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Transcript of Project: Ghana Emergency Medicine Collaborative Document Title: Assessing Fluid and Volume Status...
Project: Ghana Emergency Medicine Collaborative
Document Title: Assessing Fluid and Volume Status
Author(s): Michelle Munro (University of Michigan), MS 2012
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2
Assessing Fluid & Volume Status
Ghana Emergency Nurses Collaborative
Michelle Munro, MS, CNM, FNP-BC
February 13, 2013
3
Introductions
Name Role at KATH Favorite thing to do in Kumasi Questions you want answered over the next
two weeks?
4
Critical Outcomes
Assesses, identifies and manages patients with fluid and electrolyte abnormalities.
5
Specific Outcomes
Discuss the basic management principles of fluid and electrolyte abnormalities.
Apply the medico-legal aspects pertaining to fluid and electrolyte abnormalities with regard to the emergency nurse.
Apply the above-mentioned knowledge when analyzing a case scenario (paper based and real life scenarios).
List the drugs used in your unit to manage fluid and electrolyte abnormalities.
Delineate the nursing process in the management of a patient with fluid and electrolyte abnormalities.
6
What are some fluids in the body?
Blood Lymph Cerebrospinal Fluid Amniotic Fluid Aqueous Humor Fluid Saliva Gastric Acid Pericardial Fluid Peritoneal Fluid Semen
Mucous Breast milk Pleural Fluid Sweat Synovial Fluid Urine Tears Sebum (skin oil) Vomit Vaginal Secretions
7
The Role of Fluids
Function to transport nutrients and wastes to and from cells
Maintain body temperature
Facilitate digestion & elimination
Lubricate joints & other body tissues 8
A body in balance
Fluid is in a state of balance when:
Its water & electrolyte components are present in the proper proportions
Fluids are distributed normally between compartments
Lost body water and electrolytes are replaced
Excess water and electrolytes are eliminated9
Fluid Compartments
Intracellular Fluid in the cells
Provides the cells with the internal aqueous medium necessary for their chemical functions
Extracellular Intravascular – refers to the space within the arteries, veins, &
capillaries Interstitial – between the cells and vascular compartments
Found outside the body cells and serve as the body’s transport system
Carry water, electrolytes, nutrients, and oxygen to the cells and remove waste of cellular metabolism 10
Underlying Concepts
11
Video
Fluid & Electrolyte Imbalance: An Overview (30 minutes)
12
What else do we need to consider with fluid balance?
Electrolytes A electrolyte is any compound that, when dissolved in water,
separates into electrically charged particles, which are call ions. Cations – positively charged ions
Potassium (K+) Sodium (Na+) Hydrogen (H+) Calcium (Ca2+) Magnesium (Mg2+)
Anions – negatively charged ions Chloride (Cl-) Phosphate (HPO4
-)
Non-electrolytes A substance that does not ionize and do not carry an electrical
charge Glucose 13
Review of electrolytes: Sodium (Na+)
Normal plasma levels: 135-145 mEq/L
Functions Maintains blood volume Controls water shifting between compartments Major cation involved in sodium-potassium pump necessary for
nerve impulses Interacts with calcium to maintain muscle contraction Major cation in bicarbonate & phosphate acid-base buffer system
Regulation Renin-angiotensin-aldosterone system 14
Review of electrolytes: Potassium (K+)
Normal plasma levels: 3.5-5.0 mEq/L
Functions Affects osmolality Major cation involved in sodium-potassium pump necessary for
transmission of nerve impulses Promotes nerve impulses, especially in heart & skeletal muscles Assists in conversion of carbohydrates to energy & amino acids
into proteins Promotes glycogen storage in liver Assists maintenance of acid-base balance through cellular
exchange with hydrogen
Regulation Renin-aniotensin-aldosterone system 15
Video
Hyperkalemia & Hypokalemia Video (9 minutes & 45 seconds) – skip between 5
minutes & 30 seconds to 8 minutes
16
Review of electrolytes: Calcium (Ca2+)
Normal plasma levels: 4.5-5.5 mEq/L
Functions Nonionized form promotes strong bones & teeth Promotes blood coagulation Promotes nerve impulse conduction, decreases neuromuscular irritability Strengthens & thickens cell membrane Assists in absorption & utilization of vitamin B12 Activates enzymes for many chemical reactions Inhibits cell membrane permeability to sodium Activates actin-myosin muscle contraction
Regulation Parathormone
Increases calcium resorption from bone Increases calcium reabsorption form kidney tubules Increases calcium absorption from gastrointestinal tract 17
Review of electrolytes: Magnesium (Mg2+)
Normal plasma levels: 1.5-2.5 mEq/L
Functions Promotes metabolism of carbohydrates, fats, & proteins Activates many enzymes (B12 metabolism) Promotes regulation of Ca, PO4, K Promotes transmission of nerve impulses, muscle contraction, & heart
function Powers sodium-potassium pump Promotes conversion of adenosine triphosphate (ATP) to adenosine
diphosphate (ADP) for energy release Inhibits smooth muscle contraction
