Fluid and Electrolytes CSON Spring 2009 PREPARED BY

Fluid and Electrolytes CSON Spring 2009 PREPARED BY CARLA HILTON, MSN, RN PRESENTED AND REVISED BY REBECCA POWERS, MSN, RN 15 questions from all of powers’ stuff…

Water Balance = Homeostasis • Water in the body is used to or for: • Transporting nutrients & oxygen to cells • Removing waste from cells • Provides medium in which electrolyte chemical reactions can occur • Regulation of body temperature • Lubricates joints and membranes • Provides medium for food digestion • liter of water weighs 2. 2 lbs • The most accurate way to measure fluid status in a person is daily weights, not I&O!!!

Water Distribution • ICF: Intracellular fluid • ECF: Extracellular fluid (lymph system, interstitial fluid, intravascular fluid or plasma) • TCF: Transcellular fluid (cerebral spinal fluid, fluid in joints, GI tract, and peritoneal fluid) • Third spacing: (a condition where fluid accumulates in a pocket that isn’t really serving a purpose. Acieties (sp? )where fluid hangs out in your abd. The fluid is coming from somewhere else. ) • More fluid in intracellular than anywhere else in the body!

Osmolarity / Osmolality n. Osmole: nthe amount of substance that dissociates in solution to form one mole of osmotically active particles n. Concentration osmoles of solution measured in

Osmolarity / Osmolality is measured in milli. Osmols/Kg (m. Osm/Kg) Osmolarity is measured in milli. Osmols/L (m. Osm/L) Evaluates serum and urine in clinical practice Normal: serum osmolality 275 – 295 m. Osm/K Lality= total volume will equal 1 L plus the amount of volume taken up by the solids! The koolaid and water equal a L • Larity= volume is going to be less than 1 L. The koolaid minus the water. • • •

Concentrations of Solutions • Isotonic: Same osmolarity as blood plasma…no osmotic “pull” • Hypotonic: Less concentration than blood plasma…lower osmotic pressure • Hypertonic: More concentration than blood plasma…. higher osmotic pressure

Movement of Water • Intracellular & extracellular approximately same osmolality • Solvent (water) and solutes (electrolytes) move across selectively permeable membranes (compartments) in the body (the bigger the particle, the slower they move, and they may need a little boost…)

Review of Terms • • • Osmosis Diffusion Active transport Passive transport Filtration Hydrostatic pressure

Osmosis Review • Movement of water only • Speed of movement affected by: • temperature of fluid • concentration of fluid • electrical charge of particles in solution • The higher the solute concentration, the greater the osmotic pressure is.

Other Mechanisms of Movement • Diffusion: Solute (or gas) moves from area of higher concentration to area of lower concentration • Facilitated diffusion: Solute moves against concentration gradient (passive transport) • Active transport: Solute moved against concentration gradient using ENERGY

Active Transport • Na+/K+ pump: Maintains the higher concentrations of extracellular Na+ and intracellular K+ • In the cell, K is King. i. e. K is the major cation of the cell, Na is outside the cell.

Continued • Filtration: solutes & solvent move together in response to fluid pressure; moves from area of high pressure (hydrostatic pressure) to area of low pressure • Hydrostatic pressure: The force within a fluid compartment (as in the vascular system) The pressure that forces the fluid out of your capillaries. • Colloidal Osmotic Pressure – pulls it back into the capillaries.

Regulation of Body Fluids • Intake: osmoreceptors sense osmolality of serum, signals the hypothalamus, stimulates thirst – Impact on intake: Age (decreases desire to drink), conciousness, ability to take in fluids • Output: kidneys, lungs, GI tract, skin • Sensible: measurable…. urine output, excessive perspiration, diarrhea, vomiting • Insensible: immeasurable…normal perspiration, normal breathing • Output for adults should be one m. L/kg (of body weight) an hour

Role of the Kidneys • Filter approx 180 Liters of blood per day; GFR (glomerular filtration rate) • Produces urine between 1 -2 Liters/day • If loss of 1% to 2% of body water, will conserve water by reabsorbing more water from filtrate; urine will be more concentrated • If gain of excess body water, will excrete more water from filtrate; urine will be more diluted

Hormonal Control • Antidiuretic hormone (ADH): Prevents diuresis; “water saving” • Question: Osmoreceptors sensing a/an increase in osmolality will cause the release of ADH • ADH acts on kidneys via the renal tubules. Makes them more permeable to water. The water will move from the tubes back into your body.

