed signs of improved hydration with better urine output.

- Electrolyte Imbalance: Sodium levels increased slightly after 24 hours of fluid replacement; potassium remained elevated, requiring close monitoring and adjustments to her diuretic regimen.

- Gas Exchange: Shortness of breath improved with supplemental oxygen, and O2 saturation increased to 96%.

- Skin Integrity: Swelling in the lower extremities was reduced with elevation and compression stockings, preventing further skin breakdown to prevent further electrolyte imbalances.