Nursing Care of Patients with Altered Fluid, Electrolyte, and Acid-Base Balance

Homeostasis / Balance, Fluid,electrolyte, water

 Ability to maintain internal equilibrium by adjusting physiologic processes
 Reestablishment and maintenance a goal in managing fluid, electrolyte, and acid-base imbalance
REMEMBER!!pag may kulang dagdagan pag may sobra bawasa.
BODY FLUID COMPOSITION
Water
- Transport of nutrients
- Medium for metabolic reactions
- Regulation of body temperature

Electrolytes
- Water balance regulation
- Acid-base balance
- Enzyme reactions
- Neuromuscular activity
BODY FLUID DISTRIBUTION
Intracellular fluid (ICF)
• Found within cells
• Essential for normal cell function
Extracellular fluid (ECF)
• Located outside of cells
• Interstitial fluid
• Intravascular fluid
• Transcellular fluid
SOLUTES
• ICF
- Potassium(major) – hypo/hyperkalemia (body/muscle weakness)
- Magnesium
- Phosphate
- Glucose
- Oxygen
• ECF
- Sodium(major)
- Chloride
- Bicarbonate
FIGURE 10-1 THE MAJOR FLUID COMPARTMENTS OF THE BODY.
 -
- 40% - ICF
- 20% - ECF
- Total of 60% water on total body weight
- 5% - plasma on total body weight
-
BODY FLUID MOVEMENT
Osmosis
 Osmoralty
- Concentration of a solution
 Osmotic pressure and tonicity
Diffusion
 Simple
 Facilitated (carrier-mediated)
Filtration
 Balance of hydrostatic, osmotic pressure
Active transport
 Sodium-potassium pump
FIGURE 10-3 EXCHANGE OF GASES, NUTRIENTS, WATER, AND WASTES BETWEEN THE THREE FLUID
COMPARTMENTS OF THE BODY

Lungs - contains sufficient amount of water as protection and to maintain homeostasis

Dx: Pleural effusion – too much fluid of the lungs (DOB C-manifestation)

GI – Dx: Constipation – low amount of water

Nursing Management-Increase OFI

kidney– to secrete waste products.

Dx: Azotemia – increase in waste products(toxins) in blood

FIGURE 10-4 OSMOSIS WATER MOLECULES MOVE THROUGH A SELECTIVELY PERMEABLE MEMBRANE
FROM AN AREA OF LOW SOLUTE CONCENTRATION TO AN AREA OF HIGH SOLUTE CONCENTRATION.

----TO ADD
FIGURE 10-5 THE EFFECT OF TONICITY ON RED BLOOD CELLS. A IN AN ISOTONIC SOLUTION, RBCS
NEITHER GAIN NOR LOSE WATER, RETAINING THEIR NORMAL BICONCAVE SHAPE D, IN A HYPERTONIC
SOLUTION, CELLS LOSE WATER AND SHRINK IN SIZE. C. IN A HYPOTONIC SOLUTION, CELLS ABSORS
WATER AND MAY BURST (HEMOLYSIS).

ISOTONIC SOLUTION – no changes in RBC ( ex. NSS,PLR)

- Used in dehydrated and burn pt

HYPERTONIC SOL – shrink of cells (RBC) (ex. D5 LR-common), NS)

HYPOTONIC SOL – absorbed water/Rupture of RBC (Hemolysis)(ex. 0.45 ½ normal saline, .225 or ¼
normal saline

FIGURE 10-6 FLUID BALANCE BETWEEN THE INTRAVASCULAR AND INTERSTITIAL SPACES IS MAINTAINED
IN THE CAPILLARY BEDS BY A BALANCE OF FILTRATION AT THE ARTERIAL END AND OSMOTIC DRAW AT
THE VENOUS END.

___to add

Arterial – away from pressure

Venous – pabalik

FIGURE 10-7 THE SODIUM-POTASSIUM PUMPSODIUM AND POTASSIUM IONS ARE MOVED ACROSS THE
CELL MEMBRANES AGAINST THEIR CONCENTRATION GRADIENTSTHIS ACTIVE TRANSPORT PROCESS IS
FUELED BY ENERGY FROM ATP

BODY FLUID REGULATION

 Thirst (bc NS sense the loss of electrolyte)
NM-Rehydration > ISOTONIC SOLUTION (normal saline)
 Primary regulator of water intake
 Kidneys
 Regulates volume, and osmolality of body fluids (Anuric - lack of urine production
 Renin-angiotensin-aldosterone system
 Helps maintain intravascular fluid balance(electrolyte) and blood pressure.
BODY FLUID REGULATION
 Antidiuretic hormone ( regulates exretion)
- Regulates water excretion from kidneys
 Atrial natriuretic peptide ( Distention or Fluid overload)
- Released by atrial muscle cells in response to distention from
fluid overload
FIGURE 10-8 THE RENIN-ANGIOTENSIN ALDOSTERONE SYSTEM DECREASED BLOOD VOLUME AND RENAL
PERFUSION SET OFF A CHAIN OF REACTIONS LEADING TO RELEASE OF ALDOSTERONE FROM THE
ADRENAL CORTEX INCREASED LEVELS OF ALDOSTERONE REGULATE SERUM K AND NA, BLOOD P

RESSURE, AND WATER BALANCE THROUGH EFFECTS ON THE KIDNEY TUBULES.

