CONTENT 26

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FLUID AND ELECTROLYTE IMBALANCE
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WATER

• TRANSPORT NUTRIENTS TO CELLS WASTES FROM
  CELLS.
• FACILITATES CELLULAR METABOLISM CELLULAR
  CHEMICAL FUNCTIONING
• SOLVENT FOR ELECTROLYTES NONELECTROLYTE
• MAINTAIN NORMAL BODY TEMP
• DIGESTION ELIMINATION

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FLUID COMPARTMENTS

• INTRACELLULAR ICF - 40 ADULT BODY WT. OR 70
  TOTAL BODY WATER.
• EXTRACELLULAR ECF - 20 ADULT BODY WT. OR 30
  TOTAL BODY WATER.

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TOTAL BODY FLUID

• 50 - 60 BODY WT OF NORMAL ADULT
• THE MORE OBESE THE PERSON THE SMALLER THE OF
  TOTAL BODY WATER THAN COMPARED WITH BODY WT.
• FEMALES LESS BODY FLUID THAN MALES

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ELECTROLYTES

• CATIONS POSITIVE CHARGE
• ANIONS NEGATIVE CHARGE
• NONELECTROLYTES UREA GLUCOSE
• SOLVENTS- LIQUIDS THAT HOLD SUBSTANCE IN SOLUTION
• SOLUTES - SUBSTANCES THAT ARE DISSOLVED IN
  SOLUTION

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MEASUREMENT OF ELECTROLYTES

• MILLIEQUIVALENT mEq - UNIT OF MEASURE TO
  DESCRIBE THE CHEMICAL ACTIVITY OF AN ELECTROLYTE
  (ex)
• ex. 20 mEq of Potassium chloride
• ONE mEq ACTIVITY OF 1 HYDROGEN
• TOTAL CATIONS TOTAL ANIONS

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ELECTROLYTES

• SODIUM Na
• POTASSIUM K
• CALCIUM Ca
• MAGNESIUM Mg
• CHLORIDE Cl -
• BICARDBONATE HCO3 -
• PHOSPHATE HPO4-

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FLUID AND ELECTROLYTE MOVEMENT

• OSMOSIS
• DIFFUSION
• ACTIVE TRANSPORT
• FILTRATION

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OSMOSIS

• Movement of water from an area of lower
  concentration to an area of higher concentration.
  ( Make the cell shrink!)
• OSMOLARITY - PULLING POWER or Osmotic
  pressurewater pulling pressure
• Another term for osmolaritytonicity. Fluids or
  solutions can be classified as isotonic,
  hypotonic, hypertonic, ( Ex. Like in IV
  solutions)

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Movement of Fluids

• Isotonicfluid has same tonicity or osmolarity as
  blood ex. 0.9 N. S.
• Hypotonicfluid that has lower osmolarity than
  blood. (water leaves the ECF enters the cells
  ICF the cells Swell) ex. D5 W -it starts
  out hypertonic but after the sugar is quickly
  dissolved it becomes more hypotonic. Another
  fluid is 0.45NS

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Movement of fluids

• Hypertonic solutions exert greater osmotic
  pressure or water pull than blood. Ex. D5 ½ NS.
  Water leaves the cell ( Cell Shrinks) and enters
  the bloodstream or ECF

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DIFFUSION

• Substances move from an area of higher
  concentration to an area of lower concentration.
  Ex. If you pour cream into coffee- the cream
  becomes eventually distributed equally, if you
  stir the coffee, the diffusion occurs at a
  quicker rate!