Regulation Parathormone
Increases or decreases magnesium reabsorption in kidney tubules relative to body need
18
Review of electrolytes: Chloride (Cl-)
Normal plasma levels: 98-106 mEq/L
Functions Regulates extracellular volume Promotes acid-base balance through exchange with
bicarbonate in red blood cells (chloride shift) Promotes protein digestion through hydrochloric (HCl)
acid; acid pH required for activation of protease
19
Review of electrolytes: Phosphate (HPO4-)
Normal plasma levels: 1.2-3.0 mEq/L
Functions Nonionized form promotes bone & teeth rigidity Promotes acid-base balance through phosphate buffer system Necessary for ATP production
Regulation Parathormone
Increases phosphate resorption from bone Inhibits phosphate reabsorption in kidney tubules Increases phosphate absorption in gastrointestinal tract as needed20
Movement of Fluids & Electrolytes
Homeostasis – maintaining equilibrium Fluid constantly shifts between compartments,
exchanging nutrients and waste products
Factors that regular the shifting of fluids: Osmosis Diffusion Active Transport Filtration
21
Osmosis
The movement of water through a semipermeable membrane from an area containing a lesser concentration of particles to an area of greater concentration of particles.
22
Concentrated sugar solution (Water less concentrated)
Movement of water
Dilute sugar solution (water more concentrated)
sugar
Hans Hillewaert, Wikimedia Commons
Osmolality
Osmolality refers to the number of milliosmoles per kilogram of water
Whenever there is a difference in osmolality between the cell and the plasma, fluid shifting is likely to occur
23
Diffusion
Refers to the passive process by which molecules move through a cell membrane from an area of higher concentration to an area of lower concentration without an expenditure of energy.
For example: electrolytes move passively from an area of higher concentration to an area of lower concentration, such as from the small bowel at the end of digestion into the blood stream
24
Active Transport
When an electrolyte moves against a concentration gradient, from an area of lower concentration to an area of higher concentration
Energy is required
For example: The sodium-potassium pump transports sodium from inside the cell to the outside of the cell
25
Filtration
Filtration pressure – the sum of (1) the forces tending to move water and dissolved substances out of the blood vessels and (2) the opposing forces
Hydrostatic pressure – the pressure exerted by the weight of fluid within a compartment Pushes fluid out of the arterial end of the capillary into the interstitial
compartments for cellular nourishment
Colloid osmotic pressure – the osmotic pressure exerted by large molecules, such as proteins Tends to hold fluid in a compartment
Filtration – the process by which water and certain smaller particles pass through a semipermeable membrane, assisted by hydrostatic and filtration pressures 26
Filtration
27
blood flow
filtration pressure
interstitial hydrostatic pressurecapillary colloidal osmotic pressure
Trisha Paul, University of Michigan
Regulation of Fluid Balance
Thirst
Lymphatic System
Neuroendocrine System Hormones Baroreceptors
Gastrointestinal System
Renal System28
Thirst
The stimulation or inhibition of the thirst response depends on changes in local plasma osmolality
Inhibit thirst by decreased osmolality: High intake of fluids Fluid retention Low sodium intake Excessive IV infusion of hypotonic solutions
Stimulate thirst by increased osmolality: Decrease in fluid intake Excessive fluid loss Excessive sodium intake (either orally or intravenously)
29
Lymphatic System
Sponges up excess fluid that is not reabsorbed into the capillaries
When the lymphatic system is not functioning properly, fluid excess occurs in the interstitial compartments
30
Neuroendocrine System
Regulates body fluid volume by producing and secreting hormones that stimulate or inhibit osmotic receptors in the carotid arteries and aortic arch
Hormones: Antidiuretic hormone (ADH) – opposes fluid loss Aldosterone – promotes the reabsorption of sodium and the
excretion of potassium resulting in the passive reabsorption of water Thyroid hormones (T4 & T3) – influence cardiac output
Baroreceptors: Specialized nerve endings in the walls of large veins and arteries and
in the atria of the heart that respond to the slightest changes in pressure inside the blood vessels
31
Gastrointestinal System
Absorbs fluid from dietary intake
Produces about 7 to 9 liters of glandular and tissue secretions per day
Gastrointestinal fluid contains many nutrients, including electrolytes
For example: Excessive diarrhea and vomiting can result in dehydration & hypokalemia
32
Renal System
Renal system works interdependently with the neuroendocrine system to regulate the volume to extracellular fluid
The kidneys are targeted by: The renin–angiotensin system (RAS) or
the renin–angiotensin–aldosterone system (RAAS), which is a hormone system that regulates blood pressure and water (fluid) balance.
