Fluids and Electrolytes

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FLUIDS and ELECTROLYTES BODY FLUIDS Functions of Fluids Body fluids: Facilitate in the transport [nutrients, hormones, proteins, & others…] Aid in removal of cellular metabolic wastes Provide medium for cellular metabolism Regulate body temperature Provide lubrication of musculoskeletal jts. Component in all body cavities [parietal, pleural… fluids] Water is the principal body fluid & essential for life.

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FLUIDS and ELECTROLYTES FLUIDS and ELECTROLYTES BODY FLUIDS ICF ECF 40% TBW 20% TBW P IS Distribution of Body Fluids – 50-70% of total body weight; infant [70-80%], elderly [45-50%] 60-kg man TBW = 0.6 x 60 kg = 3.6 L ICF = 0.4 x 60 kg = 24 L ECF = 12 L 3L 9L

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FLUIDS and ELECTROLYTES BODY FLUIDS Factors that Dictate Body Water Requirement Amount needed to give the proper osmotic concentration Amount needed to replace water lost excretion Normal Routes of water gain and loss INTAKE OUTPUT ml /day ml /day Fluid intake 1,200 Food 1,000 Metabolic water 300 TOTAL 2,500 Insensible loss 700 Sweat 100 Feces 200 Urine 1,500 TOTAL 2,500

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FLUIDS and ELECTROLYTES FLUID EXCHANGE BETWEEN BODY FLUID COMPARTMENTS Osmotic Pressure Gradient Oncotic P (Colloid osmotic P) Capillary P (Hydrostatic P) ICF ECF P ISF

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FLUIDS and ELECTROLYTES Control of Osmotic Pressure, Volume & Electrolyte Concentration OBLIGATORY Reabsorption occurs in the proximal tubules 178 L/day of glomerular filtrate (80% reabsorbed) 2  to solute reabsorption independent of the water requirement FACULTATIVE Reabsorption occurs in the distal & collecting tubules independent of the active solute transport dependent of body’s need of water under the control of ADH

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FLUIDS and ELECTROLYTES FLUIDS and ELECTROLYTES DISTURBANCES IN FLUID BALANCE EDEMA (Dropsy)  in the interstitial fluid volume of about 2 L or more due to increase transudation of fluid from capillaries 2° to: Increased HP [pregnancy, CHF] Decreased OP [malnutrition, end-stage liver dse, nephrotic syndrome]

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FLUIDS and ELECTROLYTES DISTURBANCES IN FLUID BALANCE CELL OVERHYDRATION excess of water in the ECC w/ a normal amount of solute or a deficient amount of solute occurs in prolonged and excessive diuresis, forcing hypotonic fluids to produce diuresis in the presence of renal impairment fluid overload from  production of adrenal corticoid hormones [Cushing’s syndrome]

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FLUIDS and ELECTROLYTES DISTURBANCES IN FLUID BALANCE CELL OVERHYDRATION Symptoms Weight gain & edema Cough, moist rales, dyspnea [fluid congestion in lungs] CVP, bounding pulse,neck vein engorgement [fluid excess in the vascular system] Bulging fontanelles  Hg and Hct Nausea & vomiting

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FLUIDS and ELECTROLYTES DISTURBANCES IN FLUID BALANCE CELL OVERHYDRATION Management Restrict fluids to lower fluid volume Diuretics or hypertonic saline Continuous assessments to prevent skin breakdown Record daily weight to assess progress of treatment

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FLUIDS and ELECTROLYTES DISTURBANCES IN FLUID BALANCE CELL DEHYDRATION (DHN) loss of body fluids, particularly from the extracellular fluid compartment water loss > water intake Causes Fever Insufficient water intake Diarrhea, vomiting Excess urine output [Diabetes insipidus, diuretics] Excessive perspiration, burns Hemorrhage, shock, metabolic acidosis

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FLUIDS and ELECTROLYTES DISTURBANCES IN FLUID BALANCE CELL DEHYDRATION (DHN) Symptoms Thirst, dry mucus membranes, sunken eyeballs “Doughy“ abdomen, dry skin w/ poor turgor  temp, weight loss  HR,  RR,  BP Restlessness,irritability, disorientation, convulsion, coma [22-30% body H 2 0 loss] Management Fluid replacement therapy & continued fluid maintenance

