منتدى تمريض مستشفى غزة الاوروبي_Fluids and Electrolytes

8/3/2019 Fluids and Electrolytes_

1/52

EGH-NSG.ForumPalestine.com


2/52

FLUIDS and ELECTROLYTES

Prepared byABED SHAGORA

In-service EducationDepartment

EGH

2011 - 2012


3/52


4/52

FLUIDS and ELECTROLYTES

BODY FLUIDS

Functions of Body Fluids Facilitate in the transport [nutrients, hormones,

proteins, & others]

Aid in removal of cellular metabolic wastes

Provide medium for cellular metabolism

Regulate body temperature

Provide lubrication of musculoskeletal joints.

Component in all body cavities [parietal, pleural

fluids]

Water is the principal body fluid & essential for life.


5/52

BODY FLUIDS

ICF ECF

40% TBW 20% TBW

P IS

Distribution of Body Fluids 50-70% of totalbody weight;infant [70-80%], elderly [45-50%]

60-kg man

TBW = 0.6 x 60 kg = 36 L

ICF = 0.4 x 60 kg

= 24 L

ECF

= 12 L

3L 9L


6/52

Factors that Dictate Body Water Requirement

1) Amount needed to give the proper osmoticconcentration

2) Amount needed to replace water lost excretion

Normal Routes of water gain and loss

INTAKE OUTPUTml/day ml/day

Fluid intake 1,200Food 1,000

Metabolic water 300

TOTAL 2,500

Insensible loss 700Sweat 100

Feces 200

Urine 1,500

TOTAL 2,500


7/52

FLUID EXCHANGE BETWEEN BODY

FLUID COMPARTMENTS

Osmotic Pressure Gradient

Oncotic P(Colloid osmotic P)

Capillary P(Hydrostatic P)

ICF ECF

P ISF


8/52

Control of Osmotic Pressure, Volume &Electrolyte Concentration

OBLIGATORY Reabsorption occurs in the proximal tubules 178 L/day of glomerular filtrate (80%

reabsorbed)

2 to solute reabsorption independent of the water requirement

FACULTATIVE Reabsorption

occurs in the distal & collecting tubules independent of the active solutetransport

dependent of bodys need of water under the control of ADH


9/52

DISTURBANCES IN FLUID BALANCE

EDEMA

in the interstitial fluid volume ofabout 2 L or more due to increasetransudation of fluid from capillaries2 to:

Increased HP [pregnancy, CHF] Decreased OP [malnutrition, end-stage liver disease, nephroticsyndrome]


10/52


CELL OVERHYDRATION

excess of water in the ECC w/ anormal amount of solute or a deficientamount of solute

occurs in prolonged and excessivediuresis, forcing hypotonic fluids toproduce diuresis in the presence ofrenal impairment

fluid overload from production ofadrenal corticoid hormones [Cushingssyndrome]


11/52


CELL OVERHYDRATION

Symptoms Weight gain & edema Cough, moist rales, dyspnea [fluid

congestion in lungs] CVP, bounding pulse, neck vein

engorgement [fluid excess in thevascular system]

Bulging fontanelles Hg and Hct Nausea & vomiting


12/52


CELL OVERHYDRATION

Management Restrict fluids to lower fluid

volume Diuretics or hypertonic saline Continuous assessments to

prevent skin breakdown

Record daily weight to assessprogress of treatment


13/52


CELL DEHYDRATION

loss of body fluids, particularly fromthe extracellular fluid compartment

water loss > water intake

Causes Fever Insufficient water intake Diarrhea, vomiting

Excess urine output [Diabetesinsipidus, diuretics]

Excessive perspiration, burns Hemorrhage, shock, metabolic

acidosis


14/52


CELL DEHYDRATION

Symptoms Thirst, dry mucus membranes, sunken

eyeballs

Doughy abdomen, dry skin w/ poorturgor temp, weight loss HR, RR, BP Restlessness,irritability, disorientation,

convulsion, coma [22-30% body H20loss]

Management Fluid replacement therapy & continued

fluid maintenance


15/52

Volume Disorders 2 Alteration in SodiumBalance

ExpansionIsotonic Inc N No net change Isotonic fluid

ingestionHypertonic Inc Dec ICF ECF Sea water

ingestion

Hypotonic Inc Inc ECF ICF Hypotonic IVFContraction

Isotonic Dec N No net change DiarrheaHypertonic Dec Dec ICF ECF Diabetes insipidusHypotonic Dec Inc ECF ICF Addisons disease