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ACTIVE TRANSPORT

• PROCESS THAT REQUIRES ENERGY FOR THE MOVEMENT OF
  SUBSTANCES THROUGH A CELL MEMBRANE FROM LESSER
  CONCENTRATION TO HIGHER CONCENTRATION
• PUMPING UPHILL
• AMINO ACIDS, GLUCOSE, Na, Cl, H, K, PO4, Ca, Mg2

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FILTRATION

• PASSAGE OF both water and smaller molecules
  THROUGH A SEMI-PERMEABLE MEMBRANE FROM HIGH
  PRESSURE TO ONE OF LOWER PRESSURE Some things
  are allowed through the membrane and some
  molecules are not or may be too big
• INVOLVED IN THE PROPER FUNCTIONING OF THE
  GLOMERULI OF THE KIDNEYS

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FLUID SOURCES

• INGESTED FLUIDS
• WATER IN FOOD
• WATER FROM METABOLIC OXIDATION

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FLUID LOSSES

• URINE THROUGH THE KIDNEYS
• INTESTINAL TRACT IN FECES
• SKIN PERSPIRATION
• Sensible fluid loss those you are aware of, ex.
  urination
• Insensible fluid loss may not recognize the
  loss, ex. perspiration, respiration, via stools
• Avg. adult loses about 2500ml each day ( sensible
  and insensible fluid loss)

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HOMEOSTATIC MECHANISM

• Primary control of water in body is through
  pressure sensors in the vascular system, which
  stimulate/inhibit the release of anti-diuretic
  hormone (ADH) from the Pituitary gland acting on
  the kidneys to either retain fluid or excrete
  more fluid.

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EFFECTS ON AGING

• DECREASE IN TOTAL BODY WT
• ALTERED SENSE OF TASTE
• ALTERED SENSE OF THIRST
• LOSS OF NEPHRONS DECREASED BLOOD FLOW

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ETIOLOGY, CLINICAL MANIFESTATION, MGT

• HYPOCALCEMIA-
• HYPERCALCEMIA
• HYPOMAGNESEMIA
• HYPERMAGNESEMIA
• HYPOPHOSPHATEMIA
• HYPERPHOSPHATEMIA

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CAUSES, CLINICAL MANIFESTATION

• FLUID VOLUME DEFICIT
• FLUID VOLUME EXCESS
• HYPONATREMIA
• HYPERNATREMIA
• HYPOKALEMIA
• HYPERKALEMIA

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NURSING ASSESSMENT

• THIRST
• TEARING SALIVATION
• SKIN TEMP APPEARANCE
• EDEMA
• VITAL SIGNS
• NECK HAND VEIN FILLING

• INTAKE OUTPUT
• URINE VOLUME CONCENTRATION
• SKIN TONGUE TURGOR
• DEGREE OF MOISTURE ORAL CAVITY
• BODY WT
• FACIAL APPEARANCE

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NURSING MANAGEMENT

• DIETARY MODIFICATION
• FLUID INTAKE MODIFICATION
• MEDICATION ADMINISTRATION
• IV THERAPY
• BLOOD BLOOD PRODUCTS REPLACEMENT
• TPN

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Acid Base Balance

• Hydrogen ions (H) another ion that must remain
  within balance it determines whether fluids are
  acid or base.
• Acidsubstance that releases H ion stronger the
  acid, more H ion released for ex. Hydrochloric
  acid (HCL) in stomach.
• Basesubstance that binds hydrogen ions (H). A
  common base in the body is bicarbonate (HC03).
  Alkali is another word for base
• Both acids/bases formed in body as part of normal
  metabolic processes
• The ECF maintains delicate balance between
  acids/bases and is determined by the PH. Normal
  serum PH 7.35-7.45 below 7.35acid above
  7.45alkali.

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Acid base ControlBuffers,lungs,kidneys

• Cellular blood buffers first line to control
  and maintain balance of the PH.
• These include proteins, bicarbonates,
  phosphates, Hgb. They all try to soak up the
  extra H ions if PH is too acid and release H
  ions if the PH is too alkaline.

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Control of Acid-Base

• Lungs 2nd line of defense. When serum blood is
  too acid(PH decreased) Lungs blow off additional
  carbon dioxide (C02) through rapid deep
  breathing.This reduces the amount of C02
  available to make carbonic acid in the body
• When serum blood is too alkaline (PH increased)
  the lungs try to conserve C02 through shallow
  respirations

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Control of Acid Base

• Kidneys 3rd line of defense and the slowest to
  respond taking 24-48 hrs lag
• Regulate the amount of bicarbonate (HC03) base.
• If serum PH is more acidic, kidneys reabsorb HC03
  rather than excreting it, thus neutralizing the
  acid
• If serum PH increases and is more alkaline,
  kidneys excrete additional HC03 to get rid of
  extra base. Additionally, kidneys also buffer PH
  by forming acids and ammonia which is a base

