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Intravenous Therapy: IVF, Electrolytes, TPN

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Information about Intravenous Therapy: IVF, Electrolytes, TPN

Published on August 19, 2008

Author: internist69

Source: slideshare.net

Description

for the basic IV therapy for nursing practice, regards the discussion on intravenous fluids, electrolytes, and total parenteral nutrition

rsm, md
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Dr. Ronald Sanchez – Magbitang EDUCATIONAL ATTAINMENT NEHS UST – B.S. Biology (Pre-Med) SLU – Doctor of Medicine (“Emeritus”) TRAININGS Dr. PJGMRMC – Internal Medicine Children's Medical Center – Hematology RITM – 1 st In-Country Training in HIV/AIDS CONVENTIONS/SYMPOSIA Philippine College of Physicians Philippine Association of Hospital Administrators Philippine Hospital Association PRESENT POSITION Chief of Hospital Gov. Eduardo L. Joson Memorial Hospital Daan Sarile, Cabanatuan City

EDUCATIONAL ATTAINMENT

NEHS

UST – B.S. Biology (Pre-Med)

SLU – Doctor of Medicine (“Emeritus”)

TRAININGS

Dr. PJGMRMC – Internal Medicine

Children's Medical Center – Hematology

RITM – 1 st In-Country Training in HIV/AIDS

CONVENTIONS/SYMPOSIA

Philippine College of Physicians

Philippine Association of Hospital Administrators

Philippine Hospital Association

PRESENT POSITION

Chief of Hospital

Gov. Eduardo L. Joson Memorial Hospital

Daan Sarile, Cabanatuan City

... was born on the 28th of July, year nineteen hundred and sixty-six, 10am at the Galang's Maternity Clinic in Batangas St., Santa Cruz, Manila, Philippines with a twin sister, Ruby, and they are the youngest among the four siblings. Dr. Magbitang is from Brgy. Bonifacio, San Leonardo, Nueva Ecija, Philippines, where presently he is living with his wonderful and loving family. He had his primary education from San Leonardo Central School where he graduated with honor. Then, had his secondary education from Nueva Ecija High School at Cabanatuan City. Thereafter, finished his Bachelor in Science, Biology from the University of Santo Tomas as preparatory course and subsequently obtained his Doctor of Medicine from the Saint Louis University in Baguio City and graduated "Emeritus". Subsequently, after his Internship at PJGMRMC he passed the Medical Board Examination on the following year. He had his Residency Training in the Department of Internal Medicine from Dr. Paulino J. Garcia Memorial and Research Center in Cabanatuan City, where he was the Chief Resident for the last 2 years of his training. And, became an Associate Fellow of The Philippine College of Physicians and member of the Philippine Association of Medical Specialists, Philippine Association of Hospital Administrators, and Philippine Hospital Association He had numerous positions in different prestigious medical and non-medical, and NGO's local and national associations and societies. He was once the Medical Section Head and the Chief of Clinics, and presently the Chief of Hospital of Eduardo L. Joson Memorial Hospital at Daan Sarile, Cabanatuan City. Dr. Ronald S. Magbitang Internal Medicine Chief of Hospital Gov. Eduardo L. Joson Memorial Hospital

... was born on the 28th of July, year nineteen hundred and sixty-six, 10am at the Galang's Maternity Clinic in Batangas St., Santa Cruz, Manila, Philippines with a twin sister, Ruby, and they are the youngest among the four siblings. Dr. Magbitang is from Brgy. Bonifacio, San Leonardo, Nueva Ecija, Philippines, where presently he is living with his wonderful and loving family. He had his primary education from San Leonardo Central School where he graduated with honor. Then, had his secondary education from Nueva Ecija High School at Cabanatuan City. Thereafter, finished his Bachelor in Science, Biology from the University of Santo Tomas as preparatory course and subsequently obtained his Doctor of Medicine from the Saint Louis University in Baguio City and graduated "Emeritus". Subsequently, after his Internship at PJGMRMC he passed the Medical Board Examination on the following year. He had his Residency Training in the Department of Internal Medicine from Dr. Paulino J. Garcia Memorial and Research Center in Cabanatuan City, where he was the Chief Resident for the last 2 years of his training. And, became an Associate Fellow of The Philippine College of Physicians and member of the Philippine Association of Medical Specialists, Philippine Association of Hospital Administrators, and Philippine Hospital Association He had numerous positions in different prestigious medical and non-medical, and NGO's local and national associations and societies. He was once the Medical Section Head and the Chief of Clinics, and presently the Chief of Hospital of Eduardo L. Joson Memorial Hospital at Daan Sarile, Cabanatuan City.

 

 

 

BASIC INTRAVENOUS THERAPY TRAINING PROGRAM FLUIDS AND ELECTROLYTES: Problems/Imbalances Common IV Solutions

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FLUIDS AND ELECTROLYTES BODY FLUIDS Refers to the body water in which electrolytes are dissolved Described as “a sea within” Water – is the largest single constituent of the body, representing 45% - 74% of the body weight, depending on age, gender and body fat

BODY FLUIDS

Refers to the body water in which electrolytes are dissolved

Described as “a sea within”

Water – is the largest single constituent of the body, representing 45% - 74% of the body weight, depending on age, gender and body fat

 

FLUIDS AND ELECTROLYTES In the newborn infant – almost ¾ of the body weight is water, with the greatest percentage found in extracellular compartment By adulthood the young male’s body water is only 60% and 2/3 of this is in the intracellular compartment In the average young female – only approximately 50% of body weight (due to increased amount of fat in women which is essentially water-free

In the newborn infant – almost ¾ of the body weight is water, with the greatest percentage found in extracellular compartment

By adulthood

the young male’s body water is only 60% and 2/3 of this is in the intracellular compartment

In the average young female – only approximately 50% of body weight (due to increased amount of fat in women which is essentially water-free

FLUIDS AND ELECTROLYTES Total Body water = 60% body weight Approximate size of body compartment in 70-kg adult Total = 42.5 L 0 100 200 300 1% 5% 14% 28 liters Transcellular 1L Plasma 3.5L Interstitial 10 liters Extracellular Water 20% BW Intracellular water 40% BW Osmolality – mOsm/L

Total Body water = 60% body weight

 

FLUIDS AND ELECTROLYTES Functions of Body Fluids: Transport nutrients to the cells and carries waste products away from the cells Maintains blood volume Regulates body temperature Serves as aqueous medium for cellular metabolism Assists in digestion of food through hydrolysis Acts as solvents in which solutes are available for cell function Serves as medium for the excretion of waste products

Functions of Body Fluids:

Transport nutrients to the cells and carries waste products away from the cells

Maintains blood volume

Regulates body temperature

Serves as aqueous medium for cellular metabolism

Assists in digestion of food through hydrolysis

Acts as solvents in which solutes are available for cell function

Serves as medium for the excretion of waste products

FLUIDS AND ELECTROLYTES Body Fluids are distributed in the body in 2 compartments: Intracellular (ICF) – within the cell, approximately 2/3 of the body fluid; located primarily in the skeletal muscle mass, provides the aqueous medium for cellular function

Body Fluids are distributed in the body in 2 compartments:

Intracellular (ICF) – within the cell, approximately 2/3 of the body fluid; located primarily in the skeletal muscle mass, provides the aqueous medium for cellular function

2. Extracellular (ECF) – outside the cell, maintains blood volume & serves as the transport system & from the cells a. Interstitial fluid – between the cells, fills spaces between most cells and comprises 15% of BW, e.g. lymph FLUIDS AND ELECTROLYTES

2. Extracellular (ECF) – outside the cell, maintains blood volume & serves as the transport system & from the cells

a. Interstitial fluid – between the cells, fills spaces between most cells and comprises 15% of BW, e.g. lymph

FLUIDS AND ELECTROLYTES 2. Extracellular (ECF) – outside the cell, maintains blood volume & serves as the transport system & from the cells b. Intravascular fluid – in the blood vessels, the PLASMA (i.e. watery colorless fluid of lymph and blood in which RBC, WBC and platelets are suspended) comprises 5% of BW, approximately 3L of the average 6L of blood volume is made up of plasma and the remaining 3L is made up of other blood components