Volume ECF ICF Water ConditionsDisorder Vol. Vol. Shift


16/52

ELECTROLYTES

salts or minerals in extracellularor intracellular body fluids

Sodium major cation of ECF

Potassium major cation of ICF

Chloride - major anion of ICF

Protein in ICF > ISF


17/52

ELECTROLYTE Composition

Electrolyte Conc Plasma (mEq/L) ISF ICF

Sodium, Na+ 142 141 10Potassium, K+ 5 4.1 150

Calcium, Ca++ 5 4.1 -Magnesium, Mg++ 3 3 40

(155)Chloride, Cl- 103 115 15Bicarbonate, HCO3- 27 29 10Biphosphate, HPO4- 2 2 100Sulfate, SO4-2 1 1 20Protein 16 1 60Organic foods 6 3.4 -

(155)


18/52

ELECTROLYTES

Functions of Electrolytes

Contribute most of the osmoticallyactive particles in body fluids

Provide buffer systems for pHregulation

Provide the proper ionicenvironment for normalneuromuscular irritability & tissuefunction


19/52

Hyponatremia [Na+ < 135 mEq/L;

Normal = 135-145 mEq/L]Causes Na+ intake Na+ excretion [diaphoresis, GI

suctioning] Adrenal insufficiency

Assessment N & V, abdominal cramps, weight loss Cold, clammy skin, skin turgor Apprehension, HA, convulsions, focal

neurologic deficit, coma [cerebral edema] Fatigue, postural hypotension Rapid thready pulse

ELECTROLYTES


20/52

Hyponatremia

Management Provide foods high in sodium Administer NSS IV Assess blood pressure frequently

[measure lying down, sitting &

standing]

ELECTROLYTES


21/52

Hypernatremia [Na+ >145 mEq/L;Normal = 135-145 mEq/L] Causes Excessive, rapid IV admn of NSS Inadequate water intake Kidney disease

Assessment Dry, sticky mucus membranes Flushed skin

Rough dry tongue, firm skin turgor Intense thirst Edema, oliguria to anuria Restlessness, irritability [cerebral

DHN]

ELECTROLYTES


22/52

Hypernatremia

Nursing Intervention Weigh daily

Assess degree of edema frequently Measure I & O Assess skin frequently & institute

nursing measures to prevent

breakdown Encourage sodium-restricted diet

ELECTROLYTES


23/52

Hyperkalemia [K+ > 5.5 mEq/L;Normal = 3.5-5.5 mEq/L]

Causes

Renal insufficiency Adrenocortical insufficiency Cellulose damage [burns] Infection Acidotic states

Rapid infusion of IV soln w/potassium-conserving diuretics

ELECTROLYTES


24/52

Hyperkalemia

Assessment Thready, slow pulse Shallow breathing N & V, diarrhea, intestinal colic Irritability Muscle weakness, flaccid

paralysis Numbness, tingling Difficulty w/ phonation,

respiration

ELECTROLYTES


25/52

Hyperkalemia

Nursing Interventions Administer kayexalate as

ordered Administer/monitor IV infusion

of glucose & insulin Control infection

Provide adequate calories &carbohydrates Discontinue IV or oral sources

of K+

ELECTROLYTES


26/52

Hypokalemia [K+ < 3.5 mEq/L;Normal = 3.5-5.5 mEq/L]

Causes Renal insufficiency Adrenocortical insufficiency Cellulose damage [burns] Infection Acidotic states Rapid infusion of IV solution

potassium-conserving diuretics

ELECTROLYTES


27/52

Hypokalemia

Assessment Thready, rapid, weak pulse

Faint heart sounds BP Skeletal muscle weakness or absent reflexes Shallow respirations Malaise, apathy, lethargy Loss of orientation Anorexia, vomiting, weight loss Gaseous intestinal distention

