7/27/2019 Fluid and Electrolite
1/82
ASUHAN KEPERAWATAN
PADA GANGGUAN
KESEIMBANGAN CAIRAN,ELEKTROLIT & ASAM-BASA
TUTI HERAWATI, MN
7/27/2019 Fluid and Electrolite
2/82
Fungsi Air dalam Fisiologi Manusia
1. Media semua reaksi kimia tubuh
2. Berperan dalam pengaturan distribusi kimia &
biolistrik dalam sel3. Alat transport hormon & nutrien
4. Membawa O2 dari paru-paru ke sel tubuh
5. Membawa CO2 dari sel ke paru-paru
6. Mengencerkan zat toksik dan waste productserta membawanya ke ginjal dan hati
7. Distribusi panas ke seluruh tubuh
7/27/2019 Fluid and Electrolite
3/82
DISTRIBUSI CAIRAN TUBUH
Komponen terbesar
dipengaruhi usia, jenis kelamin & jml lemak
Neonatus 80 %, Dewasa 60% BB, lansia 45-50% BB
wanita (17-39 th) : 50% BB
pria (17-39 th): 60% BB
7/27/2019 Fluid and Electrolite
4/82
4
7/27/2019 Fluid and Electrolite
5/82
7/27/2019 Fluid and Electrolite
6/82
Elektrolit
Zat yang terlarut dalam cairan yang
terpisah dalam ion-ion yg mengandung
muatan elektrik
CATIONion bermuatan +
ANIONion bermuatan -
Cations = Anions satuan : milliequivalents / liter (mEq/L)
7/27/2019 Fluid and Electrolite
7/82
7/27/2019 Fluid and Electrolite
8/82
7/27/2019 Fluid and Electrolite
9/82
PERPINDAHAN CAIRAN &
7/27/2019 Fluid and Electrolite
10/82
PERPINDAHAN CAIRAN &
ELEKTROLIT
Diffusion
Active Transport
Osmosis Filtration
7/27/2019 Fluid and Electrolite
11/82
DIFFUSION
perpindahan molekul dari
tekanan/konsentrasi tinggi ke
tekanan/konsentrasi rendah Transport Pasif& tdk memerlukan energi
7/27/2019 Fluid and Electrolite
12/82
7/27/2019 Fluid and Electrolite
13/82
ACTIVE TRANSPORT
7/27/2019 Fluid and Electrolite
14/82
ACTIVE TRANSPORT
SYSTEM
perpindahan molekul dari tekanan/
konsentrasi rendah ke konsntrasi tinggi dgn
menggunakan energi (ATP) Requires specific carrier molecule as well
as specific enzyme (ATPase)
Sodium, potassium, calcium, magnesium,plus some sugars, & amino acids use it
7/27/2019 Fluid and Electrolite
15/82
7/27/2019 Fluid and Electrolite
16/82
OSMOSIS
perpindahan air dari konsentrasi zat terlarut
rendah ke konsentrasi zat terlarut tinggi
melalui membran
osmolaritas: ukuran konsentrasi suatu larutan
- isotonus konsentrasi larutan = plasma
darah
7/27/2019 Fluid and Electrolite
17/82
7/27/2019 Fluid and Electrolite
18/82
Pengukuran Osmolality di klinik
Serum 280-300mOsm/kg; Urine 50-
1400mOsm/kg
Osmolality = 2 * Na + Glu + BUN mg/dl18 2.8
7/27/2019 Fluid and Electrolite
19/82
Isotonik
Tekanan osmolaritas plasma?
280-300 mosm/kg
Osmolaritas ECF ditentukan oleh Na
NaCl 0,9 %, RL
7/27/2019 Fluid and Electrolite
20/82
HYPOTONIC HYPERTONIC
Rendah Na atau tinggi
h2O dari isotonik
Jika di infuskan ke
darah, cairan akan
pindah ke intra sel &
menyebabkan edema
sel 0,45 % NaCl
Jika diinfuskan ke
darah, cairan intra sel
ke intravaskular
menyebabkan selmengecil
NaCl 3 %, whole
blood, Albumin,koloid, dextrose 10 %,
dextrose 40 %, Total
parenteral Nutrition
7/27/2019 Fluid and Electrolite
21/82
7/27/2019 Fluid and Electrolite
22/82
Tekanan Cairan
1. Tekanan osmotik & onkotikTekanan osmotik: tekanan untuk mencegah
aliran osmotik cairanTekanan onkotik (osmotik koloid): gaya tarik s/
koloid (albumin)agar air tetap berada dalam
plasma darah.
