fluids, acid, burns

40% SOLIDS

60% FLUIDS

BODY FLUID AMOUNT AND DISTRIBUTION

a. 2/3

b. ½
c. Intravascular

d. interstitial

e. transcecullar

60% FLUIDS

a. icf

b. ecf

c. found within the blood vessels

d. Fluid that surrounds the cells

e. Makes up the smallest part; CSF and synovial fluid

Third Spacing (Fluid Shift)

Fluid trapped in areas not contributing to ICF and ECF balance (not usable in circulation)

a. Ascites, Pleural Effusion, Pericardial effusion, angioedema

b. Decreased urine output despite normal intake

c. burns and liver failure

Third Spacing (Fluid Shift)

a. ex

b. early sign

c. Commonly happens with

sodium

potassium

calcium

magnesium

cations

- Cl (Chloride)

- HCO3 (Bicarbonate)

- PO4-3 (Phosphate)

anion

Osmosis

H2O moves from low solute concentration to higher solute concentration

Osmolality- 275-295 mOsm/kg

Is the solute concentration per kilogram of solvent

● Expressed as mOsm/kg

Osmolarity

Solute concentration per Liter of solution

Expressed as mOsm/L

a. Starling’s Law of Capillary Forces

b. Hydrostatic Pressure and Osmotic pressure

a. Normal movement of fluids through the capillary wall into the tissue depends on

b. Capillary forces are the two forces at every capillary membrane

Hydrostatic pressure

Also called hydraulic pressure

● It is the pressure exerted by fluid on the walls of the blood vessels

● It pushes fluids out of the capillary toward the ICF

Osmotic pressure

Is the pressure exerted by the solutes within the plasma

● It pulls fluid into the capillary from the ICF

Oncotic Pressure

It is osmotic pressure specifically exerted by the plasma proteins, like albumin, within the bloodstream

○ Keeps fluid in the blood vessels

○ Thus, the loss of albumin causes fluid leaking into the tissues causing = EDEMA

crystalloid or colloid solutions

can be used to temporarily replace blood or replenish fluid losses from the body.

a. Mineral salts dissolved in water

b. - NS (0.9% NaCl) - Half NS (0.45% NaCl)

c. Replaces lost fluids

Crystalloids

a. description

b. ex

c. use

Colloid

a. Contains large proteins or starch

b. Albumin, - Dextran - Hetastarch

c. Expands plasma volume

TONICITY

Is the ability of solutes to cause an osmotic driving force that promotes water movement from one compartment to another

from ICF to ECF or ECF to ICF

a. Same Solute Concentration as plasma

b. No Fluid Shift

c. 0.9% NSS, LR

d. dehydration, mild shock

e. burns or diarrhea

Isotonic

a. solute

b. effect

c. ex

d. indicated

e. LR for

a. Less solute, but more water

b. swell

c. 0.45% NaCl & 0.225% NaCl

d. cerebral edema

e. move back into the cell

Hypotonic

a. solute

b. effect

c. ex

d. cause

e. cause water to

a. More solutes, less water

b. Cells shrink for severe edema

c. Mannitol

d. evere edema and cerebral edema

Hypertonic

a. solutes

b. effect

c. ex

d. indicated

Fluid Overload

Air Embolism

Infection/ Sepsis

iv 3 systemic complications

Fluid Overload

Caused by rapid excessive IV infusion; cardiac, renal, or hepatic disease

a. Crackles, Dyspnea, Increased Blood pressure

b. slow rate, high fowler

c. infusion pump, i/o, lung func

Fluid Overload

a. ss

b. mngmnt

c. prevention

Air Embolism

Air entry into central vein or the line disconnects

a. Chest pain, cyanosis, Decreased blood pressure

b. clamp line, left trendelenburg, o2

c. remove air fm tube

Air Embolism

a. ss

b. mnmgmnt

c. prevention

Infection/ Sepsis

Caused by contaminated solution or improper aseptic technique

a. Fever, chills, tachycardia,

b. Stop the infusion, abx

c. sterile insertion

d. 3 days

e. 24 h

Infection/ Sepsis

a. ss

b. mngmnt

c. prevention

d. IV sites should be changed every

e. IV bottles should be changed every

Phlebitis

Infiltration

Extravasation

Local Complications

Phlebitis

Chemical, mechanical, or bacterial irritation

a. Redness, warmth, pain along vein

b. Remove IV ● Apply warm compress

c. Aseptic technique ● Secure the line

phlebitis

a. ss

b. m

c. prevention

Infiltration

Occurs when IV fluid leaks back into tissue (non-vesicant/not irritating)

