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Chapter 7

Chapter 7. Nursing Care of Clients with Alterations in Fluid, Electrolyte, or Acid-base Balance. Fluid Balance in the Body. Functions of fluid in the body medium for transport and exchange of nutrients medium for metabolic reactions regulates body temperature

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Chapter 7

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  1. Chapter 7 Nursing Care of Clients with Alterations in Fluid, Electrolyte, or Acid-base Balance

  2. Fluid Balance in the Body • Functions of fluid in the body • medium for transport and exchange of nutrients • medium for metabolic reactions • regulates body temperature • form for body/cell structure and shock absorber • provides insulation and lubrication

  3. Fluid Compartments • Intracellular - fluid within the cells • extracellular - fluid outside of the cells • interstitial - in the spaces between the cells • intravascular - within the ateries and veins • transcellular - urine, digestive secretions • Third-spacing - trapped extracellular fluid • Edema - accumulation in interstitial spaces

  4. ICF and ECF • ICF- fluid within the cells accounts for about 40% of total body weights. Electrolytes, glucose and oxygen. • Extracellular fluid- Fluid outside of the cells. About 20% of total body weight. Found in 3 compartments: • - Interstitial fluid- Spaces between most of the cells of the body 15% of total body weight. • Intravascular fluid or plasma- In the arteries, veins and capillaries. About 5% of body weight. • Transcellular fluid- cerebrospinal fluid, urine, digestive secretions, perspiration and small amounts of fluid found within organs and joints. Less than 1% of body weight. • ECF- Transports oxygen and nutrients to cells and waste away.

  5. Distribution • Electrolytes are found in both fluid compartments, although the concentration or amount of individual electrolytes in the ICF and ECF differs. • Na+, chloride (CL), and bicarbonate (HCO3) are plentiful in extracellular fluid. • Potassium (K+), magnesium (Mg+), and phosphate • (PO4) are plentiful in the intracellular fluid. • The cell membrane and capillary walls separate the body fluid compartments. Water and solutes move across these membranes by the processes of osmosis, diffusion, filtration and active transport.

  6. Membrane Transport Processes • Osmosis - water moves across a membrane that is permeable to water but not to solutes,

  7. Osmosis • Osmosis is responsible for water movement between the ICF and ECF compartments. • Water moves toward a higher solute concentration!

  8. Membrane Transport Processes Diffusion - when molecules move from an area of high concentration to an area of low concentration to become evenly distributed

  9. Diffusion • Molecules move across a semipermeable membrane from an area of higher solute concentration to an area of lower concentration.

  10. Filtration • Process in which water and solutes move across capillary membranes driven by fluid pressure. This pressure is created by the pumping action of the cardiac muscle and gravity. • A balance between filtration and osmosis regulates the movement of water between the intravascular and interstitial spaces in the capillary beds of the body. • Membranes are selectively permeable, they allow water and some solutes o2, co2, electrolytes and glucose to cross. Block proteins and large molecules.

  11. Membrane Transport Processes Active transport - molecules are moved, carried across a cell membrane, usually large water soluble molecules - glucose

  12. Regulatory Mechanisms • Thirst - primary regulator of water intake, fluid balance prevent dehy. • Kidneys - Renin-Angiotensin-Aldosterone Mechanism • regulate fluid volume and electrolyte balance • Antidiuretic Hormone Mechanism (ADH) • secreted by pituitary, acts on kidney to increase water absorption, decrease.

  13. Regulatory Mechanisms • The kidneys, by selectively reabsorbing water and electrolytes maintain the volume and osmolality of body fluids. • Renin-Angiotensin-Aldosterone System-Maintains the intravascular fluid balance and blood pressure. • Antidiuretic Hormone- Regulates water excretion from the kidneys.

  14. Renin-Angiotensin-Aldosterone System • A fall in blood flow to the kidneys (decreased fluid volume), stimulates receptors in the kidney to produce renin (an enzyme). Renin coverts angiotensinogen in the blood into angiotensin one. • The lungs then convert angiotension one to angiotension two by ACE. • Angiotension TWO constricts blood vessels which raises blood pressure, it also stimulates thirst, releases aldosterone from the adrenal cortex and acts directly on the kidneys, causing them to retain sodium and water, thus restoring blood volume.

  15. Antidiuretic Hormone • Regulates water excretion from the kidneys. • Receptors in the hypothalamus detect changes in osmolality and blood volume stimulating ADH production and release as needed. • When ADH is present more water is reabsorbed in the kidney; urine output falls, blood volume is restored and serum osmolality drops as the water dilutes body fluids. • See disorders: diabetes insipidus, inappropriate ADH secretion (SIADH).