7/27/2019 Fluid and Electrolite
23/82
PLASMA PROTEINS (albumin)
mempengaruhi serum osmolarity
berupa anion
Diseimbangkan dg Na Mempertahankan cairan di dlm
vascular dan dppt menarik cairan dari
interstitial
7/27/2019 Fluid and Electrolite
24/82
Tekanan Hidrostatik
Tekanan cairan melawan
dinding vaskuler
Tekanan hidrostatik (
filtration force)
tekanan yang digunakan oleh
air dalam sistem tertutup
7/27/2019 Fluid and Electrolite
25/82
FILTRATION
Perpindahan cairan melalui mebran
semipermeabel dari area tekanan hidrostatik
tinggi ke area yg lebih rendah. Arterial end of capillary has hydrostatic
pressure > than osmotic pressure so fluid
& diffusible solutes move out of capillary
7/27/2019 Fluid and Electrolite
26/82
7/27/2019 Fluid and Electrolite
27/82
THIRD SPACING
Large quantities of fluid from the
intravascular compartment shift into the
interstitial space; is inaccessible to thebody
May be caused by lowered plasma proteins,
increased capillary permeability &lymphatic blockage
Can be seen with trauma, inflammation,
disease
7/27/2019 Fluid and Electrolite
28/82
7/27/2019 Fluid and Electrolite
29/82
INTAKE & OUTPUT
INTAKE
Oral fluids -
including ice, gelatin,etc.
Parenteral fluids
Tube feedings with
flushes
Catheter irrigants
that are not
withdrawn
OUTPUT
Urine output
Liquid feces
Vomitus
NG drainage
Excessive sweating Wound drainage
Draining fistula
Rapid or labored RR
7/27/2019 Fluid and Electrolite
30/82
Normal fluid and electrolyte requirements
Daily water requirements
Weight (kg) x 25-35 mL = mL fluid required daily25 mL/kg for CHF or renal disease
30 mL/kg for average adults35 mL/kg for patients with infection or drainingwounds
Daily electrolyte requirements
Sodium 2 - 3 mEq/100ml H2O /day
Potassium 1 - 2 mEq/100ml H2O /day
Chloride 2 - 3 mEq/100ml H2O /day
7/27/2019 Fluid and Electrolite
31/82
Electrolytes This provides information about serum Na+, K+, Cl-, HCO3-
BUN and Cr These measures provide an indication of renal perfusion. An elevatedBUN generally reflects intravascular depletion. Creatinine is a usefulindicator of acute renal failure.
CBC The CBC may provide some indication of hemoconcentration in cases ofdehydration. The WBCs and differential cell count are useful indicatorsof infection. Platelets can elevate as acute phase reactants.
Urine
AnalysisThe specific gravity of the urine is related to the patient's hydrationstate. In cases of renal disease, it can help classify the condition. Urine
ions can be specifically requested, and are helpful in determining
whether sodium is being retained or not.
Examinations to identify fluid/electrolyte problems
7/27/2019 Fluid and Electrolite
32/82
Serum/UrineOsmolarity
A true measure of serum osmolarity can be compared to the calculated
osmolarity. Normally, true osmolarity is about 10 mEq/L higher than calculated
due to the presence of particles which are not in the basic osmolarity equation.
If there is a greater "osmolar gap" than this, the presence of additional particlesshould be considered (such as alcohol or mannitol). The osmolarity of serum
determines whether a patient is in an isotonic state or if this state has been
disturbed. Urine osmolarity is helpful in determining if the kidney is doing its
job of concentrating urine.Total Protein Total protein, and sometimes albumin levels, are indirect measures of both liver
function (where they are produced), dietary protein intake, and renal loss. If
serum protein levels fall, the intravascular oncotic pressure falls and fluid
migrates to "third spaces". This can be seen in liver disease, nephrotic
syndromes, malnutrition and other cases.
Arterial BloodGas In addition to providing information about the patient's blood gases andassisting in classification of acidosis or alkylosis, the ABG yields information
about bicarbonate levels. Usually, STAT electrolytes can also be obtained from
a blood gas sample, with turn around time better than serum chemistry.
7/27/2019 Fluid and Electrolite
33/82
Fluid Imbalances
Fluid excess:
CHF
Kidney failure
Fluid deficit:
Diarrhea
Blood loss
7/27/2019 Fluid and Electrolite
34/82
Assessment of Fluid Balance
Health History
Daily Weight
Intake and Output Vital Signs
Skin Turgor
Mucous Membranes
Hand Vein Filling/Emptying
LabsUrine SG; Hb&Ht; Sodium; Total Protein;Albumin; Serum Osmolarity; BUN; Creatinine
7/27/2019 Fluid and Electrolite
35/82
Responses to imbalances ?
