fluid, electrolytes, acid, base Pearson

Electrolyte

An ionic compound whose aqueous solution conducts an electric current and are found in all body fluids.

Conditions with fluid and electrolyte imbalance

Dehydration, renal failure, acute and chronic illness

Water makes up what percentage of the body?

60%

Water is important to health and cellular functioning by

1 a medium for metabolic reactions within cells, 2 a transporter for nutrients, waste products, and other substances, 3 a lubricant, 4 an insulator and shock absorb-er, 5 one means of regulating and maintaining body temperature.

Cations

ions with a positive charge

Anions

ions with a negative charge

Cations examples

sodium (Na+) , potassium ( K+) , calcium ( Ca2+), magnesium (Mg2+)

Anions examples

chloride (Cl-), bicarbonate (HCO3-), Phosphate (HPO4 2-), and sulfate (SO4 2-)

intracellular fluid

makes up 2/3 of total body fluid in adults and contains solutes and provides a medium in which metabolic processes of the cell take place.

Solutes

substances dissolved in a liquide such as oxygen, electrolytes, glucose, proteins called crystalloids or colloids

crystalloids

salts that readily dissolve in solution

colloids

protein molecules and other substances that do not readily dissolve in solution

Composition of intracellular fluid

Primary cations are Potassium (K+) and magnesium (Mg2+) . The major anions are phosphate (HPO4 2-) and sulfate (SO4 2-).

extracellular fluid

fluid outside the cell, 1/3 of fluid, has two compartments Intravascular and Interstitial.

Intravascular fluid or plasma

makes up 20% of extracellular fluid

interstitial fluid

fluid between cells make up 75% or ECF

composition of extracellular fluid

Largest quanities Sodium (Na+) , chloride (Cl-) , bicarbonate (HCO3-).

Difference between Intravascular fluid and Interstitial fluid

Protein in the Intravascular fluid lots of albumin.

Osmosis

Diffusion of water through a selectively permeable membrane from area of low concentrated solution to area of high concentrated solution

isotonic solution

A solution in which the concentration of solutes is essentially equal to body fluid. example normal saline- 0.9% sodium chloride.

hypertonic solution

A solution in which the concentration of solutes is greater than normal body fluid example is 3% sodium chloride.

hypotonic solution

A solution in which the concentration of solutes is less than that of the normal body fluid example is 0.45% sodium chloride or half normal saline

Diffusion

the natural movement of molecules due to their random motion, can occur across the capillary membranes.

rates of diffusion depend on

1. Size of molecules: Larger molecules diffuse more slowly than small ones.
2. Concentration of solution: Solutes move from a solution of higher concentration to one of lower concentration via diffusion.
3. Temperature of solution: Diffusion occurs more q

Filtration

A process that separates materials based on the size of their particles. movement from area of high pressure to lower pressure

active transport

Energy-requiring process that moves material across a cell membrane against a concentration difference. its especially important in maintaining sodium and potassium ion concentrations of the extracellular and intracellular fluid compartments.

Normal sodium levels

135-145 mEq/L

sodium largely

controls and regulates water balance

Normal serum potassium level

3.5-5.0 mEq/L

Potassium important for

maintaining correct ratio of potassium in icf vs ecf for neuromuscular response to stimuli. vital for skeletal, cardiac, and smooth muscle activity. must eat it everyday not stored. fruits, veggies, meats, fish

Calcium importance

1) MUSCLE CONTRACTION and relaxation 2) BLOOD CLOTTING 3) COFACTOR FOR ENZYMES

Normal total serum calcium level

9-11 mg/dL

Normal Serum Magnesium Level

1.5-2.5 mEq/L

Magnisum

in skeleton and icf. important for intracellular metabolism especially with adenosine triphosphate- ATP, necessary for protein and DNA synthesis, regulates neuromuscular and cardiac function. foods with this cereal grains, nuts, dried fruit, legumes, gree