a. Cool, swollen, slow flow

b. Stop IV ● Elevate the limb ● Apply warm/cold compress

c. Monitor the patient hourly ● Secure the catheter ● Avoid flexion areas

Infiltration

a. ss

b. m

c. prevention

Extravasation

Caused by vesicant or irritant drug leakage (Example: Potassium

a. redness, blister, necrosis

b. Stop the infusion ● Give antidote

c. Verify IV patency ● Avoid flexion sites

Extravasation

a. ss

b. m

c. prevention

Thrombophlebitis

Clot with vein inflammation

a. swelling, sluggish flow

b. Stop the IV ● Apply compress (cold then warm) ● Elevate the extremity

c. Avoid trauma ● Assess hourly

Thrombophlebitis

a. ss

b. m

c. prevention

Hematoma

Caused by vein perforation, poor insertion, large cannula

a. Bruising, swelling

b. Remove IV ● Apply Ice for 24 hours ● Elevate limb

c. Gentle technique, firm (pressure after remova)

Hematoma

a. ss

b. m

c. prevention

Clot/ Obstruction

Caused by kinked tubing, slow flow, empty bag

a. Sluggish flow, blood backflow

b. Restart IV ● Do not irrigate or milk the line

c. Keep the flow steady ● Flush before and after giving IV medications

Clot/ Obstruction

a. ss

b. m

c. p

Diffusion

Solutes move from one area of higher concentration to an area of lower concentration

● Form of passive transport (it does not use energy/ATP)

Filtration

Movement of water and solutes from an area of high hydrostatic pressure to an area of low hydrostatic pressure

Sodium-Potassium Pump

Maintains balance of sodium and potassium inside and outside the cell ● Keeps the cell electrically stable and healthy

● Uses ATP (Active Transport)

a. 1-2L of urine/day

b. 1 mL/kg/hr

Kidneys

a. Well-hydrated adults usually excrete

b. is the general output for all groups

a. Sweating

b. Na, Cl, K

c. 500 mL/day due to evaporation

skin

a. Visible/Sensible Water Loss:

b. solutes in sweat

c. Insensible Water Loss

a. respiration (insensible loss)

b. 300 mL/day under normal conditions

Lungs

a. Water vapor loss via

b. Fluid loss:

a. 100-200 mL/day

b. 8L

c. Diarrhea and Fistulas

GI Tract

a. Fluid loss:

b. of fluid circulates through the GI system daily, but most of it is reabsorbed

c. can lead to significant water loss

Serum Osmolality- 275-290 mOsm/kg

Shows how concentrated the blood is and mainly depends on sodium, but also BUN and glucose

Urine Osmolality- 200-800 mOsm/L

Measures how concentrated urine is based on urea, creatinine, and uric acid

a. Urine Specific Gravity- 1.005-10.30

b. Concentrated

c. Diluted

a. Compares urine density to water

b. High Urine Specific Gravity

c. Low Urine Specific Gravity

BUN (Blood Urea Nitrogen)- 10-20 mg/dL

Increases with dehydration and GI bleeding

Creatinine- 0.7-1.4 mg/dL

Best indicator of renal function

a. Men: 42-55% ,Women: 35-47%

b. dehydration or Polycythemia

c. overhydration, anemia

hematocrit

a. normal

b. Increases with

c. dec w

a. 75-200 mEq per 24 hours

b. Na retention, dehydration

c. High Na intake

urine sodium

a. normal

b. dec

c. inc

a. adh

b. aldosterone

c. cortisol

d. pth

a. From the Posterior Pituitary ● Released during dehydration and when there is low blood volume