ELECTROLYTES


28/52

Hypokalemia

Nursing Interventions Administer K+ supplements to

replace losses Be cautious in administering

drugs that are not potassium-sparing

Monitor acid-base balance Monitor pulse, BP and ECG

ELECTROLYTES


29/52

Hypercalcemia [Ca > 5.8 mEq/L;Normal = 4.5-5.8 mEq/L] Causes Hyperparathyroidism Immobility Increased vitamin D intake Osteoporosis & osteomalacia [early

stages] Assessment

N & V, anorexia, constipation Headache, confusion Lethargy, stupor Decreased muscle tone Deep bone/flank pain

ELECTROLYTES


30/52

Hypercalcemia

Nursing Interventions

Encourage mobilization Limit vitamin D intake Limit calcium intake Normal saline Administer diuretics Calcitonin

ELECTROLYTES


31/52

Hypocalcemia [Ca < 4.5 mEq/L;Normal = 4.5-5.8 mEq/L]

Causes Acute pancreatitis Diarrhea Hypoparathyroidism Lack of vitamin D I the diet Long-term steroid therapy

Assessment Painful tonic muscle & facial spasms Fatigue, dyspnea Laryngospasm, convulsions

ELECTROLYTES


32/52

Hypocalcemia

Nursing Interventions

Administer oral Ca lactate orIV CaCl2 or gluconate Providing safety by padding

side rails

Administer dietary sources ofcalcium Vitamin D Provide quiet environment

ELECTROLYTES


33/52

Hyermagnesemia [Mg > 3.0 mEq/L;

Normal = 1.5-3.0 mEq/L] Causes Renal insufficiency, dehydration Excessive use of Mg-containing

antacids or laxatives Assessment Lethargy, somnolence, confusion N & V Muscle weakness, depressed reflexes

pulse and respirations Nursing Intervention Withhold Mg-contg drugs/foods; Ca

admn

fluid intake, unless CI

ELECTROLYTES


34/52

Hypomagnesemia [Mg < 1.50 mEq/L;

Normal = 1.5-3.0 mEq/L] Causes Low intake of Mg in the diet Prolonged diarrhea Massive diuresis Hypoparathyroidism

Assessment Paresthesias, muscle spasm Confusion, hallucination, convulsions

Ataxia, tremors, hyperactive deepreflexes

Flushing of the face, diaphoresis Nursing Intervention

Provide good dietary sources of Mg

ELECTROLYTES


35/52

IV FLUID REPLACEMENT THERAPY

Indications

Replacement of abnormal fluid &electrolyte losses [surgery, trauma,

burns, GI bleeding]

Maintenance of daily fluid &electrolyte needs

Correction of fluid disorders

Correction of electrolyte disorders


36/52

Types of Solutions

Isotonic 0.9% sodium chloride (NSS) Lactated Ringers solution

Hypotonic 5% dextrose and water (D5W) 0.45% sodium chloride 0.33% sodium chloride

Hypertonic 3% NaCl Protein solution

Colloids Salt pour albumin Plasmanate,

Dextran


37/52

4/2/1 Rule

4 ml/kg/hr for first 10 kg (=40ml/hr)

then 2 ml/kg/hr for next 10 kg (=20ml/hr)then 1 ml/kg/hr for any kgs over that

This always gives 60ml/hr for first 20 kg

then you add 1 ml/kg/hr for each kg over 20kg

This boils down to: Weight in kg + 40 =

Maintenance IV rate/hour.

For any person weighing more than 20kg


38/52

B U R N S

BURNS wounds caused by excessive exposure to the

following agents or causes:

Causes of Burns:

Thermal [moist or dry heat] Electrical Chemical [strong acids and strong alkali Radiation [UV, x-rays, radium, sunburns]


39/52

CLASSIFICATION OF BURNS

Superficial Partial thickness (1st degree) Outer layer of dermis Erythema, pain up to 48 hrs

Healing 1-2 wks [sunburn] Deep Partial thickness (2nd degree) Epidermis & dermis Blisters & edema, frequently quite painful Healing 14-21 days

Full thickness (3rd degree) Epidermis, dermis, subcutaneous fat Dry, pearly white or charred in appearance Not painful Eschar must be removed; may need grafting