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FLUIDS and ELECTROLYTES Volume Disorders 2° Alteration in Sodium Balance Expansion Isotonic Inc N No net change Isotonic fluid ingestion Hypertonic Inc Dec ICF  ECF Sea water ingestion Hypotonic Inc Inc ECF  ICF Hypotonic IVF Contraction Isotonic Dec N No net change Diarrhea Hypertonic Dec Dec ICF  ECF Diabetes insipidus Hypotonic Dec Inc ECF  ICF Addison’s dse Volume ECF ICF Water Conditions Disorder Vol. Vol. Shift

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FLUIDS and ELECTROLYTES ELECTROLYTES salts or minerals in extracellular or intracellular body fluids Sodium – major cation of ECF Potassium – major cation of ICF Chloride - major anion of ICF Protein – in ICF > ISF

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FLUIDS and ELECTROLYTES ELECTROLYTE Composition Electrolyte Conc Plasma (mEq/L) ISF ICF Sodium, Na+ 142 141 10 Potassium, K+ 5 4.1 150 Calcium, Ca++ 5 4.1 - Magnesium, Mg++ 3 3 40 (155) Chloride, Cl- 103 115 15 Bicarbonate, HCO3- 27 29 10 Biphosphate, HPO4- 2 2 100 Sulfate, SO4-2 1 1 20 Protein 16 1 60 Organic foods 6 3.4 - (155)

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FLUIDS and ELECTROLYTES ELECTROLYTES Functions of Electrolytes Contribute most of the osmotically active particles in body fluids Provide buffer systems for pH regulation Provide the proper ionic environment for normal neuromuscular irritability & tissue function

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FLUIDS and ELECTROLYTES FLUIDS and ELECTROLYTES Hyponatremia [Na + < 135 mEq/L; Normal = 135-145 mEq/L] Causes  Na+ intake  Na+ excretion [diaphoresis, GI suctioning] Adrenal insufficiency Assessment N & V, abdominal cramps, weight loss Cold, clammy skin,  skin turgor Apprehension, HA, convulsions, focal neurologic deficit, coma [cerebral edema] Fatigue, postural hypotension Rapid thready pulse ELECTROLYTES

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FLUIDS and ELECTROLYTES Hyponatremia [Na + < 135 mEq/L; Normal = 135-145 mEq/L] Management Provide foods high in sodium Administer NSS IV Assess blood pressure frequently [measure lying down, sitting & standing] ELECTROLYTES

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FLUIDS and ELECTROLYTES Hypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L] Causes Excessive, rapid IV adm’n of NSS Inadequate water intake Kidney disease Assessment Dry, sticky mucus membranes Flushed skin Rough dry tongue, firm skin turgor Intense thirst Edema, oliguria to anuria Restlessness, irritability [cerebral DHN] ELECTROLYTES

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FLUIDS and ELECTROLYTES Hypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L] Nursing Intervention Weigh daily Assess degree of edema frequently Measure I & O Assess skin frequently & institute nursing measures to prevent breakdown Encourage sodium-restricted diet ELECTROLYTES

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FLUIDS and ELECTROLYTES Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L] Causes Renal insufficiency Adrenocortical insufficiency Cellulose damage [burns] Infection Acidotic states Rapid infusion of IV sol’n w/ potassium-conserving diuretics ELECTROLYTES

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FLUIDS and ELECTROLYTES Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L] Assessment Thready, slow pulse Shallow breathing N & V, diarrhea, intestinal colic Irritability Muscle weakness, flaccid paralysis Numbness, tingling Difficulty w/ phonation, respiration ELECTROLYTES

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FLUIDS and ELECTROLYTES Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L] Nursing Interventions Administer kayexalate as ordered Administer/monitor IV infusion of glucose & insulin Control infection Provide adequate calories & carbohydrates Discontinue IV or oral sources of K+ ELECTROLYTES

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FLUIDS and ELECTROLYTES Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L] Causes Renal insufficiency Adrenocortical insufficiency Cellulose damage [burns] Infection Acidotic states Rapid infusion of IV sol’n w/ potassium-conserving diuretics ELECTROLYTES

