NURSING

APPLICATION:
WEEK
Fluids, 6 and Acid-Base Balance;
Electrolytes,
Alterations of Cardiovascular Function
FLUIDS,
ELECTROLYTES,
AND ACID-BASE
BALANCE
 WATER DISTRIBUTION

Plasma Osmolality
• Measure the number of solutes in plasma
Plasma Oncotic Pressure
• Measure of pressure exerted by solutes in plasma
• Albumin
Together, both determine the direction of water movement

3
• Hydrostatic pressure
Oncotic pressure
•
FLUID DISTRIBUTION
• Renin-Angiotensin-Aldosterone System (RAAS)

4
THE KIDNEYS
Sodium

Chloride

Regulation
• Renin-angiotensin-aldosterone system
• Aldosterone – sodium & water reabsorption
• K+ and H+ excretion
• Connect the dots to high blood pressure and
ACE inhibitors: we are stopping the
conversion

5
 FLUIDS – KEY TERMS
• Intravascular
• Blood plasma (~5% of body weight)

• Intracellular
• All fluids within cells (~40% of body weight)

• Extracellular
• All fluid outside of the cells (~20% of body weight)

• Interstitial
• The space between cells and outside the blood vessels (~15% of body weight)

• Third-spacing
• Large amounts of intravascular fluid are lost to interstitial spaces

6
ALTERATIONS TO FLUID VOLUME
Isotonic alterations
• Total body water changes accompany proportional changes in the concentrations of electrolytes
• Isotonic fluid loss causes dehydration and hypovolemia (ex. Hemorrhage, severe wound drainage, inadequate fluid
intake)
• Isotonic fluid excess causes hypervolemia (ex. Excessive administration of IV fluids, hypersecretion of aldosterone),
common treatment: diuretics
Hypotonic alterations
• Occur when the osmolality of the ECF is less than normal (Ex. Sodium deficit or water excess)
• Leads to cellular overhydration (cell swelling/edema)
Hypertonic alterations
• Develop when the osmolality of the ECF is elevated above normal. (ex. Increased concentration of ECF sodium=
hypernatremia, or deficit of ECF water, or both)
• ECF hypertonicity attracts water from the intracellular space, causing ICF dehydration

7
ALTERATIONS TO FLUID VOLUME

8
 TYPES OF IV FLUID ADMINISTRATION

• Isotonic
• 0.9% NaCl (Normal Saline)
• Ringers Lactate

• Hypotonic
• 0.45% NaCl

• Hypertonic
• D5W in ½ NS (0.45%)

9
ASSESSMENT OF FLUIDS
Why do we give fluids?

Multi-system effects:

• CVS
• Respiratory
• Neuromuscular
• Renal
• Integumentary
• GI
• Age-related considerations?

10
FLUID OVERLOAD VS. FLUID DEFICIT
Fluid Volume Overload (Hypervolemia) Fluid Volume Deficit (Hypovolemia)
• Causes: • Causes:
• Inadequately controlled IV therapy
• Inadequate intake of fluids and solutes
• Kidney disease
• Long term steroid therapy • Fluid shifts between compartments
• Excessive sodium ingestion • Excessive losses of isotonic body fluids
• Heart failure
• Syndrome of Inappropriate Anti-Diuretic • Signs and symptoms:
Hormone (SIADH) • Increased pulse, flat veins, decreased urine
• Signs and symptoms: output, dry skin, poor skin turgor
• Elevated BP, dyspnea, crackles, increased urine
output, edema, increased body weight

11
 QUIZ QUESTION:
The nurse is caring for a client with heart failure. On assessment, the nurse notes that
the client is dyspneic, and crackles are audible on auscultation. What additional
manifestations would the nurse expect to note in this client if excess fluid volume is
present?
a) Weight loss and dry skin
b) Flat neck and hand veins and decreased urinary output
c) An increase in BP and increased respirations
d) Weakness and decreased BP