Normal serum chloride level

95-105 mEq/L

Chloride

functions with sodium to regulate serum osmoalality and blood volume. kidney absorbs sodium chloride follows, in gastric juices in hydrochloric acid, involved in regulating acid base balance. buffer in oxygen and carbon dioxide exchange in RBC. same foods

Phosphate

children higher levels than adults and newborns 2x that of adults. involved in chemical actions of cells and essential for muscle, nerves, and rbc. involved in metabolism of protein, fat, and carbohydrate. absorbed from intestine and found in meat, fish,

Bicarbonate

Primary function is regulating acid-base balance as an essential component of carbonic acid-bicarbonate buffering system. Extracellular levels regulated by the kidneys. excreted if to much is present. doesn't need to be ate is produced through metabolic p

Sodium is regulated by

1 Renal re absorption or excretion and
2 aldosterone increases sodium re absorption in collecting duct of nephrons

Sodium Function is

1 regulating ECF volume and distribution
, 2 maintaining blood volume, and
3 transmitting nerve impulses an contracting muscles

Potassium is regulated by

1 renal excretion and conservation,
2 aldosterone increases potassium excretion,
3 movement into and out of cells,
4 insulin helps move potassium into cells; tissue damage and acidosis shift potassium out of cells into ECF

Potassium functions

1 Maintaining ICF osmolality,
2 transmitting nerve and other electrical impulses,
3 regulating cardiac impulse transmission and muscle contraction,
4 skeletal and smooth muscle function,
5 regulating acid-base balance

calcium regulated by

1 redistribution between bones and ECF and
2 parathyroid hormone and calcitriol increase serum calcium levels;calcitonin decreases serum levels

Calcium functions

1 Blood clotting,
2 nerve impulse transmission,
3 forming bones and teeth,
4 regulating muscle contractions,
5 maintaining cardiac pacemaker automatically,
6 activating enzymes such as pancreatic lipase and phospholipase

Magnesium regulated by:

1 conservation and excretion by kidneys and
2 intestinal absorption increased by vitamin D and parathyroid hormone

Magnesium functions

1 intracellular metabolism,
2 operating sodium-potassium pump,
3 relaxing muscle contractions,
4 transmitting nerve impulses, and
5 regulating cardiac function

Chloride regulated by:

1 excreted and reabsorbed along with sodium in the kidneys and
2 Aldosterone increases chloride reabsorption with sodium

Chloride functions

1 hydrochoric acid (HCl) production,
2 regulating ECF balance and vascular volume,
3 regulating acid-base balance,
4 buffer in oxygen-carbon dioxide exchange in RBCs

Phosphate regulated by:

1 Excretion and reabsorption by kidneys,
2 parathyroid hormone decreases serum levels by increasing renal excretion,
3 reciprocal relationship with calcium: increasing serum calcium levels when decreasing phosphate levels; decreasing serum calcium increas

Phosphate function

1 Forming bones and teeth
2 Metabolizing carbohydrate, protein, and fat
3 Cellular metabolism; producing ATP and DNA
4 Muscle, nerve, and RBC function
5 Regulating acid-base balance
6 Regulating calcium levels

normal serum levels phosphate

2.5-4.5 mg/dL

Bicarbonate regulation

1 Excretion and reabsorption by the kidneys
2 Regeneration by kidneys

Bicarbonate function

Major body buffer involved in acid-base regulation

normal serum levels bicarbonate

24-28 mEq/L

What affects total body water?

age, sex, and body fat

Infants body water content

65%- loose more fluid through the kidney as they are less able to conserve water than adults due to immaturity. Respiration are more rapid and body surface area is greater causing . dehydratequicker and fontanels , weight loss or gain are indicators of fl

60 and older total body water content

50%-normal aging process affect fluid balance by decreased thirst response, antidiuretic hormone level normal or elevated, nephrons less able to conserve water. skin turgor not valid assessment for fluid balance. cardiovascular problems contribute to flui

women total body water content

is lower than men due to more fat and less muscle

newborn total body water

75%

Child total body water

50%- need fluid replacement during vigorous exercise, need to comsume a varity of fluids and limit intake of caffeine

ethnicity and water content

African Americans greater sensitivity which increases the salt content.

diarrhea leads to fluid and electrolyte loss watch for

sodium and chloride loss, evaluate degree of dehydration, educate and respond quickly especially with kids.

