Fluid, Electrolyte, and Acid-Base Balance

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Acid Base Balance and Nursing Intervention

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Fluid, Electrolyte, and Acid-Base Balance

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Learning Outcomes Discuss the function, distribution, movement, and regulation of fluids and electrolytes in the body. Describe the regulation of acid–base balance in the body, including the roles of the lungs, the kidneys and buffers. Identify factors affecting normal body fluid, electrolyte, and acid–base balance. Discuss the risk factors for and the causes and effects of fluid, electrolyte, and acid–base imbalances. Collect assessment data related to the client’s fluid, electrolyte, and acid–base balances.

Learning Outcomes:

Learning Outcomes Identify examples of nursing diagnoses, outcomes, and interventions for clients with altered fluid, electrolyte, or acid–base balance. Teach clients measures to maintain fluid and electrolyte balance. Implement measures to correct imbalances of fluids and electrolytes or acids and bases such as enteral or parenteral replacements and blood transfusions. Evaluate the effect of nursing and collaborative interventions on the client’s fluid, electrolyte, or acid–base balance.

Learning Outcomes:

A delicate (fragile) balance of fluids, electrolytes, and acids and bases is maintained in the body. This balance depends on multiple physiologic processes that regulate fluid intake and output and the movement of water and substances dissolved in it between body compartments.

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Water is vital to health and normal cellular function. It serves as a medium for metabolic reactions within the cells; a transporter for nutrients, waste products, and other substances; a lubricant; an insulator; a shock absorber; and one means of regulating and maintaining body temperature.

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The body’s fluid is divided into two major compartments: intracellular and extracellular. Intracellular fluid (ICF) is found within the cells, and extracellular fluid (ECF) is found outside the cells.

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The two main compartments of the ECF are intravascular fluid (plasma) and interstitial fluid (surrounds the cells). Other compartments of ECF include lymph and transcellular fluids such as cerebrospinal, pericardial, pancreatic, pleural, intraocular, biliary, peritoneal, and synovial fluids. Intracellular fluid is vital to normal cell functioning.

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It contains solutes such as oxygen, electrolytes, and glucose, and it provides a medium in which metabolic processes of the cell take place. Extracellular fluid is the transport system that carries nutrients to and waste products from the cells.

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Fluids and electrolytes move among the body compartments by osmosis, diffusion, filtration, and active transport. The volume and composition of body fluids is regulated through several homeostatic mechanisms: the kidneys, the endocrine system, the cardiovascular system, the lungs, and the gastrointestinal system.

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The antidiuretic hormone (ADH), also called arginine vasopressin (AVP), the renin-angiotensin-aldosterone system.

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Movement of Body Fluids Osmosis Diffusion Filtration Active transport

Movement of Body Fluids:

Osmosis: Water molecules move from the less concentrated area to the more concentrated area in an attempt to equalize the concentration of solutions on two sides of a membrane.

Osmosis: Water molecules move from the less concentrated area to the more concentrated area in an attempt to equalize the concentration of solutions on two sides of a membrane. :

Diffusion: The movement of molecules through a semipermeable membrane from an area of higher concentration to an area of lower concentration.

Diffusion: The movement of molecules through a semipermeable membrane from an area of higher concentration to an area of lower concentration. :

Schematic of filtration pressure changes within a capillary bed. On the arterial side, arterial blood pressure exceeds colloid osmotic pressure, so that water and dissolved substances move out of the capillary into the interstitial space. On the venous side, venous blood pressure is less than colloid osmotic pressure, so that the water and dissolved substances move into the capillary.

Schematic of filtration pressure changes within a capillary bed. On the arterial side, arterial blood pressure exceeds colloid osmotic pressure, so that water and dissolved substances move out of the capillary into the interstitial space. On the venous side, venous blood pressure is less than colloid osmotic pressure, so that the water and dissolved substances move into the capillary.:

Regulating Body Fluids Fluid intake Thirst Fluid output Urine Insensible loss Feces Maintaining homeostasis Kidneys ADH Renin-angiotensin-aldosterone system

Regulating Body Fluids:

ECF and ICF contain ions (charged particles). Anions are negative ions and cations are positive ions called electrolytes. The number of cations and anions in should be equal.

