Fluid and Electrolyte Disorders Uta Tichawa, MSN, APRN-BC, CCRN DePaul University 1 Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

2 Fluid and Electrolyte Balance Necessary for life, homeostasis Nursing role: help prevent, treat fluid, electrolyte disturbances Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

3 Fluids Approximately 60% of typical adult is fluid Varies with age, body size, gender Intracellular fluid Extracellular fluid Intravascular Interstitial Transcellular “Third spacing”: loss of ECF into space that does not contribute to equilibrium Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Body weight of adult male 55-60%, female 50-55%, newborn 75-80% Very little in adipose tissues Loss of 20% - fatal Elderly - decreases to 45-50% of body weight R/T decreased muscle mass, smaller fat stores, and decrease in body fluids 4 Fluids Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Intracellular (ICF) Fluid within the cells themselves 2/3 of body fluid Located primarily in skeletal muscle mass Provide nutrients for metabolism: High in K, Po4, protein Moderate levels of Mg, So4 Assists in cellular metabolism 5 Compartments Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Extracellular (ECF) 1/3 of body fluid Comprised of 3 major components Intravascular Plasma Interstitial Fluid in and around tissues Transcellular Over or across the cells 6 Compartments Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Extracellular Nutrients for cell functioning Na Ca Cl Glucose Fatty acids Amino Acids 7 Compartments Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Intravascular Component Plasma fluid portion of blood Made of: water plasma proteins small amount of other substances 8 Compartments Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Interstitial component Made up of fluid between cells Surrounds cells Transport medium for nutrients, gases, waste products and other substances between blood and body cells Back-up fluid reservoir 9 Compartments Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Transcellular component 1% of ECF Located in joints, connective tissue, bones, body cavities, CSF, and other tissues Potential to increase significantly in abnormal conditions 10 Compartments Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Osmosis Low to high Water potential Diffusion High to low Movement of particles Both can occur at the same time 11 Osmosis versus Diffusion Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

12 Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Active Transport Allows molecules to move against concentration and osmotic pressure to areas of higher concentration Active process – energy is expended 13 Regulation of Fluids Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Na / K pump Exchange of Na ions for K ions More Na ions move out of cell More water pulled into cell ECF / ICF balance is maintained 14 Active Transport Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Insulin and glucose regulation CHO consumed Blood glucose peaks Pancreas secretes insulin Blood glucose returns to normal 15 Active Transport Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Concentration of body fluids – affects movement of fluid by osmosis Reflects hydration status Measured by serum and urine Solutes measured - mainly urea, glucose, and sodium Measured as solute concentration/Kg 16 Osmolality Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Because osmolar concentration of body fluids is very dilute, difference between osmolality & osmolarity values is negligible They are commonly used interchangeably; osmolarity is easier to measure, so it is more commonly used to express osmotic pressure of body 17 Osmolality vs Osmolarity Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Serum Osm/L = (serum Na x 2) + BUN/3 + Glucose/18 Normal serum value - 280-300 mOsm/Kg Serum <240 or >320 is critically abnormal Normal urine Osm – 250 – 900 mOsm / kg 18 Osmolality Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Fluid Volume Shifts 19 Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Oral liquids- ~1300ml/day Water in foods – ~1000ml/day Meats and vegetables ~ 60-90% water Water from oxidation - ~300ml/day 10ml/cal of food metabolized Parenteral fluids Enteral feedings 20 Sources of Water Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Skin Perspiration – 0-1000 ml/day Lungs - ~300-400 ml/day Increases with increased respiratory rate or depth or dry climate GI Tract - ~ 100-200 ml/day Kidneys - ~ 1-2 L/day Insensible loss ~ 600 ml/day (evaporation) 1ml/kg of body wt/hr in all ages 21 “Normal” Water Loss Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

22 Other Causes of Water Loss Fever Burns Diarrhea Vomiting N-G Suction Fistulas Wound drainage Mechanical ventilation Increased metabolism Diabetes Insipidus Uncontrolled DM ATN Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Fluid normally shifts between intracellular and extracellular compartments to maintain equilibrium between spaces Fluid not lost from body but not available for use in either compartment – considered third-space fluid shift (“third-spacing”) Enters serous cavities (transcellular) 23 Fluid Volume Shifts Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