Acute hemorrhage leads to fluid imbalance manifested by hypovolemia watch for

fatigue, tachycardia, low hemoglobin and hematocrit. anticipate need for fluid replacement, admin whole blood, packed cells or colloids

Electrolyte loss or excess can lead to change in cognition watch for

confusion and Loss of consciousness. Assess mentation and rule out head trauma.

most common condition of fluid imbalance is

dehydration, in which the body loses more water than it takes in

dehydration or fluid volume deficit manifestations

Dry to tenting skin
Dry mucous membranes
Increased hemoglobin and
hematocrit
Thirst
Decreased urine output
Weight loss

dehydration or fluid volume deficit definition

Fluids are lost secondary to
diarrhea, vomiting, inability to
take in fl uids, excessive
perspiration, or increased
basal metabolic rate due to
fever, hyperthyroidism, or
medications

dehydration or fluid volume deficit interventions

Administer fluids via either the
oral or intravenous route and
treat the underlying cause.

Fluid intake for the average healthy adult should be around

2,500 mL/day, about 1,500 of which comes from drinking fluids; the rest comes from food

The primary regulator of fluid intake is

thirst center in the hypothalamus, which is triggered by decreased volume of ECF or increased osmolality of ECF. After drinking fluid, it takes 30-60 minutes for water to be absorbed into the body, increasing the fluid volume and decreasing the osmolality

The body loses fluid through four routes, which are:

1. Urine: major route of fluid output; volume increases as fluid intake increases, decreases if loss through perspiration is large
2. Insensible fluid loss: not noticeable or measurable, occurs through skin (diffusion and unmeasurable perspiration) and lu

Fluid loss can lead to alterations in thermoregulation due to body losing ability to regulate its loss due to hypovolemia. interventions include.

replace fluids, move to air, shade and possible fluid replacements.

Several mechanisms regulate the volume and composition of body fluids, those being:

Kidneys:
Antidiuretic hormone (ADH):
Renin-angiotensin-aldosterone system:
Atrial natriuretic factor (ANF):

Kidneys:

primary regulator of body fluids and electrolytes; act through selective absorption and excretion of water and electrolytes in urine

Antidiuretic hormone (ADH):

synthesized by the hypothalamus and secreted by the posterior pituitary, regulates water absorption by the collecting ducts of the kidneys and influences urine volume

Renin-angiotensin-aldosterone system:

an enzyme pathway that acts on the blood vessels and nephrons of the kidneys; net effect is restoration of blood volume through sodium and water retention

Atrial natriuretic factor (ANF):

a hormone released by cells in the atrium of the heart; causes water loss and inhibits thirst, reducing vascular volume.

Fluid loss leads to decreased perfusion watch for

pulses equal and present, nail beds, color, body position for comfort, orientation. Admin oxygen as needed and anticipate need for pharmacotherapy to improve cardiac output.

assessment for fluid imblance to identify underlying source of imbalance and address potential complications check for

vital signs, intake and output, daily weights, skin turgor, mentation

Modifiable risk factors for fluid imbalance

Stress, medications, heat related illnesses

Stress and fluid imbalance

increased cellular metabolism, blood glucose concentration, catecholamine levels, increases production of ADH which decreases urine production