12
EDEMA

2/11/20XX 13
REVIEW: IMPORTANT MECHANISMS RELATED TO
EDEMA
Capillary Hydrostatic Pressure Capillary (Plasma) Oncotic Pressure
• Capillary hydrostatic pressure (blood pressure) • Capillary (plasma) oncotic pressure osmotically
facilitates the outward movement of H2O from
the capillary to the interstitial space attracts water from the interstitial space through
and into the capillary.
• Ex:
• With this, lost or diminished plasma albumin
• Increased capillary hydrostatic pressure can
contributes to decreased plasma pressure.
cause edema from either venous
obstruction or salt/water retention. • Because there is less oncotic attraction of the
fluids within the capillaries, fluid moves into the
• This causes a pressure increase behind the interstitial space, causing edema.
obstruction, pushing fluid out of the
capillaries and into the interstitial spaces

Albumin is a protein that keeps fluid in the intravascular space, limiting movement into the
interstitial space

14
EDEMA
Causes can be:
• Generalized or organ-specific
• Cardiac or renal
• Pitting edema
• Heart failure, pregnancy, post-partum
• Non-pitting edema
• Lymphedema, localized

15
 WHAT SIGNS AND SYMPTOMS
DO YOU EXPECT TO SEE IN A
PATIENT WITH EDEMA?
• Weight gain, swelling, puffiness
• Tight fitting clothes and shoes
• Limited movement of affected joints
• Blood flow may be impaired:
• Slower healing wounds
• Risk of infection
• Pressure sores
• Dehydration

PRESENTATION TITLE 16
 HYPONATREMIA
• Normal levels: 135 – 145 mmol/L
• A patient is hyponatremic at Na+ <135 mmol/L
• Causes:
• Increased sodium excretion, excessive diuresis, vomiting
• Inadequate sodium intake
• Dilution of serum sodium
• SIADH
• Signs and symptoms:
• Lethargy, confusion, decreased deep tendon reflexes, seizures,
coma
• Hypovolemia: hypotension, tachycardia
• Treatment
• Dependent on cause
• Ex. SIADH: Fluid restriction
• Hypovolemia: Supplemental fluid

PRESENTATION TITLE 17
 HYPERNATREMIA
• Normal levels: 135 – 145 mmol/L
• A patient is hypernatremic at Na+ >145 mmol/L
• Causes:
• Decreased sodium excretion (corticosteroids, kidney disease)
• Increased sodium intake
• Decreased water intake
• Increased water loss: fever, infection, diaphoresis, watery diarrhea
• Signs and Symptoms:
• Related to cause
• Hypertension, pulmonary edema, intracellular dehydration,
convulsions
• Interventions:
• Supplemental ADH
• Diuretics
• If caused by inadequate excretion
• IV fluids if caused by fluid loss

PRESENTATION TITLE 18
 HYPOKALEMIA
• Potassium less than 3.5 mmol/L *
• Causes:
• Actual total body potassium loss: diuretics, vomiting, diarrhea,
prolonged NG suction, excessive diaphoresis
• Inadequate K+ intake (diet)
• Dilution
• Water intoxication, IV therapy
• Interventions:
• Monitor electrolyte levels
• Provide supplements (oral or IV)
• Diet
• K+ losing diuretics: HOLD
• Effects:
• Skeletal muscle weakness
• ECG changes

PRESENTATION TITLE 19
 HYPERKALEMIA
• Serum potassium level that exceeds 5.0 mmol/L *
• Causes:
• Excessive K+ intake (IV or PO)
• Decreased potassium excretion (medications, kidney
disease)
• Signs and symptoms:
• Interventions:
• Diet
• IV intake
• Medications
• Dialysis
• Effects:
• Dysrhythmias
• Cardiac arrest

PRESENTATION TITLE 20
RHYTHM CHANGES: HYPER- VS.
HYPOKALEMIA

21
HYPER- VS. HYPOKALEMIA

22
 QUIZ QUESTION
Which documentation note in the client’s record indicates that the client is at risk for
developing potassium deficit?
a) Sustained tissue damage
b) Requires nasogastric suction
c) Has a history of Addison’s disease
d) Uric acid level of 0.564 mmol/L

23
 ACID-BASE BALANCE
See separate PPT and Panopto: ABG’s in 20.

PRESENTATION TITLE 24