Fluids and Electrolytes Review

Philippine Integrated Nurse Licensure Examination

Sample Question
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The nurse is caring for a client with Congestive Heart Failure. On assessment, the nurse finds the client complaining of dyspnea and that rales are heard on auscultation. The nurse suspects fluid volume excess. Which additional sign would the nurse expect if fluid volume excess is present? A. B. C. D. Flat neck and hand veins Weight loss Increased central venous pressure Hypotension

Key to Success!
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Confidence + Adequate test Preparation and review + Effective test taking strategy + Good study habits + Working Knowledge of Basic Nursing concepts = Success in passing PINLE

Fluids and Electrolytes Outline

3 concepts
Fluids y Electrolytes y Acids and Bases
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Important Concepts
Remember the ABC y Safety of the patient y Maslow s Hierarchy of needs y Utilize the NURSING PROCESS A-D-P-I-E
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Summary of Subtopics
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Basic Definition Body Proportions and Distributions Sources Dynamics Regulation by 3 systems- renal, endocrine & GIT Balance Imbalances Application of the Nursing Process in the discussion

THE BODY FLUIDS

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A solution of solvent and solutes Our body is made up of fluids and solids About 50-60% of the body weight is WATER In a 70 Kg adult male: 60% X 70= 40-42 Liters Note that 1 kg body weight= 1 liter of water The body has two major compartments: 1 Intracellular 2. Extracellular

The Proportion of Body Fluids

Interstitial 15%

Intracellular fluid 40%

Intravascular 5%
Transcellular 1-2%

The Intracellular Fluid

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Found inside the cell surrounded by a membrane. This is compartment with the highest percentage of water in adults.

The Extracellular Fluid

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Fluid found outside the cells 1. INTERSTITIAL FLUID

Found in between the cells

2. INTRAVASCULAR FLUID
Found inside the blood vessels and lymphatic vessels

3. TRANSCELLULAR FLUID
Found inside body cavities like pleura, peritoneum, CSF

Sample question
1. A client with CHF is assessed by the nurse. Upon reviewing the chart, it is determined that his weight increased by 4.5 pounds. The nurse estimates that client has gained how many liters of fluid? A. 3 B. 1 C. 2 D. 0.5

Sources of Fluids: Fluid Input

1. Exogenous sources y Fluid intake- water from foodstuffs y IVF y Medications y Blood products 2. Endogenous sources y By products of metabolism y secretions

Fluid Losses
Routes of Fluid output y Urine Sensible losses y Fecal losses y Sweat y Insensible losses though the skin and lungs as water vapor

Sample question
2. A nurse reads a doctor s progress notes in the client s chart which states insensible fluid loss approximately 800 ml. The nurse understands that this fluid loss may occur through: A. The Gastrointestinal tract B. Urinary output C. Wound drainage D. The skin

Sample question
A nurse is administering IVF as ordered to a patient who sustained second-degree burns. In evaluating the adequacy of fluid resuscitation, the nurse understands that the most reliable indicator for fluid adequacy is the: A. Blood pressure B. Mental status C. Urine output D. Peripheral pulses

Sample question
The nurse receives the following endorsements. She is certain that which patient is at most risk for the development of fluid volume deficit? A. The client who came from the OR after a hemorroidectomy. B. The client who has Renal failure undergoing dialysis. C. The client with AIDS taking corticosteroids. D. The client with Rheumatic fever taking diuretics.

Fluid Dynamics
The movement of fluids (solutes and solvents) in the body compartment y Diffusion y Osmosis y Filtration y Active transport

The Concept of TONICITY

This is the concentration of solutes in a solution. y A solution with high solute concentration is considered as HYPERTONIC. y A solution with low solute concentration is considered as HYPOTONIC. y A solution having the same tonicity as that of body fluid or plasma is considered ISOTONIC.
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Helpful Hints
In a HYPERTONIC solution, fluid will go out from the cell, the cell will shrink. y In a HYPOTONIC solution, fluid will enter the cell, the cell will swell. y In an ISOTONIC solution, there will be no movement of fluid.
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DIFFUSION
The movement of SOLUTES or particles in a solution from a higher concentration to a lower concentration. y If a sugar is placed in plain water, the glucose molecules will dissolve and diffuse distribute in the solution.
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OSMOSIS
The force that draws water or solvent from a less concentrated solution into a more concentrated solution through a semi-permeable membrane. y The pressure that draws water inside the vessel which is more concentrated is called Osmotic pressure. y A special type of osmotic pressure is exerted by the proteins in the plasma. It is called ONCOTIC PRESSSURE.
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Sample question
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The nurse is caring for a psychiatric patient who ingested high-sodium containing foods. She suspects hypernatremia in this patient and expect to note: A. Hyperactive deep tendon reflex B. Chovstek s Sign C. Dry skin and sticky mucous membrane D. Decreased muscle tone