  16. Thirst • The thirst center in the brain is stimulated when the blood volume drops because of water losses or when the solute content of body fluids increases. • The thirst mechanism declines with age, so older adults are more vulnerable to dehydration. • Clients with impaired consciousness or who are unable to respond to thirst also are at risk

  17. Osmosis and fluid volume • Isotonic solutions such as normal saline 0.9% sodium chloride solution have the same concentration of solutes as blood plasma. Cells placed in an isotonic solution do not gain or lose water. • Hypertonic solutions such as 3% sodium chloride solution have a greater concentration of solutes than plasma. A cell placed in a hypertonic solution shrinks as water is drawn out of it into the solution. • Hypotonic solutions such as 0.45% sodium chloride have a lower solute concentration than plasma. A cell placed in a hypotonic solution swells as water moves.

  18. Dehydration - Fluid Volume Deficit

  19. The Client With Fluid Volume Deficit • Patho - excessive fluid losses, insufficient fluid intake or a combination of both; vomiting, diarrhea or GI suction. • Multisystem effects • Neurological • Integumentary • Cardiovascular • hypotension • Urinary • Musculosketel

  20. Fluid Volume Deficit • Interdisciplinary Care • Fluid Challenge • obtain base line vs, give fluid bolus, re-eval vs • IV solutions • isotonic - .9% n.s. or Ringer’s Lactate tx hypotension • hypotonic - .45% n.s. - maintenance solutions

  21. Nursing Care: Fluid Volume Deficit • Assessment of factors contributing to abnormal fluid loss • Assess intake and output, daily wt • Assess vital signs • hypotension and tachycardia • Assess for dehydration • Adm. po and IV fluids • Assess labs: LOC, Urine output

  22. Fluid Volume Excess • Fluid volume excess • overhydration - excess intake • excessive sodium intake • disease process; CHF, liver cirrhosis • Kidney failure, drugs Na retention, high Na foods, Na containing fluids • Clinical Manifestations • Tachycardia, bounding pulse,tachypnea,crackles in lungs • Of edema fluid into sub Q tissue- eyes,dep.

  23. Clinical Manifestations • Respiratory • cough • SOB, crackles and wheezes, orthopnea • pleural effusion • Cardiovascular • elevated B/P, full and bounding pulses • Abdominal • ascities • Neurological- Fatigue, altered LOC

  24. Pulmonary edema

  25. What has happened here?

  26. Nursing Care: Fluid Volume Excess • Assessment - I & O, V.S. heart sound S3 (gallop), daily wt • Administer fluids cautiously • Client teaching • sodium and fluid restriction- Na retention. • meds and side effects • signs of fluid retention • symptoms to report

  27. Electrolytes

  28. Electrolyte Disorders -SodiumNa+ 136 - 148 normal range • Hyponatremia - sodium level; Acid Base <136mEq/L. Maintains ECF volume, bal • Causes • burns, excessive sweating, G.I. losses • diuretics, Addison’s disease, renal disease • Treatment • .9% N.S. 3%N.S • loop diuretics • fluid restriction

  29. Electrolyte Imbalances • Hypernatremia - > Na+ 148mEq/L • Causes • too much Na+ in excess water • loose too much water and not enough sodium • Treatment - correct slowly over 2 days • D5W or .45% N.S. hypotonic soln to correct water deficit • low Na+ diet

  30. K+ packs a punchprimary intracellular cation. Vital

  31. Electrolyte Disorders - Potassium • K+ 3.5 to 5.0 mEq/L normal range • vital intercellular cation - helps determine cell contractility nerve and muscle cells, must be replaced • Every day! • Hypokalemia - K+ <3.5 • Causes • urinary loss • G.I. loss

  32. Potassium imbalance • The kidneys eliminate potassium very efficiently; even when potassium intake is stopped, the kidneys continue to excrete potassium. • Thus potassium must be replaced every day!!!All foods contain K+, some more plentiful than others. Which ones?

  33. Electrolyte Disorders: hypokalemia • Clinical Manifestations • neuro- decrease in reflexes • cardio - dysrhythmias, cardiac arrest • G.I. - n/v, anorexia, diarrhea • musculosketel - weakness, leg cramps • Treatment • K+ replacement • oral - need to dilute • parental - DILUTE ALWAYS, pain at site, pump dilute in IV fluids Is a must; or death!!!!!!!!!!!!!!

