Intracellular fluid
2/3 of body fluid
Most in skeletal muscle mass
Extracellular fluid
1/3 of the body fluid
Third spacing
-Fluid that is not useable for body composition
-Swelling all over body
-Peripheral edema
-They will appear to be gaining weight but hte fluid Is going to areas where there is lots of edema
Third spacing signs
-Decreased urine output with adequate fluid intake
-Burns, sepsis, bleeding
-Pitting and non pitting edema
Osmosis and osmolaity
Movement of water, sleeping on textbook and drools and sucks up the information from the textbook
Diffusion
Higher to lower concentration, kool aid into water
Filtration
Lower to higher, kidneys
What is the best way to measure fluid intake and output
Daily weight
Urine Specific Gravity
1.010-1.025
Up when depleted
Down when overloaded
BUN
10-20mg, unreliable factor of kidney function, elevate in dehydration, increased protein, only time to decrease is protein malnutrition
Creatinine
0.6-1.4, not indicated by fluid status, best indication of renal function
Hematocrit
Should take patients hemoglobin x3 and that is the hematocrit, hemoglobin (12)- hematocrit (32)
Volume depleted
Hemoglobin 12 - hematocrit 48%
Volume overload
Hemoglobin 12 -
Hematocrit 24%
ANP (atrial natriuretic peptide)
Secreted in response to excess blood volume in the heart, promotes salt and thus water excretion, normal level 20-77, determines CHF, anything greater than 200
ADH
secreted in volume depletion, holds onto fluid (synthetic= vasopressin)
Aldosterone
Holds onto sodium and water and gets rid of potassium, fluid volume deprived
Cortisol
Stress response, holds onto sodium and water
Central venous pressure
2.6 mm
Hypovolemia Causes
Diarrhea, vomiting, fever, exercise, diuretics, blood loss, burns, third spacing
Hypovolemia Clinical Manifestations
Hypotension, tachycardia, decreased urine output, decreased CVP, weight loss unless third spacing
Hypotension medical management
IV fluids, oral intake, vasopressin, ADH, antibiotics and diarrheals
Hypervolemia causes
CHF, kidney disease, neuro causes, schizophrenia
Hypervolemia manifestations
JVD, weight gain, peripheral edema, decrease in hematocrit, hypertension, tachycardia, increase in CVP, pulmonary edema (Crackles/rales)
Hypervolemia medical management
Diuretics, nutritional therapy
Crystalloid solutions
-Cheap, readily available, contain water, electrolytes and sugar
-Isotonic, hypotonic, and hypertonic (relation of concentration to things in the solution)
Isotonic solutions
-Same concentration as plasma
-Same electrolytes as plasma
-Replaces intravascular
-Once vascular space is filled then it starts replacing intracellular
-Normal saline 0.9%
-Lactated-ringer's
-D5W
Normal Saline 0.9%
Trauma, losing lots of blood, can mix with blood, cold effects (have to warm this)
Lactated ringers
-Has calcium and potassium in it
-Never use because of its potassium content (renal failure)(hyperkalemia), cold can trigger coagulation, can develop DIC
D5W
-5% dextrose in water
-When hanging on the IV pole it is isotonic, and when it is transfused it is hypotonic
-Insulin pushes dextrose into cells
-Brain issues = no D5W (causes cerebral edema, increased ICP)
Hyoptonic
-Given when the cell is dehydrated (DKA)
Replace cellular fluid
-Provide free water to excrete body wastes
-0.45% sodium chloride
-Makes cells swell up
-Goes into cells
-Worsen intravascular depletion
-Leave vascular places and go to cells
Hypertonic
-Dextrose 50%
-3 and 5% sodium chloride
-Critical care unit
-Frequent electrolyte checks
-Relieve cerebral edema
-Intravascular volume overload (brings everything to the intravascular space and out of cells)
