NF CHPT 15

Fluid & Chemical Balance

The Body’s Fluids

• Water is the most important solvent in the body

• Water transports wastes• Water carries nutrients• Water lubricates joints• Water acts as a shock absorber• Water needs to be replaced and maintained

daily

Water

• Makes up 50-60% of our body wt

• Best source of water is drinking water

• Water also comes from liquids and foods

2 compartments body fluid is in…

• Intracellular

• Extracellular

Intracellular Fluid

• The fluid that is inside the cells

Extracellular Fluid

• Water that is outside the cells

Electrolytes

• Are chemical compounds that are dissolved, absorbed and distributed in body fluids

• Electrolytes carry an electrical charge

• Na+ K+ CL- are all electrolytes

Normal electrolyte levels

• Na+ should be 135-148 meq/L

• K+ should be 3.5-5.0 meq/L

• Know these for ever……………

IMBALANCE

• When electrolytes become unbalanced, the body tries to balance it out to return it to a homeostatic state

BLOOD

• Consists of:• 3 liters of plasma• 2 liters of blood cells• _____ • Total of 5 liters

Blood cells

• For every 500 RBC’s (carry stuff)• There are 30 platelets (to clot blood)• There is 1 WBC

• Loss of blood means you must replace it with fluid or actual blood transfusion

OSMOSIS

• Helps to keep water and the stuff in it, =

• Water moves from an area of less concentration of particles to an area of higher concentration of particles to help spread those particles out and dilute the stuff

FILTRATION

• Like a coffee filter• Your kidneys filter out water and waste

through the glomerulous (kidney’s filter) from the hydrostatic pressure behind that water and waste…the water and waste gets pushed out through this kidney filter

DIFFUSION

• When “stuff” moves from an area of high concentration to an area of low concentration (think of the room deodorizer spray)

• Like the room spray, it’s really concentrated coming out of the can then I spray it in the air and the smell diffuses or moves to the other side of the room

PASSIVE DIFFUSION

• Doesn’t require any energy to do this, it just moves by itself

• What kind of energy??????

ACTIVE TRANSPORT

• Like salmon swimming up stream, this requires ATP=energy to help push it through

• This goes from an area of low concentration to an area of high concentration

• Na+ and K+ do this in a “pump system” when they are regulating themselves in the kidneys

FLUID REGULATION

• Our body regulates fluids through the kidneys

• We loose fluids in several ways…• Fluid loss needs to be watched and replaced

then maintained daily

Monitoring Intake & Output

• Keep a record of what goes in and what comes out…legal document

• Keep this record over a 24 hour period

• Dr. or IVFs determines who needs I&Os watched

Measuring I&O

• Measured in ml or cc and recorded on I & O sheet

• Totaled at end of shifts and grand totaled at end of day

• Should be compared with previous levels• Includes all routes of Intake and Output

Who is on I&Os

• Surgical pt is monitored until they are eating and drinking and voiding normal

• Pt receiving IVFs

• Pt receiving tube feeds, what goes in and what comes out must be watched

Who is on I&Os

• Pt with wound drainage or suction equipment

• Pt who has a urinary catheter

• Pt who is on diuretic therapy such as lasix or aldactone or hydrochlorothiozide. They are releasing extra body water with these medications

KEEPING TRACK

• You must use your facilities I&O record

• I&O should be done EVERY SHIFT usually at 6am-3pm-12midnight and start again at 6am

What is fluid intake exactly?

• 1) It’s the sum of all fluid that the pt took in, it includes:

• 2)All liquids the pt drank• 3)Melted ice chips, the total amt cut in ½• 4)Foods that are liquid by the time they are

swallowed like ice cream, jello (gelatin), thin cooked cereal

• 5)IVFs• 6)Feeding tube liquids

What to measure?

• Fluids• Ice chips• Certain foods• Tube feeding• IVs and IV Meds• Irrigations

• Urine• Diarrhea• Emesis• Drainage• Blood• Aspirated Irrigation

fluids

How to record fluid in…

• ALWAYS recorded in ml…• If a pt drank 8oz glass of water, how many

cc or ml is this?

