FLUIDS ELECTROLYTES WATER AND ACID BASE BALANCE 12302021

FLUIDS, ELECTROLYTES, WATER AND ACID – BASE BALANCE 12/30/2021 NRS 105 Collings 2011 1

DISTRIBUTION OF BODY FLUIDS • INTRACELLULAR – INSIDE THE CELL • EXTRACELLULAR – OUTSIDE THE CELL • INTRAVASCULAR – INSIDE THE VESSELS (ARTERIES AND VEINS) • INTERSTITIAL – NOT IN THE CELL, NOT IN THE VESSELS – BETWEEN THE CELL (contains LYMPH) • TRANSCELLULAR – CSF, PLEURAL FLUID, INTRAOCCULAR, GI, PERITONEAL, SYNOVIAL 12/30/2021 NRS 105 Collings 2011 2

BODY FLUID COMPARTMENTS 12/30/2021 NRS 105 Collings 2011 3

ELECTROLYTES IN BODY FLUIDS • NORMAL VALUES – SODIUM (Na+) – POTASSIUM (K+) – IONIZED CALCIUM (Ca++) – BICARBONATE (HCO 3) – CHLORIDE (Cl--) – MAGNESIUM (Mg++) – PHOSPHATE (PO 4 ---) 12/30/2021 NRS 105 Collings 2011 135– 145 m. Eq/L 3. 5 – 5. 0 m. Eq/L 4. 5 – 5. 5 mg/dl 22 – 26 m. Eq/L 95 – 105 m. Eq/L 1. 5 – 2. 5 m. Eq/L 2. 8 – 4. 5 mg/dl 4

MEASUREMENTS OF ELECTROLYTES • m. Eq/L – MILLIEQUIVALENTS PER LITER – THE NUMBER OF GRAMS OF A GIVEN ELECTROLYTE DISSOLVED IN A LITER OF PLASMA 12/30/2021 NRS 105 Collings 2011 5

VOCABULARY REVIEW • • • ANIONS [-] Cl-, HCO 3 -, PO 4 3 CATIONS [+]; Na+, K+ Ca+, Mg SOLUTE e. g. electrolyte SOLVENT e. g. water DIFFUSION: random movement of solute equalizes distribution of solute FILTRATION: water and ‘lytes move together across membrane under pressure; capillaries 12/30/2021 NRS 105 Collings 2011 6

VOCABULARY REVIEW • OSMOSIS: movement of H 2 O across membrane • • • [less to more] to equalize ion concentration OSMOTIC PRESSURE: drawing power to H 2 O; albumin pulls H 2 O into intravascular space ISOTONIC: same osmolarity as plasma; NS HYPERTONIC: higher osmotic pressure – pulls fluid from cells HYPOTONIC: low osmotic pressure; 0. 45% NS moves fluid into cells HYDROSTATIC PRESSURE: determines direction of filtration – high to low [capillaries] 12/30/2021 NRS 105 Collings 2011 7

OSMOSIS • MOVEMENT OF A SOLVENT (WATER) ACROSS A SEMIPERMEABLE MEMBRANE • MOVES FROM AN AREA OF LESSER SOLUTE CONCENTRATION (ELECTROLYTE) TO AN AREA OF GREATER SOLUTE CONTRATION 12/30/2021 NRS 105 Collings 2011 8

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OSMOTIC PRESSURE • THE DRAWING POWER OF WATER – A HIGHLY CONCENTRATED FLUID HAS HIGH OSMOTIC PRESSURE – DRAWS WATER TO IT • WORKS TO ATTAIN EQUILIBRIUM (BALANCE) • OSMOLARITY – DESCRIBES THE CONCENTRATION OF SOLUTIONS – THE NUMBER OF MOLECULES PER LITER OF SOLUTION 12/30/2021 NRS 105 Collings 2011 10

IV SOLUTIONS • ISOTONIC SOLUTIONS – THE SAME CONCENTRATION (OSMOLARITY) AS BLOOD PLASMA e. g. NS 0. 9% no change; ↑volume • HYPOTONIC SOLUTION – A SOLUTION OF LOWER OSMOTIC PRESSURE – LOWER CONCENTRATION OF SOLUTES THAN BLOOD PLASMA e. g. ½ NS 0. 45%, pulls fluid out of cells • HYPERTONIC SOLUTION – A SOLUTION OF HIGHER OSMOTIC PRESSURE (MORE CONCENTRATED THAN BLOOD PLASMA) e. g. D 5 NS – pulls fluid from cells 12/30/2021 NRS 105 Collings 2011 11