33
1. When blood volume is low, juxtaglomerular cells in the kidneys secrete renin directly into circulation.
2. Plasma renin then carries out the conversion of angiotensinogen released by the liver to angiotensin I.
3. c I is subsequently converted to angiotensin II by the enzyme angiotensin converting enzyme found in the lungs.
4. Angiotensin II is a potent vaso-active peptide that causes blood vessels to constrict, resulting in increased blood pressure.
5. Angiotensin II also stimulates the secretion of the hormone aldosterone from the adrenal cortex.
6. Aldosterone causes the tubules of the kidneys to increase the reabsorption of sodium and water into the blood. This increases the volume of fluid in the body, which also increases blood pressure.
34
Review: Regulation of fluid balance How does thirst regulate fluid balance? What does thirst mean?
Thirst center is located in hypothalmus & is stimulated by changes in plasma osmolality
Being thirsty can mean dehydration or fluid volume deficit
How does the lymphatic system regulate fluid balance? Soaks up excess fluid that is not reabsorbed into the capillaries
How does the neuroendocrine system regulate fluid balance? Produces & secretes hormones that stimulate or inhibit osmotic receptors in the
carotid arteries & aortic arch Hormones: antidiuretic hormone (ADH), aldosterone, thyroid hormones (T3 & T4) Baroreceptors: respond to changes in pressure
How does the gastrointestinal system regulate fluid balance? What could happen from excessive vomiting or diarrhea? Absorbs fluid from dietary intake & produces secretions that are reabsorbed Diarrhea and vomiting could lead to dehydration (fluid volume deficit) and an
electrolyte imbalance (hypokalemia)
Renal System Regulates the volume of extracellular fluid
35
Review Question
The majority of the body’s water is contained in which of the following fluid compartments?
a. interstitial b. intracellular c. extracellular d. intravascular
36
Review Answer
Intracellular About 2/3 of the body’s water (70%) exists in the
intracellular spaces
37
Review Question
One of the most common electrolyte imbalances is:
38
Review Answer
Hypokalemia
39
Review Question
If the blood plasma has a higher osmolality than the fluid within a red blood cell, the mechanism involved in equalizing the fluid concentration is:
a. Osmosis
b. Diffusion
c. Active transport
d. Facilitated diffusion
40
Review Answer
Osmosis
41
Video
Fluid & Electrolyte Imbalance: Cause and Assessment (30 minutes)
42
General Strategy: Assessment
Assessment General assessment of fluid balance Health history Physical examination Diagnostic tests
43
Assessment: Health History
Factors affecting fluid balance Lifestyle Environmental Developmental
Physiological factors Body systems review
Clinical factors Recent clinical procedures and/or treatments
44
Assessment: Factors affecting fluid balance
Lifestyle Factors Nutrition
An alteration in the intake of fluids increases risk People require at least 1,500 mL of fluid daily
Recommendation for fluid intake is 8 to 10 glasses of fluid daily (2,000 – 2,400 mL)
Clinical Examples: In a healthy person – the body compensates for excess fluid, sodium, or both by
increasing excretion In a person with cardiac, renal, or liver disease – excess intake can lead to fluid
volume excess Exercise
Fluid deficit can result from exercise or activity in hot, humid environments
Stress Physical, psychological, or environmental stressors can lead to
hormone changes that increase blood volume to improve tissue perfusion (fight or flight)
45
Lifestyle Factors: Intake & Output
46Source undetermined
Assessment: Factors affecting fluid balance
Environmental Factors
Exposure to hot, humid weather At work, with exercise, etc.
