0133427269 Module06 FluidsElectrolytes LectureOutline

Module 6 Fluids and Electrolytes The Concept of Fluids and Electrolytes Composition of body fluids Fluids (blood, serum, saline, albumin, urine, bile, hormones, cerebrospinal Electrolytes (charged ions capable of conducting electricity Homeostasis( multiple physiological processes Fluid and electrolyte balance required for good health Normal fluids and electrolytes Proportion of fluid composition 60 of healthy adults weight is water Waternormal cellular function Medium for metabolic reactions Transporter of nutrients Lubricant Insulator, shock absorber Maintain body temperature Factors affecting total body fluidage, gender, body fat Distribution and composition of body fluids See Figure 61 ELECTROLYTE COMPOSITION, p. 336 See Table 61 ELECTROLYTE CONCENTRATIONS IN BODY FLUID COMPARTMENTS, p. 337 Fluid can be intracellular or extracellularboth have oxygen, dissolved nutrients, excretory products, ions Cations are ions with positive charge Anions are ions with negative charge Milliequivalentcapacity of cations to combine with anions to form molecules Intracellular fluid (ICF)found within cells2/3 of total fluid in adults Vital to cell function Contains solutesoxygen, glucose, electrolytes Primary cations in ICF potassium, magnesium Primary anions in ICF sulfate, phosphate Extracellular fluid (ECF)outside of cells1/3 of total fluid in adults Subdivided into compartments Intravascularplasma20 of ECF Interstitialsurrounds cells, transports wastes, nutrients75 of ECF Transcellularcerebrospinal, pericardial, pancreatic, pleural, intraocular, biliary, peritoneal, synovial Principal electrolytes are sodium, chloride, bicarbonate ECF is transport system, carries nutrients to and waste products from cells Interstitial fluid transports wastes via lymph system, capillaries Maintaining balance of fluid volumes, electrolyte compositions in fluid compartments essential to health Excessive loss of electrolytes from vomiting, diarrhea can cause imbalance Movement of body fluids ( occurs across cell membranes, capillary membranes Osmosismovement of water across cell membranes ( from less concentration to greater concentration See Figure 62 OSMOSIS, p. 337 Solutes are crystalloids, colloids Osmolalityconcentration of solutes ECF osmolality determined mostly by sodium, but also glucose, urea ICF osmolality determined by potassium, glucose, urea Solventcomponent of a solution that can dissolve a solute In human body, the solvent is water Tonicityosmolality of solution Active transport (substances move across membranes using metabolic energy (See Figure 65 ACTIVE TRANSPORT, p. 339) Regulating body fluids Fluid intake At moderate activity, temperature ( adult needs 2,500 mL/day Food contributes 750 mL/day Thirstregulator of fluid intakelocated in hypothalamus Thirst triggered by osmotic pressure, vascular volume, angiotensin See Figure 66 FACTORS STIMULATING WATER INTAKE, p. 339 Fluid output Obligatory losses ( 500 mL needed to excrete wastes Maintaining homeostasis Kidneysprimary regulator Antidiuretic hormone ( regulates water excretion from kidneys See Figure 67 ANTIDIURETIC HORMONE, p. 341 Reninangiotensinaldosterone system Renin causes conversion of angiotensin to angiotensin l Angiotensin l converts to angiotensin II Aldosterone promotes sodium retention Percentage of body water greater Larger extracellular fluid volume Respiratory and metabolic rates higher See Figure 68 THE MAJOR BODY FLUID COMPARTMENTS, p. 343 Older adults Thirst response blunted Nephrons less able to conserve water Chronic diseases affect fluid and electrolyte balance Gender and body size Gastroenterieis Burns Kidney disorders Oral fluid restriction for surger Anorexia and bulimia Dehydration Exercising in hot weather See ALTERATIONS AND THERAPIES Fluids and Electrolytes, p. 347 Compensation Body continuously attempts to compensate for imbalances by shifting fluid and electrolytes from one component to another It is rare for only one type of imbalance to occur Prevalence Electrolyte disorders are found on a consistent basis in certain populations Diabetes, hypertension ( hyponatremia, hypomagnesemia, hypokalemia Use of diuretics, benzodiazepines ( electrolyte imbalances See Case