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Acid-Base Imbalances

• Most are caused by acute and chronic illnesses.
  Try to correct the underlying cause, which
  corrects the imbalance!
• Look at Lab values too acid? alkaline?
• Arterial blood gases (ABGs) from artery sample
  of blood is analyzed to detect if PH too acid or
  alkaline.
• ABGs also measure PaC02 , PaO2, HC03, and BE
• PaC02measures dissolved C02 in the blood
  regulated by the lungs with normal values PaC02(
  35-45 mmHG). A PaC02lt35 is hypocapnia a PaC02 gt
  45 is hypercapnia
• Pa02measures oxygen dissolved in plasma
• normal value Pa02 80-100mmHg Pa02lt80 indicate
  hypoxemia
• HC03- reflects renal regulation of acid base
  balance.
• Normal value HC03-22-26 mEq/L. Also may see
  BE base excess which represents amount of acid
  /base that must be added to blood sample to
  achieve PH of 7.4. Normal BE-3.0-3.0
• 2- types for each (Acidosis vs. Alkalosis)
• Acidosis Respiratory vs. Metabolic
• Alkalosis Respiratory vs. Metabolic

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Acidosis PH below 7.35

• Respiratory acidosis
• Primary problem Respiratory
• C02 is not blown off correctly,a build up of C02
  which mixes w/ water to form carbonic acid.
• Respiratory diseases COPD/emphyzema, asthma,
  hypoventilation
• C02 increases chg. LOC, confusion ( no 02 to
  brain), lungs unable to get rid of C02-instead
  they compensate -respirations become shallow w/
  muscle weakness

• Metabolic Acidosis
• Too much acid or too little HC03.
• Diabetes Mellitus and End-Stage Renal Dz.
• GI tract rich in HC03 vomiting/ NG suctioning
  may induce this problem.
• Also, hyperkalemia may be causative factor
• Lungs compensate by getting rid of/blowing off
  more C02 through Kussmauls respirations, deep
  and rapid

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Alkalosis PH above 7.45

• Respiratory Alkalosis
• Least common imbalance when lungs blow off too
  much C02- (hyperventilation) ex. anxiety
  attackor high altitudes use of mechanical
  ventilators in ICU
• and show rapid, shallow respirations
• Serum PH increases and PaCo2 decreases
• TX usually- breathe into paper bag or
  re-breathing mask to retain more C02

• Metabolic Alkalosis
• Due to excessive ingestion of HC03 or other bases
  or loss of acid from the body
• Overuse of antacids or baking soda for
  indigestion
• Also result of loss of HCL from stomach due to NG
  suctioning or vomiting/diarrhea
• Serum PH is increased as is HC03
• K and C levels get off balance ( Hypo) this
  causes the S/S of (Hypokalemia/calcemia). By
  fixing these electrolyte imbalances will help
  correct problem as well as identifying underlying
  cause

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FYI only!

• The abbreviation PaC02 Pa02 are often used
  interchangeably with PC02 and P02. The
  Ppartial pressure exerted by the gas dissolved
  in the blood. The a indicates that the sample
  is arterial blood.

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A client is hyperventilating due to anxiety.
Which of the following lab values indicates an
altered acid-base imbalance?

• A. PH. gt 7.45 mmHg.
• B. PaC02 gt 35mmHg.
• C. Hc03- gt 22 mmHg.
• D. PaC02 95

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Answer A

• Resp. Alkalosis ocurs during hyperventilation.
  The PH increases, while the PaC02 and HC03-
  decrease.
• The normal range for for Pa0280-100

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The nurse knows that a clients low bicarbonate
level may be caused by

• A. Gastro-intestinal suctioning
• B. Constipation
• C. Use of baking soda for indigestion
• D. Alcohol abuse

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Answer? A

• Vomiting, diarrhea, excessive GI suctioning (
  NGT) contribute to the loss of bicarbonate.
• Overuse of baking soda increases the bicarbonate
  (HC03-) level