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Nursing Crib Com Fluids and Electrolytes
Nursing Crib Com Fluids and Electrolytes
WALT WHITMAN
FLUID BALANCE
Water and its electrolytes are distributed in two major compartments:
63% of the total body water is found within cells across the age groups.
37% of the total body water is found outside the cells, mainly in tissue spaces, plasma of blood,
and lymph.
The intracellular and extracellular fluid compartments are maintained in a steady state to ensure
proper physiologic functioning.
Water and its electrolytes are distributed in two major compartments:
63% of the total body water is found within cells across the age groups.
37% of the total body water is found outside the cells, mainly in tissue spaces, plasma of blood,
and lymph.
The intracellular and extracellular fluid compartments are maintained in a steady state to ensure
proper physiologic functioning.
TOTAL BODY WATER
(AS PERCENTAGE OF BODY WEIGHT)
IN RELATION TO AGE AND SEX
AGE MALE FEMALE
UNDER 18 65% 55%
18-40 60% 50%
40-60 50-60% 40-50%
OVER 60 50% 40%
Step #1: Compute the total body water (TBW) based on age and sex.
TBW = (60 kg) (0.6)
= 36 kg weight of water
= 36 liters volume of water
Step #2: Compute for the intracellular fluid volume (usually 63% of the total body water is
intracellular fluid)
ICF = (36 liters) (0.63)
= 22.7 liters
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Contains high concentrations of sodium, chloride and bicarbonate.
One-third of the ECF is in plasma.
EXAMPLE: How much water is in the circulatory system of a 32-year old female patient who
weighs 52 kg?
Step #1: Compute for the total body water based on age and sex.
TBW = (52 kg) (0.5)
= 26 kg weight of water
= 26 liters volume of water
Step #2: Compute for the extracellular fluid volume (usually 37% of the total body water).
ECF = (26 liters) (0.37)
= 9.6 liters
Serum Osmolality
Reflects the amount of solute particles in a solution and is a measure of the concentration of a
given solution.
Can be calculated using the formula:
Osmserum = 2 (Na) + BUN + glucose
Normal value = 285 – 295 mosm/kg
Sodium is the most active determinant of serum osmolality and is therefore actively moved
across membranes to ensure normal osmolality.
Ions
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Sodium
Dominant extracellular ion.
About 90 to 95% of the osmotic pressure of the extracellular fluid results from sodium ions and
the negative ions associated with them.
Recommended dietary intake is less than 2.5 grams per day.
Kidneys provide the major route by which the excess sodium ions are excreted.
Sodium
In the presence of aldosterone, the reabsorption of sodium ions in the loop of Henle is very
efficient. When aldosterone is absent, the reabsorption of sodium in the nephron is greatly
reduced and the amount of sodium lost in the urine increases.
Also excreted from the body through the sweat mechanism.
Primary mechanisms that regulate the sodium ion concentration in the extracellular fluid:
Changes in the blood pressure
Changes in the osmolality of the extracellular fluid
Sodium Regulation
Increased ADH secretion, Decreased urine
INCREASED volume and increased plasma volume
SODIUM
Decreased aldosterone secretion, DECREASED
decreased sodium reabsorption SODIUM
NORMAL Na+
Potassium
Electrically excitable tissue such as muscle and nerves are highly sensitive to slight changes in
extracellular potassium concentration.
The ECF concentration of potassium must be maintained within a narrow range for tissues to
function normally.
Aldosterone also plays a major role in regulating the concentration of potassium ions in the ECF.
Circulatory system shock resulting from plasma loss, dehydration, and tissue damage causes
extracellular potassium ions to become more concentrated than normal. In response, aldosterone
secretion increases and causes potassium secretion to increase.
Potassium regulation
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NORMAL K+
DECREASED
POTASSIUM Decreased aldosterone secretion with INCREASED
decreased potassium secretion by the POTASSIUM
kidney and decreased potassium in the
urine
Calcium
Extracellular concentration of calcium ions is maintained within a narrow range.
Increases and decreases in ECF concentration of calcium ions have dramatic effects on the
electrical properties of excitable tissues.
