Transcript N246 Renal Fluid and Electrolytes created by S. Buckley, RN, MS copyright:2012 all rights reserved Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate.

N246
Renal
Fluid and Electrolytes
created by S. Buckley, RN, MS
copyright:2012 all rights reserved
Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Homeostasis
• State of equilibrium in body
• Naturally maintained by adaptive
responses
• Body fluids and electrolytes are
maintained within narrow limits
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Why nurses need to understand
fluid and electrolytes?
• Important to anticipate the potential for
alterations in fluid and electrolyte balance
associated with certain disorders and
medical therapies, to recognize the signs
and symptoms of imbalances, and to
intervene with the appropriate action.
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Enhanced understanding and
management of fluids and
electrolytes
• Composition of body fluids
• Fluid compartments/Extracellular fluid osmolality
• Factors that affect movement of water and
solutes
• Regulation of vascular volume
• Facilitated by clinical condition understanding,
nursing assessment, lab analysis
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Composition of body fluids
(water content of body)
• 60% of body weight in adult
• 45% to 55% in older adults
• 70% to 80% in infants
– Varies with gender, body mass, and age
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Changes in Water Content with
Age
Fig. 17-1
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Composition of body fluids
• In addition to water, the body contains solutes;
substances the separate in solution and conduct
electrical current.
• Concentration of solutes in solution=osmolality or
osmolarity.
• May by electrolytes or non-electrolytes:
• Cations(+), Na, K
• Anions (-), CL, HCO-3 (bicarbonate), PO
• Non-electrolytes (glucose, urea, creatinine, bilirubin)
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Fluid Compartments
• Intracellular fluid (ICF): Located within
cells
42% of body weight
• Extracellular fluid (ECF)-found outside cell
– Intravascular (plasma)
– Interstitial
– lymph
– Transcellular
30% of body weight
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Fluid Compartments of the Body
Fig. 17-2
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Transcellular Fluid
• Part of ECF
• Small but important/Approximately 1
Includes fluid in
– Cerebrospinal fluid
– Pericardial fluid
– Pleural spaces
– Synovial spaces
– Intraocular fluid
– Digestive secretions
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Factors that affect Fluid and
Electrolyte Movement
•
•
•
•
•
•
•
Membranes
Osmosis
Diffusion
Facilitated diffusion
Active transport
Hydrostatic pressure
Oncotic pressure
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Membrane physiology
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Transport process
•
•
•
•
Osmosis
Diffusion
Active transport
filtration
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Osmosis
• Movement of water between two
compartments by a membrane permeable
to water but not to solute
• Moves from low solute to high solute
concentration
• Requires no energy
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Terms associated with osmosis
• Osmotic Pressure: amount of pressure required to stop
osmotic flow of water. Determined by concentration of
solutes in solution
• Oncotic pressure: pressure exerted by colloids
(proteins, such as albumin)
• Osmotic diuresis: increased urine output (caused by
substances such as mannitol, glucose or contrast
medium)
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Osmotic movement of fluids
• Cells affected by osmolality of the fluid that
surrounds them.
• Isotonic-fluid with same osmolality as cell interior
• Hypotonic (hypoosmolar)-solutes are less
concentrated than cells.
• hypertonic (hyperosmolar)-solutes more
concentrated than cells.
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Diffusion
• Random movement of particles in all
directions from an area of high
concentration to low concentration.
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Active transport
• Relies on availability of carrier substances,
utilizes energy (ATP), to transport solutes
in and out of cells.
