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Sensible Loss
Measureable
Wound Drainage: hemovac, JP drain but NOT wound vac because it
pulls the drainage out so it is not accurately depicting true loss.
Stools, Urine: I and O for charting.
Insensible Loss
Cannot be measured in cc/ml unit.
Breathing, Perspiration
Chart: mild, moderate, severe diaphoresis
Gold Standard for Urine Output is 1500ml/hr out of total 2600 (input)
< 30 ml/hr : OR
< 16 ml/hr: OR
< 400 ml/hr = oliguria ( 16 x 24hrs): given fluids to avoid renal failure
< 2 ml/hr: OR
< 50 ml/hr = anuria (2 x 24 hrs):not functional urine- thick, syrupy, odorous. Dialysis patients.
Fluid Compartments
o
Ascites:
Hypovolemia
Respiratory Prob.
GI problems
Cerebral
Causes
CHF
Renal Failure: dialysis not working
PVD: venous return is a problem
PAD:
Liver failure:
Cirrhosis
ETOH-drink nutrition rather than eat protein
Chronic hepatitis
Cerebral edema
Cavity Bleeding
Abdominal aneurysm
Knee Effusion/Knee
bleed
Treatment
IV albumin
TPN
Paracentesis (draw about 1500-2L q day to avoid BP )
Semipermeable membrane in kidneys should never allow albumin to filter through. Albumin is necessary for COP.
Proteinuria = poor functioning kidneys= protein filtering out into urine.
If person has low serum total protein levels = protein supplements = outcome = low or absence of peripheral edema.
Part II of RAAS
fluid volume
CO
Renal perfusion
Meds that interfere with the RAAS:
ACE Inhibitors pril : keep body from secreting Aldosterone (lowers blood volume) and stop vasoconstriction.(decreases pressure)
:protects renal tissue for unknown reasons.
2.
3.
1.
o
o
o
Manifestations
ADH
Urine Excretion leading to FVD vascular space
FVD = serum electrolytes (concentrated)
Treatments
Secondary problem:
Give ADH until the primary problem can be solved.
o
o
o
ADH
Urine exretion leading to FVE in vascular space
FVE = serum electrolytes (diluted)
2.
Fluid Imbalances
Normal=
275-310
FLUID VOLUME DEFICITS; FVD
Dehydration:
(Hypertonic
dehydration)
Osmolality:
> 310
Hypovolemia:
Osmolality:
FVD/Isotonic
Fluid loss.
275-310 normal
N/V/D
Inadequate intake of
fluids
Exercise without fluid
replacement
Hemorrhage
Shock
CO
hypoxic
circulating
volume.
FLUID VOLUME EXCESS: FVE
Hypervolemia:
Osmolality:
FVE/Isotonic
Fluid excess
275-310 normal
Water
Intoxication
2x circulating
volume
Osmolality:
< 275
Weakening heart
CHF
Solutes/electrolytes :
K+ loss = cardiac arrhythmias
Cells expand/burst
ELECTROLYTES:
If fluid is then all electrolyte levels (concentrated)
If fluid is then all electrolyte levels (dilute)
Osmolality
BUN
Creatinine
Hematocrit
Urine Na+
275-310
10-20
0.6 1.5
37 54%
50 - 130
Machine at same
level as atria.
4 - 10
Fluid Volume
related
Swan or Balloon
Wedge
Systemic
Arterial
Pressure
Arterial Line
25/9
Mean of 15
Fluid Volume
related
Fluid Volume
related
BMP: gives anion gap for Critical Care Patients: means there is not a balance of + and - electrolytes. The ranges may be normal but
specific electrolytes dont match. This may explain why as a nurse you are giving K+ to a patient with normal ranges.
ELECTROLYTES IMBALANCES / REASONS
HYPO:
o
o
o
o
o
o
HYPER:
Inadequae intake
Excessive loss via secretion
Water gain (dilute)
Shifting into compartments (too much K+ goes into cell, insulin)
Hormonal disorders
Imbalance with other electrolytes with inverse proportions (Ca/PO4 )
o
o
o
o
o
o
ELECTROLYTES
Electrolyte
S/Sx
Hypo
S/Sx
< 135
Hyper
Na+
135-145
> 145
K+
3.5- 5.0
> 5.0
< 3.5
Think pt. on
digoxin and lasix
for CHF.
EKG: tall tented T waves/ HYPER High T waves
Mag
> 2.5
1.5 -2.5
Respiratory Rate
Heart Rate/bradycardia
DTR (less than 2)
Think the opposite of the Mag toxic mom. Climbing the walls.
The mom has low mag so we add Magnesium to increase
supply. Low mag = seizures
> 11
Phosphorous
2.8- 4.5
> 4.5
<9
Cardiac contractility:
Constipation (give Ca to PO4 )
Hypophosphatemia
Think : Renal
Issue
Chloride
96-106
Hypocalcemia
Anorexia
Altered Mental Status
DTR ( +3 or +4)
Tetany
CLonus
+ Chvosteks/Trousseaus
< 2.8
Hypercalcemia
Anorexia
Altered Mental Status
< 96
Muscle Cramps
GIVE: Phoslo
> 106
Altered LOC/weakness
THINK: Na+ if something is wrong with Clprobably something is wrong with Na+
TONICITY OF SOLUTIONS
Isotonic: cells dont shrink or swell
Normal Osmolality 275-310
0.9 % sodium chloride (NS)
LR
5% dextrose injections (D5W)
Osmotic Diuresis
Occurs with TPN: hypertonic fluid
Must start slow at D20 and add 24 hrs. worth of electrolytes, fats, etc.. = very thick, sticky fluid put in pt. vascular space. May notice
UO is increasing of up to 3000 per shift which is 2x the normal 1500. Why? The concentration of vascular space is making cells give
up their water so pt. is getting nutrition at expense of cellular dehydration.
Correct this problem by diluting TPN. Run concurrent hypo at same time as TPN to dilute concentration in vascular space: An
example order may say: start TPN, increase by 10ml per shift to goal rate of 85ml. This allows pancreas to catch up to allow for
increasing sugar from TPN. Slowly taper up. It may also say: Run NS concurrently for a total rate of 125.
So if you start TPN at 30ml then the NS would run at 95ml.
At next shift TPN at 40ml then the NS would run at 85ml.
Once at goal rate of TPN at 85ml then NS would run and stay at 40.
One tapers up and the other tapers down. Always taper back down to avoid hypoglycemic reaction.
Occurs with Acute Renal Failure:
Occurs in head injuries when we use osmotic diuretics to cerebral edema.