R l ti f b d t l (d h d ti )
7/27/2019 Fluid and Electrolite
36/82
Regulation of body water loss (dehydration)
Aldosterone
Na
+&Water reabsorbtion
in renal tubules
Release ADH
Water retention
7/27/2019 Fluid and Electrolite
37/82
Neuro Endocrine Mechanisms
Central Nervous System Ischemic
Response- massive hemorrhage causes dec.
in ECF volume & response that constrictsafferent arterioles & dec. GFR
Baroreceptor Reflex- stretch receptors in
large arteries that react to a dec. in ECF &respond with dec. in GFR
P 207
7/27/2019 Fluid and Electrolite
38/82
Page 207
7/27/2019 Fluid and Electrolite
39/82
7/27/2019 Fluid and Electrolite
40/82
Page 208
7/27/2019 Fluid and Electrolite
41/82
CAUSES OF FVD
Abnormal GI fluid
loss such as N&V or
drainage of GI tract Abnormal fluid loss
from skin such as
high temperature or
burns Increased water
vapor from the lungs
such as hyperpnea
Conditions that
increase renal
excretion of fluidssuch as diuretics &
hypersomolar tube
feedings
Decrease in fluidintake
Third-space shift
such as ascites or
trauma
7/27/2019 Fluid and Electrolite
42/82
SIGNS & SYMPTOMS OF FVD
Dry mucous membranes
Weight loss -mild at 2%,moderate at 5%, &
severe deficit at 8%
Orthostatic hypotension& increase in
pulse rate
Body temperature usually subnormal
Flat neck veins & decrease in CVP
Decreased urinary output & altered
sensorium
7/27/2019 Fluid and Electrolite
43/82
NURSING MANAGEMEMT OF FVD
Monitoring I&O on a regular schedule
depending on the patient
If urine output is below 30 mL / hr. notifythe physician
May check urine specific gravity q 8hrs.
Weigh patient daily at the same time &recognize that a change of 2.2 lbs.
represents a loss of 1000 mL
Monitorskin turgor, oral membranes, lab
7/27/2019 Fluid and Electrolite
44/82
FLUID VOLUME EXCESS
Hypervolemia or FVE is result of
expansion of fluid compartment from an
increase in total sodium content Kidney receives signal to save sodium &
water to compensate for cirrhosis, CHF,
renal failure, excessive Na-containing fluid Labs may show dec.:hematocrit, serum
Na, serum osmolality, urine sp. Gr; inc.
BUN
7/27/2019 Fluid and Electrolite
45/82
SIGNS & SYMPTOMS OF FVE
SOB & orthopnea
Edema & weight gain
Distended neck veins & tachycardia
Increased blood pressure
Crackles & wheezes
Maybe ascites & pleural effusion
Increase in CVP
NURSING MANAGEMENT OF
7/27/2019 Fluid and Electrolite
46/82
NURSING MANAGEMENT OFFVE
MonitorI & O plus monitor for physical
signs of hypervolemia
Check foredema & weigh patient daily
Restrict sodium intake as prescribed
Limit intake of fluids
Watch for signs ofpotassium imbalance
Monitor for signs ofpulmonary edema
Place patient in semi-Fowlers position
7/27/2019 Fluid and Electrolite
47/82
SODIUM (NA)*
Main extracellular fluid (ECF) cation
Helps govern normal ECF osmolality
Helps maintain acid-base balance
Activates nerve & muscle cells
Influences water distribution (with chloride)
N: 135-145 mEq/L
7/27/2019 Fluid and Electrolite
48/82
7/27/2019 Fluid and Electrolite
49/82
Hyponatremia: serum Na < 130 mEq/L
Sodium deficit calculation: [(normal Na(mEq/L))(measured Na(mEq/L)] x TBW (L)
7/27/2019 Fluid and Electrolite
50/82
Hypernatremia: serum Na > 150 mEq/L
7/27/2019 Fluid and Electrolite
51/82
Hypernatremia: serum Na > 150 mEq/L
Significant neurological effects usually seen withNa > 160 mEq/L
Free water deficit calculation:
measured Na (mEq/L)
desired Na (mEq/L) X TBW (L)} - TBW (L)
Use 145mEq/L as desired Na; estimate TBW as
0.6L/kg x body weight (kg)
7/27/2019 Fluid and Electrolite
52/82
7/27/2019 Fluid and Electrolite
53/82
7/27/2019 Fluid and Electrolite
54/82
POTASSIUM (K)*
Dominant cation in intracellular fluid (ICF)
Regulates cell excitability
Permeates cell membranes, thereby
affecting cells electrical status
Helps control ICF osmolality & ICF
osmotic pressure
7/27/2019 Fluid and Electrolite
55/82
POTASSIUM (K+)
MOVEMENT
INFLUENCED
BY:Changes in pH
Insulin
Adrenal hormones
Changes in serum
sodium
IMPORTANT IN:
Neuromuscular
irritability
Intracellular
osmotic activity
Acid-base balance
7/27/2019 Fluid and Electrolite
56/82
7/27/2019 Fluid and Electrolite
57/82
7/27/2019 Fluid and Electrolite
58/82
7/27/2019 Fluid and Electrolite
59/82
Fluid electrolyte management
Estimating the fluid problem1) Check the weightRapid changes in weight likely represent changes in TBW.(2)History
Ask about losses (diarrhea, vomiting, how much, how often),attempts at replacement (what fluids used, how much given,how successful), urine output.