Exposure to environmental toxins Can lead to fluid & electrolyte loss through vomiting,
diarrhea, or both
47
Assessment: Factors affecting fluid balance
Developmental Factors
Younger children The younger the child, the greater the risk for fluid deficit Are at greater risk because of immature kidneys, increased body
surface area, and increased metabolic activity
Adolescents Are at increased risk due to hormonal activity and teenage pregnancy
Older adults Are at increased risk due to the incidence of chronic diseases (heart
problems, kidney problems, etc.) & a decreased thirst mechanism
48
Proportion of Body Water by Age
Age Percent of Body Weight
Neonate 77%
6 months 72%
2-16 years 60%
20-39 years 59% (female) to 60% (male)
40-59 years 47% (female) to 55% (male)
65 years and older 45% to 50%49
Assessment: Physiological factors
Cardiovascular problems
Respiratory problems
Gastrointestinal problems
Renal problems
Integumentary problems
Trauma50
Assessment: Cardiovascular Problems Cardiovascular
problems Fluid overload due to
heart disease
When the left ventricle cannot contract efficiently, the buildup of fluid pressure has a retrograde effect, causing an increase in left atrial pressure followed by increased pulmonary pressure, which lead to pulmonary congestion 51
Wapcaplet, Wikimedia Commons
De-oxygenated blood from body
Oxygenated blood to body
De-oxygenated blood to lungs
Oxygenated blood to heartOxygenated
blood to heart
Decreased blood flow through lungs and to body
Back-up of blood flow increases size of right ventricle
Normal Cardiopulmonary Blood Flow Blood Flow with Severe Congestion
Assessment: Respiratory Problems
Respiratory problems
Any situation or pathology that increases the respiratory rate also increases the amount of fluids lost
Patrick J. Lynch, Wikimedia Commons
52
Assessment: Gastrointestinal Problems
Gastrointestinal problems
Vomiting, diarrhea, ileostomies, & fistulas all lead to increased fluid loss
Liver disease can result in fluid overload
53
Assessment: Renal Problems
Renal problems
End-stage renal disease can first lead to fluid deficit & then fluid overload
Gray’s Anatomy
54
Assessment: Integumentary Problems
Integumentary problems
Loss of protective skin barriers can lead to fluid loss & third spacing This is where fluid is physiologically
unavailable because it is trapped in an inaccessible area Ascites – fluid in the peritoneal space Pericardial effusion – fluid in the pericardial
space Pleural effusion – fluid in the pleural space
Np0x, Wikimedia Commons
55
Assessment: Trauma
Trauma
Tissue damage can lead to fluid loss
Sepsis can lead to more fluid, electrolyte, and protein loss
Head trauma can result in either fluid deficit or fluid excess
56
Superficial (first degree) burn
Partial thickness (second degree) burn
QuinnHK,Wikimedia Commons
Snickerdo,Wikimedia Commons
Craig0927,Wikimedia Commons
Full thickness (third degree) burn
K.Aainsqatsi,Wikimedia Commons
Assessment: Clinical factors
Surgery
Medications
Gastrointestinal intubation
Intravenous therapy Can contribute to fluid volume excess or deficit
57
Assessment: Surgery
Surgery
Fluid volume deficit related to blood loss or infection
58
Assessment: Medications
Medications
Fluid volume deficit from medications such as diuretics (Lasix) & oral hypoglycemics (Metformin)
Fluid volume excess from medications such as narcotics (Morphine) & steroids
59
Assessment: Gastrointestinal Intubation
Gastrointestinal intubation
Fluid volume deficit related to nasogastric tube & diarrhea associated with tube feedings
60
NASOGASTRIC TUBE
NASOGASTRIC TUBE
Alan Hoofring, Wikimedia Commons
Assessment: Intravenous Therapy
Intravenous therapy
Can contribute to fluid volume excess or deficit
Fluid Volume Deficit - if IV replacement is not enough to meet patient’s needs
Fluid Volume Excess – if IV replacement is more than the patient needs (i.e., too fast a rate)
Michaelberry, Wikimedia Commons
61
Assessment: Physical Exam
Standard clinical measurements Temperature Blood pressure Pulse Respiration rate
Weight 2.2 kg (1 lb) = 1 L of fluid loss or gain
Measuring intake & output when necessary Intake: measure intake orally, by tube, and/or by IV Output: measure output by urine, diarrhea, vomiting, suction,
and/or would drainage
62
Assessment: Physical Exam Integumentary exam
Edema Pitting edema can be assessed over the
indentation left over a 5 second period on the tibia, foot, sacrum (there is no uniform scale for measurement – most are similar to the one described below)
1+ = 2mm depression, barely detectable. Immediate rebound.