• Na, K, hydrogen, glucose, amino-acids,
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Filtration
• Movement of water and solutes from area
of high hydrostatic pressure to area of low
hydrostatic pressure that is created by
“weight” of fluid. Kidney is example; (filters
180L/day plasma)
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Hydrostatic Pressure
• Force within a fluid compartment
• Major force that pushes water out of
vascular system at capillary level
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Fluid Movement in Capillaries
• Amount and direction of movement
determined by
– Capillary hydrostatic pressure
– Plasma oncotic pressure
– Interstitial hydrostatic pressure
– Interstitial oncotic pressure
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Fluid Exchange Between
Capillary and Tissue
Fig. 17-8
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Fluid Shifts
• Plasma to interstitial fluid shift results in
edema
– Elevation of hydrostatic pressure
– Decrease in plasma oncotic pressure
– Elevation of interstitial oncotic pressure
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Fluid Shifts (Cont’d)
• Interstitial fluid to plasma
– Fluid drawn into plasma space with increase
in plasma osmotic or oncotic pressure
– Compression stockings decrease peripheral
edema
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Fluid Movement between
ECF and ICF
• Water deficit (increased ECF)
– Associated with symptoms that result from cell
shrinkage as water is pulled into vascular
system
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Fluid Movement between
ECF and ICF (Cont’d)
• Water excess (decreased ECF)
– Develops from gain or retention of excess
water
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Fluid Spacing
• First spacing
– Normal distribution of fluid in ICF and ECF
• Second spacing
– Abnormal accumulation of interstitial fluid
(edema)
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Fluid Spacing (Cont’d)
• Third spacing
– Fluid accumulation in part of body where it is
not easily exchanged with ECF; fluid trapped
and unavailable for functional use (ascites)
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3rd spacing, fluid shift from
intravascular to interstitial space;
edema
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Regulation of Water Balance
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Hypothalamic regulation
Pituitary regulation
Adrenal cortical regulation
Renal regulation
Cardiac regulation
Gastrointestinal regulation
Insensible water loss
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Normal fluid balance
• Intake: fluids, food, oxidation=~2500ml
• Output: skin and lungs (insensible loss)-900ml, feces-100ml,
urine-1500ml=~2500ml/day
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Hypothalamic Regulation
• Osmoreceptors in hypothalamus sense
fluid deficit or increase
– Stimulates thirst and antidiuretic hormone
(ADH) release
– Result in increased free water and decreased
plasma osmolarity
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Pituitary Regulation
• Under control of hypothalamus, posterior
pituitary releases ADH
• Stress, nausea, nicotine, and morphine
also stimulate ADH release
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Adrenal Cortical Regulation
• Releases hormones to regulate water and
electrolytes
– Glucocorticoids
• Cortisol
– Mineralocorticoids
• Aldosterone
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Factors Affecting Aldosterone
Secretion
Fig. 17-9
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Renal Regulation
• Primary organs for regulating fluid and
electrolyte balance
– Adjusting urine volume
• Selective reabsorption of water and electrolytes
• Renal tubules are sites of action of ADH and
aldosterone
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Effects of Stress on F&E
Balance
Fig. 17-10
Cardiac Regulation
• Natriuretic peptides are antagonists to the
RAAS
– Produced by cardiomyocytes in response to
increased atrial pressure
– Suppress secretion of aldosterone, renin, and
ADH to decrease blood volume and pressure
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Gastrointestinal Regulation
• Oral intake accounts for most water
• Small amounts of water are eliminated by
gastrointestinal tract in feces
• Diarrhea and vomiting can lead to
significant fluid and electrolyte loss
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Insensible Water Loss
• Invisible vaporization from lungs and skin
to regulate body temperature
– Approximately 600 to 900 ml/day
is lost
– No electrolytes are lost
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Gerontologic Considerations
• Structural changes in kidneys decrease
ability to conserve water
• Hormonal changes lead to decrease in
ADH and ANP
• Loss of subcutaneous tissue leads to
increased loss of moisture
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Gerontologic Considerations (Cont’d)
• Reduced thirst mechanism results in
decreased fluid intake
• Nurse must assess for these changes and
implement treatment accordingly
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Fluid and Electrolyte
Imbalances
• Common in most patients with illness
– Directly caused by illness or disease (burns or
heart failure)
– Result of therapeutic measures
(IV fluid replacement or diuretics)
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Extracellular Fluid Volume
Imbalances
• ECF volume deficit (hypovolemia)
– Abnormal loss of normal body fluids (diarrhea,
fistula drainage, hemorrhage), inadequate
intake , or plasma-to-interstitial fluid shift
– Treatment: replace water and electrolytes with
balanced IV solutions
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Extracellular Fluid Volume
