Fluid, Electrolyte, and AcidAcidBase Balance

Dr. Manal Kassab
23Feb2011 23Feb2011

DAILY MAINTENANCE FLUID REQUIREMENTS
Body Weight (kg) Amount of fluid per day (Basal Maintenance)

1 ± 10 100 ml/ kg 11 ± 20 1000ml + 50 ml/ kg for each kg>10 kg 20 1500 ml + 20 ml/ kg for each kg > 20 kg Normometabolic state, at rest; Estimated fluid requirements-----increased or decreased from these parameters -----increased/decreased of H2O losses, e.x Elevated body temperature CHF

Distribution of body fluids
Water is the major constitutes of body tissues TBW range (of total body weight) from
40% - 60% adults 75% infants Loss of 20% - fatal

Distribution of body fluids, or total body water (TBW), involves the presence of Intracellular (ICF) Extracellular (ECF) fluids

So where are these fluids kept?
Body fluids are divided between the intracellular & extracellular department Most of our body fluid (2/3) is found in the intracellular department.

ICF
Contains solutes such as Oxygen, electrolytes protein & glucose. ICF provides a medium in which metabolic processes of the cell take place. ICF contain electrolytes as K, Mg (primary electrolytes)

Extracellular (ECF)
Fluid outside the cells It is the transport system that carries nutrients & waste products to and from the cells Newborn 50% of body fluid contained within ECF Toddler 30% of body fluid contained within ECF

Abundance

Medium to dissolve body solutes (Na+, O2)

Place for metabolic reaction

Transport of nutrients, waste & other substances BTW Blood & cell

Insulator Lubricant Regulating & maintaining body Temp

Shock absorber

ICF & ECF contain

Oxygen & CO2

Dissolved nutrients

Excretory products

Ions (dissolved salts)

Ex NaCl breaks into Na+ Ion & Cl- Ion (electrolytes) +ve charge ion (Cation) _ve (anion) K+ major cation ICF & it maintain ICF balance Na+ major cation ECF It control water balance

Composition of body fluids
Electrolytes are measured in milliequivalents per liter of water ( mEq/L). Other body fluids such as gastric and intestinal secretions also contain electrolytes

Mechanisms of fluid movements
Water is retained in the body in a relatively constant amount and it is almost freely exchangeable among all body fluid compartments (ICF & ECF)

Transport mechanisms are the basis for all activity
within the cells, and since they have limited ability to store materials, movement in and out of cells must be rapid. Internal control mechanisms (such as thirst, antidiuretic hormone (ADH), and aldosterone (which enhances sodium reabsorption) are responsible for distribution & maintenance of fluid balance.

Regulation of Fluids in Compartments

The principles involved in this shifting are Diffusion Filtration Osmosis Active transport

Diffusion
Molecules moves from a solution of higher concentration

To

a solution of lower concentration

This motion affected by
Temperature Size of solution
ex Container of water & Crystal drink Spreading & color even

Stopped

near equal state

Hydrostatic pressure/ Filtration

movement of fluid& solutes

from

an area of higher hydrostatic pressure one of lower pressure

to

The pressure created by the weight of fluids Its caused from pressure on capillaries

Moves water & solutes into interstitial spaces

Osmotic pressure

water movement across the cell membranes

from low solute concentration (low osmotic pressure)

higher concentration of solute (high osmotic pressure)

No energy required

Movement of water in the body between cells (extracellular fluid) is caused by osmosis. This is created by magnetic forces in the body, which keep the movement in balance. As water flows, changes in pressure create movement across the cell membranes. Any changes in pressure will allow proteins, minerals and other nutrients being carried by the blood to escape into spaces between vessels and deprive the cells of their vital needs to sustain life.