B U R N S


40/52

STAGES OF BURNS

1st: Shock/Fluid Accumulation Phase

1st 48 hrs

IVC

ISC Generalized DHN [fluid shifting] Hypovolemia [plasma loss], BP, C.O. Hemoconcentration, Hct [liquid blood

component ISC] Oliguria [ renal perfusion], ADH release &

aldosterone HyperK, hypoNa Metabolic acidosis

B U R N S


41/52

STAGES OF BURNS

2nd: Diuretic/Fluid Remobilization Phase

After 48 hrs

ISC

IVC Hypervolemia, Hemodilution, Hct Diuresis [ renal perfusion], ADH &

aldosterone secretion HypoK, hypoNa [K moves back into the cells,

Na+ still trapped in the edema fluids Metabolic acidosis

B U R N S


42/52

STAGES OF BURNS

3rd: Recovery Phase

5th day onwards

Hypocalcemia Ca is lost on the exudates Ca is utilized in the granulation tissue

formation Negative nitrogen balance

Due to stress response protein catabolism Protein intake is lesser than the demand

HypoK

B U R N S


43/52

ASSESSMENT

1. Assess extent of body surface burned Greater morbidity & mortality for burns

affecting face, hands & perineum

Assess for dyspnea, stridor, hoarseness2. Assess extent of burn injury

Rule of nine immediate appraisal Lund-Browder chart more accurate Berkows method based on clients age &

changes that occur in proportion of head & legsto the rest of the body as one grows

B U R N S


44/52

ASSESSMENT

B U R N S

9%

9% 9%Front=18%Back=18%

18% 18%

1%

Burn EvaluationChart


45/52

ASSESSMENT

3. Assess depth of burn Major burns 2nd degree over 30% of body Hospitalization - eyes, face, neck, hands,

perineum, genitalia4. Assess unique contributing factors

Age of client Health history

Diabetes, preexisting ulcers Tetanus immunization

B U R N S


46/52

EMERGENCY MANAGEMENT

Stop the burning process Remove patient from source of injury Advise client to roll on the ground if clothing is

in flame [STOP-DROP-ROLL] Throw a blanket over the client to smother theflame

Remove clothing only if hot or for scald burn Immerse affected part in cold water [10 min] Irrigate copiuosly w/ large amount of running

water w/ chemical burns [except w/phosphorus]

Interrupt power source w/ electrical burn

B U R N S


47/52

MANAGEMENT

Maintenance of adequate airway

Promoting comfort: relieve pain

Promoting fluid-electrolyte, acid-base balance

Preventing infection

Maintaining adequate nutrition

Wound care

B U R N S


48/52

METHODS OF TREATING BURNS

Open method or Exposure method Face, neck, perineum, trunk Allowing exudate to dry in 3 days

Occlusive Less pain, absorption of secretion, comfort,

transportability, accelerated debridement Aesthetic considerations

Semi-open method Covering of wound w/ topical antimicrobials:

Silver sulfadiazine 1% (Flamazine) Silver nitrate 0.5% soln Mafenide acetate (sulfamylon acetate)

B U R N S


49/52

BIOLOGIC DRESSING (Skin Graft)

Allograft Skin taken from other person [cadaver]

Autograft Same person

Heterograft Different species Xenograft [segment of skin from animal

such as pig or dog]

B U R N S


50/52

FLUID REPLACEMENT

Types of fluids:

Colloids

Blood Plasma & plasma expanders Electrolytes

Lactated Ringers Non-electrolyte

D5W

B U R N S


51/52

FLUID REPLACEMENT

EVANS Formula:

C 1ml x % burns x kgBW

E - 1ml x % burns x kgBW Glucose 5% for insensible loss 2,000ml D5W

Administer soln 1st 24 hrs [1st 8hrs], [16hrs]

BROOKE Formula: [Administer as in Evans]

C 0.5ml x % burn x kgBW E - 1.5ml x % burns x kgBW Water 1000ml D5W

B U R N S


52/52

FLUID REPLACEMENT

MOORES BURN BUDGET:

75 ml of plasma, 75 ml of electrolyte-contg

fluid for q 1%TBSA plus 2000 D5WHYPERTONIC RESUSCITATION Formula:

Hypertonic salt containing 300mEq of Na+,100mEq of Cl-, 200mEq lactate

Administered to maintain urinary output of 30-40 ml/hr

B U R N S

Documents

منتدى تمريض مستشفى غزة الاوروبي_Fluids and Electrolytes