Imbalances (Cont’d)
• Fluid volume excess (hypervolemia)
– Excessive intake of fluids, abnormal retention
of fluids (CHF), or interstitial-to-plasma fluid
shift
– Treatment: remove fluid without changing
electrolyte composition or osmolality of ECF
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Nursing Management
Nursing Diagnoses
• Hypovolemia
– Deficient fluid volume
– Decreased cardiac output
– Potential complication: hypovolemic shock
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Nursing Management
Nursing Implementation
(Cont’d)
• Neurologic function
– LOC
– PERLA
– Voluntary movement of extremities
– Muscle strength
– Reflexes
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Nursing Management
Nursing Diagnoses (Cont’d)
• Hypervolemia
– Excess fluid volume
– Ineffective airway clearance
– Risk for impaired skin integrity
– Disturbed body image
– Potential complications: pulmonary edema,
ascites
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Nursing Management
Nursing Implementation
• I&O
• Monitor cardiovascular changes
• Assess respiratory status and monitor
changes
• Daily weights
• Skin assessment
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Electrolytes
• Substances whose molecules dissociate
into ions (charged particles) when placed
into water
– Cations: positively charged (Na, K, Ca2, Mg2)
– Anions: negatively charged (HCO3, CL, PO4 3)
– Measurement; International standard is millimoles per liter
(mmol/L), U.S. uses milliequivalent (mEq)
– Ions combine mEq for mEq
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Electrolyte Composition
• ICF
– Prevalent cation is K+
– Prevalent anion is PO43-
• ECF
– Prevalent cation is Na+
– Prevalent anion is Cl-
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Sodium
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•
Serum levels; 135-145mEq/L
Responsible for water balance and
determination of plasma osmolality
Cation+,plays a major role in
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–
ECF volume and concentration (movement of Clclosely associated with Na+)
•
Imbalances can exist in different volume
states: euvolemia (normal volume), hypovolemia (low volume),
hypervolemia (increased volume)
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Na+ (continued)
– Generation and transmission of nerve
impulses
– Acid–base balance (combining HCO3 and CL to alter
pH)
– Impacted by hormonal control (aldosterone, ADH)
• Dietary level: current recommendation 500mg-2300mg/day,
Western diet; 4000-6000mg/day!!! Primary source; table salt (NaCL)
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Differential Assessment of
ECF Volume
Fig. 17-12
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Potassium
• Major cation of ICF
• Serum level: 3.5-5.0mEq/L
• Necessary for
– Transmission and conduction of nerve and
muscle impulses
– Control via sodium-potassium pump (contained
within cell membrane of all cells/utilizes ATP)
– Inverse relationship between Na+ and K+reabsorption in the
kidney; factors that cause Na+ retention cause K+ loss in the
urine.
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K+ (continued)
• Kidneys eliminate 90% of K+, thus if renal function
impaired, toxic levels may be retained.
• Dietary level: 40-60mEq/day, Western diet inclusive of K+
salt substitutes may contain K+
• Maintenance of cardiac rhythms/function
• Acid–base balance
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Calcium (Ca2+)
• Function: transmission of nerve impulses,
muscle/myocardial contraction, blood clotting, formation
of teeth and bones
• Balance controlled by PTH, calcitonin, vitamin D
• Obtained from diet, daily need: 1-1.5G/d
• More than 99% combined with phosphorus
and concentrated in skeletal system
• Inverse relationship with phosphorus
• Serum Level:8.5-10.5 mg/dl
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Tests for Hypocalcemia
Fig. 17-15
Phosphate/phosphorus (PO4-/P+)
• Serum Level: 2.5-4.5mg/dL
• Primary anion in ICF
• Essential to function of muscle, red blood
cells, nervous system and Ca+levels
• Deposited with calcium for bone and tooth
structure, Ca+ and P+ exist in a reciprocal balance
• Required for release of O2 from
hemoglobin
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PO4- (continued)
• Involved in acid–base buffering system
(phosphate buffer), ATP production, and cellular
uptake of glucose
• 90% excreted by Kidneys; requires
adequate renal functioning
• Dietary level; intake via balanced diet,
daily need: 800-1600mg/dl
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Magnesium
• 2nd most abundant cation in ICF
• Serum level: 1.4-2.1 mEq/L
• Daily need: 300-350mg (average Western diet
contains 170-720mg/day)
• Coenzyme in metabolism of protein,
carbohydrate and Ca+ absorption and
utilization (Factors that regulate calcium balance appear to
influence magnesium balance)
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Mg+
(continued)
• Acts directly on myoneural junction to
transmit electrical impulses (relaxes lung muscles
that open airways)
• Important for normal cardiac function
• Powers Na+/K+ pump
• Plays essential role in secretion and action
of insulin (impacts BG)
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Chloride
• Major ECF anion
• Serum level: 95-108 mEq/L
• Function; circulates with Na+ and H2O to
help maintain cellular integrity, fluid
balance and osmotic pressure
• Affects acid/base balance (enzyme activator,
serves as buffer in exchange of O2 and CO2 in RBC’s)
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CL- (continued)
• In conjunction with Ca+, Mg+, helps maintain
nerve transmission/muscle function
• Vital role in production of HCL
• Obtained primarily from foods (processed) and
table salt, daily need: ~750mg.