FILTRATION
The movement of both solute and solvent by hydrostatic pressure, ie, from an area of a higher pressure to an area of a lower pressure. y An example of this process is urine formation. y Increased hydrostatic pressure is one mechanism producing edema.
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Active transport
This is the movement of solutes across a membrane from a lower concentration to a higher concentration with utilization of energy. y Example is the Sodium-Potassium pump- a primarily active transport process.
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Sample question
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The nurse reviews the laboratory report of a patient with fluid volume deficit. Which of the following laboratory findings will support this condition? A. WBC count of 9,000 B. Creatinine of 1 mg/dl C. Sodium of 140 mEq/L D. Hematocrit of 58%

Sample question
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The client is taking a high dose of Furosemide. To determine the progress of the therapy, the nurse performs which of the following important action? A. Monitor urinary pH B. Check the temperature periodically C. Weight the patient daily D. Obtain a serial serum Sodium level

Regulation of Body fluid balance

1. The Kidney y Regulates primarily fluid output by urine formation y Releases RENIN y Regulates sodium and water balance

Regulation of Body fluid balance

2. Endocrine regulation y Regulates primarily fluid intake by thirst mechanism y ADH increase water reabsorption on collecting duct y Aldosterone increases Sodium retention in the distal nephron y ANF Promotes Sodium excretion and inhibits thirst mechanism

Regulation of Body fluid balance

3. Gastro-intestinal regulation y The GIT digests food and absorbs water y Only about 200 ml of water is excreted in the fecal material per day

The ELECTROLYTES
Electrolytes are charged ions capable of conducting electricity and are solutes in all compartment. y ANIONS are Negatively charged ions: Bicarbonate, chloride, PO4y CATIONS are positively charged ions: Sodium, Potassium, magnesium, calcium.
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Helpful mnemonics
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PI-SO Potassium is inside Phosphate is inside Sodium is outside Chloride is outside

Regulation of Electrolyte Balance

1. Renal regulation y Occurs by the process of glomerular filtration, tubular reabsorption and tubular secretion. y Urine formation If there is little water in the body, it is conserved. If there is water excess, it will be eliminated.

Regulation of Electrolyte Balance

2. Endocrinal regulation y Hormones play a role in electrolyte regulation y Aldosterone promotes Sodium retention and Potassium excretion y ANF promotes Sodium excretion y Parathormone promotes Calcium retention and Phosphate excretion y Calcitonin promotes Calcium excretion and Phosphate excretion

THE CATIONS
SODIUM y POTASSIUM y CALCIUM y MAGNESIUM
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SODIUM
The MOST ABUNDANT cation in the ECF Normal range is 135-145 mEq/L y Major contributor of plasma osmolarity FUNCTIONS y 1. participates in the Na-K pump y 2. assists in maintaining blood volume y 3. assists in nerve transmission and muscle contraction y Aldosterone increases sodium retention y ANF increases sodium excretion
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POTASSIUM
MOST ABUNDANT cation in the ICF Normal range is 3.5-5.0 mEq/L Major electrolyte maintaining ICVF balance FUNCTIONS y 1. maintains ICF Osmolality y 2. nerve conduction and muscle contraction y 3. metabolism of carbohydrates, fats and proteins y Aldosterone promotes renal excretion of K+ y Acidosis promotes exchange of K+ for H+ in the cell
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CALCIUM
Majority of calcium is in the bones and teeth y Normal serum range 8.5-10 mg/dL FUNCTIONS y 1. formation and mineralization of bones/teeth y 2. muscular contraction and relaxation y 3. cardiac function y 4. blood clotting y 5. enzyme activation
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CALCIUM
Regulation: y GIT absorbs Ca+ in the intestine with the help of Vit. D y Kidney Ca+ is filtered in the glomerulus and reabsorbed in the tubules y PTH increases Ca+ by bone resorption, Ca+ retention and activation of Vitamin D y Calcitonin released when Ca+ is high, it decreases Ca+ by excretion in the kidney

MAGNESIUM
Second to K+ in the ICF Normal range is 1.3-2.1 mEq/L FUNCTIONS y 1. intracellular production and utilization of ATP y 2. protein and DNA synthesis y 3. neuromuscular irritability
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THE ANIONS
CHLORIDE y PHOSPHATES y BICARBONATES
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CHLORIDE
The MAJOR Anion in the ECF Normal range is 95-108 mEq/L FUNCTIONS y 1. major component of gastric juice aside from H+ y 2. together with Na+, regulates plasma osmolality y 3. participates in the chloride shift y 4. acts as chemical buffer
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PHOSPHATES
The MAJOR Anion in the ICF y Normal range is 2.5-4.5 mg/L FUNCTIONS y 1. component of bones y 2. needed to generate ATP y 3. components of DNA and RNA y PTH decreases PO4 in blood by renal excretion y Calcitonin increases renal excretion of PO4
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BICARBONATES
Present both in ICF and ECF y Normal range- 22-26 mEq/L FUNCTION y 1. regulates acid-base balance y 2. component of the bicarbonate-carbonic acid buffer system
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IMBALANCE: EXCESS
1. HYPERNATREMIA y More than 145 mEq/L y Fluid moves out of cell crenation y Etiology: sodium intake, IVF, water loss in excess of water, diarrhea y S/SX: dry, sticky tongue, thirst