Study Part 1 ( Hope Balan is a 22-year-old female who presents at the university clinic Prevention Lifestyle factors diet, exercise, stress -- affect fluid and electrolyte balance Modifiable risk factors Stress can increase cellular metabolism, blood glucose concentration, catecholamine levels, and production of ADH Medications may contribute to imbalance ( diuretics, antipsychotic agents Heat-related illness 6000 individuals treated annually in EDs for heat-related illness Symptoms include fatigue, weakness, headache, gastrointestinal symptoms Prevention includes Limit outdoor activity during hottest part of the day Take frequent breaks for rest and water Drink water before feeling thirsty Wear lightweight clothes Work or exercise with others Assessment Nursing assessment ( see FLUID AND ELECTROLYTE ASSESSMENT, p. 349 Current fluid, electrolyte status Skin Mucous membranes Eyes Cardiovascular system Respiratory system Appearance (e.g., edema) Clinical measurements Daily weights Vital signs Fluid intake and output Oral fluids, ice chips Foods that are liquid at room temperature Tube feedings Parenteral fluids IV medications Catheter or tube irrigants Urinary output Vomitus, liquid feces Tube drainage Wound, fistula drainage Diagnostic tests Urine sodium and chloride excretionindicators of renal perfusion Case Study Part 2 ( It has been 2 weeks since Ms. Balan was seen at the university clinic Interventions and therapies Independent Monitor intake and output Weigh client daily Engage client in plan of care, especially meal planning Provide client edutation Collaborative Initiating intravenous therapy Intravenous management Monitor fluid balance Medication administration Blood transfusions Pharmacologic therapy See MEDICATIONS FLUIDS AND ELECTROLYTES, p. 353 Electrolyte correction to restore balance Hyperkalemiaelevated potassium Hypokalemiadeficit potassium Hypernatremiaexcess sodium Hyponatremiadeficit sodium Review The Concept of Fluids and Electrolytes Relate Link the Concepts Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Part 3 ( Ms. Balan is admitted to the hospital Exemplar 6.1 Fluid and Electrolyte Imbalance Exemplar overview Factors affecting ability to maintain balance Illness Trauma, surgery Medications Isotonic imbalances vs. osmolar imbalances Isotonic imbalances ( occur when water and electrolytes are lost or gained in equal proportions so that osmolality of body fluids remains constant Osmolar imbalances ( involve the loss or gain of only water so that the osmolality of the serum is altered Four categories of fluid imbalance may occur An isotonic loss of water and electrolytes An isotonic gain of water and electrolytes A hyperosmolar loss of water only A hypo-osmolar gain or water only Fluid volume deficit and dehydration Fluid volume deficit (FVD)decrease in intravascular, interstitial, and/or intracellular fluid Dehydrationloss of fluid alone Pathophysiology and etiology FVD can develop slowly or rapidly Pregnancy Clinical manifestations See CLINICAL MANIFESTATION AND THERAPIES Fluid Volume Deficit and Dehydration, p. 53 Symptoms relate to severity Loss of skin turgor Weight loss Hypotension Thirst Children Irritability Lethargy, sleepiness Risk for Injury related to postural hypotension Confusion Activity Intolerance Planning Client will achieve fluid and electrolyte balance Client will drink 1,500 mL fluid per day Client will relate the need to replace fluids lost during exercise with sports drink Client will return to normal hydration status Planning for pediatric clients Parents will relate strategies to prevent dehydration Parents will relate home management of fluid replacement Parents will describe when to seek medical attention Implementation Accurate intake and output Weigh daily Vital signs Administer fluids as ordered Administer IV fluids via electronic pump Monitor laboratory values Monitor level of consciousness (LOC) Reposition every 2 hours Institute fall precautions Teach prevention of orthostatic hypotension, maintaining fluid intake, prevention of fluid deficit Evaluation Client has water and electrolytes that are balanced Urinary output is within normal limits Increased interstitial fluid osmotic pressure Blocked lymphatic drainage Etiology See Box 