Parathyroid hormone (PTH) secreted by the parathyroid glands increases extracellular calcium
levels.
Calcitonin is secreted by the thyroid gland.
It reduces blood levels of calcium when they are too high.
Calcium Regulation
Increased Calcitonin secretion with
decreased bone resorption
NORMAL Ca++
INCREASEDCAL
CIUM
DECREASED
CALCIUM Increased parathyroid hormone secretion with
increased bone resorption, increased intestinal
calcium absorption, and increased renal calcium
reabsorption
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Compute for the IVF rate for today if the patient is to be connected to an adult venoset.
What would be your choice of IVF?
Maintenance Therapy:
Minimum Water Requirements
Weighing the patient daily is the best means of assessing net gain or loss of fluid, since the
gastrointestinal, renal and insensible fluid losses of the hospitalized patient are unpredictable.
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TYPE OTHER NAME RESULTING SERUM
OSMOLALITY
Hypotonic volume loss Hypertonic or Elevated serum
hyperosmolar osmolality
dehydration
Hypertonic volume loss Hypotonic or Decreased serum
hypoosmolar osmolality
dehydration
Isotonic volume loss Isotoniic or Normal serum
normoosmolar osmolality
dehydration
Symptoms:
Anorexia
Nausea
Vomiting
Apathy
Weakness
Orthostatic lightheadedness
Syncope
Weight loss is an important sign and provides an estimate of the magnitude of the volume
deficit.
Other physical findings:
Orthostatic hypotension
Poor skin turgor
Sunken eyes
Absence of axillary sweat
Oliguria
Tachycardia
Shock and coma (severe volume depletion)
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More severe deficits accompanied by circulatory compromise should be treated initially through
intravenous isotonic fluid replacement until hemodynamic stability has been restored. One to two
liters of fluid should be given over the first hour.
Parenteral Solutions
Parenteral Solutions
(Crystalloids)
COMMONLY USED PARENTERAL SOLUTIONS
IV Solutions Osmolality Glucose Sodium Chloride
(mosm/kg) (g/liter) (meq/liter) (meq/liter)
5% D/W 252 50 - -
10% D/W 505 100 - -
50% D/W 2525 500 - -
0.45% NaCl 154 - 77 77
0.9% NaCl 308 - 154 154
3% NaCl 1026 - 513 513
Ringer’s 282 - 130 109
lactate
5% D/NR 294 50 147 147
5% D/NM 290 50 77 77
ECF Volume Excess
Manifestations:
Weight gain is the most sensitive and consistent sign of ECF volume excess.
Edema is usually not apparent until 2 to 4 kg of fluid have been retained.
Dyspnea
Tachycardia
Jugular venous distention
Hepatojugular reflux
Rales on pulmonary auscultation
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Causes:
Heart, liver or renal failure
Excessive renal sodium and water retention
Unnecessary salt administration
Treatment
Must address not only the ECF volume excess but also the underlying pathologic process.
Treatment of the nephrotic syndrome and the cardiovascular volume overload associated with
renal failure.
Treatment of heart failure and cirrhosis
.
Fluid and Electrolyte Management
Sodium
The primary extracellular cation.
Always accompanies water in the extracellular fluid compartment.
Hyponatremia
Defined as serum concentration less than 135 meq/L.
Most common electrolyte abnormality observed in a general hospitalized population.
Initial approach is the determination of serum osmolality.
Hyponatremia
SERUM OSMOLALITY
ISOTONIC HYPERTONIC
Hyponatremia HYPOTONIC Hyponatremia
Hyperproteinemia Hyponatremia
Hyperglycemia
Hyperlipidemia Mannitol, sorbitol,
Glycerol, maltose
VOLUME STATUS
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Hyponatremia
VOLUME STATUS
Hypovolemic Hypervolemic
Euvolemic
Una <10 meq/L
U >20 meq/L SIADH Edematous states:
Extrarenal salt na
Renal salt loss Postop HypoNa Congestive heart failure
Dehydration Hypothyroidism
Diuretics Hepatic disease
Diarrhea Psychogenic
ACE-inhibitors Nephrotic syndrome
Vomiting Nephropathies polydipsia Advanced CHF
Mineralo- Beer potomania
Corticoid lack Drug reactions
Treatment
Hypertonic (3%) saline with furosemide is indicated for symptomatic hyponatremic patients.