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FLUIDS and ELECTROLYTES Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L] Assessment Thready, rapid, weak pulse Faint heart sounds  BP Skeletal muscle weakness  or absent reflexes Shallow respirations Malaise, apathy, lethargy Loss of orientation Anorexia, vomiting, weight loss Gaseous intestinal distention ELECTROLYTES

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FLUIDS and ELECTROLYTES Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L] Nursing Interventions Administer K+ supplements to replace losses Be cautious in administering drugs that are not potassium-sparing Monitor acid-base balance Monitor pulse, BP and ECG ELECTROLYTES

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FLUIDS and ELECTROLYTES Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L] Causes Hyperparathyroidism Immobility Increased vitamin D intake Osteoporosis & osteomalacia [early stages] Assessment N & V, anorexia, constipation Headache, confusion Lethargy, stupor Decreased muscle tone Deep bone/flank pain ELECTROLYTES

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FLUIDS and ELECTROLYTES Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L] Nursing Interventions Encourage mobilization Limit vitamin D intake Limit calcium intake Normal saline Administer diuretics Calcitonin ELECTROLYTES

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FLUIDS and ELECTROLYTES Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L] Causes Acute pancreatitis Diarrhea Hypoparathyroidism Lack of vitamin D I the diet Long-term steroid therapy Assessment Painful tonic muscle & facial spasms Fatigue, dyspnea Laryngospasm, convulsions (+) Trousseau’s and Chvostek’s signs ELECTROLYTES

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FLUIDS and ELECTROLYTES Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L] Nursing Interventions Administer oral Ca lactate or IV CaCl 2 or gluconate Providing safety by padding side rails Administer dietary sources of calcium Vitamin D Provide quiet environment ELECTROLYTES

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FLUIDS and ELECTROLYTES Hyermagnesemia [Mg > 3.0 mEq/L; Normal = 1.5-3.0 mEq/L] Causes Renal insufficiency, dehydration Excessive use of Mg-containing antacids or laxatives Assessment Lethargy, somnolence, confusion N & V Muscle weakness, depressed reflexes  pulse and respirations Nursing Intervention Withhold Mg-cont’g drugs/foods; Ca adm’n  fluid intake, unless CI ELECTROLYTES

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FLUIDS and ELECTROLYTES Hypomagnesemia [Mg < 1.50 mEq/L; Normal = 1.5-3.0 mEq/L] Causes Low intake of Mg in the diet Prolonged diarrhea Massive diuresis Hypoparathyroidism Assessment Paresthesias, muscle spasm Confusion, hallucination, convulsions Ataxia, tremors, hyperactive deep reflexes Flushing of the face, diaphoresis Nursing Intervention Provide good dietary sources of Mg ELECTROLYTES

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FLUIDS and ELECTROLYTES IV FLUID REPLACEMENT THERAPY Indications Replacement of abnormal fluid & electrolyte losses [surgery, trauma, burns, GI bleeding] Maintenance of daily fluid & electrolyte needs Correction of fluid disorders Correction of electrolyte disorders

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FLUIDS and ELECTROLYTES IV FLUID REPLACEMENT THERAPY Types of Solutions Isotonic 0.9% sodium chloride (NSS) Lactated Ringer’s sol’n Hypotonic 5% dextrose and water (D5W) 0.45% sodium chloride 0.33% sodium chloride Hypertonic 3% NaCl Protein sol’ns Colloids Salt pour albumin Plasmanate, Dextran

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B U R N S BURNS wounds caused by excessive exposure to the following agents or causes: Causes of Burns: Thermal [moist or dry heat] Electrical Chemical [strong acids and strong alkali Radiation [UV, x-rays, radium, sunburns]

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CLASSIFICATION OF BURNS Superficial Partial thickness (1 st degree) Outer layer of dermis Erythema, pain up to 48 hrs Healing 1-2 wks [sunburn] Deep Partial thickness (2 nd degree) Epidermis & dermis Blisters & edema, frequently quite painful Healing 14-21 days Full thickness (3 rd degree) Epidermis, dermis, subcutaneous fat Dry, pearly white or charred in appearance Not painful Eschar must be removed; may need grafting B U R N S