62 CLINICAL CONDITIONS THAT CAUSE EDEMA, p. 364 Risk factors Decreased cardiac output Increased fluid volume Kidney dysfunctions Clinical manifestations See CLINICAL MANIFESTATIONS AND THERAPIES Fluid Volume Excess, p. 366 Weight gain 5 body weight Circulatory overload Full bounding pulse Distended neck, peripheral veins Increased central venous pressure Cough, dyspnea, orthopnea Moist crackles Polyuria Ascites Peripheral edema or anasarca if severe Decreased hematocrit and BUN Altered mental status and anxiety Heart failure Collaboration Diagnostic tests Serum electrolytes, osmolality Serum hematocrit, hemoglobin Renal, liver function studies BUN, creatinine Pharmacologic therapy Loop diuretics Thiazide-type diuretics Potassium-sparing diuretics Fluid management Restrict fluids Ineffective Health Maintenance Planning Client regains fluid balance Client has clear lungs, eupneic breathing Client maintains intact skin Client avoids infection Client has increased activity tolerance Client makes appropriate food choices Implementation Weigh daily Maintain intake, output records Administer oral fluids carefully Oral hygiene every 2 hours Teach sodium restriction diet Administer medications Report imbalances Teach client medication safety Reposition every 2 hours Reduce skin shearing Provide alternative mattress, foot cradle, heel protectors Position in Fowler position Monitor laboratory results Elevate area with edema Evaluation Changes in weight, respirations, edema Client understanding of diet Electrolyte imbalance Overview All body fluids contain electrolytes Electrolytes are normally gained and lost in relatively equal amounts Signs and symptoms of electrolyte imbalance are subtle If imbalance is minimal ( s/sx are subtle If imbalance is moderate to severe ( multisystem effects occur and can lead to death if not reversed Sodium Most abundant electrolyte in extracellular fluid Normal serum values ( 135 145 mEq/L Balance is affected by food intake Educate clients to maintain appropriate sodium intake ( see Box 6-4 FOODS HIGH IN SODIUM, p. 371 Hypernatremia Serum sodium levels greater than 145 mEq/L Critical values greater than 160 mEq/L Hyponatremia Serum sodium levels fall below 125 mEq/L Critical values below 115 mEq/L (or 124 mEq/L according to new studies) Potassium Primarily intracellular cation Hyperkalemia Serum potassium greater than 5.3 mEq/L Critical value greater than 7.0 mEq/L Hypokalemia Serum potassium less than 3.5 mEq/L Critical value below 2.5 mEq/L Chloride Most prevalent in extracellular fluid Hyperchloremia Serum chloride greater than 105 mEq/L Hypochloremia Serum chloride less than 95 mEq/L Calcium Has several functions in the body Hypercalcemia Serum calcium greater than 11 mg/dL Hypocalcemia Serum calcium less than9 mg/dL Nursing Process Assessment Review of lab data for specific electrolyte excess or deficit Subjective data such as abnormal thirst, frequent urination Objective data such as vital signs, mental status exam Diagnosis Fluid Volume Deficit Risk for Electrolyte Imbalance Decreased Cardiac Output Planning Client will maintain electrolyte levels within normal limits Client will be free of symptoms Client will maintain regular heart rhythm and output Implementation Monitor electrolyte levels daily or more frequently if needed Monitor intake and output Observe for signs of dehydration Observe for signs and symptoms of fluid and electrolyte excess or deficiency Evaluation Clients electrolyte status returns to appropriate levels Client maintains appropriate weight Client maintains equality of intake and output Review Fluid and Electrolyte Imbalance Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 6.2 Acute Renal Failure Overview Kidneys control fluid, electrolyte balance, acidbase balance, blood pressure Body functions with only one Renal failurekidneys unable to remove accumulated metabolites from blood ( altered fluid, electrolyte, acidbase balance Characterized by azotemiaincreased levels of nitrogenous wastes Acute renal failure (ARF) commonly caused by ischemia and nephrotoxins Acute kidney injury (AKI) ( new term RIFLE ( new classification system Risk of injury Injury Failure Loss of function End-stage renal failure Pathophysiology and etiology See