DIFFUSION • RANDOM MOVEMENT OF A SOLUTE (ELECTROLYTE, GAS) ACROSS A SEMIPERMEABLE MEMBRANE – CREAM IN COFFEE – OXYGEN, CARBON DIOXIDE BETWEEN ALVEOLI AND BLOOD VESSELS • MOVES FROM AREAS OF HIGH CONCENTRATION TO AN AREA OF LOWER CONCENTRATION ACROSS A CONCENTRATION GRADIENT 12/30/2021 NRS 105 Collings 2011 12

NRS 105. 320 W 2009 12/30/2021 NRS 105 Collings 2011 13

ACTIVE TRANSPORT • REQUIRES METABOLIC ACTIVITY AND USES ENERGY TO MOVE SUBSTANCES ACROSS CELL MEMBRANES. – ENABLES LARGER SUBSTANCES TO MOVE INTO CELLS – MOLECULES CAN ALSO MOVE TO AN AREA OF HIGHER CONCENTRATION (UPHILL) – SODIUM, POTASSIUM PUMP • POTASSIUM PUMPED IN • SODIUM PUMPED OUT 12/30/2021 NRS 105 Collings 2011 14

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FILTRATION • WATER AND SUBSTANCES MOVE TOGETHER ACROSS A MEMBRANE BECAUSE OF FLUID PRESSURE – OCCURS IN CAPILLARY BEDS – MOVEMENT FROM AN AREA OF HIGHER PRESSURE TO AN AREA OF LOWER PRESSURE (HYDROSTATIC PRESSURE) – B/P changes – e. g. hemorrhage, ICP 12/30/2021 NRS 105 Collings 2011 16

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REGULATION OF BODY FLUIDS • HOMEOSTASIS IS MAINTAINED THROUGH – FLUID INTAKE – HORMONAL REGULATION – FLUID OUTPUT 12/30/2021 NRS 105 Collings 2011 18

FLUID INTAKE • Thirst control center located in the hypothalamus – Osmoreceptors monitor serum osmolarity – When osmolarity increases [blood more concentrated] thirst sensation • Salt increases serum osmolarity – Protective against dehydration • High glucose also increases serum osmolarity – Symptoms of diabetes 12/30/2021 NRS 105 Collings 2011 19

FLUID INTAKE • AVERAGE ADULT INTAKE – 2200 – 2700 ml PER DAY • ORAL 1100 – 1400 ml PER DAY • SOLID FOODS 800 – 1000 ml PER DAY • OXIDATIVE METABOLISM – 300 ml PER DAY 12/30/2021 NRS 105 Collings 2011 20

HORMONAL REGULATION • ADH (ANTIDIURETIC HORMONE) – STORED IN THE POSTERIOR PITUITARY AND RELEASED IN RESPONSE TO SERUM OSMOLARITY – Prevents diuresis – saves water – PAIN, STRESS, CIRCULATING BLOOD VOLUME AFFECT THE RELEASE OF ADH • ↑ IN ADH = ↓ IN URINE OUTPUT 12/30/2021 NRS 105 Collings 2011 21

HORMONAL REGULATION • RENIN-ANGIOTENSIN-ALDOSTERONE – INITIATED BY A CHANGE IN RENAL PERFUSION • RENIN, PRODUCED BY KIDNEYS, IS RELEASED IN RESPONSE TO LOW PERFUSION RELATED TO A DECREASE IN EXTRACELLULAR VOLUME – RENIN PRODUCES ANGIOTENSIN I – ANGIOTENSIN I QUICKLY COVERTED TO ANGIOTENSIN II – ANGIOTENSIN II IS A POTENT selective VASOCONSTRICTOR – ALSO INCREASES RENAL PERFUSION • ↑ blood flow to kidneys • Stimulate release of Aldosterone 12/30/2021 NRS 105 Collings 2011 22