Hormonal Control • RAA (Renin-angiotensin-aldosterone): cascade initiated by decrease in renal perfusion or low Na+ • If extracellular volume is decreased renal perfusion decreases renin secreted by kidneys renin acts to produce angiotensin I which then converts to angiotensin II results in massive vasoconstriction increases renal arterial perfusion and causes increased thirst, a release of aldosterone (causes the retention of Na and Water)

Hormonal Control • Aldosterone: • Angiotensin II causes the adrenal gland to release aldosterone • Aldosterone causes the kidneys to retain Na+ and water • Volume regulator…. released if Na+ is low and K+ is high; increases reabsorption of Na+ (where salt goes, water follows) and the excretion of K+

ANP • Atrial Natriuretic Peptide: (ANP): secreted from atrial cells of heart (in response to too much volume in the blood) • acts as diuretic • inhibits thirst mechanism • suppresses the RAA cascade

Thirst Mechanism • Regulated by the hypothalamus • Stimulates thirst: • increased osmolality of ECF • decreased ECF • dry mucous membranes • Causes: eating salty foods, inadequate intake, excessive water loss

Pressure Sensors Baroreceptors: Nerve receptors that sense pressure in blood vessels (think barometer measures pressure in the atmosphere, this measures pressure in the blood vessels) • Low pressure: sensors in the cardiac atria; stimulate SNS (sympathetic nervous system) & inhibits PSNS (parasympathetic nervous system) (sns will increase heart rate and BP) • High pressure: sensors in the aortic arch, carotid sinus, and the juxtaglomerular apparatus in the kidney; stimulates PSNS and inhibits the SNS (psns will decrease your heart rate and lower BP)

Pressure Sensors • Osmorecptors: Sense Na+ concentration • Positioned on surface of hypothalamus • Increase in Na+ concentration: stimulates release of ADH • Decrease in Na+ concentration: inhibits release of ADH

ELECTROLYTES and OTHER LABS RELATED TO FLUID VOLUME STATUS

Electrolytes • Minerals and salts: electrolytes • Cations: Positively charged; sodium, potassium, calcium, magnesium • Major cation in ECF is sodium • Anions: Negatively charged; chloride, bicarbonate, sulfate • Major cation in ICF is potassium

Hyponatremia Usually loss of Na w/o loss of fluid • Causes – – – Salt wasting fr. Kidney Adrenal insufficiency GI losses Profuse sweating Diuretics SIADH • Syndrome of inappropriate Anti-Diruetic Hormone – Inadequate Na intake • Physical Exam – – – – Apprehension Personality change Postural hypotension Tachycardia Convulsions/coma NV&D Anorexia

Hyponatremia cont’d • Labs – Serum Na+ below 135 m. Eq/L – Serum Osmolality below 280 m. Osm/kg – Urine specific gravity below 1. 010 • Treatment • Restrict water • Sodium replacement

Hypernatremia • Causes – – ingestion of salt Iatrogenic (we caused it) aldosterone Water deprivation • Signs & Sxms – – Thirst, sticky tongue Dry, flushed skin Fever Convulsions, irritability

Hypernatremia cont’d • Labs – Serum Na+ above 145 m. Eq/L – Serum Osmolality above 295 m. Osm/kg – Urine specific gravity above 1. 030 • Treatment • Hypotonic IV solution • or D 5 W

Urine Na+ Studies • Urine Na+ – Assesses volume status – Aids in diagnosing hyponatremia & acute renal failure • Random normal range = 50 -130 m. Eq/L • 24 hour = 75 -200 m. Eq/L

Hypokalemia • Causes – Diuretics that “waste” potassium – D, V, & gastric suction – aldosterone – Polyuria, sweating – Iatrogenic – K+ poor solutions • Signs & Sxms – Weakness, fatigue – muscle tone – Hypoactive bowel sounds and distention – Weak, irregular pulse – Paresthesias – SOMETHING ABOUT CARDIAC FUNCTION

Hypokalemia cont’d • Labs – K+ below 3. 5 m. Eq/L – ECG abnormalities • Treatment • Oral K+ or IV solution w/K+ • Increased dietary K+