FIGURE 10-9 ANTIDIURETIC HORMONE RELEASE AND EFFECT. INCREASED SERUM OSMOLALITY OR A
FALL IN BLOOD VOLUME STIMULATES THE RELEASE OF ACH FROM THE POSTERIOR PITUITARY ADH
INCREASES THE PERMEABILITY OF DISTAL TUBULES, PROMOTING WATER READSORPTION

_____TO ADD

THE PATIENT WITH A FLUID VOLUME DEFICIT

-Decrease in intravascular, interstitial, and/or intracellular fluid in the body
- Dehydration - S/Sx > Sunken eyeball, skin turgor, scanty urine, dryness of skin , increase Temp
- loss of water alone
- Often used interchangeably
 Pathophysiology
- Causes
- Vomiting and diarrhea –
- Gastrointestinal suctioning, intestinal fistulas, and intestinal drainage
- Diuretics, renal disorders(CKD/ACKD), and endocrine disorders(SIADH/DI)
Types
- potassium sparing– spironolactone
- Loop – furosemide
- Osmotic - Mannitol

- Hot environment – NM – increase OFI

- Hemorrhage –
•Pathophysiology
 Hypovolemia from loss of ECF
SHOCK- HYPO-TACHY-TACHY
Hypotension-tachycardia-tachypnea
 Third spacing
- Shift of fluid out of vascular space into unusable space ( ex. Burn)
- Triggered by stress hormones
- Difficult assessment Shock, multiorgan failure
Manifestations
- Rapid weight loss and pale skin
 - Decreased skin turgor and urine output
- Tachycardia.
- Decreased systolic blood pressure and venous pressure ( BP-100/80)
Interprofessional care
-Diagnosis
- Serum electrolytes Serum osmolality ( Blood chem-should NPO post MN)
- Hemoglobin and hematocrit(CBC )
- Urine specific gravity and osmolality (urinalysis)
- Hemodynamic pressures(Overall assess)
Fluid management
 Oral rehydration
 Safest, Host effective
Advised to increase OFI 6-8 glasses/day
Hydrate solution, Gatorade, salt and sugar – however not effective when continuous vomit/diarrhea
 IV therapy

Health promotion
- Teaching to prevent fluid volume deficits
- Carefully monitor intake and output
 Assessment
- Health history
- Physical assessment
 Priorities of care
- Restoration of adequate fluid volume
Diagnoses, outcomes, and interventions
 Deficient Fluid Volume
 Ineffective Tissue Perfusion - BP effects
 Risk for Injury – body weakness , safety precautions
 Continuity of care -
Assess patient's understanding of cause of the deficit.
THE PATIENT WITH A FLUID VOLUME EXCESS
Pathophysiology
 Heart or renal failure – the fluid that should be pump on the body retain.
Finding - Crackles upon auscultation in heart, pitting edema
 Cirrhosis of the liver
 spAdrenal gland disorders
 Corticosteroid administration
 Stress conditions causing release of ADH and aldosterone
 Excessive sodium intake ( should decrease soidum intake bc sodium attracts water)
 Medication side effects

Manifestations
Extracellular
- Hypovolemia
- Circulatory overload
Interstitial
- Peripheral
- Generalized
Monitor – I and O, Daily weight(same time of the day and same weighing scale)
Complications
- Congestive heart failure – DOB C-manifestation
- pulmonary edema – DOB/SOB

Interprofessional care
-Diagnosis
-Serum electrolytes, osmolality
-Serum hematocrit, hemoglobin often decreased
-Renal, Liver function

• Interprofessional care
Medications
 - Diuretics
- Loop
- -Thiazide-type
- Potassium-sparing
Treatments
- Fluid management
– careful monitoring , strict regulation of IVF
-Dietary management
Health promotion
- Relationship between sodium intake and water retention
Assessment
-Health history
Physical assessment
- Weight, vital signs, circulatory signs Lung sounds, dyspnea, cough
- Urine output, mental status(check for sensory and LOC)
Priorities of care
Supporting cardiovascular, respiratory function
ACB(airway, circulatory, breathing)
Diagnoses, outcomes, and interventions
- Fluid Volume Excess
- Risk for Impaired Skin Integrity
- Impaired Gas Exchange
Continuity of care
- Teaching to manage underlying cause of fluid volume excess
- Prevent future episodes of excess fluid volume
- Assessment and monitor of I and O, Weight
- VS
- Client education
TABLE 10-3 COMPARISON OF THE MANIFESTATIONS OF FLUID IMBALANCE
_____TO ADDDD