HORMONAL REGULATION • ALDOSTERONE – ACTS ON THE DISTAL PROTION OF THE RENAL TUBLES TO INCREASE THE REABSORPTION OF SODIUM AND THE SECRETION AND EXCRETION OF POTASSIUM AND HYDROGEN – WATER IS RETAINED BECAUSE SODIUM IS RETAINED – Sodium & water retained → restored blood volume [protective] – HTN, plaque, etc same cycle [edema] 12/30/2021 NRS 105 Collings 2011 23

HORMONAL REGULATION • ATRIAL NATRIURETIC PEPTIDE (ANP) – ANP IS A HORMONE SECRETED FROM ATRIAL CELLS OF THE HEART IN RESPONSE TO ATRIAL STRETCHING AND AN INCREASE IN CIRCULATING BLOOD VOLUME – ANP acts as a diuretic, causes Na+ loss, inhibits thirst decreased blood volume • Protective if blood volume high • Not protective in cardiac disease [Na+ imbalance] 12/30/2021 NRS 105 Collings 2011 24

FLUID OUTPUT REGULATION • ORGANS OF WATER LOSS – KIDNEY – LUNGS – SKIN – GI TRACT 12/30/2021 NRS 105 Collings 2011 25

FLUID OUTPUT REGULATION • KIDNEYS – MAJOR REGULATORY ORGANS OF FLUID BALANCE • RECEIVE ABOUT 180 LITERS OF PLASMA TO FILTER EACH DAY • 1200 – 1500 ml OF URINE PRODUCED EACH DAY • URINE VOLUME CHANGES RELATED TO VARIATION ON THE AMOUNT AND TYPE OF FLUIDS INGESTED • Minimum volume of urine to excrete wastes [e. g. urea] is about 400 ml/ day 12/30/2021 NRS 105 Collings 2011 26

FLUID OUTPUT REGULATION • SKIN – INSENSIBLE WATER LOSS • OCCURS THROUGH THE SKIN AND LUNGS – SENSIBLE WATER LOSS • EXCESS PERSPIRATION (CAN BE SENSIBLE OR INSENSIBLE) – INSENSIBLE + SENSIBLE FLUID LOSS THROUGH THE SKIN – 500 – 600 ml EACH DAY 12/30/2021 NRS 105 Collings 2011 27

FLUID OUTPUT REGULATION • LUNGS – EXPIRE APPROXIMATELY 500 ml OF WATER DAILY • INCEASE IN WATER LOSS RELATED TO ADMINISTRATION OF OXYGEN • Clients on high O 2 need extra fluids to compensate 12/30/2021 NRS 105 Collings 2011 28

FLUID OUTPUT REGULATION • GI TRACT – 3 – 6 LITERS OF ISOTONIC FLUID MOVES INTO THE GI TRACT AND THEN RETURNS TO THE EXTRACELLULAR FLUID SPACE • Vomiting increases GI losses + electrolytes – 200 ml OF FLUID IS LOST IN THE FECES EACH DAY • DIARRHEA CAN INCREASE THIS LOSS 12/30/2021 NRS 105 Collings 2011 29

REGULATION OF ELECTROLYTES • MAJOR CATIONS IN BODY FLUIDS – SODIUM (Na+) – POTASSIUM (K+) – CALCIUM (Ca++) – MAGNESIUM (Mg++) 12/30/2021 NRS 105 Collings 2011 30

REGULATION OF ELECTROLYTES • SODIUM REGULATION – MOST ABUNDANT CATION IN THE EXTRACELLULAR FLUID – MAJOR CONTRIBUTOR TO MAINTAINING WATER BALANCE • NERVE TRANSMISSION ** LOC, peripheral • REGULATION OF ACID-BASE BALANCE • CONTRIBUTES TO CELLULAR CHEMICAL REACTIONS – SODIUM IS TAKEN IN VIA FOOD AND BALANCE IS MAINTAINED THROUGH ALDOSTERONE 12/30/2021 NRS 105 Collings 2011 31

