Está en la página 1de 65

Fluids and Electrolytes

Review

Philippine Integrated Nurse Licensure Examination


Sample Question

 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. Flat neck and hand veins


B. Weight loss
C. Increased central venous pressure
D. Hypotension
Key to Success!

 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
 Electrolytes
 Acids and Bases
Important Concepts

 Remember the ABC


 Safety of the patient
 Maslow’s Hierarchy of needs
 Utilize the NURSING PROCESS
◦ A-D-P-I-E
Summary of
Subtopics
 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
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
Intracellular 15%
fluid
40%

Intravascula
r
5%
Transcellular
1-2%
The Intracellular Fluid

 Found inside the cell surrounded by a membrane.

 This
is compartment with the highest percentage
of water in adults.
The Extracellular Fluid

 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
 Fluid intake- water from foodstuffs
 IVF
 Medications
 Blood products
2. Endogenous sources
 By products of metabolism
 secretions
Fluid Losses
Routes of Fluid output
 Urine
 Fecal losses Sensible losses
 Sweat
 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
 Diffusion
 Osmosis
 Filtration
 Active transport
The Concept of TONICITY

 This is the concentration of solutes in a solution.


 A solution with high solute concentration is
considered as HYPERTONIC.
 A solution with low solute concentration is
considered as HYPOTONIC.
 A solution having the same tonicity as that of
body fluid or plasma is considered ISOTONIC.
Helpful Hints

 In a HYPERTONIC solution, fluid will go out from


the cell, the cell will shrink.
 In a HYPOTONIC solution, fluid will enter the cell,
the cell will swell.
 In an ISOTONIC solution, there will be no
movement of fluid.
DIFFUSION

 The movement of SOLUTES or particles in a


solution from a higher concentration to a lower
concentration.
 If a sugar is placed in plain water, the glucose
molecules will dissolve and diffuse distribute in
the solution.
OSMOSIS

 The force that draws water or solvent from a less


concentrated solution into a more concentrated
solution through a semi-permeable membrane.
 The pressure that draws water inside the vessel
which is more concentrated is called Osmotic
pressure.
 A special type of osmotic pressure is exerted by
the proteins in the plasma. It is called ONCOTIC
PRESSSURE.
Sample question

 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.
 An example of this process is urine formation.
 Increased hydrostatic pressure is one mechanism
producing edema.
Active transport

 Thisis the movement of solutes across a


membrane from a lower concentration to a
higher concentration with utilization of energy.
 Example is the Sodium-Potassium pump- a
primarily active transport process.
Sample question
 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
 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
 Regulates primarily fluid output by urine
formation
 Releases RENIN
 Regulates sodium and water balance
Regulation of Body fluid
balance

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

3. Gastro-intestinal regulation
 The GIT digests food and absorbs water
 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.
 ANIONS are Negatively charged ions:
Bicarbonate, chloride, PO4-
 CATIONS are positively charged ions: Sodium,
Potassium, magnesium, calcium.
Helpful mnemonics

 PI-SO
 Potassium is inside
 Phosphate is inside
 Sodium is outside
 Chloride is outside
Regulation of Electrolyte
Balance

1. Renal regulation
 Occurs by the process of glomerular filtration,
tubular reabsorption and tubular secretion.
 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
 Hormones play a role in electrolyte regulation
 Aldosterone promotes Sodium retention and
Potassium excretion
 ANF promotes Sodium excretion
 Parathormone promotes Calcium retention
and Phosphate excretion
 Calcitonin promotes Calcium excretion and
Phosphate excretion
THE CATIONS
 SODIUM
 POTASSIUM
 CALCIUM
 MAGNESIUM
SODIUM
 The MOST ABUNDANT cation in the ECF
 Normal range is 135-145 mEq/L
 Major contributor of plasma osmolarity
FUNCTIONS
 1. participates in the Na-K pump
 2. assists in maintaining blood volume
 3. assists in nerve transmission and muscle
contraction
 Aldosterone increases sodium retention
 ANF increases sodium excretion
POTASSIUM
 MOST ABUNDANT cation in the ICF
 Normal range is 3.5-5.0 mEq/L
 Major electrolyte maintaining ICVF balance
FUNCTIONS
 1. maintains ICF Osmolality
 2. nerve conduction and muscle contraction
 3. metabolism of carbohydrates, fats and protein
 Aldosterone promotes renal excretion of K+
 Acidosis promotes exchange of K+ for H+
in the cell
CALCIUM
 Majority of calcium is in the bones and teeth
 Normal serum range 8.5-10 mg/dL
FUNCTIONS
 1. formation and mineralization of bones/teeth
 2. muscular contraction and relaxation
 3. cardiac function
 4. blood clotting
 5. enzyme activation
CALCIUM
Regulation:
 GIT absorbs Ca+ in the intestine with the help
of Vit. D
 Kidney Ca+ is filtered in the glomerulus and
reabsorbed
in the tubules
 PTH increases Ca+ by bone resorption, Ca+
retention
and activation of Vitamin D
 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
 1. intracellular production and utilization of ATP
 2. protein and DNA synthesis
 3. neuromuscular irritability
THE ANIONS