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The principal electrolytes in the ECF are sodium, chloride, and bicarbonate. Other electrolytes such as potassium, calcium, and magnesium but in much smaller quantities.

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Plasma and interstitial fluids (major components of ECF) contain essentially the same electrolytes and solutes with the exception of proteins, which are plentiful in the plasma.

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The primary electrolytes in the ICF are potassium, magnesium, phosphate, and sulfate. As in ECF, other electrolytes are present within the cells, but in smaller concentrations.

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Distribution of Body Fluids

Distribution of Body Fluids:

Regulating Electrolytes Sodium Potassium Calcium Magnesium Chloride Phosphate Bicarbonate

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Regulation Acid-Base Balance

Regulation Acid-Base Balance:

An important part of regulating the chemical balance or homeostasis of body fluids is regulating their acidity or alkalinity, which is measured as pH. The pH reflects the hydrogen concentration of the solution.

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The higher the hydrogen ion concentration, the lower the pH (more acidic) and vice versa. Body fluids are maintained within a narrow range that is slightly alkaline (arterial blood is between 7.35 and 7.45).

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Several body systems, including buffers, the respiratory system, and the renal system, are actively involved in maintaining the narrow pH range necessary for optimal function. The lungs and kidneys help maintain a normal pH by either excreting or retaining acids and bases.

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Buffers (substance that keeps a constant balance between acid and alkali) prevent excessive changes in the pH by removing or releasing hydrogen ions. The major buffer system in ECF is the bicarbonate (HCO3) and carbonic acid (H2CO3) system.

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The amounts of bicarbonate and carbonic acid in the body vary. However, as long as a ratio of 20 parts of bicarbonate to 1 part of carbonic acid is maintained, pH remains within normal limits. In addition, plasma proteins, hemoglobin, and phosphates function as buffers.

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Regulation of Acid-Base Balance Low pH = acidic High pH = alkalinic Body fluids maintained between pH of 7.35 and 7.45 by Buffers Respiratory system Renal system

Regulation of Acid-Base Balance:

Buffers Prevent excessive changes in pH Major buffer in ECF is HCO 3 and H 2 CO 3 Other buffers include: Plasma proteins Hemoglobin Phosphates

Buffers:

The lungs help regulate acid–base balance by eliminating or retaining carbon dioxide, a potential acid. Combined with water, carbon dioxide forms carbonic acid. This chemical reaction is reversible.

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Working together with the bicarbonate–carbonic acid buffer system, the lungs regulate acid–base balance and pH by altering the rate and depth of respirations.

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Carbon dioxide is a powerful stimulator of the respiratory center. When blood levels of carbonic acid and carbon dioxide rise, the respiratory center is stimulated and the rate and depth of respiration increase. Carbon dioxide is exhaled and carbonic acid levels fall.

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By contrast when bicarbonate levels are excessive, the rate and depth of respirations are reduced, causing carbon dioxide to be retained, carbonic acid to rise, and excess bicarbonate to be neutralized.

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The respiratory system response to changes in pH is rapid, occurring within minutes.

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The kidneys are the ultimate long-term regulator of acid–base balance. They are slower to respond to changes, requiring hours to days to correct imbalances, but their response is more permanent and selective than that of the other systems.

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Kidneys maintain acid–base balance by selectively excreting or conserving bicarbonate and hydrogen ions. When excess hydrogen ion is present and the pH falls (acidosis), the kidneys reabsorb and regenerate bicarbonate and excrete hydrogen ions

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In the case of alkalosis and a high pH, excess bicarbonate is excreted and a hydrogen ion is retained.

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Factors Affecting Body Fluid, Electrolyte, and Acid-Base Balance Age Gender Body size Environmental temperature Lifestyle

Factors Affecting Body Fluid, Electrolyte, and Acid-Base Balance:

Age—infants and growing children have much greater fluid turnover than adults because of their higher metabolic rates, increase fluid loss, immature kidneys (infants), rapid respiratory rate (infants), and greater body surface area (infants).