For asymptomatic patients, approach includes water restriction, isotonic saline infusion and
administration of demeclocycline.
Hypernatremia
Serum sodium > 145 meq/L
Develops from excess water loss, frequently accompanied by an impaired thirst mechanism.
Hypernatremia: Treatment
Directed toward correcting the cause of the fluid loss and replacing water and, as needed,
electrolytes.
Calculation of water deficit:
When calculating fluid replacement, both the deficit and the maintenance requirement should be
added to each 24-hour replacement regimen.
Hypokalemia
A total body deficit of about 350 meq occurs for each 1 meq/L decrement in serum potassium
concentration.
Changes in blood pH and hormones (insulin, aldosterone, and β-adrenergic agonists)
independently affect serum potassium levels.
Hypokalemia: Clinical Findings
Symptoms and Signs:
Muscular weakness
Fatigue
Muscle cramps
Constipation or ileus
Flaccid paralysis, hyporeflexia, and rhabdomyolysis
Laboratory Findings:
Decreased amplitude and broadening of the T waves
Prominent U waves
Depressed ST segments
T wave inversion
Atrioventricular block (1st, 2nd, 3rd degree AV blocks)
Cardiac arrest
Hypokalemia: Treatment
SEVERITY RECOGNITION MANAGEMENT
Mild Low serum potassium levels Dietary potassium
Rarely symptomatic replacement
+/- EKG manifestations
No arrhythmia
orhemodynamic instability
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Moderate Low serum potassium, usually Intravenous potassium
symptomatic with EKG replacement, maximum
abnormalities dilution of 40 meq/L,
+/- arrhythmia, but running at max rate of 5
hemodynamically stable meq/hr
Severe With arrhythmia and evidence IV potassium
of hemodynamic instability replacement, maximum
dilution of 100 meq/L,
max rate of 10 meq/hr
ORAL POTASSIUM REPLACEMENTS
AMOUNT meq OF K ANION NAMES
LIQUIDS 15 ml 10 Cl 5% Potassium chloride
15 ml 20 Cl 10% Potassium chloride
15 ml 40 Cl 20% Potassium chloride
15 ml 20 Gluconat Potassium gluconate
e
POWDERS Packet 15 Cl K-lor
Packet 20 Cl Potassium chloride
Packet 25 Cl K-lyte
TABLETS 1 8 Cl Slow-K
1 8 Cl Micro-K extencaps
1 10 Cl K-dur 10
1 20 Cl K-dur 20
POTASSIUM CONTENT OF FOODS
VERY HIGH HIGH
(12-20 meq) (5-12 meq)
BEANS Garbanzo beans Kidney beans Navy
Soy beans beans
Lima beans Pinto
beans
FRUIT (1/2 cup or as Papaya (one medium) Apricots (3 halves)
stated) Banana (6”)
Cantaloupe (1/4”)
Honeydew melon (1/4”)
Orange (3”) and orange
juice
Pear (one large)
Prunes (4) and prune
juice
Rhubarb
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VEGETABLES (1/2 cup or Artichoke (one)
as stated) Avocado (1/4)
Brussel sprouts
Carrot (7 ½”) and chard
Ketchup (1 tbsp)
Potato (one baked, one
broiled, 10 fries, ½ cup
mashed)
Pumpkin and spinach
Tomato (one) and tomato
juice
Hyperkalemia
Many are spurious or associated with acidosis
Common practice of repeatedly clenching and unclenching the fist during venipuncture may
raise the potassium concentration by 1-2 meq/L by causing local release of potassium from
forearm muscles.
CAUSES OF HYPERKALEMIA
SPURIOUS Leakage from erythrocytes if separation of serum
from clot is delayed.