IMBALANCE: EXCESS
2. HYPERKALEMIA y K+ more than 5.0 mEq/L y Etiology: IVF with K+, acidosis, Hyper-alimentation and K+ replacement y ECG: peaked T waves and wide QRS

IMBALANCE: EXCESS
3. HYPERCALCEMIA y Serum calcium more than 10.5 mg/dL y Etiology: Overuse of calcium supplements, excessive Vit. D, malignancy, prolonged immobilization, thiazide diuretic y ECG: Shortened QT interval

IMBALANCE: EXCESS
4. HYPERMAGNESEMIA y Serum magnesium more than 2.1 mEq/L y Etiology: use of Mg antacids, Renal failure, Mg medications y S/SX: depressed tendon reflexes, oliguria, RR

IMBALANCE: EXCESS
5. HYPERCHLOREMIA y Serum chloride more than 108 mEq/L y Etiology: sodium chloride excess

IMBALANCE: EXCESS
HYPERPHOSPHATEMIA y Serum PO4 more than 4.5 mg/dL y Etiology: Tissue trauma, chemotherapy. PO4 containing medications, osteoporosis
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IMBALANCE : DEFICIENCY
1. HYPONATREMIA y Na level is less than 135 mEq/L y Water is drawn into the cell cell swelling y Etiology: prolonged diuretic therapy, excessive burns, excessive sweating, SIADH, plain water consumption y S/SX: nausea, vomiting, seizures

IMBALANCE : DEFICIENCY
2. HYPOKALEMIA y K+ level less than 3.5 mEq/L y Etiology: use of diuretic, vomiting and diarrhea y ECG: flattened , depressed T waves, presence of U waves

IMBALANCE : DEFICIENCY
3. HYPOCALCEMIA y Calcium level of less than 8.5 mg/dL y Etiology: removal of parathyroid gland during thyroid surgery, vit. D deficiency, Furosemide, infusion of citrated blood y s/sx: Tetany, (+) Chovstek s (+) Trousseaus s y ECG: prolonged QT interval

ACIDACID-BASE CONCEPTS
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Acid- substance that can donate or release hydrogen ions Carbonic acid, Hydrochloric acid

ACIDACID-BASE CONCEPTS
Base- substance that can accept hydrogen ions Bicarbonate

ACIDACID-BASE CONCEPTS
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Buffer- substance that can accept or donate hydrogen Hemoglobin buffer Bicarbonate : carbonic acid buffer Phosphate buffer

ACIDACID-BASE CONCEPTS
Acid- substance that can donate or release hydrogen ions Carbonic acid, Hydrochloric acid y Base- substance that can accept hydrogen ions Bicarbonate y Buffer- substance that can accept or donate hydrogen Hemoglobin buffer Bicarbonate : carbonic acid buffer Phosphate buffer
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Helpful Hints
Carbon dioxide is considered to be ACID because of its relationship with carbonic acid y pH measures the degree of acidity and alkalinity. It is inversely related to Hydrogen. Normal ph 7.35-7.45 y Decreased pH- ACIDIC-increased Hydrogen pH below 7.35 y Increased pH- ALKALOSIS-decreased hydrogen pH above 7.45
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Remember
a high hydrogen acidic pH is low y a low hydrogen alkalosis pH is high
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a high CO2 may mean acidic y a low CO2 may mean alkalosis
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Dynamics of Acid and bases

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Acids and bases are constantly produced in the body. They must be constantly regulated. CO2 and HCO3 are crucial in the balance. A ratio of 20:1 is maintained (HCO3:H2CO3) Respiratory and renal system are active in regulation.

Ways to balance the acids and bases

Excretion y Acid can be excreted, and Hydrogen can be excreted in ACIDOTIC condition. y Bicarbonate can be excreted in ALKALOTIC condition.

Ways to balance the acids and bases

Production y Bicarbonate can be produced in ACIDOTIC condition. y Hydrogen can be produced in ALKALOTIC condition.

Ways to balance the acids and bases

The respiratory system compensates for metabolic problems y CO2 (acid) can be exhaled from the body to normalize the pH in ACIDOSIS. y CO2 (acid) can be retained in the body to normalize the pH in ALKALOSIS.

Ways to balance the acids and bases

The kidney can compensate for problems in the respiratory system y The Kidney reabsorbs and generates Bicarbonate (alkaline) in ACIDOSIS. y The Kidney can excrete H+ excess (Acidosis) to normalize the pH in ACIDOSIS.

Ways to balance the acids and bases

The kidney can excrete bicarbonate (alkali) in conditions of ALKALOSIS. y The kidney can retain H+ (acid) in conditions of ALKALOSIS.
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Ways to balance the acids and bases

Chemical buffers can also participate in the balance of acid-base y 1. Carbonic acid- bicarbonate buffer y 2. Phosphate buffer y 3. protein buffer- ICF and hemoglobin The action is immediate but very limited