 CHLORIDE
 PHOSPHATES
 BICARBONATES
CHLORIDE
 The MAJOR Anion in the ECF
 Normal range is 95-108 mEq/L
FUNCTIONS
 1. major component of gastric juice aside from
H+
 2. together with Na+, regulates plasma
osmolality
 3. participates in the chloride shift
 4. acts as chemical buffer
PHOSPHATES
 The MAJOR Anion in the ICF
 Normal range is 2.5-4.5 mg/L
FUNCTIONS
 1. component of bones
 2. needed to generate ATP
 3. components of DNA and RNA
 PTH decreases PO4 in blood by renal excretion
 Calcitonin increases renal excretion of PO4
BICARBONATES
 Present both in ICF and ECF
 Normal range- 22-26 mEq/L
FUNCTION
 1. regulates acid-base balance
 2. component of the bicarbonate-carbonic acid
buffer system
IMBALANCE: EXCESS

1. HYPERNATREMIA
 More than 145 mEq/L
 Fluid moves out of cell crenation
 Etiology:↑ sodium intake, IVF, water loss in excess
of water, diarrhea
 S/SX: dry, sticky tongue, thirst
IMBALANCE: EXCESS

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

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

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

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

 HYPERPHOSPHATEMIA
 Serum PO4 more than 4.5 mg/dL
 Etiology: Tissue trauma, chemotherapy. PO4
containing medications, osteoporosis
IMBALANCE : DEFICIENCY

1. HYPONATREMIA
 Na level is less than 135 mEq/L
 Water is drawn into the cell cell swelling
 Etiology: prolonged diuretic therapy, excessive
burns, excessive sweating, SIADH, plain water
consumption
 S/SX: nausea, vomiting, seizures
IMBALANCE : DEFICIENCY

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

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

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

 Base- substance that can accept hydrogen ions


◦ Bicarbonate
ACID-BASE CONCEPTS

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

 Acid- substance that can donate or release hydrogen


ions
◦ Carbonic acid, Hydrochloric acid
 Base- substance that can accept hydrogen ions
◦ Bicarbonate
 Buffer- substance that can accept or donate
hydrogen
◦ Hemoglobin buffer
◦ Bicarbonate : carbonic acid buffer
◦ Phosphate buffer
Helpful Hints
 Carbon dioxide is considered to be ACID
because of its relationship with carbonic acid
 pH measures the degree of acidity and
alkalinity. It is inversely related to Hydrogen.
Normal ph 7.35-7.45
 Decreased pH- ACIDIC-increased Hydrogen—
pH below 7.35
 Increased pH- ALKALOSIS-decreased hydrogen
—pH above 7.45
Remember

a high hydrogen acidic pH is low


 a low hydrogen alkalosis pH is high

a high CO2may mean acidic


 a low CO2 may mean alkalosis
Dynamics of Acid and bases

 Acids and bases are constantly produced in the bo


 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 regulati
Ways to balance the acids and
bases

Excretion
 Acid can be excreted, and Hydrogen can be
excreted in ACIDOTIC condition.
 Bicarbonate can be excreted in ALKALOTIC
condition.
Ways to balance the acids and
bases

Production
 Bicarbonate can be produced in ACIDOTIC
condition.
 Hydrogen can be produced in ALKALOTIC
condition.
Ways to balance the acids and
bases

The respiratory system compensates for metabolic


problems
 CO2 (acid) can be exhaled from the body
to normalize the pH in ACIDOSIS.
 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
 The Kidney reabsorbs and generates Bicarbonate
(alkaline) in ACIDOSIS.
 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.
 The kidney can retain H+ (acid) in conditions
of ALKALOSIS.
Ways to balance the acids and
bases

Chemical buffers can also participate in the


balance of acid-base
 1. Carbonic acid- bicarbonate buffer
 2. Phosphate buffer
 3. protein buffer- ICF and hemoglobin

The action is immediate but very limited