REGULATION OF ELECTROLYTES • POTASSIUM REGULATION – MAJOR ELECTROLYTE AND PRINCIPLE CATION IN THE INTRACELLULAR FLUID – REGULATES METABOLIC ACTIVITIES – REQUIRED FOR GLYCOGEN DEPOSITS IN THE LIVER AND SKELETAL MUSCLE – REQUIRED FOR TRANSMISSION OF NERVE IMPULSES, NORMAL CARDIAC CONDUCTION AND NORMAL SMOOTH AND SKELETAL MUSCLE CONTRACTION – REGULATED BY DIETARY INTAKE AND RENAL EXCRETION 12/30/2021 NRS 105 Collings 2011 32

REGULATION OF ELECTROLYTES • CALCIUM REGULATION – STORED IN THE BONE, PLASMA AND BODY CELLS • 99% OF CALCIUM IS IN THE BONES AND TEETH • 1% IS IN EXTRACELLULAR FLUID – 50% OF CALCIUM IN THE EXTRACELLULAR FLUID IS BOUND TO PROTEIN (ALBUMIN) • 40% IS FREE IONIZED CALCIUM – May be measured as Ionized or total Ca 12/30/2021 NRS 105 Collings 2011 33

REGULATION OF ELECTROLYTES • CALCIUM REGULATION – CALCIUM IS NECESSARY FOR • BONE AND TEETH FORMATION • BLOOD CLOTTING • HORMONE SECRETION • CELL MEMBRANE INTEGRITY • CARDIAC CONDUCTION • TRANSMISSION OF NERVE IMPULSES • MUSCLE CONTRACTION 12/30/2021 NRS 105 Collings 2011 34

REGULATION OF ELECTROLYTES • MAGNESIUM – – ESSENTIAL FOR ENZYME ACTIVITIES NEUROCHEMICAL ACTIVITIES CARDIAC AND SKELETAL MUSCLE EXCITABILITY REGULATION • DIETARY • RENAL • PARATHYROID HORMONE – 50 – 60% OF MAGNESIUM CONTAINED IN BONES • 1% IN EXTRACELLULAR FLUID; MINIMAL AMOUNT IN CELL 12/30/2021 NRS 105 Collings 2011 35

REGULATION OF ELECTROLYTES • ANIONS – CHLORIDE (Cl-) – BICARBONATE (HCO 3 -) – PHOSPHATE (PO 4 ---) 12/30/2021 NRS 105 Collings 2011 36

REGULATION OF ELECTROLYTES • CHLORIDE REGULATION – MAJOR ANION IN ECF – CHLORIDE FOLLOWS SODIUM – REGULATED BY DIETARY INTAKE AND THE KIDNEYS 12/30/2021 NRS 105 Collings 2011 37

REGULATION OF ELECTROLYTES • BICARBONATE REGULATION – MAJOR CHEMICAL BUFFER WITHIN THE BODY – FOUND IN BOTH ECF AND ICF – ESSENTIAL TO ACID-BASE BALANCE – REGULATED BY THE KIDNEYS 12/30/2021 NRS 105 Collings 2011 38

REGULATION OF ELECTROLYTES • PHOSPHORUS – PHOSPHATE REGULATION (TERMS USED INTERCHANGEABLY) • BUFFER ANION FOUND MOSTLY IN ECF • MAINTAINS BONES AND TEETH • INVERSE RELATIONSHIP BETWEEN PHOSPHATE AND CALCIUM • PHOSPHATE ALSO PROMOTES NORMAL NEUROMUSCULAR FUNCTION 12/30/2021 NRS 105 Collings 2011 39

REGULATION OF ACID-BASE BALANCE • VOCABULARY – BUFFER • A SUBSTANCE THAT CAN EITHER ABSORB OR RELEASE A HYDROGEN ION (H+) – ARTERIAL p. H REFLECTS THE CONCENTRATION OF HYDROGEN IONS IN THE BLOOD – THE p. H SCALE • MEASURES THE ACIDITY OR ALKALINITY OF A FLUID • NORMAL RANGE FOR ARTERIAL BLOOD 7. 35 – 7. 45 12/30/2021 NRS 105 Collings 2011 40