  34. Electyrolyte Disorders: Hyperkalemia • K+ >5mEq/L • Causes • inadequate excretion of K+ - Renal disease • Excessive intake of K+ - K+ sparing diuretics, salt substitutes • Clinical Manifestations • Neuromuscular activity - tremors, twitching • Cardiac - dysrhythmias

  35. Electrolyte Imbalance: hyperkalemia • Treatment • potassium loosing diuretics - lasix • Insulin - D50 - sodium bicarb • causes K+ to shift back into the cells • Kayexalate - exchange resin (Na+ and Ca+) • oral, NGT, enema • Sorbitol - promote bowel elimination

  36. Fluid Balance, Lets Review • What are the causes of “Fluid Volume Deficit?” • Clinical Manifestations? • Neuro? Integ? Cardiovascular? • Urinary? Muscular/skeletal?

  37. Fluid Volume Excess • What are the causes of “Fluid Volume Excess?” • What are the clinical manifestations? • Respiratory? • Cardiovascular? • Abdominal? • Neurological?

  38. Nursing Care - Fluid Volume Excess • What should you assess for? What might you find? • What should you teach and why?

  39. Electrolyte Disorders • Hypokalemia K+ < 3.5 • What are some of the causes? • Clinical Manifestations? • Neuro? Cardio? G.I.? Musculo/skel? • Treatment?

  40. Electrolyte Disorders • Calium Disorders • Ca+ 8.8 - 10.0mg/dL normal range • hyper and hypocalcemia • secondary to other disease processes • Hypercalcemia • hyperparathyriodism - thyroid tumor, bone CA • Hypocalcemia • hypoparathyriodism, parathyroid surgery

  41. Electrolyte Disorders • Phosphorus PO4 2.5 - 4.5mg/dL • Hypophosphatemia • TPN, high concentrated glucose soln • GI loss, ETOH withdrawal • Hyperphosphatemia • Renal failure - builds up in blood stream

  42. Electrolyte Disorders • Magnesium Mg+ 1.3 - 2.1mEq/L • Hypomagnesium • ETOH abuse • GI disorders -impaired absorption-diarrhea • Diuretics • Hypermagnesemia • Renal Disease

  43. Acid base balance

  44. Acid-Base Balance • For optimal cell function acid base balance must remain within the normal pH range of 7.35-7.45. 7 is neutral. • Thus this would imply that the ratio of bicarbonate to carbonic acid is about 20:1. • The hydrogen ion concentration of a solution is measured as its pH. • As hydrogen ion concentration increases the pH falls, and the solution becomes more acidic. • As hydrogen ion concentration falls, the pH rises, and the solution becomes more alkaline or basic.

  45. Acid Base • Acids are continually produced by metabolic processes in the body. • Two types of acids • 1. Volatile – Which can be eliminated as a gas. Co2 • 2. Nonvolatile- Must be metabolized or excreted from the body in fluid. Hydrochloric acid, lactic acid, phosphoric acid. • Three systems in the body work together to maintain a normal pH despite continuous acid production: Buffers system, respiratory system, and renal system.

  46. Normal pH systems • Buffer- Chemicals that prevent major changes in pH by attaching to or releasing hydrogen ion. (hemoglobin, plasma proteins, inorganic phosphates) • Respiratory system- Regulates carbonic acid in the body by eliminating or retaining carbon dioxide. Acute increases in either carbon dioxide or hydrogen ions in the blood stimulate the respiratory center in the brain to increase the rate and depth of respirations. This eliminates carbon dioxide from the body; carbonic acid levels fall and the pH goes to a normal range. Occurs within minutes; becomes less effective over time. • Alkalosis (pH above 7.45) depresses the respiratory center, the rate and depth of respirations decrease and co2 is retained • Patients with chronic lung dx may have high co2 levels in blood

  47. Normal pH systems • Renal system- responds slowly(hrs to days). Longe term regulation of acid-base balance. • The kidneys regulate bicarbonate levels in the ECF and can either excrete or retain hydrogen ion as needed. • When excess hydrogen ions are present and the pH falls, the kidneys excrete hydrogen ions and retain bicarbonate. • When bicarbonate levels are high(pH incr) the kidneys retain hydrogen ion and excrete bicarbonate to restore acid-base balance.

  48. Assessment of Acid Base • Acid-base balance is evaluated by measuring arterial blood gas. • ABG’s • Elements Measured: • PaCO2, PaO2, bicarbonate and the pH. • Arterial blood is used because it reflects acid-base balance throughout the body and allows evaluation of oxygenation. • Pressure for at least 5 minutes after lab draw. RN, respiratory therapist or lab tech with specialized training. Arteries are high pressure vessles. • ABG’s are analyzed to identify acid-base disorders and their probably cause, extent of the imbalance, monitor treatment.

  49. Acid -Base Definitions • Acid - a molecule that can contribute a hydrogen ion • Base - a molecule that can accept or remove a hydrogen ion • Buffer - substance that controls hydrogen ion concentration in a soln by absorbing H+ when acid is added or by releasing H+ when base is added

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