• Remember that 30mL or cc =1ounce

EQUIVALENTS

• 1 ounce = 30cc or mL• 1 tsp = 5cc or mL• 1 Tbsp = 15cc or mL• 8ounces = 240cc or mL

Check the labels

• Food labels indicate how many ounces it contains

• Facility may have little chart of popcicle =?• Water glass = ? 4 oz jello = ?

FLUID OUTPUT

• What liquids do you count as output?• Urine emesis• Blood loss diarrhea• Wound or tube drainage• Aspirated drainage such as NG output• The wt of a chux pad or diaper must be

counted

How will you know if the patient has had enough in and enough out?

• #1 check with what Dr. wants• Patient’s with normal kidney function

should urinate 30mLs/hr• Children should urinate 10-15mLs/hr

• Usually what goes in should come out. Dr. starts initial IV order so be calculating

Let’s do a problem

• INTAKE (I’s)• 6 ounces of juice in for breakfast• 2 ounces of milk in for breakfast• 8 ounces water in for lunch• 16 ounces pop in for dinner• How many mLs did this pt take in

• OUTPUT (O’s)• 350mLs in a.m.• 220mLs at noon• 530mLs H.S.• How many mLs out did the pt have

What’s wrong with this picture?

FLUID IMBALANCES

• Due to:• • water or fluid movement• • or• • water or fluid loss

HYPOVOLEMIA

• Low volume in the extracellular compartments• Due to:• 1) Inadequate fluid intake• 2) Fluid loss in excess of fluid intake like

vomiting• 3) 3rd spacing• 4) injury such as an amputated limb in MVA

Treatment of hypovolemia

• Replacement of fluids by oral or IV

• Oral when not severe• IVFs when loss is severe

• If due to 3rd spacing, may need protein (albumin) so that water will follow protein back into the blood vessels

HYPERVOLEMIA

• Too much water in = edema• Fluid goes to dependent places like feet• Pitting edema is extreme fluid overload

• Edema doesn’t occur unless the body has 3 liters over what it needs

Treatment of hypervolemia

• If untreated, circulatory failure will occur because there is too much fluid for the heart to pump around…drown

• Treatment includes…

Treatment of hypervolemia

• Treat the disorder causing the overload, if it’s the slow heart, meds to increase the pumping action of the heart are needed

• Reduce or limit oral intake• Reduce salt, where salt goes, water…• Stop IVFs• Administer drugs to release water like lasix,

hydrochlorothiazide or aldactone• Use a combination of all of these

Lasix (furosemide)

• Diuretic – people call this a “water pill”• Side Effects:

– can work too much = dehydration– Hypokalemia = change in heart rhythm called a

dysrhythmia (bad heart beat)– Decrease BP– So now you’ll have dizzy, confusion, nausea

Third spacing

• Remember low proteins caused lots of water to move out of the cells and into the other spaces because there was no protein to follow?

• Causes swelling, can lead to hypotension and shock, your body thinks it has no fluid because it’s NOT in the right places

Treatment of 3rd spacing

• An infusion of albumin which is protein found in plasma (plasma is the fluid in blood, cytoplasm-like jelly with waste and electrolytes in it).

• The water will move back in to the spaces to follow the albumin then you can take the water and albumin out with lasix

• Pt will urinate a lot

Intravenous Solutions

• Their purpose is to:

• Maintain or restore fluid balance when pt can’t take p.o.

• To maintain or replace electrolytes• To provide a source of calories

Names of some IVFs

• Normal saline 0.9% NS• Dextrose 5% + water D5W• ½ Normal saline .45% NS• 5% Dextrose+ .45% NS D5 1/2 NS

• 5% Dextrose + .45%NS + 20Kmeq KCL• D5 1/2% NS+20meqKCL

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REMEMBER…

• If you forgot to record it, IT WASN”T DONE

• Don’t be lazy and forget to do all of your job

The End