2. Extracellular (ECF) – outside the cell, maintains blood volume & serves as the transport system & from the cells

b. Intravascular fluid – in the blood vessels, the PLASMA (i.e. watery colorless fluid of lymph and blood in which RBC, WBC and platelets are suspended) comprises 5% of BW, approximately 3L of the average 6L of blood volume is made up of plasma and the remaining 3L is made up of other blood components

FLUIDS AND ELECTROLYTES 2. Extracellular (ECF) – outside the cell, maintains blood volume & serves as the transport system & from the cells c. Transcellular – 1% to 3% of BW, the smallest division of the ECF compartment and contains approximately 1 – 2 L of fluid in any given time (e.g. CSF, pericardial, synovial, intraocular, pleural fluids, sweats, and digestive secretions

2. Extracellular (ECF) – outside the cell, maintains blood volume & serves as the transport system & from the cells

c. Transcellular – 1% to 3% of BW, the smallest division of the ECF compartment and contains approximately 1 – 2 L of fluid in any given time (e.g. CSF, pericardial, synovial, intraocular, pleural fluids, sweats, and digestive secretions

 

FLUIDS AND ELECTROLYTES Total Body water = 60% body weight Approximate size of body compartment in 70-kg adult Total = 42.5 L 0 100 200 300 1% 5% 14% 28 liters Transcellular 1L Plasma 3.5L Interstitial 10 liters Extracellular Water 20% BW Intracellular water 40% BW Osmolality – mOsm/L

Total Body water = 60% body weight

FLUIDS AND ELECTROLYTES There is a continuous exchange of fluid between the fluid compartment , of these spaces only the plasma is directly influenced by the intake or elimination of fluid from the body There is also the so called third space fluid shift or “third spacing” where there is a loss of ECF into a space that does not contribute to the equilibrium between ICF & ECF

There is a continuous exchange of fluid between the fluid compartment , of these spaces only the plasma is directly influenced by the intake or elimination of fluid from the body

There is also the so called third space fluid shift or “third spacing” where there is a loss of ECF into a space that does not contribute to the equilibrium between ICF & ECF

FLUIDS AND ELECTROLYTES “ Third spacing” occurs in: Ascites Burns Peritonitis Bowel obstruction Massive bleeding into body cavity or joints

“ Third spacing” occurs in:

Ascites

Burns

Peritonitis

Bowel obstruction

Massive bleeding into body cavity or joints

FLUIDS AND ELECTROLYTES Pathophysiology: The decrease in urine output despite adequate fluid intake (due to fluid shifts out of the intravascular space) + kidneys receive less blood and compensate by decreasing the urine output

Pathophysiology:

The decrease in urine output despite adequate fluid intake (due to fluid shifts out of the intravascular space) + kidneys receive less blood and compensate by decreasing the urine output

FLUIDS AND ELECTROLYTES Signs and Symptoms of Intravascular Fluid Volume Deficit are: Increased heart rate Decreased blood pressure Decreased CVP Edema Decreased BW Imbalances in fluid I & O

Signs and Symptoms of Intravascular Fluid Volume Deficit are:

Increased heart rate

Decreased blood pressure

Decreased CVP

Edema

Decreased BW

Imbalances in fluid I & O

FLUIDS AND ELECTROLYTES Output of Fluid – vary due to following: Increased temperature Increased respiration Draining wounds Ostomies Gastric suction

Output of Fluid – vary due to following:

Increased temperature

Increased respiration

Draining wounds

Ostomies

Gastric suction

FLUIDS AND ELECTROLYTES Sources of water: Liquids Water-containing foods Metabolic activities or oxidation

Sources of water:

Liquids

Water-containing foods

Metabolic activities or oxidation

FLUIDS AND ELECTROLYTES Elimination of Fluid: Sensible loss (measurable) Insensible (not measurable, e.g. skin, lungs, feces) INSENSIBLE WATER LOSS ?

Elimination of Fluid:

Sensible loss (measurable)

Insensible (not measurable, e.g. skin, lungs, feces)

INSENSIBLE WATER LOSS ?

FLUIDS AND ELECTROLYTES Water Balance I & O ( in adult eating 2500/day) Output 100 Feces 2500 Total 2500 Total 1400 Urine 300 Oxidation 500 Perspiration 1000 Food Intake 500 Breathing 1200 Liquids Amount of loss (ml) Route Amount of gain (ml) Route Intake

Water Balance I & O ( in adult eating 2500/day)

FLUIDS AND ELECTROLYTES Routes Gain and Losses: Kidneys Usual daily urine volume in adult = 1 – 2 L General Rule: 1 ml/kg/hour in all age groups

Routes Gain and Losses:

Kidneys

Usual daily urine volume in adult = 1 – 2 L

General Rule: 1 ml/kg/hour in all age groups

FLUIDS AND ELECTROLYTES Routes of Gain & Losses: Skin Sensible perspiration or sweating Chief solutes are Na, Cl, & K Actual sweat losses vary from 0 – 1000ml or more every hour depending on environmental temperature Conditions: fever – increased water loss through skin and lungs burns – natural skin barrier is destroyed

Routes of Gain & Losses:

Skin

Sensible perspiration or sweating

Chief solutes are Na, Cl, & K

Actual sweat losses vary from 0 – 1000ml or more every hour depending on environmental temperature

Conditions:

fever – increased water loss through skin and lungs

burns – natural skin barrier is destroyed

FLUIDS AND ELECTROLYTES Routes of Gain & Losses: Lungs Normally eliminate water vapor (insensible loss) Rate is at 300 – 400ml/day Loss is greater with increased respiratory rate or depth

Routes of Gain & Losses:

Lungs

Normally eliminate water vapor (insensible loss)

Rate is at 300 – 400ml/day

Loss is greater with increased respiratory rate or depth

FLUIDS AND ELECTROLYTES Routes of Gain & Losses: Gastrointestinal Tract Loss is at 100 – 200ml /day Because the bulk of fluid is reabsorbed in the small intestine diarrhea and fistulae are associated with large losses

Routes of Gain & Losses:

Gastrointestinal Tract

Loss is at 100 – 200ml /day

Because the bulk of fluid is reabsorbed in the small intestine

diarrhea and fistulae are associated with large losses

FLUIDS AND ELECTROLYTES Laboratory Tests for Evaluating Fluid Status: Osmolality Reflects the concentration of fluid that affects the movement of water between fluid compartments by osmosis Measures the solute concentration per kilogram in blood and urine Also measures the ability of a solution to create osmotic pressure and affects movement of water Most reliable in measuring urine concentration Reported as milliosmoles per kilogram of water (mOsm/kg) Normal serum osmolality = 280 – 300 mOsm/kg Normal urine osmolality = 50 – 1400 mOsm/kg

Laboratory Tests for Evaluating Fluid Status:

Osmolality

Reflects the concentration of fluid that affects the movement of water between fluid compartments by osmosis

Measures the solute concentration per kilogram in blood and urine

Also measures the ability of a solution to create osmotic pressure and affects movement of water

Most reliable in measuring urine concentration

Reported as milliosmoles per kilogram of water (mOsm/kg)

Normal serum osmolality = 280 – 300 mOsm/kg

Normal urine osmolality = 50 – 1400 mOsm/kg

FLUIDS AND ELECTROLYTES Laboratory Tests for Evaluating Fluid Status: Osmolarity Reflects the concentration of the solutions Measured in milliosmoles per liter (mOsm/L)

Laboratory Tests for Evaluating Fluid Status:

Osmolarity

Reflects the concentration of the solutions

Measured in milliosmoles per liter (mOsm/L)

FLUIDS AND ELECTROLYTES Comparison of Serum & Urine Osmolality: Fluid volume excess Diabetes insipidus Fluid volume deficit SIADH Urine SIADH Renal Failure Diuretic use Adrenal insufficiency Free water loss Diabetes insipidus Sodium overload Hyperglycemia Uremia Serum Factors decreasing Factors increasing Fluid

Comparison of Serum & Urine Osmolality:

FLUIDS AND ELECTROLYTES ELECTROLYTES Chemical compounds in solution that have the ability to conduct an electrical current Distributed in different concentrations in the intracellular, intravascular, & interstitial They break into ions: Cations – positively charge (Na, K, Ca, Mg, H ions) Anions – negatively charge (Cl, bicarbonate, phosphate, sulfate, proteinate ions)

ELECTROLYTES

Chemical compounds in solution that have the ability to conduct an electrical current