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In elderly people normal aging process and the likelihood of the presence of chronic diseases may affect fluid balance. Thirst is blunted ( not sharp ); nephrons are less able to conserve water in response to ADH.

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Gender and body size—fat cells contain little water and lean tissue has an increased water content. People with a greater percentage of body fat have less body fluid. Women have proportionally greater body fat than men and have less body water than men.

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Environmental temperature—individuals with illness and participation in strenuous exercise are at risk for fluid and electrolyte imbalances when the environmental temperature in high the loss of water and salt in sweat.

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Lifestyle—diet (intake of fluid and electrolytes), exercise (calcium balance), and stress (increases cellular metabolism, blood glucose concentration, and cathecholamine levels) affect fluid and electrolyte and acid–base balance. Heavy alcohol consumption decreases calcium, magnesium, and phosphate levels and increases the risk of acidosis from breakdown of fat.

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Risk Factors for Fluid, Electrolyte, and Acid-Base Imbalances Chronic diseases Acute conditions Medications Treatments Extremes of age Inability to access food and fluids

Risk Factors for Fluid, Electrolyte, and Acid-Base Imbalances:

Chronic diseases (e.g., lung disease, heart failure, Cushing’s or Addison’s diseases, diabetes mellitus, and cancer), acute conditions (e.g., acute gastroenteritis, burns, crushing injuries, surgery, or fever), medications (e.g., diuretics, corticosteroids, and NSAIDs), treatments (e.g., chemotherapy, intravenous therapy or total peripheral nutrition, nasogastric suction, enteral feedings, mechanical ventilation) and other factors (such as the very young and the very old, inability to access food and fluids independently) .

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Fluid imbalances are of two basic types: isotonic and osmolar. Isotonic imbalances occur when water and electrolytes are lost or gained in equal proportions so that the osmolality of body fluids remains constant. Osmolar imbalances involve the loss of only water so that the osmolality of the serum is altered.

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Fluid Imbalances Isotonic loss of water and electrolytes (fluid volume deficit) Isotonic gain of water and electrolytes (fluid volume excess) Hyperosmolar loss of only water (dehydration) Hypo-osmolar gain of only water (overhydration)

Fluid Imbalances:

Fluid imbalances are of two basic types: isotonic and osmolar. Isotonic imbalances occur when water and electrolytes are lost or gained in equal proportions so that the osmolality of body fluids remains constant.

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Osmolar imbalances involve the loss of only water so that the osmolality of the serum is altered. Thus there are four categories of fluid imbalances: an isotonic loss of water and electrolytes (fluid volume deficit), an isotonic gain of water and electrolytes (fluid volume excess), a hyperosmolar loss of only water (dehydration), and a hypo-osmolar gain of only water (overhydration).

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The risk for dehydration increases with older age due to decreased thirst sensation. Also at risk for dehydration are clients who are hyperventilating or have prolonged fever or are in diabetic ketoacidosis and those receiving enteral feedings with insufficient water.

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Common manifestations of dehydration include weight loss, decreased skin turgor and capillary refill, dry mucous membranes, weak, rapid pulse, decreased blood pressure and orthostatic hypotension, increased specific gravity of the urine, hematocrit and blood urea nitrogen.

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Overhydration may occur if only water is replaced or from the syndrome of inappropriate antidiuretic hormone (SIADH), which can result from some malignant tumors, AIDS, head injury, or administration of certain drugs such as barbiturates or anesthetics.

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Common manifestations of overhydration include weight gain, full bounding pulse, tachycardia, elevated blood pressure, distended neck and peripheral veins, adventitious lung sounds, shortness of breath, and confusion.

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Collecting Assessment Data Nursing history Physical assessment Clinical measurement Review of laboratory test results Evaluation of edema

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The nursing history includes current and past medical history, medications, and functional, developmental, and socioeconomic factors. Common risk factors for fluid and electrolyte imbalances

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The nurse also needs to elicit data about the client’s food and fluid intake, fluid output, and the presence of signs or symptoms suggestive of altered fluid and electrolyte balance. The Assessment Interview provides examples of questions to elicit information regarding fluid, electrolyte, and acid–base balance.