Hyperkalemia • Causes – Renal failure – Fluid vol. deficit – Massive cellular injury (trauma/burns) – Iatrogenic – Potassium “sparing” diuretics – Addison’s disease • Signs & Sxms – Anxiety – Dysrrhythmias – Paresthesia (numbness, pins & needles feeling) – Weakness – Diarrhea

Hyperkalemia cont’d • Labs – Serum K+ above 5. 0 m. Eq/L. – ECG abnormalities – can lead to arrest (if too high or too low) • Treatment Kayexalate IV Na+ bicarb IV Ca+ gluconate Regular insulin and hypertonic dextrose IV • Limit via diet • Possible dialysis • •

Hypocalcemia • Causes – Rapid admin of blood w citrate – Hypoalbuminemia – Hypoparathyroidism – Vit. D deficiency – Pancreatitis – Stuff that relates back to preexisting conditions • Signs & Sxms – Numbness, tingling of fingers & mouth – Hyperactive reflexes – Tetany- a muscle contraction that stays contracted – Muscle cramps – Pathological fractures

Hypocalcemia cont’d • Labs – Serum Ca++ below 4. 5 m. Eq/L – ECG abnormalities • Treatment • Increase dietary intake • IV calcium gluconate • Ca+ & vit D supplements

Hypercalcemia • Causes – – – Hyperparathyroidism Osteometastasis Paget’s disease Osteoporosis Prolonged immobilization • Signs & Sxms – – – Anorexia, N & V Weakness, lethargy Low back pain (stones) Decreased LOC Personality changes Cardiac arrest

Hypercalcemia cont’d • Labs – Serum Ca++ above 5. 5 m. Eq/L – X-rays showing osteoporosis – Stones & BUN / creatinine fr. FVD or renal damage • Treatment • Lasix (diuretic) • Increased fluids

Hypomagnesemia • Causes – Inadequate intake • Alcohol, Malnutrition – Inadequate absorption • V&D, Gastric aspirate • Fistulas, Sm. Bowel – Loss fr. Diuretics – Polyuria • Signs & Sxms – Tremors – Hyperactive deep tendon reflexes – Confusion – Dysrhythmias

Hypomagnesemia cont’d • Labs – Serum Mg++ below 1. 5 m. Eq/L • Treatment • Mag sulfate IV • Oral replacement • Increase dietary intake

Hypermagnesemia • Causes – Renal failure – Excess intake of magnesium • Signs & Sxms – Most frequently seen in acute – Hypoactive deep tendon reflexes & drowsiness – Decreased depth and rate of resp. – Hypotension – flushing

Hypermagnesemia cont’d • Labs – Serum Mg++ levels above 2. 5 m. Eq/L • Treatment • • IV calcium gluconate Loop diuretics NS or LR IV solutions Dialysis

Additional Lab Data • Hematocrit – Measures the volume % of RBC’s in whole blood • Normal: M = 40 -50%; F = 37 -47% – Increases with dehydration (hemoconcentration) – Decreases with overhydration (hemodilution)

Hematocrit & Fluid Volume Status From “Fluids & Electrolytes Made Incredibly Easy” 4 th ed. Fluids & Electrolytes Made Incredibly Easy

Lab Data (cont’d) • Blood urea nitrogen (BUN) – Measures kidney function – Normal range: 7 -20 mg/d. L – Varies with protein intake, fever, dehydration, GI bleeding, liver failure, etc.

Lab Data (cont’d) • Creatinine – End product of muscle metabolism – Better indicator of renal function than BUN • Doesn’t vary w protein intake or metabolic state – Normal range: 0. 7 -1. 5 mg/d. L in 24 hr urine collection – Serum: adult female: 0. 5 to 1. 1 mg/d. L adult male: 0. 6 to 1. 2 mg/d. L

Lab Data (cont’d) • Urine Specific Gravity – Measures ability of kidney to excrete or conserve water • Normal range = 1. 010 - 1. 025 – Increased S. G. = concentrated urine – Decreased S. G. = dilute urine

Lab Data (cont’d) • Serum Osmolarity – Most accurate for kidney function • Remember norm? – 280 -295 m. Osm/L – Measured directly through blood – Indirectly using Serum Osmolarity Formula

Maintaining Fluid Balance

Fluid Imbalances • Isotonic – Deficit – water, electrolytes and solutes lost in equal proportions to body solutions – Excess – water, electrolytes and solutes gained in equal proportions to body solution – FVD - fluid volume deficit-HYPOVOLEMIA – FVE - fluid volume excess-HYPERVOLEMIA