-Dehydration
-Pulmonary edema is biggest concer
Colloids
-More expensive
-Plasma expander, replace plasma loss
-Effect clotting ability
-Increase cardiac output
-Stay in vascular system longer
-Blood and albumin
Blood administration
-Cross match
-Prime with normal saline
-Infused less than 4 hours
-Two licensed professionals approval
-Older the blood = higher potassium count
Blood reactions
-Allergic reaction
-Hemolytic reactions
-Be with patient for 30 mins
PICC lines and midline cath
-Longer IV access
-Own protocol
-long term antibiotics
-Need consent
-TPN, antibiotics
Air embolism
-Central lines are the biggest risk
-Turn then on their side, right side up, head down (Trendelenburg's)
-Keep air at the top of the heart
-Prevent from getting into pulmonary circulation
IV complecations
-Fluid overload
-Air embolism
-Febrile reaction
-Infection
IV infiltration
-Pale, swollen, and cold
-Get the IV out and get another one started
-Elevate extremity
-Fluid is leaking out into interstitials space
IV infiltration (types of issues)
-Vesicants- necrose the tissue and cause blisters
-Chemo drugs, D-50, 3% and 5% NS, vasopressors, potassium, hypertonic solutions
-Reverse agent: hyaluronic acid
Phlebitis
-Red, warm and swollen, infection in the vein, elevate extremity and get the IV out
CVAD
-PICC line
-Central line
-Implanted infusion port
How do we measure CVP? (central venous pressure?
Fluid status in the right atrium
Pneumothorax
Puncture lung, air in the lung
Bleeding symptoms
-Tachycardic, hypotensive
-treat like fluid defecit
No lactated ringers in..?
Renal patients (has potassium in it and they can't excrete
Intracranial pressure
5-15
Burn patients
-Third-spacing
-Present as hypovolemia
-Look hypervolemic but are hypovolemic
-Low BP, urine output
-HR elevated
Sodium
-135-145
-Concern = brain
-Foods = cheese, lunchmeat, bologna, taco seasoning
-Brain = LOC, confused, weak, seizures, relative or absolute loss of sodium
Relative loss of sodium
Accompanied by fluid loss or gain
Absolute loss of sodium
Accompanied by a true sodium loss or gain
Hyponatremia Cause
-Less than 135
-Sweating, heat exposure wound drainage, diuretics, hypoaldosteronism
Hyponatremia symptoms
-Musculoskeletal weakness (respiratory system, decreased respiratory effort)
-Seizure, coma
-Headache, confusion, fatigue
-Restlessness
-decreased deep tendon reflexes
-hyperactive bowel sounds
-CV changes depend on fluid status
How to fix hyponatremia
-Replace levels slowly
-Correct volume before sodium
-NS then do hypertonic saline
-Increase sodium intake
Hyperatremia
Sodium greater than 145
-Hyperventilation
-Sepsis
-Take in a lot of sodium
-TBI: increase sodium on purpose to suck water out of cells
Hyperatremia symptoms
-Thirst
-Extreme fatigue
-Confusion, and lack of energy
-Muscle twitching or spasms
Hypernatremia correction
-Go slow
-0.5mEq per hour
-Sodium wasting diuretics
-Aldosterone blocking meds
-Increase water intake
Potassium
-Transmission of electrical impulses in the muscles
-Heart concerned with
-3.5-5
-Heart is a muscle, the diaphragm, breathing is an issue
-Associated with renal failure
Hypokalemia interventions
-Cardiac monitor and watch for cardiac arrhythmias
-Caused by vomiting, diarrhea, loop, thiazide diuretics, cushing disease, decreased potassium intake, most related to IV insulin administration
Hypokalemia symtoms
-Everything slows down
-Slow cardiac arrhythmias, muscle weakness and cramps, irritability, confusion, drowsiness,weak pulse, orthostatic hypotension, increased risk for dig toxicity
(0.6-1.2)
-Flat T wave, prominent U wave
Never give potassium....