REGULATION OF ACID-BASE BALANCE • BIOLOGICAL REGULATION OF Ph – BUFFERING SYSTEMS • HYDROGEN IONS ARE ABSORBED OR RELEASED BY THE CELLS – SWITCH PLACES WITH POTASSIUM • HEMOGLOBIN-OXYHEMOGLOBIN SYSTEM • CHLORIDE SHIFT WITHIN RBCs 12/30/2021 NRS 105 Collings 2011 41

REGULATION OF ACID-BASE BALANCE • PHYSIOLOGICAL: Lungs, Kidneys – LUNGS Early response • ↑ HYDROGEN & CARBON DIOXIDE [acidosis] Stimulates ↑ Respiratory rate, depth → exhaled CO 2 • ↓ Co 2 & H+ [alkalosis] → retain CO 2 by ↓RR • EXAMPLES – DIABETIC KETOACIDOSIS – CO 2 RETAINING PATIENTS WITH COPD 12/30/2021 NRS 105 Collings 2011 42

Acid – Base Regulation - Kidneys • Takes longer/lasts longer – Hours to days • Increased or decreased production of Bicarb, excretion of H+ by ammonia formation, phosphoric acid • Acid excess [acidosis] → reabsorption of bicarb, • Phosphate + H+ = H 3 PO 4 and NH 3 - + H+ = NH 4 → excretion of H+, lowers acid 12/30/2021 NRS 105 Collings 2011 43

ELECTROLYTE IMBALANCES • SODIUM IMBALANCE – HYPONATREMIA [< 135 m. Eq/L serum Na] • GI LOSSES [vomiting/diarrhea] • KIDNEY DISEASE • SKIN LOSS – PERSPIRATION • PSYCHOGENIC POLYDYPSIA • SIADH (SYNDROME OF INAPPROPRIATE ADH) 12/30/2021 NRS 105 Collings 2011 44

ELECTROLYTE IMBALANCES • SODIUM IMBALANCES – HYPERNATREMIA [>145 m. Eq/L] • EXCESS SALT INTAKE • INFUSION OF HYPERTONIC SALINE ( 3%, 5%) • EXCESS ALDOSTERONE • DIABETES INSIPIDUS [low ADH/thirst/dilute urine excreted – Na+ not excreted] • DEHYDRATION [H 2 O follows Na+, but Na+ does not follow H 2 O] 12/30/2021 NRS 105 Collings 2011 45

ELECTROLYTE IMBALANCES • POTASSIUM – HYPOKALEMIA [<3. 5 m. Eq/L] – Common, affects cardiac conductivity/ function • POTASSIUM WASTING DIURETICS • DIARRHEA, VOMITING • ALKALOSIS [shifts into cells in exchange for H+] • EXCESSIVE ALDOSTERONE SECRETION • POLYURIA • EXCESSIVE PERSPIRATION • TREATMENT OF DKA WITH INSULIN [decreases serum potassium by redistributing it into cells] 12/30/2021 NRS 105 Collings 2011 46

ELECTROLYTE IMBALANCES • POTASSIUM K+ – HYPERKALEMIA [>5 m. Eq/L] – Cardiac conduction, altered ECG, arrest • RENAL FAILURE • FLUID VOLUME DEFICIT • CELL DAMAGE FROM BURNS, TRAUMA • ADRENAL INSUFFICIENCY • RAPID INFUSION OF STORED BLOOD • POTASSIUM SPARING DIURETICS • SALT SUBSTITUTES 12/30/2021 NRS 105 Collings 2011 47

ELECTROLYTE IMBALANCES • Hypocalcemia [ionized Ca < 4. 5 m. Eq/L OR total serum Ca < 8. 5 m. Eq/L] • Illnesses affecting thyroid, parathyroid • Renal failure [not excreting Phosphate] alcoholics, pancreatitis • Neuromuscular and Cardiac sx • ↑↑reflexes, cramps, numbness/tingling 12/30/2021 NRS 105 Collings 2011 48

ELECTROLYTE IMBALANCES • Hypercalcemia [serum Ionized Ca+ > 5. 5 or total serum Ca > 10. 5 m. Eq/L] – Immobility, osteoporosis, neoplasm → bone loss of Ca into blood – Kidney stones, ↓ reflexes, N&V 12/30/2021 NRS 105 Collings 2011 49