Thrombocytosis
Marked leukocytosis
Repeated fist clenching during phlebotomy
Specimen drawn from arm with infusion
DECREASED EXCRETION Renal failure, acute and chronic
Severe oliguria
Renal secretory defects
Adrenocortical insufficiency
Hyporeninemic hypoaldosteronism
Spironolactone, triamterene, ACE-I, trimethoprim,
NSAIDs
CAUSES OF HYPERKALEMIA
SHIFT FROM TISSUES Burns, rhabdomyolysis, hemolysis
Metabolic acidosis
Hyperosmolality
Insulin deficiency
Hyperkalemic periodic paralysis
Succinylcholine, arginine, digitalis toxicity, beta-
adrenergic blockers
EXCESSIVE INTAKE Over treatment, orally or parenterally
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Hyperkalemia: Clinical Findings
Weakness and flaccid paralysis
Abdominal distention and diarrhea
ECG is not a sensitive method, but if abnormalities are present, the most common findings are:
Peaked T waves
ST segment elevation
Tachyarrhythmia / supraventricular tachycardia
Ventricular tachycardia
Ventricular fibrillation
Cardiac arrest
Hyperkalemia: Treatment
Confirm that the elevated level of serum potassium is genuine.
Measure plasma potassium.
Withholding of potassium.
Giving cation exchange resins by mouth or enema: polystyrene sulfate, 40-80 g/day in divided
doses.
Emergent treatment is indicated if cardiac toxicity or muscular paralysis is present, or if
hyperkalemia is severe (> 6.5-7 meq/L) even in the absence of ECG changes.
Insulin plus 10-50% glucose may be employed to deposit potassium with glycogen in the liver.
Calcium may be given intravenously as an antagonist ion.
Stimulate transcellular shifts by giving beta-adrenergic agonist drugs.
Sodium bicarbonate as an emergency measure.
Hemodialysis or peritoneal dialysis.
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Loop Increased renal K 0.5-2 hours Furosemide 40-160 mg Variable
diuretic excretion IV or orally with or
without NaHCO3, 0.5-3
meq/kg daily
Sodium Ion exchange 1-3 hours Oral: 15-30 g in 20% 0.5-1 meq/g
polystyrene resin binds K sorbitol (50-100 ml)
sulfonate Rectal: 50 g in 20%
(Kayexalate sorbitol
Hemodialysi Extracorporeal K 48 hours Blood flow > 200-300 200-300
s removal ml/min; Dialysate K = 0 meq
Peritoneal Peritoneal K 48 hours Fast exchange, 3-4 L/hr 200-300
dialysis removal meq
POTASSIUM TRANSCELLULAR SHIFTING CARDIAC STABILIZER
EXCRETION
Dialysis Glucose and insulin Calcium
Diuretics infusion every 6 gluconate 10%
Ion- hours via slow IV
exchange Sodium bicarbonate push every 15
resins infusion every 6 minutes for a
administere hours maximum of
d orally or Beta-adrenergic three doses
transrectall agonist nebulization
y every 6 hours
CAUSES OF HYPOCALCEMIA
DECREASED INTAKE OR Malabsorption
ABSORPTION
Small bowel bypass, short bowel
Vitamin D deficit
INCREASED IONS Alcoholism
Chronic renal insufficiency
Diuretic therapy (furosemide or
bumetanide)
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ENDOCRINE DISEASES True and pseudohypoparathyroidism
Calcitonin hypersecretion
PHYSIOLOGIC CAUSES Alkalosis and decreased response to vit. D
Decreased serum albumin
Hyperphosphatemia
Aminoglycosides, loop diuretics, foscarnet
Hypocalcemia: Treatment
Severe symptomatic hypocalcemia:
In the presence of tetany, arrhythmias or seizures, calcium gluconate 10% is administered
intravenously for 10-15 minutes or via calcium infusion.
10-15 mg of calcium per kilogram body weight, or 6-8 10-ml vials of 10% calcium gluconate
(558-744 mg of calcium) is added to 1 liter of D5W and infused over 4 to 6 hours.
