Chapter 17-Fluid & Electrolyte Balance
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| Osmolality | concentration of blood; normal serum level 275-295=isotonic
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| Isotonic | equal osmolality of blood; no fluid shift, just increasing fluids
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| Hypertonic | more concentrated than blood; pulls fluid into vascular space from interstitial & intracellular spaces
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| Hypotonic | less concentrated than blood; fluid moves out to cells & interstitial space
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| Diffusion | movement of particles from high concentration to low concentration
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| Osmosis | movement of fluid or H2O from low to high concentration
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| Facilitated Diffusion | movement with a carrier molecule (i.e., insulin)
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| Active Transport | moving against grain with ATP
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| Fluid Compartments | Intracellular--inside the cell
Extracellular--everything outside cell; Interstitial-between intravascular & intracellular space; Lymph-sewer system of body, drains interstitial spaces into venous system; Vascular-veins, arteries, capillaries; CSF
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| Hydrostatic pressure | push of the fluid from inside the vascular space; push from the inside outf
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| Colloid Osmotic Pressure | Colloid=big cells, Albumin, RBCs; do not go through membranes easily, so pull fluids into vascular spaces
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| Elevation of Venous Hydrostatic Pressure--Reason for Edema #1 | too much fluid in vascular space, seeps out in interstitial space
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| Decrease in colloid osmotic pressure --Reason for Edema #2 | Loses pull and allows fluid to seep out
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| Increase in Interstitial Oncotic Pressure; break in vascular space (bruise, burn victim) --Reason for Edema #3 | Where colloids go, fluids go;
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| Regulation of H2O Balance-Hypothalamic | Thirst center
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| Regulation of H2O Balance-Pituitary | Pituitary gland secretes ADH, keeps fluids; reabsorbs Na & H2O
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| Regulation of H2O Balance-Adrenal Cortical | Adrenal gland secretes cortico/glucosteroids; secretes aldosterone that controls retension of Na; secretes cortisol that controls waking cycle
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| Regulation of H2O Balance-Renal | Kidneys secrete Renin. Kidneys very fussy,like continuous fluid; if not getting enough, release renin, which converts to angiotensinogen, then angiotensin I, then angiotensin II which causes vasocontriction (incr. bp)
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| Regulation of H2O Balance-Cardiac | When the heart gets flooded, it swells. When myocardium stretches too much it releases BNP (natural diuretic for kidneys) Tells kidneys to excrete fluid. Abnormally high BNP is indicator for CHF
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| Regulation of H2O Balance-GI | Colon reabsorbs H20; about 8L/day
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| Regulation of H2O Balance-insensible H2O | Loss of H2O from breathing/sweating-600-900mL/day
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| Fluid Replacements | Crystalloids (clear) IV fluids
Colloids (big cells) Albumin, RBC, blood products--sponges
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| Albumin | Given to maintain, raise & hold bp; hold fluids in vascular space
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| Blood & blood products | RBCs, FFP (given to incr. clotting factor--to reverse high INR-coumadin), platelets, cryoprecipitate (given to treat high PTT-heparin
Very concentrated, give diuretics between units to protect the heart from fluid overload
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| Hespan | Synthetic colloid, used to help increase bp
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| Lipids | given w/TPN;
TPN is hypertonic; 70% glucose--have to listen to lungs for crackles
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| Fluid Volume imbalance--how to tell if out of balance?? | I&Os; severely dehydrated pt, not a lot of output
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| Fluid Volume imbalance--how to tell if out of balance?? | If heart gets overload=incr hr, crackles in lungs, decreased sats,incr RR. look at BNP lab
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| Fluid Volume imbalance--how to tell if out of balance?? | Always access for edema; ankles if sitting; hips and thighs if lying down
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| Hypernatremia (Na >145) High osmolality (more Na than H2O in blood) | can be a sign of dehydration
S&S: intense thirst, lethargic, seizures (neuro)
Tx: 0.9NS or 0.45 fluids
Do not want rapid fluid switch
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| Hyponatremia (Na <135) Low osmolality (lots of fluid in vascular space) | S&S: confusion/tremors, seizures (neuro,) lethargy
Manifestations: diarrhea, vomiting, NG tube suction
Tx: 0.9%NS
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| Hypokalemia (K <3.5) | Causes: diarrhea, vomiting, NG suction, diurectics
S&S: leg cramps, parathesia, numbness, tingling (in legs)
Tx: PO, IVPB-max 10mEq/hr on perph line, 20mEq/h on central line
Biggest risk: ventricular arrhythmias, VTach, PVCs--run stat labs to chk K and
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| Hyperkalemia (K >5.5) | Causes: Salt substitutes, Mrs. Dash(takes Na out, add K), chronic renal failure (can't excrete K), tissue injury, ACE, ARB inhibitors cause kidneys to retain more K
Biggest risk: Cardiac arrhythmia, 1st brady, then 3rd degree block, tented/peaked T-waves
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| Treatments for Hyperkalemia | sodium bicarb-pushes K into cells
Calcium gluconate-protects heart
Insulin&D50-pushes K into cells
Kayexalate-PO or rectal
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| Hypocalcemia(Ca <8.5) Always look for Adj for Albumin lab | Cause: chronic kidney disease, incr. phosphate, diurectics, ETOH, diarrhea
S&S: Chvostek's-touch side of cheek=twitch; Trousseau's=hand tremor w/bp cuff or tourniquet, numbness & tingling around the mouth
Tx: PO, IV (symptomatic, use IV first)
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| Hypercalcemia (Ca >10.5) | Causes: multiple myeloma, bone mets, hyperparathyroid
S&S: lethary, decreased reflexes, kidney stones, fractures
Biggest thing: find cause; flush out
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| Hypophosphatemia (P <2.8) | Causes: ETOH abuse, malabsorption
Biggest Concerns: muscle weakness, respiratory muscle weakness (trouble getting pts off vent,) hypercalcemia
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| Hyperphosphatemia (P >4.5) | Causes: Chronic renal failure, chemo agents, hypoparathyroid
S&S: hypocalcemia S&S
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| Hypomagnesemia (<1.5) | Causes: diarrhea, vomiting, ETOH abuse, NGT suction, diuretics
S&S: confusion, hyperactive deep tendon reflexes
Tx:PO, IV
Worry about cardiac arrhythmias, PVCs
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| Hypermagnesemia (>2.5) | Causes: usually created--given to slow muscle contraction; given in OB
High mag levels & EKG chgs, give calcium gluconate
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| If you have Respiratory Acidosis... | You are retaining too much CO2; can occur with hypoventilation--post op pts, sedated. High CO2 levels=lethargy. To increase ventilation, coughing, deep breathing, inflate lungs--has nothing to do with O2
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| If you have Metabolic Acidosis... | S&S: deep rapid RR, trying to get rid of CO2 (Kussmaul Respirations); trying to get rid of CO2 acid
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| If you have Respiratory Alkalosis... | Pt. is hyperventilating; getting rid of too much CO2(acid). Breath into paper bag
Causes: anxiety, pain, emotional distress
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| If you have Metabolic Alkalosis... | Pt. not ventilating well. Trying to maintain CO2.
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