Distributed in different concentrations in the intracellular, intravascular, & interstitial

They break into ions:

Cations – positively charge (Na, K, Ca, Mg, H ions)

Anions – negatively charge (Cl, bicarbonate, phosphate, sulfate, proteinate ions)

FLUIDS AND ELECTROLYTES General Functions of Electrolytes Promote neuromuscular irritability Maintain body fluid volume and osmolality Distribute body water between compartments Regulate acid-base balance

General Functions of Electrolytes

Promote neuromuscular irritability

Maintain body fluid volume and osmolality

Distribute body water between compartments

Regulate acid-base balance

Approximate Major Electrolyte Content in Body Fluid * main electrolyte Cations: Cations: 17 Proteinate 5 Organic Acids 1 Sulfate (SO 4 -- ) 40 Proteinate 2 Phosphate (HPO 4 -- ) 10 Bicarbonate (HCO 3 - ) 26 Bicarbonate (HCO 3 - ) 150 Phosphates & Sulfates 103 Chloride (Cl - ) Anions: Anions: 2 Magnesium (Mg ++ ) 10 Sodium (Na + ) 5 Calcium (Ca ++ ) 40 Magnesium (Mg ++ ) 5 Potassium (K + ) 150 * Potassium (K + ) 142 * Sodium (Na + ) mEq/L Electrolytes mEq/L Electrolytes Intracellular Fluid (ICF) Extracellular Fluid (ECF) Plasma

Approximate Major Electrolyte Content in Body Fluid

FLUIDS AND ELECTROLYTES The Electrolytes: Cations: Sodium Potassium Calcium Magnesium Anions: Chloride Bicarbonate Phosphate

The Electrolytes:

Cations:

Sodium

Potassium

Calcium

Magnesium

Anions:

Chloride

Bicarbonate

Phosphate

FLUIDS AND ELECTROLYTES Sodium (Na + ) Normal concentration = 138 – 145 mEq/L Most prevalent cation in the extracellular Controls the osmotic pressure of the ECF compartment Importance: essential for neuromuscular functioning helps in the maintenance of acid-base balance

Sodium (Na + )

Normal concentration = 138 – 145 mEq/L

Most prevalent cation in the extracellular

Controls the osmotic pressure of the ECF compartment

Importance:

essential for neuromuscular functioning

helps in the maintenance of acid-base balance

FLUIDS AND ELECTROLYTES Potassium (K + ) Normal concentration = 3.5 – 5.0 mEq/L Major cation of the cell intracellularly K enters the cell during anabolism (tissue formation) or glycogenesis K goes out the cell during catabolism (tissue breakdown) – trauma, dehydration, starvation Mostly located in intracellular compartment Importance: has a direct effect on the excitability of nerves and muscles contributes most to the intracellular osmotic pressure helps maintain acid-base balance and kidney function

Potassium (K + )

Normal concentration = 3.5 – 5.0 mEq/L

Major cation of the cell intracellularly

K enters the cell during anabolism (tissue formation) or glycogenesis

K goes out the cell during catabolism (tissue breakdown) – trauma, dehydration, starvation

Mostly located in intracellular compartment

Importance:

has a direct effect on the excitability of nerves and muscles

contributes most to the intracellular osmotic pressure

helps maintain acid-base balance and kidney function

FLUIDS AND ELECTROLYTES Calcium (Ca ++ ) Normal concentration = 4.5 – 5.8 mEq/L Has 2 forms: Ionized (free) calcium – physiologically active Ca bound to plasma proteins

Calcium (Ca ++ )

Normal concentration = 4.5 – 5.8 mEq/L

Has 2 forms:

Ionized (free) calcium – physiologically active

Ca bound to plasma proteins

FLUIDS AND ELECTROLYTES Calcium (Ca ++ ) Free ionized Ca is needed for: Blood coagulation Muscle function (smooth, skeletal, cardiac) Nerve function Bone and teeth formation Calcium level depends on 3 hormones: Parathormone – decreased Ca & increase P Vitamin D – from sunlight, for Ca absorption Calcitonin – decreases Ca levels preventing bone resorption, opposes effects of PTH and Vit D on bones

Calcium (Ca ++ )

Free ionized Ca is needed for:

Blood coagulation

Muscle function (smooth, skeletal, cardiac)

Nerve function

Bone and teeth formation

Calcium level depends on 3 hormones:

Parathormone – decreased Ca & increase P

Vitamin D – from sunlight, for Ca absorption

Calcitonin – decreases Ca levels preventing bone resorption, opposes effects of PTH and Vit D on bones

FLUIDS AND ELECTROLYTES Magnesium (Mg ++ ) Normal concentration = 1.5 – 2.5 mEq/L About 50% is located in bones, 5% in ECF, and 45% in the ICF compartment Vital for enzyme activation reactions, especially in carbohydrate metabolism Has a sedative effect on CNS

Magnesium (Mg ++ )

Normal concentration = 1.5 – 2.5 mEq/L

About 50% is located in bones, 5% in ECF, and 45% in the ICF compartment

Vital for enzyme activation reactions, especially in carbohydrate metabolism

Has a sedative effect on CNS

Laboratory Values Used in Evaluating Fluid and Electrolyte Status 3.5-5.5 g/dL 3.5-5.5 g/dL Serum Albumin 3.9-6.1 mmol/L 70-110 mg/dL Serum Glucose Volume fraction: 0.39-0.47 Female: 39-47 % Volume fraction: 0.44-0.52 Male: 44-52 % Hematocrit 10:1 BUN/Creatinine ratio 62-133 mmol/L 0.7-1.5 mg/dL Serum creatinine 3.5-7 mmol/L of urea 10-20 mg/dL BUN 280-295 mmol/L 280-300 mOsm/kg Serum osmolality 24-30 24-30 Carbon Dioxide content 96-106 96-106 Serum Chloride 0.80-1.5 2.5-4.5 Serum Phosphorus 0.80-1.2 1.5-2.5 mEq/L Serum Mg 2.1-2.6 8.5-10.5 mg/dL Total serum Ca 3.5-5.5 3.5-5.5 mEq/L Serum K 135-145 mmol/L 135-145 mEq/L Serum Na SI Units Usual Reference Guide Test

Laboratory Values Used in Evaluating Fluid and Electrolyte Status < 6.6 < 6.6 typical urine 4.5-8.0 4.5-8.0 Urinary pH 500-800 500-800 mOsm/L typical urine 40-1400 mmol/kg 50-1400 mOsm/L extreme range Urine Osmolality 1.010-1.020 random specimen with normal intake Physiologic range after fluid restriction: 1.025-1.035 1.025-1.035 Urinary Specific Gravity 110-250 110-250 mEq/day Urinary Cl 40-80 40-80 mEq/day Urinary K 50-220 mmol/day 50-220 mEq/day Urinary Na SI Units Usual Reference Guide Test

FLUIDS AND ELECTROLYTES Regulation of Body Fluid Compartments Movement of particles through the cell membrane occurs via the following transport mechanisms: Passive transport: Osmosis Diffusion Filtration Active transport Na-K pump

Regulation of Body Fluid Compartments

Movement of particles through the cell membrane occurs via the following transport mechanisms:

Passive transport:

Osmosis

Diffusion

Filtration

Active transport

Na-K pump

Osmosis – movement of fluid to area of high concentration and gradual equalization of solute concentration Diffusion – movement of fluid and solutes and equalization of solute concentration A B

Osmosis – movement of fluid to area of high concentration and gradual equalization of solute concentration

Diffusion – movement of fluid and solutes and equalization of solute concentration

FLUIDS AND ELECTROLYTES OSMOSIS The movement of water through a semipermeable membrane from a solution that has a low concentration of particles towards a solution that has a high concentration of particles Normal serum osmolality = 280-300 mOsm/kg Osmolality of ECF and ICF is always equal

OSMOSIS

The movement of water through a semipermeable membrane from a solution that has a low concentration of particles towards a solution that has a high concentration of particles

Normal serum osmolality = 280-300 mOsm/kg

Osmolality of ECF and ICF is always equal

FLUIDS AND ELECTROLYTES DIFFUSION Is the natural tendency of substance to move from an area of higher concentration to one of lower concentration Occurs through the random movement of ions and molecules Particles will distribute themselves evenly Example: exchange of O 2 and CO 2 between pulmonary capillaries and alveoli