b. From the adrenal cortex ● Retains Sodium and Water; Excretes Potassium

c. Causes Sodium and fluid retention when elevated

d. From Parathyroid gland ● Regulates Calcium and Phosphates

HYPOVOLEMIA

Loss of ECF > Fluid Intake ● Water and Electrolytes lost proportionally

a. Diabetes Insipidus, third spacing, n/v

b. Hypotension, dehydration, oliguria

c. oral fluids, i/o, IV isotonic then hypotonic if severe

HYPOVOLEMIA

a. causes

b. ss

c. m

HYPERVOLEMIA

Excess ECF due to Na+ and H2O retention

a. Heart Failure, Cirrhosis, corticosteroids

b. edema, crackles, low hct and bun

c. no sodium and h2o, semi fowler, diuretics

HYPERVOLEMIA

a. cause

b. ss

c. mnmgmnt

a. 135-145 mEq/L

b. brain and nervous system

c. ADH ○ Thirst Mechanism ○ RAAS ○ Kidneys regulate Na Level

d. Bread, meats, pizza

sodium

a. normal

c. Imbalances affect

d. controlled by

e. diet source

a. Confusion, H/A, Seizures

b. Restrict Fluids

Hyponatremia

a. ss

b. mnmngt

a. Hypernatremia

b. Desmopressin

c. Give Fluids (Hypotonic); Mouth Care

Hypernatremia

a. ss

b. diabetic insi

c. mngmnt

a. 3.5-5.0 mEq/L

b. Muscle contraction and nerve impulse, acid-base balance

c. 98% Intracellular, 2% extracellular

d. Chocolate, Nuts, Seeds

POTASSIUM

a. normal

c. %intra and extra

d. function

e. source

a. <3.5 mEq/L

b. 2.5-3.0 mEq/L

c. <2.5 mEq/L

d. Alkalosis, Loop & Thiazide Diuretics, Mg Deficiency

e. Cramps, Muscle Weakness

f. Flat T wave, U wave, ST Depression

g. IV Drip Potassium

HYPOKALEMIA

a. serum

b. mod

c. severe

d. causes

e. ss

f. ecg

h. m

a. 6.1-7.0 mEq/L

b. >7.0 mEq/L

c. Acidosis, Burns

d. Paresthesias

e. Peaked T wave, Widened QRS Wave, Absent P wave

f. Kayexalate; IV Calcium Gluconate

Hyperkalemia

a. mod

b. severe

c. cause

d. ss

e. ecg

f. m

a. 8.8-10.4 mg/dL

b. 4.5-5.1 mg/dL

c. pth

d. calcitonin

e. inverse rs

f. Muscle Contraction ○ Blood Clotting

g. Sardines, Salmon, Dairy products

CALCIUM

a. normal

b. ionized

c. Secreted when Calcium decreases; pulls Calcium from bones

d. Secreted when Calcium increases; inhibits bone resorption and lets kidneys excrete Ca

e. Phosphorus has an — with Calcium.

f. func

g. source

a. Hypoparathyroidism, Thyroid Surgery, CKD

b. Chvostek & Trousseau Signs, Seizures

c. Prolonged QT and ST

d. IV calcium gluconate, Calcium Chloride

e. Seizure precautions

Hypocalcemia

a. cause

b. ss

c. ecg

d. med

e. nsg cons

a. Hyperparathyroidism, Thiazide diuretics

b. Muscle weakness, fatigue, kidney stones

c. Shortened QT and ST

d. Calcitonin, Bisphosphonates, Mithramycin

e. High-fiber diet

Hypercalcemia

a. cause

b. ss

c. ecg

d. med

e. nsg cons

a. 1.8-2.0 mg/dL

b. enzyme activation, Neuromuscular function

c. bones

d. Dark chocolate, green leafy vegetables, sea food

MAGNESIUM

a. normal

b. funct

c. stored in

d. source

a. alc, gi loss, diuretics

b. tremors, hyperreflexia

c. arrhythmia, pvc

d. mg replacement

HYPOMAGNESEMIA

a. cause

b. neuro effect

c. ecg

d. focus

a. renal failure, mg intake

b. weakness, dec reflex

c. bradycardia, arrest

d. stop mg, give ca

hypermagnesemia

a. cause

b. neuro effect

c. ecg

d. focus

a. 2.7-4.5 mg/dL

b. 85% stored in bones and teeth

c. Energy metabolism (ATP metabolism) ○ Bone & Teeth formation

d. Dairy, Dried Beans, Egg,

PHOSPHORUS

a. normal

b. loc

c. func

d. source

a. alc, refeeding

b. weakness, confusion, bone pain

c. oral/iv phosphate, vit d

d. monitor muscle and respi

hypophosphatemia

a. cause

b. ss

c. med

d. focus

a. renal failure, hypoparathyroidism

b. tetany, cramps, calcification

c. binders, dialysis

d. monitor ca and phosphorus

hyperphosphatemia

a. cause

b. ss

c. med

d. focus

● Calcium ↑ = Phosphorus ↓ (Inverse)