Table 6-9 CAUSES OF ACUTE RENAL FAILURE, p. 375 Prerenal ARFmost common Results from conditions that affect renal blood flow, perfusion Glomerular filtration rate (GFR)rate at which fluid is filtered through kidneys GFR falls when cardiac output drops, renal blood flow 20 Postrenal ARFobstructive causes of ARF Intrinsic/intrarenal ARFcaused by kidney disease and acute tubular necrosis Acute tubular necrosis (ATN)primary cause is prolonged ischemia Risk factors for ischemic ATN Hypovolemiadecreased circulating blood volume Major surgery Sepsis Trauma Burns Ischemia lasting more than 2 hours ( severe, irreversible damage to kidney tubules Nephrotoxins associated with ATN Aminoglycoside antibiotics Radiologic contrast media Nephrotoxins destroy tubular cells Rhabdomyolysis (muscle cell breakdown) accounts for 715 of all cases of ARF Hemolysis (RBC destruction) releases hemoglobin, same effect as rhabdomyolysis Etiology All hospitalized clientsapproximately 5 develop ARF Older adultsARF occurs in 20 Prerenal causes common in older adults ( poor kidney perfusion Children in ICUARF seen in 23 Risk factors Major trauma or surgery Infection Hemorrhage Severe heart failure Severe liver disease Lower urinary tract obstruction Ageolder adults at greater risk Child with renal insufficiency Prevention Contrast-induced nephropathy is third most common cause of hospital-acquired renal failure Identifying clients at risk and knowledge of adverse effects allows nurses to assist in prevention Lifespan considerations Renal failure presents differently in younger and older adults Younger adults ( marked oliguria is dramatic symptom, Older adults ( may not display oliguria Postural hypotension is common in older adults Pediatric manifestations Healthy child suddenly becomes ill with nonspecific symptoms ( significant illness, injury May include nausea, vomiting, lethargy, edema, gross hematuria, oliguria, hypertension Child appears pale, lethargic See Table 611 ELECTROLYTE IMBALANCES IN ACUTE AND CHRONIC KIDNEY DISEASE IN CHILDREN, p. 379 Collaboration Prevention is goal Maintain vascular volume, cardiac output, blood pressure Avoid nephrotoxic drugs If ARF develops, key goal ( maintain fluid and electrolyte balance Identify, correct underlying cause Prevent additional damage Restore urine output, kidney function Compensate for renal impairment Interdisciplinary approach critical Diagnostic tests Urinalysis Specific gravity Proteinuria Presence of RBCs Cell casts Loop diuretics such as furosemide Combination of fluids, diuretics may wash out nephrons, reducing toxins Resulting urine output may prevent oliguria, reduce azotemia and imbalances Osmotic diuretics, such as mannitol (Osmitrol, Isotel) See MEDICATIONS Acute Renal Failure, pp. 381-382 Discontinue nephrotoxic drugs and drugs that interfere with renal perfusion Blood volume expanders IV fluids Gastrointestinal drugs (prevent GI bleeding) Antacids (Amphojel, Nephrox, ALternaGEL) Blood continuously circulated for 12 hours or more See Table 68 CONTINUOUS RENAL REPLACEMENT THERAPIES, p. 30 See Figure 615 CONTINUOUS ARTERIOVENOUS HEMOFILTRATION, p. 30 Vascular access for hemodialysis and continuous renal replacement therapy Complications, mortality higher with catheter access than with AV fistulas, grafts Peritoneal dialysis Peritoneal membrane serves as dialyzing surface Less risk for unstable client ( fluid and solutes removed more gradually Increases risk for developing peritonitis See Figure 620, PERITONEAL DIALYSIS, p. 385 Nursing process Assessment History Diagnosis Excess Fluid Volume related to renal dysfunction and sodium retention Imbalanced Nutrition Less Than Body Requirements related to anorexia, nausea, vomiting, catabolic state Ineffective Renal Tissue Perfusion related to hypovolemia, sepsis, or drug toxicity Risk for Altered Skin Integrity related to uremia and reduced tissue perfusion Risk for Altered Cardiac Perfusion secondary to hyperkalemia Risk for Infection related to invasive procedures Compromised Family Coping related to sudden hospitalization Planning Clients weight will return to baseline Clients urine output is greater than 30 mL/hr Clients hemoglobin and hematocrit values are within normal limits Clints electrolytes are within