DIFFUSION

Is the natural tendency of substance to move from an area of higher concentration to one of lower concentration

Occurs through the random movement of ions and molecules

Particles will distribute themselves evenly

Example: exchange of O 2 and CO 2 between pulmonary capillaries and alveoli

FLUIDS AND ELECTROLYTES FILTRATION The process by which water and diffusible substances move together in response to fluid pressure This process is active in capillary beds Example: Passage of water and electrolytes from the arterial capillary bed to the interstitial fluid

FILTRATION

The process by which water and diffusible substances move together in response to fluid pressure

This process is active in capillary beds

Example:

Passage of water and electrolytes from the arterial capillary bed to the interstitial fluid

 

FLUIDS AND ELECTROLYTES ACTIVE TRANSPORT The movement of substances across the cell membrane by chemical activity or energy expenditure, that allows cells to admit larger molecules Example: sodium-potassium pump – Na is pumped out of the cell, K is pumped in against pressure gradient

ACTIVE TRANSPORT

The movement of substances across the cell membrane by chemical activity or energy expenditure, that allows cells to admit larger molecules

Example:

sodium-potassium pump – Na is pumped out of the cell, K is pumped in against pressure gradient

 

FLUIDS AND ELECTROLYTES Regulation of Body Fluids Homeostatic mechanism responsible for the balance of fluid and electrolytes within the body are: Kidneys Heart and Blood vessels Lungs Glands Other Mechanisms

Regulation of Body Fluids

Homeostatic mechanism responsible for the balance of fluid and electrolytes within the body are:

Kidneys

Heart and Blood vessels

Lungs

Glands

Other Mechanisms

FLUIDS AND ELECTROLYTES Regulation of Body Fluids Homeostatic mechanism responsible for the balance of fluid and electrolytes within the body are: Other mechanisms: Baroreceptors Renin-Angiotensin-Aldosterone System ADH and thirst Osmoreceptors Release of Atrial Natriuretic Peptide

Regulation of Body Fluids

Homeostatic mechanism responsible for the balance of fluid and electrolytes within the body are:

Other mechanisms:

Baroreceptors

Renin-Angiotensin-Aldosterone System

ADH and thirst

Osmoreceptors

Release of Atrial Natriuretic Peptide

Types of Fluid Balance And Imbalance

FLUIDS AND ELECTROLYTES Types of Fluid Balance and Imbalance: Saline ECF, reflects the volume of water and salt Water Osmolar proportion of water and salt (concentration)

Types of Fluid Balance and Imbalance:

Saline

ECF, reflects the volume of water and salt

Water

Osmolar proportion of water and salt (concentration)

FLUIDS AND ELECTROLYTES Saline Balance Refers to maintaining the proper volume of ECF and the three mechanisms involved in regulating saline balance Aldosterone – a major regulator of saline balance (ECF volume)

Saline Balance

Refers to maintaining the proper volume of ECF and the three mechanisms involved in regulating saline balance

Aldosterone – a major regulator of saline balance (ECF volume)

FLUIDS AND ELECTROLYTES Saline Imbalance Changes in the volume of extracellular fluid compartment Mechanisms in Regulating Saline Balance (ECF Volume): Pituitary Gland - Aldosterone Atrial Natriuretic Peptide Neural Mechanism

Saline Imbalance

Changes in the volume of extracellular fluid compartment

Mechanisms in Regulating Saline Balance (ECF Volume):

Pituitary Gland - Aldosterone

Atrial Natriuretic Peptide

Neural Mechanism

FLUIDS AND ELECTROLYTES Mechanisms in Saline Balance Regulation (ECF Volume) Pituitary Gland: Ineffective blood volume (decrease blood circulation/ decrease ECF volume) Stimulates adrenal cortex Secrete aldosterone Increase Na + reabsorption in distal tubule, collecting ducts Increase saline retention Increase in volume of water Relieveing saline imbalance

Mechanisms in Saline Balance Regulation

(ECF Volume)

Pituitary Gland:

Ineffective blood volume (decrease blood circulation/ decrease ECF volume)

Stimulates adrenal cortex

Secrete aldosterone

Increase Na + reabsorption in distal tubule, collecting ducts

Increase saline retention

Increase in volume of water

Relieveing saline imbalance

FLUIDS AND ELECTROLYTES Mechanisms in Saline Balance Regulation (ECF Volume) Atrial Natriuretic Peptide: Atrial distention (increase ECF) Release Peptides Acts on kidney Increase renal excretion of Na + & water Relieveing distention

Mechanisms in Saline Balance Regulation

(ECF Volume)

Atrial Natriuretic Peptide:

Atrial distention (increase ECF)

Release Peptides

Acts on kidney

Increase renal excretion of Na + & water

Relieveing distention

FLUIDS AND ELECTROLYTES Mechanisms in Saline Balance Regulation (ECF Volume) Neural mechanism: Decrease ECF volume Stimulate renal sympathetic nerves Release of Renin and stimulate the kidneys Decrease renal secretion of saline Increase ECF volume Atrial distention Mechano-receptors in the wall of left atrium Decrease activity of sympathetic nerve Increase excretion of saline by the kidney

Mechanisms in Saline Balance Regulation

(ECF Volume)

Neural mechanism:

Decrease ECF volume

Stimulate renal sympathetic nerves

Release of Renin and stimulate the kidneys

Decrease renal secretion of saline

Increase ECF volume

Atrial distention

Mechano-receptors in the wall of left atrium

Decrease activity of sympathetic nerve

Increase excretion of saline by the kidney

FLUIDS AND ELECTROLYTES Saline Imbalance: Saline Deficit ECF volume deficit Isotonic contraction Isosmotic dehydration Hypovolemia Extracellular volume depletion

Saline Imbalance: Saline Deficit

ECF volume deficit

Isotonic contraction

Isosmotic dehydration

Hypovolemia

Extracellular volume depletion

FLUIDS AND ELECTROLYTES Saline balance: Saline Deficit Causes: Vomiting Diarrhea Extreme diaphoresis Blood loss through hemorrhage Burns Bed rest Fistula drainage Salt wasting disorder Third-space fluid accumulation NGT suctioning Excessive diuretic use Intestinal decompression

Saline balance: Saline Deficit

Causes:

Vomiting

Diarrhea

Extreme diaphoresis

Blood loss through hemorrhage

Burns

Bed rest

Fistula drainage

Salt wasting disorder

Third-space fluid accumulation

NGT suctioning

Excessive diuretic use

Intestinal decompression

FLUIDS AND ELECTROLYTES Saline balance: Saline Deficit Clinical Manifestations: - dehydration Weight loss Postural BP drop Increased small vein filling time Neck vein flat or collapsing with inspiration Dizziness, syncope Oliguria or anuria Decreased CVP Decreased skin turgor Longitudinal furrow in the tongue Dry mucous membrane Hard, dry stools Decreased tears and sweat Sunken eyeballs Hypovolemic shock

Saline balance: Saline Deficit

Clinical Manifestations: - dehydration

Weight loss

Postural BP drop

Increased small vein filling time

Neck vein flat or collapsing with inspiration

Dizziness, syncope

Oliguria or anuria

Decreased CVP

Decreased skin turgor

Longitudinal furrow in the tongue

Dry mucous membrane

Hard, dry stools

Decreased tears and sweat

Sunken eyeballs

Hypovolemic shock

FLUIDS AND ELECTROLYTES Saline balance: Saline Deficit Laboratory Values: Urinalysis – increased Cl Blood studies – increased BUN, increased Hct, increased plasma protein, increased Na Medical Therapy: Saline replacement through IV related to complication of medical therapy Dx – potential for injury related to complication

Saline balance: Saline Deficit

Laboratory Values:

Urinalysis – increased Cl

Blood studies – increased BUN, increased Hct, increased plasma protein, increased Na

Medical Therapy:

Saline replacement through IV related to complication of medical therapy

Dx – potential for injury related to complication

FLUIDS AND ELECTROLYTES Saline Imbalance: Saline Excess ECF volume excess Isotonic expansion Hypervolemia Circulatory overload

Saline Imbalance: Saline Excess

ECF volume excess

Isotonic expansion

Hypervolemia

Circulatory overload

FLUIDS AND ELECTROLYTES Saline balance: Saline Excess Causes: Endocrine imbalance Hyperaldosteronism Cushing’s syndrome Glucocorticoid therapy Secondary to disease process Chronic renal failure CHF Cirrhosis Excess IV infusion of saline solutions (0.9% saline, Ringer’s)