Fluid Disturbances Osmolar Imbalances – Hyperosmolar – Dehydration – Hypoosmolar – Water excess – Loss or excesses of water only – Leads to alteration in concentration of serum

ISOTONIC FLUID DISTURBANCES

Fluid Volume Deficit (FVD) • Water AND solutes lost in equal proportion. – – – Diarrhea, vomiting, fistulas, drains Bleeding, burns Fever, excessive perspiration Inadequate fluid intake Diuretics GI suctioning

FVD: Signs & Symptoms • Mild –Dry mouth, furrowed tongue –Orthostatic or postural hypotension –Restlessness & anxiety –Tachycardia –Less than 5% weight loss • Moderate – Confusion, irritability, thirst, cool & clammy – Urine output 30 cc/hr or less – Rapid weight loss – Slowed vein filling

FVD: Signs & Symptoms (cont’d) • Severe – Pale – Flattened neck veins, delayed capillary refill – Urine output less than 10 cc/hr – Marked hypotension, tachycardia, weak or absent pulses (shock) – Can lead to unconsciousness

FVD: Labs • Lab findings vary depending on the cause –Decreased H/H with hemorrhage –Increased Hct –Elevated BUN –Urine specific gravity greater than 1. 030

FVD: Nursing Diagnosis Statement • Example: –Fluid volume deficit r/t active fluid volume loss as evidenced by decreased blood pressure (90/50 mm. Hg), thirst, fever (102°), rapid heart rate (110 bpm), urine output less than or equal to 25 m. L/hr, & urine specific gravity of 1. 040.

FVD: Goal Statement • Client will achieve fluid balance AEB – urine output equal to or greater than 30 m. L/hr – Elastic skin turgor and moist mucous membranes

FVD: Medical Interventions • Treat cause • Replacing fluids intravenously • isotonic if hypotensive (expand plasma volume) • hypotonic if normotensive (provides electrolytes and water) • Encourage fluids • Ensure adequate O 2 and perfusion • Increase blood counts, BP, & albumin levels • Teaching

FVD: Nursing Interventions • Ensure patent airway, adjust O 2 levels as ordered • Lower HOB if tolerated or not contraindicated • Direct pressure to bleeding, if present • Administer meds, blood, albumin, & IV fluids

FVD: Nursing Interventions (cont’d) • • • Weigh patients daily Provide skin care Maintain strict I&O Monitor vital signs Monitor lab work

FVD: Teaching • • • Nature of condition & causes Warning S/S Treatments & importance of compliance Change positions slowly Monitor BP & pulse rate Give prescribed medications

Fluid Volume Excess (FVE) • Water AND solutes gained in excess of normal body levels • Causes: – Isotonic fluid overload – Excess sodium intake – CHF, renal failure, cirrhosis – Increase in steroids or serum aldosterone

FVE: Signs & Symptoms • Generalized – Acute weight gain • Mild-mod 5 -10% • Severe > 10% – Edema • dependent, sacral, pulmonary • Cardiovascular – Tachycardia, bounding pulse, distended neck veins, increased BP • Respiratory – Dyspnea, tachypnea, crackles, frothy cough

FVE: Lab Values • Decreased hematocrit • Decreased BUN • Low O 2 levels

FVE: Nursing Diagnosis Statement • Fluid volume excess r/t excess fluid intake aeb Hct of 23, 10# weight gain in two days, dyspnea (Pt states, “I can’t get enough air. ”), and crackles on inspiration and expiration in all lobes.

FVE: Related Nursing Diagnoses • Ineffective breathing pattern r/t increased fluids • Impaired skin integrity r/t excess fluids • Confusion

FVE: Client Goals & Outcomes Aimed at cause • Decrease circulating fluid volume • Lower BP and pulse • Improve breathing status • Maintain skin integrity • Teaching

FVE: Goal Statement • Client will achieve fluid balance manifest in following outcomes – Clear breath sounds – Denies dyspnea and affirms the ability to breathe adequately

FVE: Nursing Interventions • • Restrict Na+ & fluid intake Watch for edema - dependent & respiratory Provide measures to facilitate breathing Provide skin care for weeping & edema

FVE: Nursing Interventions (cont’d) • Monitor response to medications • Accurate I/O, Consistent daily weight, VS, monitor labs • Advise HCP if poor response to therapy – Hemodialysis may be needed

FVE: Teaching • • • Nature of condition and causes Signs and symptoms Treatments and importance of compliance Need to monitor BP, P, O 2 Sat, & weight Rationale for Na+ and fluid restrictions Medications

Osmolar Imbalances

Hyperosmolar: Dehydration • Loss of water = increased serum osmolality increased serum Na+ Compensatory Mechanism: water shifts out of cells (ICF) into the ECF…. . if not corrected, water continues to move out of cells (ICF) and into ECF causing the cells to shrink…. shrunken cells don’t function properly!!

