![ELECTROLYTE IMBALANCES
● SODIUM IMBALANCE
– HYPONATREMIA [< 135mEq/L serum Na]
•
GI LOSSES [vomiting/diarrhea]
•
KIDNEY DISEASE
•
SKIN LOSS – PERSPIRATION
•
PSYCHOGENIC POLYDYPSIA
•
SIADH (SYNDROME OF INAPPROPRIATE ADH)
27](https://image.slidesharecdn.com/fluidsandelectrolytes-240731132514-891001a9/85/Fluids-and-Electrolytes-for-nursing-pptx-27-320.jpg)
![ELECTROLYTE IMBALANCES
● SODIUM IMBALANCES
– HYPERNATREMIA [>145mEq/L]
•
EXCESS SALT INTAKE
•
INFUSION OF HYPERTONIC SALINE ( 3%, 5%)
•
EXCESS ALDOSTERONE
•
DIABETES INSIPIDUS [low ADH/thirst/dilute urine
excreted – Na+ not excreted]
•
DEHYDRATION [H2O follows Na+, but Na+ does not
follow H2O]
28](https://image.slidesharecdn.com/fluidsandelectrolytes-240731132514-891001a9/85/Fluids-and-Electrolytes-for-nursing-pptx-28-320.jpg)
![ELECTROLYTE IMBALANCES
● POTASSIUM K+
– HYPOKALEMIA [<3.5mEq/L]
•
Common, affects cardiac conductivity/ function
•
POTASSIUM WASTING DIURETICS
•
DIARRHEA, VOMITING
•
ALKALOSIS [shifts into cells in exchange for H+]
•
EXCESSIVE ALDOSTERONE SECRETION
•
POLYURIA
•
EXCESSIVE PERSPIRATION
•
TREATMENT OF DKA WITH INSULIN [decreases serum
potassium by redistributing it into cells] 29](https://image.slidesharecdn.com/fluidsandelectrolytes-240731132514-891001a9/85/Fluids-and-Electrolytes-for-nursing-pptx-29-320.jpg)
![ELECTROLYTE IMBALANCES
● POTASSIUM K+
– HYPERKALEMIA
[>5mEq/L]
•
Cardiac conduction, altered ECG, arrest
•
RENAL FAILURE
•
FLUID VOLUME DEFICIT
•
CELL DAMAGE FROM BURNS, TRAUMA
•
ADRENAL INSUFFICIENCY
•
RAPID INFUSION OF STORED BLOOD
•
POTASSIUM SPARING DIURETICS
•
SALT SUBSTITUTES
30](https://image.slidesharecdn.com/fluidsandelectrolytes-240731132514-891001a9/85/Fluids-and-Electrolytes-for-nursing-pptx-30-320.jpg)
![ELECTROLYTE IMBALANCES
● Hypocalcemia [ionized Ca < 4.5 mEq/L OR total
serum Ca < 8.5mEq/L]
•
Illnesses affecting thyroid, parathyroid
•
Renal failure [not excreting Phosphate] alcoholics,
pancreatitis
•
Neuromuscular and Cardiac sx
•
↑↑reflexes, cramps, numbness/tingling
31](https://image.slidesharecdn.com/fluidsandelectrolytes-240731132514-891001a9/85/Fluids-and-Electrolytes-for-nursing-pptx-31-320.jpg)
![ELECTROLYTE IMBALANCES
● Hypercalcemia [serum Ionized Ca+ > 5.5 or total
serum Ca > 10.5 mEq/L]
•
Immobility, osteoporosis, neoplasm → bone loss of Ca
into blood.
•
Kidney stones, ↓ reflexes, N&V.