Saline balance: Saline Excess

Causes:

Endocrine imbalance

Hyperaldosteronism

Cushing’s syndrome

Glucocorticoid therapy

Secondary to disease process

Chronic renal failure

CHF

Cirrhosis

Excess IV infusion of saline solutions (0.9% saline, Ringer’s)

FLUIDS AND ELECTROLYTES Saline balance: Saline Excess Clinical Manifestations: Weight gain (0.5kg/day) – sign of volume expansion Edema Vascular expansion Crackles or rales in lungs – fluid accumulation Dyspnea, orthopnea due to volume overload Increased CVP (5 – 10 cmH 2 0) – right atrium

Saline balance: Saline Excess

Clinical Manifestations:

Weight gain (0.5kg/day) – sign of volume expansion

Edema

Vascular expansion

Crackles or rales in lungs – fluid accumulation

Dyspnea, orthopnea due to volume overload

Increased CVP (5 – 10 cmH 2 0) – right atrium

FLUIDS AND ELECTROLYTES Saline balance: Saline Excess Laboratory Values: Elevated CVP Chest x-ray – fluid accumulation in the lungs Blood studies – normal serum Na Hematocrit – normal or decrease, depending on the cause, if occurs slowly the Hct remains normal Treatment: treat the underlying cause

Saline balance: Saline Excess

Laboratory Values:

Elevated CVP

Chest x-ray – fluid accumulation in the lungs

Blood studies – normal serum Na

Hematocrit – normal or decrease, depending on the cause, if occurs slowly the Hct remains normal

Treatment: treat the underlying cause

 

FLUIDS AND ELECTROLYTES Water Balance and Imbalance Refers to the maintenance of the proportion of salt to water in the blood Important Facts: Serum Na concentration is a useful measure of water balance (normal serum Na = 135 – 145 mEq/L in adults of all ages) If the serum Na is decreased: The osmolality of blood is decreased Blood is less concentrated than normal Blood has excess water relative to the amount of salt If the serum Na is increased: Osmolality of blood has increased Blood is more concentrated The blood has a deficit of water relative to the amount of salt

Water Balance and Imbalance

Refers to the maintenance of the proportion of salt to water in the blood

Important Facts:

Serum Na concentration is a useful measure of water balance (normal serum Na = 135 – 145 mEq/L in adults of all ages)

If the serum Na is decreased:

The osmolality of blood is decreased

Blood is less concentrated than normal

Blood has excess water relative to the amount of salt

If the serum Na is increased:

Osmolality of blood has increased

Blood is more concentrated

The blood has a deficit of water relative to the amount of salt

FLUIDS AND ELECTROLYTES Normal and Abnormal Routes of Water Entry and Exit - Parenteral - Rectal 300 ml Metabolic water 1,200 ml Water in food 1,200 ml Drink Oral Gastrointestinal Average Volume (per 24 hours) Route of Entry

Normal and Abnormal Routes of Water Entry and Exit

FLUIDS AND ELECTROLYTES Normal and Abnormal Routes of Water Entry and Exit - Hemorrhage - Paracentesis procedures Others: - Drainage from lesions 600 ml Insensible perspiration Skin - Fistula - Emesis 100 ml Fecal Gastrointestinal 400 ml Respiratory 1,500 ml Renal Average Volume (per 24 hours) Route of Exit

Normal and Abnormal Routes of Water Entry and Exit

FLUIDS AND ELECTROLYTES Water Balance and Imbalance The major regulators of oral water intake are: Thirst Habit patterns Social influence Three major mechanism of thirst: Cellular dehydration thirst Baroreceptor – mediated thirst Angiotensin – mediated thrist

Water Balance and Imbalance

The major regulators of oral water intake are:

Thirst

Habit patterns

Social influence

Three major mechanism of thirst:

Cellular dehydration thirst

Baroreceptor – mediated thirst

Angiotensin – mediated thrist

FLUIDS AND ELECTROLYTES Water Balance and Imbalance Cycle of Urine Excretion: Increase in osmolality of blood Hypothalamus Pituitary Gland Release of ADH Collecting ducts of kidneys Reabsorption of water back to the blood stream Dilute the blood Restore osmolalilty Note: The excretion of urine (of water) is controlled by ADH.

Water Balance and Imbalance

Cycle of Urine Excretion:

Increase in osmolality of blood

Hypothalamus

Pituitary Gland

Release of ADH

Collecting ducts of kidneys

Reabsorption of water back to the blood stream

Dilute the blood

Restore osmolalilty

Note: The excretion of urine (of water) is controlled by ADH.

FLUIDS AND ELECTROLYTES TYPES OF WATER IMBALANCE WATER DEFICIT: Hypernatremia Water depletion Hypertonicity Hyperosmolar balance

TYPES OF WATER IMBALANCE

WATER DEFICIT:

Hypernatremia

Water depletion

Hypertonicity

Hyperosmolar balance

FLUIDS AND ELECTROLYTES WATER DEFICIT Causes: 1. Loss of water relative to salt Renal Dibetes insipidus (salt gain due to polyuria) Osmotic diuresis (polyuria) Renal concentrating disorder Renal failure Other sources: Prolonged diarrhea without water replacement Excessive sweating without water replacement Dysfunctional humidifier of mechanical ventilators (dry air inhalation)

WATER DEFICIT

Causes:

1. Loss of water relative to salt

Renal

Dibetes insipidus (salt gain due to polyuria)

Osmotic diuresis (polyuria)

Renal concentrating disorder

Renal failure

Other sources:

Prolonged diarrhea without water replacement

Excessive sweating without water replacement

Dysfunctional humidifier of mechanical ventilators (dry air inhalation)

FLUIDS AND ELECTROLYTES WATER DEFICIT Causes: 2. Gain of salt relative to water Decrease water intake No access to water Prolonged nausea Difficulty swallowing fluid (Parkinson’s disease) Inability to respond to thirst Increase salt intake By means of tube feeding Half and half for ulcer diet Excess hypertonic NaCl or NaHCO 3

WATER DEFICIT

Causes:

2. Gain of salt relative to water

Decrease water intake

No access to water

Prolonged nausea

Difficulty swallowing fluid (Parkinson’s disease)

Inability to respond to thirst

Increase salt intake

By means of tube feeding

Half and half for ulcer diet

Excess hypertonic NaCl or NaHCO 3

FLUIDS AND ELECTROLYTES WATER DEFICIT Clinical Manifestations: Serum Na is above normal (blood is concentrated) Thirst (due to lack of water) Oliguria Confusion Lethargy Mild muscle weakness Seizures Coma (varies in severity)

WATER DEFICIT

Clinical Manifestations:

Serum Na is above normal (blood is concentrated)

Thirst (due to lack of water)

Oliguria

Confusion

Lethargy

Mild muscle weakness

Seizures

Coma (varies in severity)

FLUIDS AND ELECTROLYTES WATER DEFICIT Clinical Manifestations: Pathophysiology: Decrease Water Increase Osmolality Osmosis ICF ECF Attempt to restore osmolality Cells shrivels Cell dysfunction

WATER DEFICIT

Clinical Manifestations:

Pathophysiology:

Decrease Water

Increase Osmolality

Osmosis

ICF

ECF

Attempt to restore osmolality

Cells shrivels

Cell dysfunction

FLUIDS AND ELECTROLYTES WATER DEFICIT Laboratory Values: Urinalysis Increase in specific gravity of urine > 1.030 (normal urine sp.gr. = 1.010 – 1.030) Blood studies Increase serum Na Decrease serum protein Decrease Hct

WATER DEFICIT

Laboratory Values:

Urinalysis

Increase in specific gravity of urine > 1.030 (normal urine sp.gr. = 1.010 – 1.030)

Blood studies

Increase serum Na

Decrease serum protein

Decrease Hct

FLUIDS AND ELECTROLYTES WATER DEFICIT Medical Therapy: Replacement of fluid loss by IVF or oral route Institute or encourage oral fluid intake Administer in small amount Help patient in taking his I & O measurement Complications: Cerebral edema (therapy too rapid) Rebound fluid excess (therapy excessive) Infection Infiltration Because of IV therapy