2+ = 4mm deep pit. A few seconds to rebound.
3+ = 6mm deep pit.10-12 seconds to rebound.
4+ =8mm: very deep pit. >20 seconds to rebound.
James Heilman, Wikimedia Commons
63
Assessment: Physical Exam
Integumentary Exam Skin Tenting or Turgor
Can be assessed by grasping the skin on the back of the hand, lower arm, or abdomen between two fingers so that it is tented up. The skin is held for a few seconds then released.
A slow return of the skin to its normal position after being pinched is a sign of either moderate to severe dehydration, or aging, or both 64
Skin with decreased turgor remains elevated after being pulled up and released
sh6 pinch, flickr
Assessment: Diagnostic Tests
Blood tests for: Sodium* Plasma osmolality* Hematocrit* Blood urea nitrogen (BUN)* Creatinine Liver Function Tests Potassium Chloride Calcium Magnesium
Urine tests for: Urine osmolality*
Afrobrazilian, Wikimedia Commons
65
Focused Assessment: Fluid Volume Deficit
Generalized Sudden weight loss Decreased skin turgor Dry mucous membranes and tongue Weakness Depressed fontanels in infants
Cardiac Hypotension with compensatory tachycardia Weak, thready pulse
Gastrointestinal Constipation
Renal Urinary output decreased
Derek Jenson, Wikimedia Commons
66
Focused Assessment: Fluid Volume Excess
Generalized Weakness and fatigue Body edema, pitting edema Ascites Sudden weight gain of more than 1kg/week Jugular venous distension Bulging fontanels in an infant
Pulmonary Increased respiratory rate (may have an irregular rhythm) Crackles or dyspnea Possible pleural edema or pleural effusion
Cardiac Tachycardia Bounding pulse Hypertension Possible third heart sound (S3 gallop)
Gastrointestinal Anorexia, nausea, vomiting
Renal Increased output if kidney can compensate
Wang Kai-feng, Pan Hong-ming, Lou Hai-zhou, Shen Li-rong, Zhu Xi-yan, Wikimedia Commons
67
Review Question
An elderly woman is admitted to the medical unit with dehydration. A clinical indication of this problem is:
a. Weight loss
b. Full bounding pulse
c. Engorged neck veins
d. Kussmaul respiration
68
Review Answer
Weight Loss
Full bounding loss – seen in fluid overload Engorged neck veins – seen in fluid overload Kussmaul respiration – deep, labored
breathing pattern often associated with severe metabolic acidosis (particularly diabetic ketoacidosis)
69
Review Question
The lungs act as an acid-base buffer by
a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load
b. increasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load
c. decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load
d. decreasing respiratory rate and depth when CO2 levels in the blood are low, increasing acid load
70
Review Answer
Increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load
71
Review Question
Clinical assessment of dehydration would be confirmed if the nurse identified:
a. 2.2kg weight loss
b. Engorged neck vessels
c. Dry mucous membranes
d. Full bounding radial pulse
72
Review Answer
Dry mucous membranes
Dry mucous membranes are a clinical sign of dehydration.
Weight loss can be associated with dehydration but is not a confirming sign.
Engorged neck vessels and bounding pulse are signs of fluid overload.
73
Review Question
The client most at risk for fluid volume deficit is:
1. Elder adult
2. Adult
3. Child
4. Infant
74
Review Answer
Infant
75
Review Question
One reason older adults experience fluid and electrolyte imbalance and acid-base imbalances, is they:
a. Eat poor quality foods b. Have a decreased thirst sensation c. have more stress response d. have an overly active thirst response
76
Review Answer
Have a decreased thirst sensation
77