Active Transport

movement of substance across the cell membrane from Less concentration solution To Higher concentration By Active transport ( a carrier)
Burn calories Spend a bit energy

Osmosis versus Diffusion
Osmosis Diffusion Low to high High to low Water potential Both can occur at the same time Movement of particles Both can occur at the same time

Osmolality
Osmolality is The concentration of solutes in the body fluids, Reported as milliosmols per kilogram (mOsm/kg). Sodium is the greatest determinant of serum osmolality.

Tonicity It refers to the osmolality of solution: Tonicity is a measure of the osmotic pressure of two solutions separated by a semi-permeable membrane. Isotonic solution has the same osmolality as body fluids ( eg Normal saline 0.9%) Hypertonic solution has a higher osmolality than body fluids ( eg Normal saline 3%) Hypotonic solution has a lower osmolality than body fluids ( eg Normal saline 0.45%)

IMBALANCES It occurs when body fluids are lost in excess of fluid gain The great majority of disturbances in hydration & electrolytes balance occur secondary to vomiting & diarrhea 1-Fluid Imbalances Causes of dehydration are: 1. Lack of oral intake. 2. GI ; vomiting, diarrhea, malabsorption 3. Burns 4. Fever 5. Diabetes mellitus 6. Tachypnea as in bronchiolitis

Types of dehydration

Isotonic /Isonatremic dehydration:

Hypertonic dehydration/hypernatre mia water intake decreases & Na increases

Hypotonic/ Hyponatremia dehydration decrease in Na & retention of water

Occurrence

fluids & electrolytes losses are in same proportion as they exist in the body

10-20% of children with dehydration have hypertonic/hypernatrmic

Fluid osmolarity is not affected & there is deficit of TBW.

Proportionally greater loss of water than Na

It can be caused by excessive plain water intake and defect in renal water excretion and failure in Syndrome of inappropriate antidiuretic hormone (SIADH) CF is due to excessive lose of Na via sweat. The water shifts from ECS to ICS causing circulatory collapse.

Hypotonic/ Hyponatremia dehydration is occur in 10% of children with dehydration.

70% of children with diarrhea

occur when insensible loss of water from skin & respiration tract is high In this case the Na increase the osmotic pressure in the blood vessels that shifts the fluids from the IC to the ECS (plasma Na+ > 150 mEq/L) .

(plasma Na+ remains normal 130-150 mEq/L).

Disturbances in Fluid Volume, Electrolyte& Acid-Base Balances
Many factors affect the fluid & electrolyte balance such as illness, surgery, medications, burns, vomiting, diarrhea and nasogastric suction. The majority of childhood illnesses that caused imbalances they occur secondary to vomiting and diarrhea. The imbalances can be: 1. Total body deficit/excess of fluid and electrolyte with the osmolality of the body is not affected. 2. When relationship between fluid & electrolyte has been altered & the osmolality is altered (electrolytes+++ with dehydration & dec- with overhydration). 3. both a and b.

Factors Affecting Body Fluid, Electrolytes and AcidBase Balance
1- age: infant has immature kidneys, rapid respiration and more body surface area than adult which make the infant loses the fluid rapidly. In elderly people, the thirst response often is blunted and kidney become less able to conserve water that will affect the fluid balance. 2- Gender and Body Size: Female having more fat (people with a higher percentage of body fat have less fluid). 3- Environmental Temperature: both salt and water are lost through sweating in hot climate 4- Lifestyle: diet, exercise, stress and alcohol consumption all affect the fluid and electrolyte balance

Sodium Imbalance Hypertonic Dehydration
Gain of Na+ in excess of water
Plasma Na+ > 145 mEq / L

The causes of hypertonic/hypernatrmic can be 1. Administration of hypertonic IV fluids
2. Increase

of Na intake

3. Failure of ADH (H2O loss Increase in ECF) 4. Increase of insensible loss of water as in burn, fever, respiratory infections. 5. RF The defense mechanisms for this case are stimulation of thirst stimulation of ADH.