Medications and fluid imbalances

diuretics, antipsychotic agents affect thirst mechanism, vasoconstrictors, beta-blockers, stimulants increase risk for fluid imbalance affects thermoregulation

prevention of heat related illness begins with education. educate client on

1 limit outdoor activity during hottest part of the day
2 take frequent breaks for rest and water
3 drink water before they begin to feel thirsty
4 wear lightweight clothes
5 work or exercise with others when engaging in activity outside

questions

Qs

An emergency room nurse is assessing a client who overhydrated during a marathon. Which assessment is essential for the nurse to perform during the physical? examination? (Select all that? apply.)
A. Lung sounds
B. Eye accommodation
C. Teeth
D. Level of c

A, D, E

The student nurse is assisting the nurse in administering intravenous normal saline to a dehydrated client. The nurse explains to the student that active transport is essential in maintaining sodium and potassium ion concentrations in the? body's fluid co

D. ?"Unlike diffusion, active transport moves solutes from a solution with a lower concentration of solutes to a more concentrated? solution."
Rationale
Unlike? diffusion, active transport moves solutes against their concentration gradients from a solutio

The nurse is performing an assessment on a client who has had nothing by mouth since the previous evening. Which manifestation related to the? client's fluid restriction would be of concern to the? nurse? (Select all that? apply.)
A. Dry mucous membranes

A. Dry mucous membranes
B. Tenting skin
C. Increased hematocrit
Rationale
Oral fluid restriction can cause dehydration. The nurse should monitor for manifestations of dehydration such as dry mucous? membranes, increased? hematocrit, and tenting skin. Edem

The nurse is caring for a client with hyponatremia. What are independent interventions that the nurse can perform to help manage the? client's electrolyte? imbalance? (Select all that? apply.)
A. Involve client in meal planning
B. Administer oral sodium s

A. Involve client in meal planning
D. Monitor intake and output
E. Weigh client daily
Rationale
Monitoring intake and? output, weighing the client? daily, and involving the client in meal planning are all independent interventions that the nurse can perfo

The nurse is caring for a client with a fluid volume deficit. Which nursing intervention addresses the? client's potential for poor? perfusion?
A. Monitoring for signs of blood loss
B. Checking client?'s temperature
C. Administering whole blood
D. Assessi

D. Assessing? client's nail beds
Rationale
Fluid and electrolyte balance is related to several nursing? concepts, including? perfusion, cellular? regulation, and cognition. Fluid volume loss can lead to decreased? perfusion, so the nurse should assess? pu

A client experiencing hyperkalemia is scheduled for dialysis. The nurse anticipates an order for what therapy to help drive potassium back into the cells prior to? dialysis?
A. Insulin
B. Antidiuretic hormone
C. Potassium supplements
D. Blood transfusion

A. Insulin
Rationale
Glucose and insulin are administered to the client with hyperkalemia to help drive potassium back into the intracellular? fluid, reducing the amount of potassium in the blood. Potassium supplements would only increase the? client's po

The nurse is administering a blood transfusion to a client who is hemorrhaging. The nurse identifies that the client is experiencing a deficit in which body fluid? compartment?
A. Interstitial fluid
B. Intracellular fluid
C. Transcellular fluid
D. Intrava

D. Intravascular fluid
Rationale
Blood loss causes a deficit in the intravascular fluid? compartment, which is a subcompartment of extracellular fluid? (ECF). Transcellular and interstitial? fluids, along with? lymph, make up the other compartments of ECF

An emergency room nurse is assessing a client who overhydrated during a marathon. Which assessment is essential for the nurse to perform during the physical? examination? (Select all that? apply.)
Lung sounds
Eye accommodation
Teeth
Level of consciousness

...

The community health nurse is performing health screenings at a homeless shelter. When assessing for fluid and electrolyte? imbalances, which question is most important for the nurse to? ask?
?A. "Are you currently being treated for joint? problems?"
?B.

?D. "Describe what you eat and drink on a typical? day
Rationale
It is important for the nurse to consider socioeconomic factors affecting food and fluid intake when assessing a? client's risk for fluid and electrolyte? imbalances, especially with a vulne