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lists the focused physical assessment of fluid, electrolyte, or acid–base imbalances, including assessment of the skin, mucous membranes, eyes, fontanels (infants), cardiovascular system, respiratory system, neurologic and muscular status.

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Clinical measurement includes daily weights, vital signs, and fluid intake and output.

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Evaluation of Edema

Evaluation of Edema:

NANDA Nursing Diagnoses Deficient Fluid Volume Excess Fluid Volume Risk for Imbalanced Fluid Volume Risk for Deficient Fluid volume Impaired Gas Exchange

NANDA Nursing Diagnoses:

NANDA Nursing Diagnoses Fluid and Acid-base Imbalances as Etiology Impaired Oral Mucous Membrane Impaired Skin Integrity Decreased Cardiac Output Ineffective Tissue Perfusion Activity Intolerance Risk for Injury Acute Confusion

NANDA Nursing Diagnoses:

Desired Outcomes Maintain or restore normal fluid balance Maintain or restore normal balance of electrolytes Maintain or restore pulmonary ventilation and oxygenation Prevent associated risks Tissue breakdown, decreased cardiac output, confusion, other neurologic signs

Desired Outcomes:

Nursing Interventions Monitoring Fluid intake and output Cardiovascular and respiratory status Results of laboratory tests Assessing Client’s weight Location and extent of edema, if present Skin turgor and skin status Specific gravity of urine Level of consciousness, and mental status

Nursing Interventions:

Nursing Interventions Fluid intake modifications Dietary changes Parenteral fluid, electrolyte, and blood replacement Other appropriate measures such as: Administering prescribed medications and oxygen Providing skin care and oral hygiene Positioning the client appropriately Scheduling rest periods

Nursing Interventions:

Promoting Fluid and Electrolyte Balance Consume 6-8 glasses water daily Avoid foods with excess salt, sugar, caffeine Eat well-balanced diet Limit alcohol intake Increase fluid intake before, during, after strenuous exercise Replace lost electrolytes

Promoting Fluid and Electrolyte Balance:

Promoting Fluid and Electrolyte Balance Maintain normal body weight Learn about, monitor, manage side effects of medications Recognize risk factors Seek professional health care for notable signs of fluid imbalances

Promoting Fluid and Electrolyte Balance:

Teaching Client to Maintain Fluid and Electrolyte Balance Promoting fluid and electrolyte balance Monitoring fluid intake and output Maintaining food and fluid intake Safety Medications Measures specific to client’s problems Referrals Community agencies and other sources of help Facilitating fluid intake

Teaching Client to Maintain Fluid and Electrolyte Balance:

Practice Guidelines Facilitating Fluid Intake Explain reason for required intake and amount needed Establish 24 hour plan for ingesting fluids Set short term goals Identify fluids client likes and use those Help clients select foods that become liquid at room temperature Supply cups, glasses, straws Serve fluids at proper temperature Encourage participation in recording intake Be alert to cultural implications

Practice Guidelines Facilitating Fluid Intake:

Practice Guidelines Restricting Fluid Intake Explain reason and amount of restriction Help client establish ingestion schedule Identify preferences and obtain Set short term goals; place fluids in small containers Offer ice chips and mouth care Teach avoidance of ingesting chewy, salty, sweet foods or fluids Encourage participation in recording intake

Practice Guidelines Restricting Fluid Intake:

Correcting Imbalances Oral replacement If client is not vomiting If client has not experienced excessive fluid loss Has intact GI tract and gag and swallow reflexes

Correcting Imbalances:

Correcting Imbalances Restricted fluids may be necessary for fluid retention Vary from nothing by mouth to precise amount ordered Dietary changes

Correcting Imbalances:

Oral Supplements Potassium Calcium Multivitamins Sports drink

Oral Supplements:

Evaluation Collect data as identified in the plan of care If desired outcomes are not achieved, explore the reasons before modifying the care plan

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