Hypotonic Dehydration
Overall decrease in Na+ in ECF (Plasma Na+ < 130 mEq/L) Causes 1. Excessive plain water intake & defect in renal water excretion 2. C.F (excessive loss of Na+ via sweating) Which leads to: H2O shifting from ECF into ICU causing circulation collapse Clinical manifestations Neurological symptoms Lethargy, confusion, apprehension, depressed reflexes, seizures and coma

Overdehydration/ Edema
Over dehydration is the excess of interstitial fluid caused by: Receiving IVF very fast (Kidney Function is normal) Patient receiving dialysis or enema Edema is the presence of excess fluid in the interstitial spaces. 1. Fluid Volume excess FVE : FVE increase the capillary pressures, pushing fluid into the interstitial tissues by filtration. (e.g heart failure and renal failure). 2. Low levels of plasma proteins in blood: This will reduce the oncotic pressure so that fluid is not drawn into the capillaries from interstitial tissues. (e.g nephritic syndrome and malnutrition). OP is exerted by proteins in blood plasma that usually tends to pull water into the circulatory system

3. Allergic reaction:
The albumin can move easily from the capillaries membrane pulling with it the fluid. This can be seen also in burns & truma. capillaries become more permeable allowing the fluid to escape into interstitial tissues.

4. Increase in interstitial oncotic pressure:
The protein enter the interstitial fluid (tissue fluid) more than they leave causing increase in interstitial oncotic pressure that in turn pull the fluid into tissue as in tumors and hypothyroidism

5. Obstructed lymph flow :
This impairs the movement of fluid from interstitial tissues back into the vascular compartment.

Edema
Taking accurate daily weights is important to detect any weight changes. Vital signs, physical appearance, and changes in urine character or output are noted. Edema (general) in infants may first be seen around the eyes and in the presacral, occipital, abdominal girth or genital areas. Pitting edema, Exerting gentle pressure with the finger 5 sec having an impression in the skin that lasts for several seconds

Electrolyte Imbalance/ Potassium
Potassium (95% of K of body in ICF) a.) Hypokalemia: K serum < 3.5 mEq/L The K+ shifts from EC to IC space and also Insulin promotes K to enter skeletal muscles and hepatic cells. (Insulin moves K into cells; high concentrations of insulin thus lower serum K) Some of S&S: cardiac arrhythemia, muscle weakness, shallow breathing, polyuria Causes: Vomiting / diarrhea Malnutrition / starvation Stress due to trauma from injury or surgery. Gastric suction / intestinal fistula Potassium wasting diuretics Alkalosis

Potassium
b.) Hyperkalemia: K > 5.0 Most commonly occur in children as a result of too rapid administration of IV potassium chloride,
Significant dysrhythmias and cardiac arrest may result when potassium levels arise above 6.0 mEq/L

Caused also by
Renal failure, Shift of K from IC to EC by tissue damage Metabolic acidosis

S&S: malaise, muscle weakness, oliguria to anuria, abnormal cardiac function and D & Nausea

Hypocalcaemia
Calcium (required for activation of numerous enzymes, cardiac, neural & muscular functions a.) Hypocalcemia: Ca < 4.0 mEq/L, caused by hypoparathyroidism, Vit D deficiency, burns, infections diarrhea, renal failure, cow¶s milk formula early in infancy [phosphate] which drops the Ca level S&S: Tetany, neuromuscular irritability, convulsions, cardiac arrest, hypotension laryngospasm, numbness & seizures. b.) Hypercalcemia: Ca > 5.5 mEq/L, caused by increase administration of Vit A and D, prolonged immobilization and hyperparathyroidism. S&S: nausea, vomiting, constipation and flank pain

Acid-Base balance
Homeostasis: a balance of fluids, electrolytes and acids and bases in the body; that reflects a good health. Acid-base balance is maintained by normal pulmonary and renal excretion of carbon dioxide and acid, respectively. Acid-base balance is a dynamic relationship which reflects the concentration of hydrogen ions (H+) in the body Acid is the substance releases hydrogen ions (ex Carbonic acid) A drop in pH is called acidosis Base can accept hydrogen ions (HCO3) A rises in pH is called alkalosis PH is the relative acidity or alkalinity of a solution: # higher hydrogen ions lead to more acidity which is low pH <7. # less hydrogen ions lead to more alkalinity which is high pH >7.