32](https://image.slidesharecdn.com/fluidsandelectrolytes-240731132514-891001a9/85/Fluids-and-Electrolytes-for-nursing-pptx-32-320.jpg)
![ELECTROLYTE IMBALANCES
● Magnesium [1.5-2.5 mEq/L]
•
Malnutrition, malabsorption → ↓Mg [looks like ↓Ca] ↓ ↓ -
Mg hyperactive reflexes
•
Excess intake + renal problems → ↑Mg, ↓HR, RR, B/P,
DTR ↓ [e.g. Sulfate in L&D]
● Chloride
•
Follows Na+, Acid/base imbalance
33](https://image.slidesharecdn.com/fluidsandelectrolytes-240731132514-891001a9/85/Fluids-and-Electrolytes-for-nursing-pptx-33-320.jpg)
![REGULATION OF ACID-BASE
•
PHYSIOLOGICAL: Lungs, Kidneys
•
LUNGS Early response
•
•↑ HYDROGEN & CARBON DIOXIDE [acidosis]
•
Stimulates ↑ Respiratory rate, depth → exhaled CO2
•
•↓ Co2 & H+ [alkalosis] → retain CO2 by ↓RR
•
♡ EXAMPLES
•
– DIABETIC KETOACIDOSIS
•
– CO2 RETAINING PATIENTS WITH COPD
40](https://image.slidesharecdn.com/fluidsandelectrolytes-240731132514-891001a9/85/Fluids-and-Electrolytes-for-nursing-pptx-40-320.jpg)
![REGULATION OF ACID-BASE
•
♡ Takes longer/lasts longer
•
– Hours to days
•
♡ Increased or decreased production of Bicarb,
•
excretion of H+ by ammonia formation, phosphoric
•
acid.
•
♡ Acid excess [acidosis] → reabsorption of bicarb,
•
♡ Phosphate + H+ = H3PO4 and NH3- + H+ = NH4 →
•
excretion of H+, lowers acid
41](https://image.slidesharecdn.com/fluidsandelectrolytes-240731132514-891001a9/85/Fluids-and-Electrolytes-for-nursing-pptx-41-320.jpg)
ببFluids and Electrolytes وو for nursing .pptx
- 1. Fluid & Electrolyte balance 1
- 2. Body Composition ◦ Fluid 60% ◦ Solid 40 % Fat Protein Carbohydrate Minerals 2
- 3. Distribution of body fluids (by wt) Fluid 60% of BW ◦ Intracellular ◦ Extracellular Intrstitial Intra vascular(plasma) Intracellular 40% 25 L (cytoplasm, nucleoplasm) Intrastitial 15% 12 L (lymph, CSF, synovial fluid, aqueous humor and vitreous body of eyes, between serous and visceral membranes, glomerular filtrate of kidneys. ) Plasma 5% 3 L There is continuous ongoing equilibrium between the intracellular and extracellular spaces. 3 TBW 40 L
- 4. Fluid content according to age ◦ Total body water (TBW) vary with age: Preterm = 80-85% Term = 75% Infant= 65% Older children & adult male= 60% Adult female=50% • TBW ↓ to 60% by 1st yr of life • Female has less fluid content because of more fat cells 4
- 5. Effective circulating volume (ECV) Def: Portion of the ECF that take part in tissue perfusion. ◦ Only 5% of TBW (intra vascular fluid) are ECV ◦ Adequate ECF must be maintained all the times 5
- 6. Composition of body fluid ◦ Water ◦ Electrolytes: Inorganic salts, Sodium(Na), Potassium(K), Calcium (Ca), Chloride(Cl), Phosphate(Po4), Bicarbonate(HCO3, Sulphate(SO4) ◦ Nonelectrolytes: Minerals -iron and zinc, Glucose, Lipids, Creatinine, Urea 6
- 7. Electrolytes of body fluid ◦ Electrolytes are measured in mEq or mmol ◦ Circulating electrolytes electrically charged ◦ When positively charge called cation: Na+, K+, Ca++ ◦ When negatively charge called anions: Cl- ,HCO3-, SO4- 7
- 8. Electrolytes composition of body fluids Normal Values(serum) ◦ Cation: ◦ Sodium (Na+) 135 – 145 mEq/L ◦ Potassium (K+) 3.5 – 5.50 mEq/L ◦ Calcium (Ca++) 8.5 – 10.5 mg/dL ◦ Ionized Calcium 4.5 – 5.5 mg/dL ◦ Magnesium (Mg++) 1.5 – 2.5 mEq/L ◦ Anion: ◦ Bicarbonate (HCO- 3) 24 – 30 mEq/L ◦ Chloride (Cl--) 95 – 105 mEq/L ◦ Phosphate (PO4 ---) 2.8 – 4.5 mg/dL 8