normal limits Clients pulse rate, volume, and rhythm return to baseline Implementation Care varies based on cause of ARF, specific individual needs Maintain hourly intake and output Weigh client daily Assess vital signs every 4 hours Involve family, plan frequent small meals, administer medications Administer parenteral nutrition, assess anxiety level, knowledge level Teach client and family about care, diet, fluid restrictions, signs and symptoms of relapse, weight monitoring, drugs to avoid Provide client teaching Assess knowledge and understanding Teach client and family about diagnostic tests and therapeutic procedures Discuss dietary and fluid restrictions Teach signs and symptoms of complications Teach client how to monitor weight, blood pressure, pulse Instruct client to avoid nephrotoxic drugs and chemicals Evaluation Clients fluid status is balanced Clients nutritional needs are met Client acquires no secondary infections Review Acute Renal Failure Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 6.3 Chronic Kidney Disease Pathophysiology and etiology Pathophysiology of CRF Gradual loss of nephron units Progresses over months, years See Table 613 PATHOPHYSIOLOGY OF CHRONIC RENAL DISEASE, p. 391 Etiology Common and costly Annual cost to Medicare for clients with ESRD ( 23 billion Incidence increasing Risk factors Those with diffuse bilateral kidney disease Diabetes mellitusleading cause of ESRD Hypertension Older adults Prevention Diabetes is leading cause of ESRD in all population groups Hypertension is second leading cause In many clients, these disorders co-exist Clinical manifestations See MULTISYSTEM EFFECTS OF UREMIA, p. 394 See CLINICAL MANIFESTATIONS AND THERAPIES CHRONIC KIDNEY DISEASE, p. 396 Continuous ambulatory peritoneal dialysis (CAPD) ( empty every 46 hours Continuous cyclic peritoneal dialysis (CCPD) ( delivery device at night Disadvantages ( less effective removal of wastes, peritonitis Kidney transplant Go to nursing.pearsonhighered.com to see Chart 4 NURSING CARE OF THE CLIENT HAVING A KIDNEY TRANSPLANT Treatment of choice for ESRD Improves survival, quality of life Kidneys obtained from donations Cadaver ( death donor Living donors Diagnosis Ineffective Tissue Perfusion Renal Imbalanced Nutrition Less Than Body Requirements Excess Fluid Volume Impaired Skin Integrity Risk for Infection Disturbed Body Image Planning Client verbalizes daily fluid allotment Clients weight decreases, approaching baseline Client breathes comfortably, clear breath sounds Client remains free of infection Client shares feelings regarding change in body image Implementation Promote effective tissue perfusion Monitor intake and output, weight, vital signs Restrict fluids Monitor respiratory status Monitor laboratory studies Report electrolyte imbalances Administer medications Allow for rest periods between activities Promote balanced nutrition Monitor food intake Weigh client daily Administer antiemetics Assist with oral care Serve small meals Arrange for dietary consultation Administer parenteral nutrition Reduce risk for infection Use good hand washing techniques, standard precautions Monitor temperature and vital signs Monitor WBC count and differential Culture urine, peritoneal dialysis fluid Monitor clarity of dialysate return Provide good respiratory hygiene Restrict visits from those who are ill Promote healthy body image Involve client in care Encourage expression of feelings Include client in decision making Support positive gains Help client to develop and achieve realistic goals Provide positive reinforcement and feedback Reinforce effective coping strategies Facilitate contact with support group, community members Refer for mental health counseling Care in the community Provide client and family teaching for home care See CLIENT TEACHING ASSESSING FOR HOME CARE FOR CLIENTS WITH CHRONIC RENAL DISEASE, p. 401 Evaluation Client remains free from infection Client maintains appropriate weight Client demonstrates ability to participate in self-care Client is able to participate in desired activities Review Chronic Kidney Disease Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Reflect Case Study 2015 by Education, Inc. 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