WATER DEFICIT

Medical Therapy:

Replacement of fluid loss by IVF or oral route

Institute or encourage oral fluid intake

Administer in small amount

Help patient in taking his I & O measurement

Complications:

Cerebral edema (therapy too rapid)

Rebound fluid excess (therapy excessive)

Infection

Infiltration

FLUIDS AND ELECTROLYTES TYPES OF WATER IMBALANCE WATER EXCESS: Hyponatremia (decrease serum Na - < 135mEq/L) Water intoxication Hypotonicity

TYPES OF WATER IMBALANCE

WATER EXCESS:

Hyponatremia (decrease serum Na - < 135mEq/L)

Water intoxication

Hypotonicity

FLUIDS AND ELECTROLYTES WATER EXCESS Causes: I. General etiology: Gain or water relative to salt A. Endocrine: Stimulation of ADH Stressors Post-surgical state Nausea Pain Ectopic production of ADH

WATER EXCESS

Causes:

I. General etiology: Gain or water relative to salt

A. Endocrine:

Stimulation of ADH

Stressors

Post-surgical state

Nausea

Pain

Ectopic production of ADH

FLUIDS AND ELECTROLYTES WATER EXCESS Causes: I.General etiology: Gain or water relative to salt B. Iatrogenic – caused by medical therapy Excessive tap water enema Excessive infusion of D5W Excessive use of ultrasonic nebulizer Hypotonic irrigating solution (by process of osmosis) Excessive water ingestion after poisoning Excessive water ingestion before an UTZ examination

WATER EXCESS

Causes:

I.General etiology: Gain or water relative to salt

B. Iatrogenic – caused by medical therapy

Excessive tap water enema

Excessive infusion of D5W

Excessive use of ultrasonic nebulizer

Hypotonic irrigating solution (by process of osmosis)

Excessive water ingestion after poisoning

Excessive water ingestion before an UTZ examination

FLUIDS AND ELECTROLYTES WATER EXCESS Causes: I. General etiology: Gain or water relative to salt A. Others Psychogenic polydipsia – excessive thrist Excessive beer drinking Near drowning in fresh water Overdose of Barbiturates

WATER EXCESS

Causes:

I. General etiology: Gain or water relative to salt

A. Others

Psychogenic polydipsia – excessive thrist

Excessive beer drinking

Near drowning in fresh water

Overdose of Barbiturates

FLUIDS AND ELECTROLYTES WATER EXCESS Causes: II. General Etiology: Lost of salt related to water A. Renal Salt wasting renal disease Use of many types of diuretics (Thiazides)

WATER EXCESS

Causes:

II. General Etiology: Lost of salt related to water

A. Renal

Salt wasting renal disease

Use of many types of diuretics (Thiazides)

FLUIDS AND ELECTROLYTES WATER EXCESS Causes: II. General Etiology: Lost of salt related to water B. Gastrointestinal – due to water replacement not by salt Nasogastric suction Vomiting Diarrhea Hypotonic irrigation solutions

WATER EXCESS

Causes:

II. General Etiology: Lost of salt related to water

B. Gastrointestinal – due to water replacement not by salt

Nasogastric suction

Vomiting

Diarrhea

Hypotonic irrigation solutions

FLUIDS AND ELECTROLYTES WATER EXCESS Causes: II. General Etiology: Lost of salt related to water C. Others Burns Excessive sweating

WATER EXCESS

Causes:

II. General Etiology: Lost of salt related to water

C. Others

Burns

Excessive sweating

FLUIDS AND ELECTROLYTES WATER EXCESS Clinical Manifestations: Pathophysiology Increased Water Decrease Osmolality Osmosis ECF ICF Attempt to restore Osmolality Cell swollen Cell dysfunction

WATER EXCESS

Clinical Manifestations:

Pathophysiology

Increased Water

Decrease Osmolality

Osmosis

ECF

ICF

Attempt to restore Osmolality

Cell swollen

Cell dysfunction

FLUIDS AND ELECTROLYTES WATER EXCESS Clinical Manifestations: Decrease serum Na Malaise Headache Confusion Lethargy Seizures Coma

WATER EXCESS

Clinical Manifestations:

Decrease serum Na

Malaise

Headache

Confusion

Lethargy

Seizures

Coma

FLUIDS AND ELECTROLYTES WATER EXCESS Medical Therapy/ Management: Restrict water intake below the daily insensible losses (1,000 ml) The kidney will excrete the excess water Administration of diuretic ( Furosemide ) Administration of ADH-blocking agent Demeclocycline or LiCO 3 )

WATER EXCESS

Medical Therapy/ Management:

Restrict water intake below the daily insensible losses (1,000 ml)

The kidney will excrete the excess water

Administration of diuretic ( Furosemide )

Administration of ADH-blocking agent Demeclocycline or LiCO 3 )

 

FLUIDS AND ELECTROLYTES EDEMA Fluid accumulation of the interstitial space Maybe a sign of saline excess Governed by the net result of the ff: Blood hydrostatic pressure Interstitial fluid hydrostatic pressure Blood colloid osmotic and oncotic pressure Interstitial fluid osmotic pressure

EDEMA

Fluid accumulation of the interstitial space

Maybe a sign of saline excess

Governed by the net result of the ff:

Blood hydrostatic pressure

Interstitial fluid hydrostatic pressure

Blood colloid osmotic and oncotic pressure

Interstitial fluid osmotic pressure

 

FLUIDS AND ELECTROLYTES EDEMA Capillary Mechanism for Edema Formation 1. Increase blood hydrostatic pressure A. Increase capillary flow Local infection Inflammation B. Venous congestion External pressure Venous thrombosis Right heart failure

EDEMA

Capillary Mechanism for Edema Formation

1. Increase blood hydrostatic pressure

A. Increase capillary flow

Local infection

Inflammation

B. Venous congestion

External pressure

Venous thrombosis

Right heart failure

FLUIDS AND ELECTROLYTES EDEMA Capillary Mechanism for Edema Formation 2. Decrease blood osmotic pressure A. Decrease serum Albumin Loss of albumin Nephrotic Syndrome Protein-losing enteropathies Liver disease (Cirrhosis)

EDEMA

Capillary Mechanism for Edema Formation

2. Decrease blood osmotic pressure

A. Decrease serum Albumin

Loss of albumin

Nephrotic Syndrome

Protein-losing enteropathies

Liver disease (Cirrhosis)

FLUIDS AND ELECTROLYTES EDEMA Capillary Mechanism for Edema Formation 3. Increase fluid osmotic pressure A. Increase capillary permeability Burns Inflammation Hypersensitivity reactions Toxins Trauma

EDEMA

Capillary Mechanism for Edema Formation

3. Increase fluid osmotic pressure

A. Increase capillary permeability

Burns

Inflammation

Hypersensitivity reactions

Toxins

Trauma

FLUIDS AND ELECTROLYTES EDEMA Capillary Mechanism for Edema Formation 4. Impaired lymphatic drainage a. obstruction of the lymph node by tumors b. Surgical removal of lymph nodes c. Obstruction of lymph nodes by parasites

EDEMA

Capillary Mechanism for Edema Formation

4. Impaired lymphatic drainage

a. obstruction of the lymph node by tumors

b. Surgical removal of lymph nodes

c. Obstruction of lymph nodes by parasites

FLUIDS AND ELECTROLYTES EDEMA Medical Therapy and Interventions: Use of elastic stockings to enhance venous return Administration of diuretics or a Na-restricted diet

EDEMA

Medical Therapy and Interventions:

Use of elastic stockings to enhance venous return

Administration of diuretics or a Na-restricted diet

ELECTROLYTE BALANCE AND ELECTROLYTE IMBALANCES

ELECTROLYTE BALANCE

AND

ELECTROLYTE IMBALANCES

FLUIDS AND ELECTROLYTES ELECTROLYTE BALANCE AND IMBALANCES Electrolytes: Salts found in every body fluids K, Ca, PO 3 , Mg (major electrolytes) Enter the body primarily in the diet then enter the ECF and distributed to some other body electrolyte pool (bones/ inside cells)

ELECTROLYTE BALANCE AND IMBALANCES

Electrolytes:

Salts found in every body fluids

K, Ca, PO 3 , Mg (major electrolytes)

Enter the body primarily in the diet then enter the ECF and distributed to some other body electrolyte pool (bones/ inside cells)