● Sodium ↑ =Potassium ↓ (Inverse)

● Magnesium ↑ = Potassium ↑ = Calcium ↑

SUMMARY OF RELATIONSHIPS BETWEEN ELECTROLYTES

a. acids

b. bases

c. ph = 7.35-7.45

a. Molecules that can give H molecules to other molecules ● Solutions with pH below 7

b. Molecules that accept H molecules ● Solutions with pH above 7

c. Calculation based on percentage of H ions and amount of acids and bases in solutions

a. <7.35

b. decreased

c. increased

Acidosis

blood ph

bicarb

h+

a. >7.45

b, inc

c. dec

Alkalosis

a. blood ph

b. bicarb

c. h+

Chemical Buffer

Neutralize offending acid or base; fast; first to react

Bicarbonate Buffer System

Buffers blood and interstitial fluid; most important in ECF systems; Ratio of 20:1 (Bicarbonate to Carbonic Acid)

Phosphate Buffer System:

Reacts with acids and bases to form compounds that alter pH; effective in renal tubules

Protein Buffer System

Acts inside and outside the cell; binds with acids and bases to neutralize them

a. 35-45 mmHg

b. 22-26 mEq/L

paco2

hco3

a. 45-degree

b. 60

c. 90

Obtaining Samples ○ Sites:

a. radial

b. brachial

c. femoral

1. Check pH: Acidotic or Alklalotic

2. Check PaCO2: Low or High

3. Check HCO3: Low or High

4. Check for signs of compensation: Which value more closely corresponds to change in pH

INTERPRETING ABG

Respiratory Acidosis, Fully Compensated

● pH = 7.37

● PaCO2 = 54 mmHg

● HCO3 = 30 mEq/L

Respiratory Alkalosis, Uncompensated

● pH = 7.52

● PaCO2 = 32 mmHg

● HCO3 = 25 mEq/L

ACUTE AND CHRONIC METABOLIC ACIDOSIS

Characterized by low blood pH due to increased H+ ions or reduced HCO3 in the bloodstream

a. diuretics, excess chloride, diarrhea

b. confusion, shock, n/v

c. hco3, monitor k, stop excess chloride

ACUTE AND CHRONIC METABOLIC ACIDOSIS

a. causes

b. ss

c. med

a. (Na+) - (Cl + HCO3)

b. 8-12 mEq/L

c. Acid accumulation (Lactic acid, in shock, DKA)

ANION GAP (AG)

a. Formula:

b. normal

c. high gap

a. Decreased HCO3, Decreased pH, inc K

b. Kussmaul’s respirations

metabolic acidosis

COMPENSATORY MECHANISMS

a. assessment

b. respi

Increased pH (Decreased H+ Concentration)

○ Increased HCO3

ACUTE AND CHRONIC METABOLIC ALKALOSIS

a. Long-term diuretic use, Villous adenoma, ca carbonate

b. hypokalemia, hypocalcemia

c. slow breathing

d. excess hco3 and conserve h+

e. Carbonic anhydrase inhibitors (acetazolamide), (KCl supplement), NSS, PPI

ACUTE AND CHRONIC METABOLIC ALKALOSIS

chronic cause

ss

lungs

kidney

med

ABG: pH > 7.45

HCO3 > 26mEq/L,

PaCO2 increased

ACUTE AND CHRONIC METABOLIC ALKALOSIS dx

Low (<25 mEq/L)

High (>40 mEq/L): Mineralocorticoids or alkali-loading antacids, HCO3

Urine Chloride

dec ph, paco2, hco3

inc rr

acidosis

inc ph, paco2, hco3

dec rr

alkalosis

pH < 7.35

PaCO2 >45 mmHg

ACUTE AND CHRONIC RESPIRATORY ACIDOSIS

Airway obstruction

Respiratory Depression (Sedatives)

severe pneumonia

neuromusc disorder

acute respi acidosis

COPD ● Sleep Apnea ● Obesity Hypoventilation Syndrome

Chronic respi acidosis