Causes of Dehydration • Causes: – Diabetes insipidus, prolonged fever, watery diarrhea, hyperglycemia, failed thirst drive – Iatrogenic: hypertonic solutions (IV & tube feeding) – Diuresis of water alone

Dehydration: Signs & Symptoms • Irritability, confusion, weakness, dizziness • Decreased urine output, darkened urine • Dry, sticky mucous membranes, sunken eyeballs, poor turgor, extreme thirst !!! • Fever (insensible – continuous) • Coma • Tachycardia, weak, thready pulse, hypotension

Dehydration: Labs • • Elevated hematocrit Elevated serum osmolarity > 295 m. Osm/kg Elevated serum sodium > 145 m. Eq/L Urine specific gravity > 1. 030

Dehydration: Nursing Diagnoses • Fluid volume deficit r/t fluid loss • Deficient fluid volume r/t excessive fluid loss from GI tract • Risk for impaired skin integrity r/t altered metabolic state If you’ve lost 20% of you initial weight from dehydration, you’re probably dead

Dehydration: Potential Nursing Diagnoses • Deficient knowledge: unfamiliarity of disease process • Disturbed thought processes r/t neurologic changes / decreased cardiac output • Decreased cardiac output r/t excessive fluid loss

Dehydration: Client Goals & Outcomes • Aimed at correcting cause • Replace fluids – hypotonic, slowly rehydrate over 48 hrs (if you go too quickly, you die) • Maintain skin integrity • Teaching

Dehydration: Nursing Interventions • • • Replace fluids by PO route first SLOW admin. of salt-free IV solutions Monitor S/S cerebral & pulmonary edema Monitor accurate I/O, VS, daily weights Monitor labs Provide skin and mouth care

Dehydration: Teaching • • • Disease process of dehydration Treatments Warning signs and symptoms Medications / IV (Vasopressin – D 5 W) Importance of compliance with therapy – Fluid intake not based on thirst alone

Hypoosmolar • Water excess • Causes – SIADH or excess water intake • Signs & Sxms – Decreased LOC, convulsions, coma • Labs – Serum Na+ below 135 m. Eq/L and Serum osmolality below 280 m. Osm/kg

Nsg Dx – Goals - Interventions • Similar to FVE • Make relevant to underlying cause • Is very acute illness

Physical Assessment

History • • • Medical – Acute Illness, surgery, burns Environment – exercise, hot/cold/dry areas Diet – proteins, lytes, fluids Lifestyle – smoking/alcohol Medication history

Areas of Concern in PA • • • Mental status BP and pulse Skin I & O’s & WEIGHT Lungs

Geriatric Focus • • Body-water content (mass related) Kidney function Cardiac & respiratory function Hormonal regulatory function Thirst sensation Medication Use Skin & subcutaneous fat

Assessment of Geriatric Clients • Skin turgor – Assessment is performed where? • Cognition • Physical being • Continence

Laboratory Data • • BMP / CMP Serum osmolarity Urine specific gravity Urine sodium Hematocrit Blood urea nitrogen (BUN) Creatinine

Clients at Risk for F&E Imbalances • Age – Very young – Very old • Chronic Diseases – Cancer – Cardiovascular disease, such as congestive heart failure – Endocrine disease, such as Cushing's disease and diabetes – Malnutrition – Chronic obstructive pulmonary disease – Renal disease, such as progressive renal failure – Changes in level of consciousness

Clients at Risk for F&E Imbalances • Trauma – – Crush injuries Head injuries Burns Major surgery • Therapies – – Diuretics Steroids Intravenous (IV) therapy Total parenteral nutrition (TPN) • Gastrointestinal losses – Gastroenteritis – Nasogastric suctioning – Fistulas