Body fluid PH
Body fluids are slightly alkaline - Normal pH of arterial blood is 7.35 - 7.45 several body systems including 1. Buffers, 2. Respiratory system, 3. Renal system Are maintaining the narrow pH

Regulating Acid-Base balance
1- Buffers (Fastest) (solutions that tend to resist changes in their PH as acid/base added) Major buffers system in ECF is the carbonic acid ( H2CO3) & its conjugated base; bicarbonate (HCO3) Besides bicarbonate & carbonic acid buffers, plasma proteins, hemoglobin and phosphates also function as buffers in body fluids. HCO3 + H+ CO2 + H2O H2CO3 H2CO3 this is a weak volatile acid eliminated HCO3¯ + H+

2- Respiratory Regulation: Regulating acid-base balance by eliminating or retaining carbon dioxide (CO2) by altering the rate and depth of respirations.

If the blood level of carbonic acid (H2CO3) increase the rate and depth of respirations increase (hyperventilation) to excrete CO2 to fall the level of H2CO3 If the blood level of bicarbonate (HCO3-) increase the rate and depth of respirations decrease (hypoventilation) to retain the CO2 and rise the level of carbonic acid. - PCO2 refer to pressure of carbon dioxide in venous blood -PaCO2 refer to pressure of carbon dioxide in arterial blood. Normal PaCO2 is 35-40 mmHg

-

3- Renal Regulation: Normal serum bicarbonate level is 22-26 mEq/L - kidneys maintain acid-base balance by excreting or conserving bicarbonate (acid) & hydrogen ions - If acidity increased the kidneys reabsorb and regenerate bicarbonate and excrete H - In the case of alkalosis excess bicarbonate is excreted and H ion is retained

Acid-Base imbalances
The abnormalities in PaCO2 increase/decrease is called respiratory alkalosis/acidosis because PCO2 regulated by respiration # Increase in PaCO2 ---------------- respiratory acidosis # Decrease in PaCO2----------------respiratory alkalosis.

The abnormalities of plasma bicarbonate concentration refer to metabolic process # Increase in HCO3---------------------metabolic alkalosis # Decrease in HCO3------------------- metabolic acidosis

Acidosis or Alkalosis
Metab. acidosis Metab. alkalosis Resp. acidosis Resp. alkalosis Primary change decreased HCO3 increased HCO3 increased pCO2 decreased pCO2

Blood Gas Values PH 7.35- 7.45 PaCO2 35 ± 45 mmHg HCO3 22 -26 mEq/L

pH Compensatory response decreased decreased pCO2 increased increased pCO2 decreased increased increased HCO3 decreased HCO3

1. Look at PH level (normal 7.35-7.45)_____Lower acidic _____Higher alkalotic 2. Look at PaCO2 ( 35-45mmHg ) ________Decrease Alkalinic (Acid) ________Increase Acidic 3. Look at HCO3 (22-26mEq/L) __________Decrease Acidic (Base) _________Increase Alkaline

Respiratory Acidosis: Hypoventilation and CO2 retention cause carbonic acid level to increase which will drop the pH level below 7.35. Ex. pH 7.28 (acidic) PaCO2 74 HCO3 26 N

When respiratory acidosis occur the kidneys will retain bicarbonate to restore the normal ratio of bicarbonate:carbonic acid (20:1) in order to restore the normal pH pH 7.33 PaCO2 74 HCO3 32 (Compensated Res Acid) This can be caused by 1. asthma 2. central nervous system depression 3. anesthesia, alcohol , 4. aspiration of foreign body. 5. Pneumonia S&S 1. Headache 2. Blurred vision 3. Restlessness 4. Anxiety 5. Tremors