FLUIDS AND ELECTROLYTES Electrolytes: Normal Routes of Exit: Urine Feces Sweat Abnormal Route: Fistula drainage Emesis Gastric or intestinal suction Paracentesis Exudates

Electrolytes:

Normal Routes of Exit:

Urine

Feces

Sweat

Abnormal Route:

Fistula drainage

Emesis

Gastric or intestinal suction

Paracentesis

Exudates

FLUIDS AND ELECTROLYTES POTASSIUM BALANCE AND IMBALANCES Normal range = 3.5 – 5.0 mEq/L “ Kalium” – Latin word for potassium Potassium Homeostasis: Enters the cells through an active transport mechanism Both insulin and epinephrine cause K to enter cells Exercise causes K to exit cells initially pH of ECF also affect the distribution

POTASSIUM BALANCE AND IMBALANCES

Normal range = 3.5 – 5.0 mEq/L

“ Kalium” – Latin word for potassium

Potassium Homeostasis:

Enters the cells through an active transport mechanism

Both insulin and epinephrine cause K to enter cells

Exercise causes K to exit cells initially

pH of ECF also affect the distribution

FLUIDS AND ELECTROLYTES POTASSIUM BALANCE AND IMBALANCES Normal range = 3.5 – 5.0 mEq/L “ Kalium” – Latin word for potassium Factors that causes K shift A. Accumulation of carbonic acid May cause a mild ECF shift B. Accumulation of mineral acids Causes significant extracellular K shift C. Accumulation of organic acids Does not in itself cause a K shift

POTASSIUM BALANCE AND IMBALANCES

Normal range = 3.5 – 5.0 mEq/L

“ Kalium” – Latin word for potassium

Factors that causes K shift

A. Accumulation of carbonic acid

May cause a mild ECF shift

B. Accumulation of mineral acids

Causes significant extracellular K shift

C. Accumulation of organic acids

Does not in itself cause a K shift

FLUIDS AND ELECTROLYTES HYPOKALEMIA Serum K < 3.5 mEq/L Causes: Decrease K intake Non-iatrogenic Anorexia Fad diets Fasting Iatrogenic NPO orders Prolonged IV therapy without K Entry of K into cells Increased K excretion K loss by abnormal route

HYPOKALEMIA

Serum K < 3.5 mEq/L

Causes:

Decrease K intake

Non-iatrogenic

Anorexia

Fad diets

Fasting

Iatrogenic

NPO orders

Prolonged IV therapy without K

Entry of K into cells

Increased K excretion

K loss by abnormal route

FLUIDS AND ELECTROLYTES HYPOKALEMIA Serum K < 3.5 mEq/L Clinical Manifestations: Serum K below normal Postural hypotension Abdominal distention Diminished bowel sounds manifestation of unresponsive Constipation GI smooth muscles Skeletal muscle weakness Flaccid paralysis Polyuria, nocturia Cardiac arrythmias ECG changes: ST depression, inverted T-waves, U waves, QT prolongation

HYPOKALEMIA

Serum K < 3.5 mEq/L

Clinical Manifestations:

Serum K below normal

Postural hypotension

Abdominal distention

Diminished bowel sounds manifestation of unresponsive

Constipation GI smooth muscles

Skeletal muscle weakness

Flaccid paralysis

Polyuria, nocturia

Cardiac arrythmias

ECG changes: ST depression, inverted T-waves, U waves, QT prolongation

FLUIDS AND ELECTROLYTES HYPOKALEMIA Serum K < 3.5 mEq/L Note: Decrease K is manifested in dysfunction of all 3 kinds of muscles: Smooth Skeletal Cardiac

HYPOKALEMIA

Serum K < 3.5 mEq/L

Note:

Decrease K is manifested in dysfunction of all 3 kinds of muscles:

Smooth

Skeletal

Cardiac

FLUIDS AND ELECTROLYTES HYPOKALEMIA Serum K < 3.5 mEq/L Interventions: Constipation Postural hypotension Muscle weakness or flaccid paralysis Ineffective breathing K replacement therapy complications: GI irritation or ulceration Rebound hyperkalemia (if oliguria develops) Cardiac arrhythmias (too rapid therapy) Rebound hyperkalemia (excessive therapy) Inflammation, infection, infiltration (out of vein) Medical Therapy: Oral or IV Potassium replacement

HYPOKALEMIA

Serum K < 3.5 mEq/L

Interventions:

Constipation

Postural hypotension

Muscle weakness or flaccid paralysis

Ineffective breathing

K replacement therapy complications:

GI irritation or ulceration

Rebound hyperkalemia (if oliguria develops)

Cardiac arrhythmias (too rapid therapy)

Rebound hyperkalemia (excessive therapy)

Inflammation, infection, infiltration (out of vein)

Medical Therapy: Oral or IV Potassium replacement

FLUIDS AND ELECTROLYTES HYPERKALEMIA Serum K > 5.0 mEq/L Excess of K in the ECF Causes: Increased K intake Movement of K out of cells Decreased K excretion

HYPERKALEMIA

Serum K > 5.0 mEq/L

Excess of K in the ECF

Causes:

Increased K intake

Movement of K out of cells

Decreased K excretion

FLUIDS AND ELECTROLYTES HYPERKALEMIA Serum K > 5.0 mEq/L Clinical Manifestations: Serum K above normal Intestinal cramping Diarrhea Skeletal muscle weakness Flaccid paralysis Cardiac arrhythmias Cardiac arrest ECG changes: peaked narrow T-waves, shortened QT intervals, widened QRS, sine wave Laboratory values: acidosis

HYPERKALEMIA

Serum K > 5.0 mEq/L

Clinical Manifestations:

Serum K above normal

Intestinal cramping

Diarrhea

Skeletal muscle weakness

Flaccid paralysis

Cardiac arrhythmias

Cardiac arrest

ECG changes: peaked narrow T-waves, shortened QT intervals, widened QRS, sine wave

Laboratory values: acidosis

FLUIDS AND ELECTROLYTES HYPERKALEMIA Serum K > 5.0 mEq/L Interventions: Diarrhea Muscle weakness or flaccid paralysis Decrease ability to function Ineffective breathing Decreased cardiac output

HYPERKALEMIA

Serum K > 5.0 mEq/L

Interventions:

Diarrhea

Muscle weakness or flaccid paralysis

Decrease ability to function

Ineffective breathing

Decreased cardiac output

FLUIDS AND ELECTROLYTES HYPERKALEMIA Serum K > 5.0 mEq/L Medical Therapy: To move K into cells (insulin, glucose, HCO 3 infusion) To counteract the cardiac effects of hyperkalemia (IV Ca gluconate) Remove K from the body (dialysis, diuretics, ion-exchange resins [Na polysterene sulfonate])

HYPERKALEMIA

Serum K > 5.0 mEq/L

Medical Therapy:

To move K into cells (insulin, glucose, HCO 3 infusion)

To counteract the cardiac effects of hyperkalemia (IV Ca gluconate)

Remove K from the body (dialysis, diuretics, ion-exchange resins [Na polysterene sulfonate])

FLUIDS AND ELECTROLYTES HYPERKALEMIA Serum K > 5.0 mEq/L Complications of Medical Therapy: Hypoglycemia (insulin, glucose) Hypercalcemia (Ca gluconate) Metabolic alkalosis (IV HCO 3 ) Rebound hypokalemia (excessive therapy) Inflammation, infection, or infiltration (IV therapy) Aspiration pneumonitis (oral ion-exchange resin) Constipation (oral ion-exchange resin without sorbitol) Kayexalate – ion-exchange resin (Na polysterene sulfonate)

HYPERKALEMIA

Serum K > 5.0 mEq/L

Complications of Medical Therapy:

Hypoglycemia (insulin, glucose)

Hypercalcemia (Ca gluconate)

Metabolic alkalosis (IV HCO 3 )

Rebound hypokalemia (excessive therapy)

Inflammation, infection, or infiltration (IV therapy)

Aspiration pneumonitis (oral ion-exchange resin)

Constipation (oral ion-exchange resin without sorbitol)

Kayexalate – ion-exchange resin (Na polysterene sulfonate)