Fluid & Electrolytes Nursing DXs • Risk for imbalanced Body temperature • Ineffective Breathing pattern • Decreased Cardiac output • Deficient Fluid volume • Risk for deficient Fluid volume • Excess Fluid volume • Impaired Gas exchange • Knowledge deficient regarding disease management • Impaired Mobility • Impaired Oral mucous membrane • Impaired Skin integrity • Risk for impaired Skin integrity • Ineffective Therapeutic regimen management • Impaired Tissue integrity • Ineffective Tissue perfusion

Intravenous Fluid Therapy in Fluid Balance Disorders

ISOtonic solutions • Same osmolarity as body fluids – 280 - 300 m. Osm/kg • Expands the IVC without pulling fluids from other compartments • Examples – Normal saline (NS) – Lactated Ringers (LR)

IVs: Normal Saline (NS) • • Isotonic 0. 9% Sodium Chloride Different amounts Sample order – NS @ 75 cc/hr

IVs: Lactated Ringer’s (LR) • Isotonic Solution • Contents – Na+, Cl-, K+, Ca++, Lactate in sterile water • One strength, two common amounts • Sample orders – LR @ 100 cc/hr – RL @ 75 cc/hr

Hyp. Otonic solutions • Osmolarity less than serum • Pulls fluid from the IVC into the ICC causing cells to expand – Over hydration – Rehydration RISK • Example – ½ NS – D 5 W - after absorbed into body

IVs: Dextrose Solutions • Concentrations – 5% in water (hypotonic after enters body) – 10% in water (hypertonic) – 50% in water (rescue solution – small volume) – As additive to NS or LR • D 5 NS or D 5 LR

Hyp. ERtonic solutions • Osmolarity of solution is higher than serum osmolarity – >300 m. Osm/kg • Pulls fluid from ICC into IVC causing cells to shrink – dehydrate • Examples – D 51/2 NS - D 5 LR – 3% NS (CRITICAL Strength)

IVs: Common Additives • Potassium (never add to a bag!) • Multivitamins • Additives makes the solution hypertonic to some extent – depends on amount

IV Additives: Potassium • Available as KCl (potassium chloride) • NEVER add K+ to a bag of fluid – Added by pharmacy or premixed • Different strengths • Sample orders – NS c 20 m. Eq KCl @ 75 cc/hr – LR c 40 m. Eq KCl @ 75 cc/hr

Medications Used in Fluid & Electrolyte Imbalance Disorders

Meds: Antidiarrheals • • Assess I /O & electrolytes Provide oral care Monitor for constipation Teaching – Take as directed – Avoid overdose • Examples: Lomotil & Immodium

Meds: Antiemetics • Assess VS & emesis status before and after • Monitor for extrapyriamidal side effects – involuntary movement of eyes, face or limbs, flat affect, shuffled gait, drooling • Provide fluid replacements – Oral electrolyte solutions – Water • Sample Meds: Zofran, Phenergan & Vistaril

Meds: Diuretics • Assess – Weight, edema, skin turgor, & mucus membranes, lung sounds • Monitor – weight, I /O, electrolytes • Teaching – diet, weigh daily, & dosing times • Examples: – Thiazides (HCTZ) – HTN – Potassium sparing (spironolactone) – Osmotic (mannitol) – decrease ICP – Loop (lasix) – pull fluids

Meds: Potassium • Forms: tablets (SR), effervescent, EC, IV • Administration considerations – PO: Give on a full stomach at mealtime am/pm – IV: NEVER give as bolus, follow protocol, dilute for IV administration, can burn & lead to infiltration • Monitor: K+ levels – monitor EKG if elevated

Meds: Kayexelate • Removes K+ from system • Available as enema or by PO route – Retain enema for ½ to 1 hr – Follow resin w 100 m. L water – After expulsion, rinse colon w 1 liter of water and drain out immediately

Other Meds r/t F/E status • Glucocorticosteroids • Digoxin • Electrolyte supplements

Stuff To Add for the Test • A L of fluid weighs 2. 2 lbs – 1 lb of fluid is 454 m. L – If a L of fluid weighs 2. 2 lbs you need to be able to figure out how many m. L a ½ lb is • • 10% fluid loss is serious, but 20% loss is mostly death If you have someone who begins to have a transfusion reaction (hemolytic) watch for – Fever, low back pain, itching, hypotension, N/V, drop in urine output, chest pain, dyspnea – If you are doing VS for these people and they have these symptoms, GO FIND THE NURSE IMMEDIATELY! They don’t need any more blood whatsoever!