Respiratory alkalosis: Hyperventilation makes the CO2 to be exhaled causing the carbonic acid to fall and rise the pH above 7.45. Ex. pH 7.50 (alklosic) PaCO2 30 HCO3 23 N This can be caused by 1. Tetany 2. fever, 3. anxiety, 4. respiratory infection. With respiratory alkalosis the kidneys will excrete bicarbonate to return normal pH. pH 7.46 PaCO2 30 HCO3 20 (Compensated Res Alklosis) S&S 1. increase irritability of central and peripheral nervous system. 2. Light headache 3. Altered consciousness 4. Paresthesia of extremities 5. arrhythmias

Metabolic Acidosis (diarrhea) When bicarbonate is low in relation to the carbonic acid in the body, causing the pH to fall. Ex. pH 7.21 PaCO2 40 (N) HCO3 15.6
This can be caused by 1. Renal failure 2. Inability of the kidneys to excrete H ions. 3. Increase of anaerobic metabolism 4. Decrease in blood volume causing the kidney to function less effectively

Metabolic acidosis will stimulate the respiratory center causing the rate and depth of respiration to increase in which the CO2 is eliminated and the carbonic acid is fall). pH=7.34 PaCO2=28 HCO3= 15.6 S&S 1. Increase depth of respiration 2. Arrhythmia 3. Lethargy----coma 4. Impaired growth (rickets) 5. Wt loss 6. Anorexia 7. Muscle weakness and listlessness.

Metabolic alkalosis (vomiting): When the amount of bicarbonate in the body exceeds the normal 20:1 ratio. This can be caused with ingestion of antacid, vomiting which causing losing in H. HCO3= 30.4 (hig) pH= 7.51 (Inc) PCO2=40 The metabolic alkalosis will stimulate the respiratory center to slow and shallow the breathing (causing to retain CO2 which will increase the carbonic acid level) pH=7.46 PaCO2= 45 HCO3= 31.2 Causes are 1. Muscles hypertonic 2. vomiting 3. nasogastric suctioning 4. diuretics; 5. Hypokalemia . 6. HCO3 retention may result from, massive blood transfusion, excessive administration of sodium bicarbonate S&S 1. Weakness 2. Muscle cramp 3. Dizziness

Nursing Assessment
1. Nursing History Ask about: vomiting, diarrhea, food given during illness, urination, recent changing in behaviors and activities, wt, fever, evidence of infection, and medication. 2- Physical Assessment - skin: color , temperature, moisture, edema, turgor - mucous membrane: color , moisture - eyes: firmness - Fontanels (infants): firmness level - cardiovascular system: heart rate, peripheral pulses, blood pressure, capillary refill, venous filling - respiratory system: respiratory rate & pattern, lung sounds - neurologic: level of consciousness (LOC), orientation, motor function, reflexes.

1. Vital signs: Early phase of ECF volume depletion is increase in Temp. Pulse is rapid weak and thready in dehydration (thready pulse is an
abnormal pulse that is weak and often fairly rapid, the artery does not feel full and the rate may be difficult to count).

but the bounding pulse occurs in increase of plasma fluid volume (decrease hematocrit & HG ) and in hypertonic dehydration. In metabolic acidosis the compensatory mechanism will increase the respiratory rate. And in potassium alteration whether its increase or decrease the breathing will be shallow. BP will increase in fluid volume excess.