- 9. Distribution of Cation and Anion in ECF & ICF (mEq/l) INTRA CELLULAR FLUID CATION Mg 1.1 Ca+ 2.5 K+ 4 HCO3– 24 Prot – 14 Others 6 PO4 - 2 Na+ 13 Mg+ 17 Prot- 40 HCO3- 10 Cl- 3 ANION ANION CATION EXTRA CELLULAR FLUID Na+ 140 9 K+ 140 Cl- 140 Phos- 107
- 10. Fluid & Electrolyte balance? 10 INTAKE = OUT PUT
- 11. Daily physiological fluid balance INTAKE ◦ Ingested liquid: 1500 ml ◦ Ingested food: 800 ml ◦ Metabolism: 200 ml Total 2500 ml/day OUTPUT ◦ Kidney: 1500 ml ◦ Skin loss: 600 ml ◦ GI: 100 ml ◦ Lung 300 ml Total 2500 ml Daily fluid balance of an adult 11
- 12. Movement of fluid & electrolytes A. Passive transport (no energy required): ◦ Osmosis: Fluid move from higher concentration to lower concentration ◦ Diffusion = Molecules move from higher concentration to lower (Concentration gradient) ◦ Filtration = Fluid and diffusible substances move together across a membrane; moving from ↑ pressure to ↓ pressure ◦ Hydrostatic pressure : Fluids moves from an area of higher pressure to area of lower pressure B. Active transport( energy required): ◦ Sodium-Potassium Pump 12
- 13. Concentration of Body fluid ◦ Units of solute concentration are osmolarity and osmolality Osmolarity: Number of osmoles of solute per liter (L) of solution. It is expressed as osmol/L e.g 1 mol/L NaCl solution has an osmolarity of 2 osmol/L Osmolality : Number of osmoles of solute per kilogram(kg) of solvent. It is expressed as osmol/kg Normal serum osmolality=280-298 mosmol/kg 13
- 14. Clinical relevance of osmolality Calculation ◦ Serum osmolality (mosmol/kg) = ◦ Effective osmolality: Osmotic force that is mediating the shift of water between the ECF and the ICF = ◦ The osmotic gap (osmolal gap): is the difference between the actual osmolality (measured by the laboratory) and the calculated osmolality ◦ A normal osmolal gap is < 10 mOsm/kg 14 2(Na+ +K+) mmol/l + Urea (mmol/l)+ Glucose (mmol/l) 2 x Na+ (mmol/l )+ Glucose (mmol/l)
- 15. Regulation of Body Fluids Body fluid Homeostasis is maintained through .A Fluid intake .B Hormonal regulation .1 Antidiuretic hormone(ADH) .2 Renin-Angeotensin-Aldosterone Mechanism .3 Natriuretic Peptides .C Fluid output 15
- 16. A. Fluid intake Intake is control by hypothalamic thirst center •↑ plasma osmolality of 1–2% •↓ plasma volume 10%–15% •Baroreceptor input, angiotensin II, and other stimuli •Moistening of the mucosa of the mouth and throat •Activation of stomach and intestinal stretch receptors −ve 16
- 17. 1. Antidiuretic hormone(ADH) ADH: Secreted by the hypothalamus, and stored in the posterior pituitary gland ◦ ADH is released by, thrust, ↓ fluid volume, High serum osmolality ◦ Acton reabsorb water from collecting duct of kidney inhibit sweat glands to ↓ perspiration to conserve water acts on arterioles, causes constriction thus ↑ BP ◦ ADH is Inhibited by Excessive of fluid volume Low osmolality of serum 17 B. Hormonal regulation
- 18. 2. Renin- Angiotensin-Aldosterone Mechanism •Low blood volume •↓Renal perfusion Angiotesinogen Angiotesin I Angiotensin II Aldosterone ACE ↑ Proximal renal tubule Systemic vasoconstriction ↑ Na & Water reabsorption ↑ Na & Water retention •↑ BP Renin • ↑ ADH •↑H2O absorption • Water and salt retention •↑ effective circulating volume •↑Renal perfusion Net effect Jaxtaglomerular apparatus