• 90% excreted by kidney
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IV Fluids
•
Purposes
1. Maintenance
•
When oral intake is not adequate
2. Replacement
•
When losses have occurred
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IV Fluids (Cont’d)
• Hypotonic
– More water than electrolytes
• Pure water lyses RBCs
– Water moves from ECF to ICF by osmosis
– Usually maintenance fluids
• Isotonic
– Expands only ECF
– No net loss or gain from ICF
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IV Fluids (Cont’d)
• Hypertonic
– Initially expands and raises the osmolality of
ECF
– Require frequent monitoring of
• Blood pressure
• Lung sounds
• Serum sodium levels
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D5W
• Isotonic
• Provides 170 cal/L
• Free water
– Moves into ICF
– Increases renal solute excretion
• Used to replace water losses and treat
hyponatremia
• Does not provide electrolytes
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Normal Saline (NS)
• Isotonic
• No calories
• Expands IV volume
– Preferred fluid for immediate response
• Does not change ICF volume
• Compatible with most medications/blood
administration
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Lactated Ringer’s
• Isotonic
• More similar to plasma than NS
– Has less NaCl
– Has K, Ca, PO43-, lactate (metabolized to
HCO3)
• Expands ECF
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D5 ½ NS
• Hypertonic
• Common maintenance fluid
• KCl added for maintenance or
replacement
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D10W
•
•
•
•
Hypertonic
Provides 340 kcal/L
Free water
Limit of dextrose concentration may be
infused peripherally
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Plasma Expanders
• Stay in vascular space and increase
osmotic pressure
• Colloids (protein solutions)
– Packed RBCs
– Albumin
– Plasma
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Diuretics
• Act by increasing volume of urine
production in tx of hypertension, heart
failure, and kidney disorders.
• Electrolyte depletion common
(hypokalemia)
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Nursing interventions
• I&O, loc, nutritional status, monitor liver and
kidney function, observe for hypersensitivity,
monitor hearing and vision (loop/lasix are
ototoxic, thiazide may impact vision), monitor
alcohol and caffeine (diuretic), safety (oh),
monitor light exposure (photosensitivity), monitor
edema, labs, admin in am.
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References
*Copyright@ by S. Buckley, 2012 (all rights reserved)
Medical-Surgical Nursing
Lewis, Heitkemper, Kirksen, Obrien, Bucher,
Taber’s cyclopedic Medical Dictionary
Venes, 19th edition
Pharmacology, A nursing approach
Kee, Hayes, 3rd edition
Fluid and Electrolytes
Innerarity, Stark, 3rd edition
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References (continued)
Fluid, Electrolyte, and Acid-base Balance
Heitz, Horne-Mosby, 4th edition
IV Therapy made incredibly Easy!
McCann, Lippincott, 3rd edition
Acute Renal Failure
Hudson, Rn, MSN
Electronic source; dynamicnursingeducation.com
Fluid & Electrolytes
Chernecky, Macklin, Murphy-ende, Saunders 2002
Fluids, Electrolytes & Acid-Base Balance
Hogan, Wane, Prentice Hall nursing
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