ELECTROLYTE IMBALANCES • Magnesium [1. 5 -2. 5 m. Eq/L] – Malnutrition, malabsorption → ↓Mg [looks like ↓Ca] ↓ ↓ - Mg hyperactive reflexes – Excess intake + renal problems → ↑Mg, ↓HR, RR, B/P, DTR ↓ [e. g. Sulfate in L&D] • Chloride – Follows Na+, Acid/base imbalance 12/30/2021 NRS 105 Collings 2011 50

TYPES OF ACID-BASE IMBALANCE • RESPIRATORY ACIDOSIS • RESPIRATORY ALKALOSIS • METABOLIC ACIDOSIS • METABOLIC ALKALOSIS Name reflects underlying cause, compensation 12/30/2021 NRS 105 Collings 2011 51

Blood Gases & Acid/Base Balance • Normal arterial blood p. H: 7. 35 -7. 45 • Acidosis: p. H < 7. 35 • Alkalosis: p. H > 7. 45 • Respiratory Acidosis/Alkalosis – Reflected in Pa. CO 2: [35 -45 mg Hg] • resp rate from any cause blows off CO 2 • Resp rate from any cause conserves CO 2 – Compensation is via kidneys 12/30/2021 NRS 105 Collings 2011 52

Blood Gas & Acid/Base Balance • Metabolic Acidosis/Alkalosis – Base Excess: amount of buffer [Hgb & bicarb] – Norm: -2 m. Eq/L - +2 m. Eq/L [HCO 3 - 22 -26] – Alkalosis: BE > +2 m. Eq/L or Bicarb>26 • [from acid loss/ vomiting, gastric suction] – Acidosis: BE< -2 m. Eq/L or Bicarb < 22 • [e. g. from diarrhea, renal disease] – Compensation is via Respiratory system 12/30/2021 NRS 105 Collings 2011 53

Nursing Process: Assessment • History, risk factors: – surgery, burns, renal, respiratory or cardiac disease, GI distress, diet/fluid intake • Age – Infants - ↑ percentage of body is H 2 O • Infants/children have low tolerance for change – Adolescents – sports, recreational drugs – Older adults - ↓ kidney fx, ↓ compensation 12/30/2021 NRS 105 Collings 2011 54

Nursing Process: Assessment • Environmental factors [e. g. sweating] • Diet: intake, change • Lifestyle: etoh, smoking • Medications: diuretics, steroids, opioids, ABX, GI meds, NSAIDS, ecstasy • Assessment: – s/sx of hydration [skin, mm, pulses] wt [rapid change = fluid], I&O, Labs 12/30/2021 NRS 105 Collings 2011 55

Nursing Process: Diagnosis • [Risk for] Deficient Fluid Volume r/t vomiting AEB skin tenting, ↑ HR, dry mucous membranes • Decreased cardiac output r/t low circulating blood volume AEB weak pulses, orthostatic hypotension • Excess fluid volume r/t excess intake of free water AEB bounding pulse, 2 lb wt gain in 24 hrs • Impaired gas exchange r/t high respiratory rate 2° to acid-base imbalance AEB dizziness, confusion • Disturbed sensory perception [tactile] r/t altered calcium level 2° to pancreatitis AEB numbness in hands & feet, serum Ca 3. 8 m. Eq/L 12/30/2021 NRS 105 Collings 2011 56

Nursing Process: Goals • Pt will demonstrate moist mucous membranes, balanced I&O and stable weight within 48 hours • Pt will demonstrate serum electrolyte levels WNL within 24 hours • Pt will limit dietary fluids to 600 ml [per cardiac diet orders] daily this week 12/30/2021 NRS 105 Collings 2011 57

Nursing Process: Interventions • Strict I&O [document!] daily • Offer 240 ml of fluid of choice 1 hr after meals • Monitor daily serum electrolytes, wt • Assist pt to select foods within prescribed diet plan [e. g. fluid-restricted] • Administer IV solutions per orders • Teach client/ family to recognize acidosis s/sx this a. m. 12/30/2021 NRS 105 Collings 2011 58

Nursing Process: Evaluation • Goal met/not met/partially met? • How do you know? • Continue or revise plan 12/30/2021 NRS 105 Collings 2011 59

Questions? 12/30/2021 NRS 105 Collings 2011 60