- 19. 3. Natriuretic Peptides ◦ Natriuretic Peptides ◦ Atrial Natriuretic Peptide(ANP ) from atria ◦ Brain Natriuretic Peptide(BNP) from ventricle ◦ Action Acts like a diuretic that causes sodium loss and inhibits the thirst mechanism Inhibit rennin release Inhibit the secretion of ADH and aldosterone Vasodilatation 19
- 20. C. Regulation by fluid output 20 Daily fluid losses: 2500 ml for an adult Kidney(Urine): 55% Skin: 30% Lung: 10% GI (Stool): 2-5%
- 21. Renal handling of Fluid & Electrolytes Substance Filtered Excreted Net reabsorption Water 180 L 1.5 L 98-99% Na+ 26,000 mmol 100-250 mmol >99% Cl- 21,000 mmol 100-250 >99% K+ 800 mmol 40-120 mmol >85-95% HCO3_ 4,800 mmol 0 mmol 100% Urea 54 gm 27-32 g 40-50% 21
- 23. Regulation of Sodium & Water ◦ Major cation in the ECF (N=135 - 145 mEq/L) ◦ Combines with chloride and bicarbonate to help regulate acid-base balance ◦ Recommended daily in take 2.5gm/day ◦ Kidney regulates sodium balance and is the principal site of sodium excretion ◦ Aldosterone helps in sodium and water conservation 23
- 24. Potassium regulation ◦ Major electrolyte and principle cation in the ICF Regulates metabolic activities Required for glycogen deposits in the liver and skeletal muscle Required for transmission of nerve impulses, normal cardiac conduction and normal smooth and skeletal muscle contraction ◦ Daily intake 1-2 mEq/kg ◦ Regulated by dietary intake and renal excretion ◦ Intestine absorbs about 90% of ingested potassium ◦ Regulate by renin-angiotensin-aldosterone mechanism 24
- 25. Calcium regulation ◦ 99% of calcium is in the bones and teeth ◦ 1% is in ECF ◦ 50% of calcium in the ECF is bound to protein (albumin) ◦ 40% is free & in ionized form-Ionized calcium ◦ Ca++ is needed for Bone and teeth formation Blood clotting Hormone secretion Cell membrane integrity Cardiac conduction Transmission of nerve impulses Muscle contraction 25
- 26. Anions ◦ Chloride (Cl-) ◦ Major anion in ECF ◦ Follows sodium ◦ Bicarbonate (HCO3 -) ◦ Is the major chemical base buffer required for acid base balance ◦ Is found in ECF and ICF ◦ Regulated by kidneys 26
- 27. ELECTROLYTE IMBALANCES ● SODIUM IMBALANCE – HYPONATREMIA [< 135mEq/L serum Na] • GI LOSSES [vomiting/diarrhea] • KIDNEY DISEASE • SKIN LOSS – PERSPIRATION • PSYCHOGENIC POLYDYPSIA • SIADH (SYNDROME OF INAPPROPRIATE ADH) 27
- 28. ELECTROLYTE IMBALANCES ● SODIUM IMBALANCES – HYPERNATREMIA [>145mEq/L] • EXCESS SALT INTAKE • INFUSION OF HYPERTONIC SALINE ( 3%, 5%) • EXCESS ALDOSTERONE • DIABETES INSIPIDUS [low ADH/thirst/dilute urine excreted – Na+ not excreted] • DEHYDRATION [H2O follows Na+, but Na+ does not follow H2O] 28
- 29. ELECTROLYTE IMBALANCES ● POTASSIUM K+ – HYPOKALEMIA [<3.5mEq/L] • Common, affects cardiac conductivity/ function • POTASSIUM WASTING DIURETICS • DIARRHEA, VOMITING • ALKALOSIS [shifts into cells in exchange for H+] • EXCESSIVE ALDOSTERONE SECRETION • POLYURIA • EXCESSIVE PERSPIRATION • TREATMENT OF DKA WITH INSULIN [decreases serum potassium by redistributing it into cells] 29
- 30. ELECTROLYTE IMBALANCES ● POTASSIUM K+ – HYPERKALEMIA [>5mEq/L] • Cardiac conduction, altered ECG, arrest • RENAL FAILURE • FLUID VOLUME DEFICIT • CELL DAMAGE FROM BURNS, TRAUMA • ADRENAL INSUFFICIENCY • RAPID INFUSION OF STORED BLOOD • POTASSIUM SPARING DIURETICS • SALT SUBSTITUTES 30