Asymptomatic hypocalcemia:
Oral calcium and vitamin D preparations
Calcium carbonate is well tolerated and inexpensive.
TREATMENT OF HYPOCALCEMIA
MODALITY AMOUNT OF CALCIUM ONSET DOSE
Intravenous 93 mg (4.7 meq) per 10 Immediat 93-186 mg over 10-15
calcium ml e mins; then 10-15 mg/kg
(Calcium over 4-6 hours.
gluconate)
Oral calcium 40% elemental calcium; < 1 hour 250-500 mg calcium 3 to 5
(calcium 250 mg/624 mg tablet times a day.
carbonate) or
500 mg/1250 mg tablet
or
500 mg/1500 mg tablet
CAUSES OF HYPERCALCEMIA
INCREASED INTAKE OR Milk-alkali syndrome
ABSORPTION Vitamin D or vitamin A excess
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ENDOCRINE DISORDERS Primary and secondary hyperparathyroidism
Acromegaly
Adrenal insufficiency
NEOPLASTIC DISEASES Tumors producing PTH-related proteins
Metastases to bone
Lymphoproliferative disease
Secretion of prostaglandins and osteolytic
factors
MISCELLANEOUS Thiazide diuretics and renal transplant
CAUSES complications
Sarcoidosis and Paget’s disease of the bone
Hypophosphatasia, immobilization, iatrogenic
Magnesium
About 50% of total body magnesium exists in the insoluble state in bone.
Only 5% is present as extracellular cation; the remaining 45% is contained in cells as
intracellular cation.
Normal plasma concentration is 1.5-2.5 meq/L, with about one-third bound to protein and two-
thirds existing as free cation.
Excretion is via the kidney
Hypomagnesemia
Nearly half of hospitalized patients have unrecognized hypomagnesemia.
In critically ill patients, arrhythmias and sudden death may be complications.
CAUSES OF HYPOMAGNESEMIA
DIMINISHED ABSORPTION Malabsorption, chronic diarrhea, laxative
OR INTAKE abuse
Prolonged gastrointestinal suction
Small bowel bypass, malnutrition
Alcoholism, parenteral alimentation
INCREASED LOSS DKA, diuretic therapy, diarrhea
Hyperaldosteronism, Bartter’s syndrome
Hypercalciuria
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Renal magnesium wasting
UNEXPLAINED Hyperparathyroidism
Postparathyroidectomy
Vitamin D therapy
Aminoglycoside antibiotics, cisplatin,
amphotericin B
Clinical Findings
Symptoms and Signs:
Weakness
Muscle cramps
CNS hyperexcitability with tremors
Athetoid movements
Jerking, nystagmus
Positive Babinski response
Hypertension, tachycardia and ventricular arrhythmias
Confusion and disorientation
Laboratory Findings:
Decreased serum magnesium levels
Hypocalcemia and hypokalemia
Prolonged QT interval on the ECG
Lengthening of the ST segment on the ECG
Hypomagnesemia: Treatment
Use of IVF containing magnesium as chloride or sulfate, 240-1200 mg/day (10-50 mmol/day)
during the period of severe deficit, followed by 120 mg/day (5 mmol/day) for maintenance.
MgSO4 may also be given intramuscularly in a dosage of 200-800 mg/day (8-33 mmol/day) in
four divided doses.
Serum levels must be monitored.
Hypermagnesemia
Almost always the result of renal insufficiency and the inability to excrete what has been taken
in from food or drugs, especially antacids and laxatives.
Potentially life-threatening as it impairs both central nervous system and muscular function.
Clinical Findings
Symptoms and Signs:
Muscle weakness
Mental obtundation and confusion
Hypotension
Respiratory muscle paralysis or cardiac arrest
Laboratory Findings:
Elevated serum magnesium, BUN, creatinine, K
Decreased serum calcium
Increased PR interval on the ECG
Broadened QRS complex with elevated T waves
Hypermagnesemia: Treatment
Alleviating renal insufficiency
Administration of calcium
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Hemodialysis or peritoneal dialysis
In all things, you shall find everywhere the Acid and the Alcaly.
ABG Interpretation
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