Vital Sign
Temp Pulse R.R Increase Metabolic acidosis Incr/decr Potassium alteration B/P Increase FVE Increase Early Dehydration: phase of ECF Thready, depletion Rapid, Weak Bounding Increase plasma fluid volume

Bounding Hypertonic dehydration

Weight for infant and young children
Mild dehydration Moderate dehydration Severe dehydration

3-5% loss of body W.T

6-10% loss of body W.T

10% loss or more

Fluid volume loss of more than 50 ml/kg

Fluid volume loss of 50100ml/kg

Fluid volume loss of 100ml/kg or more

W.T for older children
Mild isometric dehydration Moderate dehydration Severe dehydration

if 3% of body weigh is lost

if 6% of body weight is lost

if 9% of body weight is lost

Anterior fontanel & eyes
FVE Dehydration Sever dehydration

Fontanel Tense & bulging

Depressed & sunken

Eyes are sunken

Suture skull becomes prominent

4. Intake and Output and Urine specific gravity. In fluid excess the USG is decreased (normal value 1.0101.025). Urine intake should approximate the output: Urine output/24hrs Neonate 50-300 mL Infant 350-550 mL Child 500-1000 mL Adolescent 700-1400 mL Adult 1500-2000 mL.

5. Neurologic Status: In dehydration the child may become irritable to lethargic and cry with high pitched or weak. In hypo/hyperkalemia: there is muscle weakness, tetany. In Hyponatremia: confusion, headache, delirium and convulsion. In hypernatremia: intracerebral bleeding, brain damage. 6. Laboratory Assessment:
A.) Arterial Blood Gases for acid-base imbalance B.) Urine specific gravity for dehydration C.) Serum and urine electrolytes D.) ECG for electrolytes imbalance.

Nursing Diagnosis
Fluid volume deficit ( Diagnostic label) R.T excessive fluid loss associated with illness/secondary to, hemorrhage; diarrhea; vomiting; burns; fever, and hyperventilation (etiology) as evidenced by/as manifested by 10 times/a day watery stool; more than 8 times vomiting, vomit the whole feeding, sunken eyes and depressed fontanel, dry skin«etc (defining characteristic/signs and symptoms).

Nursing management
* Maintenance requirements of the fluid and electrolytes that are necessary to maintain homeostasis for 24 hours, * The therapy must account for insensible loss, urine output, and caloric needs. * The maintenance calculated based on: Body weight, surface area or caloric expenditure and mostly used based on caloric expenditure. *Holliday-Segars formula (method of estimating daily caloric needs)
(Beginning at 100 kcal/kg for an infant)

Example
Fluid maintenance for a body weight of 24 Kg is: The first 10 Kg needs 100cc/Kg so = 10*100=1000 The second 10 kg needs 50cc/kg=10*50=500 And more than 20kg needs 20cc/kg=20*4=80 So in total fluid maintenance is = 1000+500+80= 1580cc/day, 1580calorie/day

Treatment phases
(I) Deficit therapy a.) Initial therapy phase: to restores the circulation with severe dehydration. Ringer¶s lactated, saline solution, plasma or albumin can be given. 11.) Repletion therapy: correct previous loss and provide therapy for normal and abnormal ongoing losses. In this phase KcL can be added. (111) Stabilization phase: maintenance and ongoing losses; oral intake may be resumed started with clear fluid.

Potassium chloride ( KcL) administration
Give no more than 40 mEq/L Never give potassium by IV push Do not administer KCL if urine output is not age appropriate

Total parenteral nutrition
1. TPN consist of carbohydrate, protein, electrolytes, vitamins, minerals and fat. 2. Indicators for TPN are:
a. malnourished / long period without enternal feeding. b. Premature infant will need TPN sooner than older child. c. Major GI tract abnormalities d. Immune deficiency e. Inflammatory bowel diseases f. Severe burns g. Renal failure h. AIDs.

3. The dextrose, amino acids, electrolytes, vitamins and elements are mixed together with a separate fat emulsion (looks like milk) administered separately in dropper without filter. 4. TPN can be administered via IV or catheter.

Catheter can be inserted for neonate and infant through external or internal jugular vein to the superior vena cava. For Older Children: The catheter can be inserted for older children through the subclavian vein to superior vena cava.

Care of infants with TPN
The line may become dislodged or clots may form. A serious infection called sepsis is a possible complication of a central line IV. Infants who receive TPN should be closely monitored by the health care team, since complications can be serious and are not unusual. Prolonged use of TPN may lead to liver problems.

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