- 31. ELECTROLYTE IMBALANCES ● Hypocalcemia [ionized Ca < 4.5 mEq/L OR total serum Ca < 8.5mEq/L] • Illnesses affecting thyroid, parathyroid • Renal failure [not excreting Phosphate] alcoholics, pancreatitis • Neuromuscular and Cardiac sx • ↑↑reflexes, cramps, numbness/tingling 31
- 32. ELECTROLYTE IMBALANCES ● Hypercalcemia [serum Ionized Ca+ > 5.5 or total serum Ca > 10.5 mEq/L] • Immobility, osteoporosis, neoplasm → bone loss of Ca into blood. • Kidney stones, ↓ reflexes, N&V. 32
- 33. ELECTROLYTE IMBALANCES ● Magnesium [1.5-2.5 mEq/L] • Malnutrition, malabsorption → ↓Mg [looks like ↓Ca] ↓ ↓ - Mg hyperactive reflexes • Excess intake + renal problems → ↑Mg, ↓HR, RR, B/P, DTR ↓ [e.g. Sulfate in L&D] ● Chloride • Follows Na+, Acid/base imbalance 33
- 34. Fluid Imbalance ◦ Fluid deficit -Dehydration ◦ Fluid excess- Hypervolemia 34
- 35. Dehydration ◦ Abnormal fluid loss causes fluid deficit called dehydration ◦ Conditions can leads to dehydration: Skin: Fever, under heater, heat exhaustion, burn GI: Gastroenteritis, fistula, intestinal obstruction Lung: Tachypnea Kidney: Polyuria e.g. diabetes Miscellaneous: Surgical drain, third spacing 35
- 36. According to serum Sodium (Na) concentration: ◦ Isonatremic (Isotonic)=S. Na 135-150 mmol/l ◦ Hyponatremic (Hypotonic)= S. Na <135 mmol/l ◦ Hypernatremic (Hypertonic)= S. Na>150 mmol/l Types of dehydration 36
- 37. What types of IV fluid ? Types of IVF used: ◦ Normal saline (0.9% NaCl/L) = 154 mEq Na+/L ◦ One-half NS (0.45% NaCl/L) = 77 mEq Na+/L ◦ One-third NS (0.33% NaCl/L) = 57 mEq Na+/L ◦ One-quarter NS (0.25% NaCl/L) = 38 mEq Na+/L ◦ One fifth NS(0.18% Nacl) = 30 mmol/l ◦ Ringer’s lactate= Na+ 130 mmol/l, K+ 4 mmol/l, Cl- 109 mmol/l, bicarb 28 mmol/l , and Ca++ 3 mg/dl ) 37
- 38. REGULATION OF ACID-BASE BALANC 38 — BUFFER A SUBSTANCE THAT CAN EITHER ABSORB OR RELEASE A HYDROGEN ION (H+) — ARTERIAL pH REFLECTS TH CONCENTRATION OF HYDROGEN IONS IN THE BLOOD — THE pH SCALE MEASURES THE ACIDITY OR ALKALINITY OF A FLUID
- 39. REGULATION OF ACID-BASE • BIOLOGICAL REGULATION OF Ph • ● BUFFERING SYSTEMS • ★ HYDROGEN IONS ARE ABSORBED OR • RELEASED BY THE CELLS. • — SWITCH PLACES WITH POTASSIUM. • ★ HEMOGLOBIN-OXYHEMOGLOBIN SYSTEM. • ★ CHLORIDE SHIFT WITHIN RBC. 39
- 40. REGULATION OF ACID-BASE • PHYSIOLOGICAL: Lungs, Kidneys • LUNGS Early response • •↑ HYDROGEN & CARBON DIOXIDE [acidosis] • Stimulates ↑ Respiratory rate, depth → exhaled CO2 • •↓ Co2 & H+ [alkalosis] → retain CO2 by ↓RR • ♡ EXAMPLES • – DIABETIC KETOACIDOSIS • – CO2 RETAINING PATIENTS WITH COPD 40
- 41. REGULATION OF ACID-BASE • ♡ Takes longer/lasts longer • – Hours to days • ♡ Increased or decreased production of Bicarb, • excretion of H+ by ammonia formation, phosphoric • acid. • ♡ Acid excess [acidosis] → reabsorption of bicarb, • ♡ Phosphate + H+ = H3PO4 and NH3- + H+ = NH4 → • excretion of H+, lowers acid 41
- 42. TYPES OF ACID-BASE IMBALAN ◦ RESPIRATORY ACIDOSIS ◦ RESPIRATORY ALKALOSIS ◦ METABOLIC ACIDOSIS ◦ METABOLIC ALKALOSIS Name reflects underlying cause, compensation 42
- 43. Blood Gases & Acid/Base Normal arterial blood pH Acidosis Alkalosis Respiratory Acidos – Reflected in PaCO2: [35 ▪︎ resp rate from any cause blo ▪︎ Resp rate from any cause con – Compensation is 43
- 44. Blood Gases & Acid/Base Metabolic Acidos – Base Excess: amount of buffer [Hg – Normal : -2mEq/L - +2mEq/L [H – Alkalosis: BE > +2mEq/L o ▪︎[from acid loss/ vomiting, gas – Acidosis: BE< -2 mEq/L or ▪︎[e.g. from diarrhea, re – Compensation is via Respira 44