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STAGES OF BURNS 1 st : Shock/Fluid Accumulation Phase 1 st 48 hrs IVC  ISC Generalized DHN [fluid shifting] Hypovolemia [plasma loss],  BP,  C.O. Hemoconcentration,  Hct [liquid blood component  ISC] Oliguria [ renal perfusion], ADH release & aldosterone HyperK, hypoNa Metabolic acidosis B U R N S

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STAGES OF BURNS 2 nd : Diuretic/Fluid Remobilization Phase After 48 hrs ISC  IVC Hypervolemia, Hemodilution,  Hct Diuresis [ renal perfusion],  ADH & aldosterone secretion HypoK, hypoNa [K moves back into the cells, Na+ still trapped in the edema fluids Metabolic acidosis B U R N S

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STAGES OF BURNS 3 rd : Recovery Phase 5 th day onwards Hypocalcemia Ca is lost on the exudates Ca is utilized in the granulation tissue formation Negative nitrogen balance Due to stress response  protein catabolism Protein intake is lesser than the demand HypoK B U R N S

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ASSESSMENT Assess extent of body surface burned Greater morbidity & mortality for burns affecting face, hands & perineum Assess for dyspnea, stridor, hoarseness Assess extent of burn injury Rule of nine – immediate appraisal Lund-Browder chart – more accurate Berkow’s method – based on client’s age & changes that occur in proportion of head & legs to the rest of the body as one grows B U R N S

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ASSESSMENT B U R N S 9% 9% 9% Front= 18% Back= 18% 18% 18% 1% Burn Evaluation Chart

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ASSESSMENT 3. Assess depth of burn Major burns – 2 nd degree over 30% of body Hospitalization - eyes, face, neck, hands, perineum, genitalia 4. Assess unique contributing factors Age of client Health history Diabetes, preexisting ulcers Tetanus immunization B U R N S

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EMERGENCY MANAGEMENT Stop the burning process Remove patient from source of injury Advise client to roll on the ground if clothing is in flame [STOP-DROP-ROLL] Throw a blanket over the client to smother the flame Remove clothing only if hot or for scald burn Immerse affected part in cold water [10 min] Irrigate copiuosly w/ large amount of running water w/ chemical burns [except w/ phosphorus] Interrupt power source w/ electrical burn B U R N S

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MANAGEMENT Maintenance of adequate airway Promoting comfort: relieve pain Promoting fluid-electrolyte, acid-base balance Preventing infection Maintaining adequate nutrition Wound care B U R N S

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METHODS OF TREATING BURNS Open method or Exposure method Face, neck, perineum, trunk Allowing exudate to dry in 3 days Occlusive Less pain, absorption of secretion, comfort, transportability, accelerated debridement Aesthetic considerations Semi-open method Covering of wound w/ topical antimicrobials: Silver sulfadiazine 1% (Flamazine) Silver nitrate 0.5% sol’n Mafenide acetate (sulfamylon acetate) B U R N S

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BIOLOGIC DRESSING (Skin Graft) Allograft Skin taken from other person [cadaver] Autograft Same person Heterograft Different species Xenograft [segment of skin from animal such as pig or dog] B U R N S

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FLUID REPLACEMENT Types of fluids: Colloids Blood Plasma & plasma expanders Electrolytes Lactated Ringers Non-electrolyte D5W B U R N S

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FLUID REPLACEMENT EVAN’S Formula: C – 1ml x % burns x kgBW E - 1ml x % burns x kgBW G lucose 5% for insensible loss – 2,000ml D5W Administer sol’n 1 st 24 hrs – ½ [1 st 8hrs], ½ [16hrs] BROOKE Formula: [Administer as in Evan’s] C – 0.5ml x % burn x kgBW E - 1.5ml x % burns x kgBW Water – 1000ml D5W B U R N S

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FLUID REPLACEMENT MOORES BURN BUDGET: 75 ml of plasma, 75 ml of electrolyte-cont’g fluid for q 1%TBSA plus 2000 D5W HYPERTONIC RESUSCITATION Formula: Hypertonic salt containing 300mEq of Na+, 100mEq of Cl-, 200mEq lactate Administered to maintain urinary output of 30-40 ml/hr B U R N S