24 Fluid Volume Imbalances Fluid volume deficit (FVD): hypovolemia Fluid volume excess (FVE): hypervolemia Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

25 Fluid Volume Deficit Loss of extracellular fluid exceeds intake ratio of water Electrolytes lost in same proportion as they exist in normal body fluids Dehydration: loss of water along with increased serum sodium level May occur in combination with other imbalances Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Fluid Volume Deficit What happens: Output  Intake  Water extracted from ECF ECF hypertonic (water moves out of the cell  cell dehydration + osmotic pressure increased (stimulates thirst receptor in the hypothalmus) ICF hypotonic with decreased osmotic pressure  posterior pituitary) secretes more ADH Decreased ECF volume  adrenal glands secrete aldosterone 26 Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Hypovolemia Dehydration Abnormally low volume of body fluid in intravascular and/or interstitial compartments Causes Vomiting Diarrhea Fever Excess sweating Burns Diabetes insipidus Uncontrolled diabetes mellitus 27 Fluid Volume Deficit Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Signs and Symptoms Acute weight loss Decreased skin turgor Oliguria Concentrated urine Weak, rapid pulse Capillary filling time elongated Decreased BP Increased pulse Sensations of thirst, weakness, dizziness, muscle cramps 28 Fluid Volume Deficit Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Increased HCT Increased BUN out of proportion to Cr High serum osmolality Increased urine osmolality Increased specific gravity Decreased urine volume, dark color 29 Fluid Volume Deficit Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Dehydration – one of most common disturbances in infants and children Additional S/S Sunken eyeballs Significant wt loss 30 FVD: Significant Points Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Older Adult Vein filling better indicator than skin turgor Have additional health problems Take various medications May ↓ intake to prevent incontinence 31 FVD: Significant Points Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

32 Fluid Volume Deficit – Nursing Management I&O, VS Monitor for symptoms: skin and tongue turgor, mucosa, UO, mental status Measures to minimize fluid loss Oral care Administration of oral fluids Administration of parenteral fluids Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Major goal prevent or correct abnormal fluid volume status before ARF occurs Encourage fluids IV fluids Isotonic solutions (0.9% NS or LR) until BP back to normal, then hypotonic (0.45% NS) Monitor I & O, urine specific gravity, daily weights 33 Interventions Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Monitor skin turgor Monitor VS and mental status Evaluation Normal skin turgor, increased UOP with normal specific gravity, normal VS, clear sensorium, good oral intake of fluids, labs WNL 34 Interventions Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Hypervolemia Isotonic expansion of ECF caused by abnormal retention of water and sodium Fluid moves out of ECF into cells and cells swell 35 Fluid Volume Excess (FVE) Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Cardiovascular – Heart failure Urinary – Renal failure Hepatic – Liver failure, cirrhosis Other – Cancer, thrombus, PVD, drug therapy (i.e., corticosteriods), high sodium intake, protein malnutrition 36 Fluid Volume Excess Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

Signs and Symptoms Weight gain Distended neck veins Periorbital edema, pitting edema Adventitious lung sounds (mainly crackles) Dyspnea Mental status changes Generalized or dependent edema 37 Fluid Volume Excess Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

VS High CVP/PAWP ↑ cardiac output Lab data ↓ Hct (dilutional) Low serum osmolality Low specific gravity ↓ BUN (dilutional) 38 Fluid Volume Excess Uta Tichawa, MSN, APRN-BC, CCRN DePaul University

39 Fluid Volume Excess Due to fluid overload or diminished homeostatic mechanisms Risk factors: heart failure, renal failure, cirrhosis of liver Contributing factors: excessive dietary sodium or sodium-containing IV solutions Manifestations: edema, distended neck veins, abnormal lung sounds (crackles), tachycardia, increased BP, pulse pressure and CVP, increased weight, increased UO, shortness of breath and wheezing Medical management: directed at cause, restriction of fluids and sodium, administration of diuretics Uta Tichawa, MSN, APRN-BC, CCRN DePaul University