-IV PUSH
-NO BOLUS
How to fix hypokalemia
-Eat watermelon
-10mEq in peripheral line
-20mEq in central line
-Vesicant
-Will hurt when injected
Hyperkalemia
-Renal failure
-Acidosis
-Burns
-Anything destroying the cell walls
Hyperkalemia symptoms
-Hypotension
-Bradycardia
-Slow cardiac transmission
-Skeletal muscle weakness
-Respiratory distress
-Reflexes
-QRS complex widens
-No P wave
Hyperkalemia treatments
-Medication (albuterol, bicarb, calcium gluconate, potassium wasting diuretics, dialysis)
-Insulin
-Diet (lots of no sodium stuff have potassium salt)
Calcium
Normal level = 8-10
-Never not have enough
-When we take it out losing albumin and calcium
-Normally it just isn't where it should be
-Deal with the heart
-Cardiac monitor
-Clotting issues with calcium imbalances
-Parathyroid hormone regulates calcium lev
Hypocalcemia causes
Fix nutrition status with the hypocalcemia
-Albumin and calcium
-renal failure
-Malnutrition
-Vitamin D deficiency
-Hypoparathyroidism
-Hyperphosphatemia
Hypocalcemia symptoms
-Tetany (muscle twitching)
-Numbness and tingling
-Chvostek signs- tap on cheek and the eye twitches
-Trousseau signs- carpal pedal spasm (hand spasm)
-Decreased cardiac output- decreased HR and BP, weak pulse
Hypocalcemia management
-replaced calcium via IV or PO
-Can give IV push
-Dietary intake
-Decrease stimuli
Hypercalcemia
-Hyperparathyroidism
-Maginancy (common oncology emergency)
Hypercalcemia causes
-Vitamin D toxicity
-Bone metastasis
Hypercalcemia symptoms
-muscle weakness
-decreased LOC
-Decreased HR
-EKG; short QT
-DVT because of coagulation
-Cyanosis
-GI decreased peristalsis
Hypercalcemia treatment
-Rehydrate
-Calcitonin
-Dialysis
-Cardiac monitor
Magnesium
-1.3-2.3
-Deal with the brain
-Imbalance = risk for seizures
Hypomagnesemia
-Alcoholism
-Hypokalemia as well (replace magnesium first)
-No absport potassium which is why we give mag 1st
-Give it slow (1g/hour)
Hypomagnesemia symptoms
Hyper-excitability with muscle weakness, tremors, generalized seizures, apathy, confusion, delirium, vertigo, aaxia, and coma, dysrhythmias, chvostek and trousseau signs
-DTR go up
Hypermagnesemia
-Pre term OB patients
-Loose deep tendon reflexes
-Loss of muscle contractions and breathing
-Can't grip hands
-rare - kidneys (good kidneys can regulate)
-DTR go down
Phosphate
2.5-4.5, inverse relationship with Ca
Chloride
Accompanies sodium, direct relationship with sodium and potassium
pH
7.35-7.45
CO2
35-45
BiCarb
22-26
respiratory acidosis
pH = less than 7.35
CO2 = greater than 45
BiCarb = can be whatever
respiratory acidosis causes
-COPD
-Pneumonia
-Drowning
-Opioid overdose
-Hypoventilation
respiratory acidosis interventions
-Pneumonia = bronchodilators
-Pulmonary edema = diuretics
-Opioid overdose = narcan
-COPD = bronchodilator
Metabolic acidosis
pH = less than 7.35
CO2= whatever
BiCarb = less than 22
Metabolic acidosis causes
-DKA
-Diarrhea
-Shock
Metabolic acidosis interventions
-Insulin and fluids
-Antidiarrheal
-IV fluids
Respiratory alkalosis
-pH = more than 7.45
-CO2 = less than 35
-BiCarb = whatever
Respiratory alkalosis symptoms
-Hypercentilatoin
respiratory alkalosis interventions
Brown bag, can help reduce brain edema on a ventilator
Metabolic alkalosis
-pH = greater than 7.45
-CO2 = whatever
-BiCarb = more then 26
metabolic alkalosis causes
-Vomiting, NG drainage
Metabolic alkalosis intervention
-Antiemetic
-IV fluids
Compensation- complete
Complete is when the pH is back between 7.35-7.45
Compensation- partial
when the pH is not back in the normal range
Potassium and alkalosis
Low potassium
Potassium and acidosis
High potassium