FLUIDS AND ELECTROLYTES CALCIUM BALANCE & IMBALANCES Facts: Calcium ions in the body are mostly located in the bones and teeth Small amount in cells of soft tissue Normal concentration = 4.5 – 5.5 mEq/L Calcium Homeostasis: Major source of calcium intake: Milk Dairy products (cheese, cream, yogurt, ice cream) Sea foods (clams) Calcium is absorbed from the GIT by active transport mechanism requiring Vitamin D Parathyroid hormone (PTH) increases activation of Vitamin D

CALCIUM BALANCE & IMBALANCES

Facts:

Calcium ions in the body are mostly located in the bones and teeth

Small amount in cells of soft tissue

Normal concentration = 4.5 – 5.5 mEq/L

Calcium Homeostasis:

Major source of calcium intake:

Milk

Dairy products (cheese, cream, yogurt, ice cream)

Sea foods (clams)

Calcium is absorbed from the GIT by active transport mechanism requiring Vitamin D

Parathyroid hormone (PTH) increases activation of Vitamin D

FLUIDS AND ELECTROLYTES HYPOCALCEMIA Occurs if the serum Ca < 4.5 mEq/L or if the ionized portion of the serum Ca is diminished Ionized hypocalcemia: total serum Ca maybe normal but ionized Ca concentration will be < normal Causes: Decreased Calcium intake or absorption Decreased physiological availability of Calcium Increased Calcium excretion Calcium loss by abnormal route

HYPOCALCEMIA

Occurs if the serum Ca < 4.5 mEq/L or if the ionized portion of the serum Ca is diminished

Ionized hypocalcemia: total serum Ca maybe normal but ionized Ca concentration will be < normal

Causes:

Decreased Calcium intake or absorption

Decreased physiological availability of Calcium

Increased Calcium excretion

Calcium loss by abnormal route

FLUIDS AND ELECTROLYTES HYPOCALCEMIA Serum Ca < 4.5 mEq/L or if the ionized portion of the serum Ca is diminished Clinical Manifestations: Decreased serum Ca (or decreased ionized Ca & normal total Ca) Paresthesias (digital or perioral) – numbness or tingling sensation *Chvostek ’s sign – tapping the Facial N. in front of the ear cause the mouth to draws up in a grimace, due to increased neuromuscular irritability *Trousseau ’s sign – carpal spasm after occluding the arterial flow to the hand with sphygmomanometer for about 3 mins Grimacing, muscle twitching, cramping Hyperactive reflexes Carpal, pedal spasm Tetany – increased irritability Laryngospasm (sudden involuntary muscular contraction of larynx) Seizures Cardiac arrhythmias

HYPOCALCEMIA

Serum Ca < 4.5 mEq/L or if the ionized portion of the serum Ca is diminished

Clinical Manifestations:

Decreased serum Ca (or decreased ionized Ca & normal total Ca)

Paresthesias (digital or perioral) – numbness or tingling sensation

*Chvostek ’s sign – tapping the Facial N. in front of the ear cause the mouth to draws up in a grimace, due to increased neuromuscular irritability

*Trousseau ’s sign – carpal spasm after occluding the arterial flow to the hand with sphygmomanometer for about 3 mins

Grimacing, muscle twitching, cramping

Hyperactive reflexes

Carpal, pedal spasm

Tetany – increased irritability

Laryngospasm (sudden involuntary muscular contraction of larynx)

Seizures

Cardiac arrhythmias

FLUIDS AND ELECTROLYTES HYPOCALCEMIA Serum Ca < 4.5 mEq/L or if the ionized portion of the serum Ca is diminished Interventions: Neuromuscular irritability Laryngospasm Paresthesia and muscle cramps Medical Therapy: Replacement of Calcium – oral or IV

HYPOCALCEMIA

Serum Ca < 4.5 mEq/L or if the ionized portion of the serum Ca is diminished

Interventions:

Neuromuscular irritability

Laryngospasm

Paresthesia and muscle cramps

Medical Therapy:

Replacement of Calcium – oral or IV

FLUIDS AND ELECTROLYTES HYPOCALCEMIA Serum Ca < 4.5 mEq/L or if the ionized portion of the serum Ca is diminished Complications of IV Calcium replacement: Cardiac arrhythmias (therapy too rapid) Rebound hypercalcemia (therapy excessive) Inflammation, infection, infiltration Tissue sloughing (after calcium infiltration) Altered bowel elimination – constipation Note: oral Ca salts are often administered with Vitamin D

HYPOCALCEMIA

Serum Ca < 4.5 mEq/L or if the ionized portion of the serum Ca is diminished

Complications of IV Calcium replacement:

Cardiac arrhythmias (therapy too rapid)

Rebound hypercalcemia (therapy excessive)

Inflammation, infection, infiltration

Tissue sloughing (after calcium infiltration)

Altered bowel elimination – constipation

Note: oral Ca salts are often administered with Vitamin D

FLUIDS AND ELECTROLYTES HYPERCALCEMIA Serum Ca > 5.5 mEq/L Excess calcium in plasma may come from the bones or from external source Causes: Increased calcium intake or absorption Release of calcium from bone Decreased calcium excretion

HYPERCALCEMIA

Serum Ca > 5.5 mEq/L

Excess calcium in plasma may come from the bones or from external source

Causes:

Increased calcium intake or absorption

Release of calcium from bone

Decreased calcium excretion

FLUIDS AND ELECTROLYTES HYPERCALCEMIA Serum Ca > 5.5 mEq/L Clinical Manifestations: Increased serum Ca Anorexia Nausea, emesis Constipation Abdominal pain Polyuria Renal calculi Fatigue Muscle weakness Impaired reflexes Headache Confusion, lethargy Personality change Psychosis Cardiac arrest ECG changes: shortened QT interval

HYPERCALCEMIA

Serum Ca > 5.5 mEq/L

Clinical Manifestations:

Increased serum Ca

Anorexia

Nausea, emesis

Constipation

Abdominal pain

Polyuria

Renal calculi

Fatigue

Muscle weakness

Impaired reflexes

Headache

Confusion, lethargy

Personality change

Psychosis

Cardiac arrest

ECG changes: shortened QT interval

FLUIDS AND ELECTROLYTES HYPERCALCEMIA Serum Ca > 5.5 mEq/L Interventions: Constipation Nausea and vomiting – nutrition Aspiration Fatigue Pain Muscle weakness Decreased level of consciousness Altered thought processes Impaired social interaction Renal calculi

HYPERCALCEMIA

Serum Ca > 5.5 mEq/L

Interventions:

Constipation

Nausea and vomiting – nutrition

Aspiration

Fatigue

Pain

Muscle weakness

Decreased level of consciousness

Altered thought processes

Impaired social interaction

Renal calculi

FLUIDS AND ELECTROLYTES HYPERCALCEMIA Serum Ca > 5.5 mEq/L Notes: Prune, cranberry juice or acid ash diet maybe use to acidify the urine Hypercalcemia due to calcium withdrawal from bone results to weak bones Hypercalcemia potentiates digitalis, may result to digitalis toxicity Thiazide diuretics decrease calcium excretion which should be withheld if hypercalcemia develops

HYPERCALCEMIA

Serum Ca > 5.5 mEq/L

Notes:

Prune, cranberry juice or acid ash diet maybe use to acidify the urine

Hypercalcemia due to calcium withdrawal from bone results to weak bones

Hypercalcemia potentiates digitalis, may result to digitalis toxicity

Thiazide diuretics decrease calcium excretion which should be withheld if hypercalcemia develops

FLUIDS AND ELECTROLYTES HYPERCALCEMIA Serum Ca > 5.5 mEq/L Medical Therapy: Infusion of IV 0.9% Saline to induce saline diuresis Calcitonin – used to decrease plasma calcium rapidly in emergency hypercalcemia Complications of Therapy: ECF volume excess (IV saline) Inflammation, infection, infiltration (any IV agent) Hypokalemia (diuretic therapy) Hypersensitivity reaction (calcitonin) Diarhhea (diphosphonates) Nausea, vomiting (plicamysin) Bone marrow suppression, liver damage, renal damage

HYPERCALCEMIA

Serum Ca > 5.5 mEq/L

Medical Therapy:

Infusion of IV 0.9% Saline to induce saline diuresis

Calcitonin – used to decrease plasma calcium rapidly in emergency hypercalcemia

Complications of Therapy:

ECF volume excess (IV saline)

Inflammation, infection, infiltration (any IV agen

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