(3)Physical exam findingsMental status, pulse, BP, body weight, mucous membranes, skin
turgor, skin color.
(4)Laboratory evaluationSerum chemistries, hematocrit, and urine studies can guidetherapy and check forcomplications.
7/27/2019 Fluid and Electrolite
60/82
HYPERNATREMIA
Collaborative management tries to
gradually lower serum sodium by
*infusion of 0.45% NaCl
*monitoring U/O & serum sodium levels
*administering fluids carefully
*restricting sodium intake
7/27/2019 Fluid and Electrolite
61/82
HYPONATREMIA
Collaborative management seeks to correct
cause & give sodium with caution due to
possible rebound fluid excess by :*infusing isotonic saline in IV fluids
*restricting oral & IV water intake
*increasing dietary sodium*monitoring for signs of hypervolemia
HYPERKALEMIA
7/27/2019 Fluid and Electrolite
62/82
TREATMENT
Watch EKG for fatal dysrthymias or
cardiac arrest
Collaborative management may include:Calcium to counteract effect on heart
Sodium bicarbonate to alkalinize fluids
Hemodialysis or peritoneal dialysis
Cation exchange resins (Kayexalate) by
mouth or enema
Small dose of insulin & dextrose
Restrict dietary K+
7/27/2019 Fluid and Electrolite
63/82
HYPOKALEMIA TX
Correct the cause
Oral or IV administration of potassium
(dilutes in IV fluids) Salt substitutes containing K+
Foods high in potassium : bananas, pears,
dried apricots; fruit juices; tea, colabeverages; milk; meat, fish; baked potato;
dried beans (cooked); ANYTHING THAT
TASTES GOOD LIKE CHOCOLATE !!
7/27/2019 Fluid and Electrolite
64/82
NORMAL
HIPERKALEMIA
HIPOKALEMIA
7/27/2019 Fluid and Electrolite
65/82
Oral therapy
Oral rehydration with electrolyte solutions is safe, efficacious and convenient. Can be used as
first line therapy in nearly all fluid and electrolyte aberrations except severe circulatorycompromise.
7/27/2019 Fluid and Electrolite
66/82
IV therapy reestablish effective circulating volume
a) What IV fluid should be used?
Initial IV therapy should be with isotonic fluid to improve effective circulating volume.
7/27/2019 Fluid and Electrolite
67/82
b) How much IV flui d should I give ini ti al ly?
Use clinical findings to determine if patient is responding (mental status, vital signs, urine
output). Repeat this infusion if necessary.
c) How should continue IV fl uids?
do not require continued IV fluids after effective circulation has been restored.
Continue IV fluids in situations where oral
rehydration will be difficult, such as high ongoing losses, severe electrolyte abnormalities,
poor mental status or inability to tolerate enteral fluids.
7/27/2019 Fluid and Electrolite
68/82
(a)Estimate remaining deficits
Volume: Check current weight and compare to desired
baseline. If using preresuscitationweight, consider the amount
of volume given in resuscitation.
(b)Estimate daily needsEstimate daily needs for water and electrolytes, as for any
patient. Adjust based on the clinical situation (e.g., fever, coma,
ventilator, etc.)
(c) Consider ongoing losses
Monitor for losses such as stool, drains, etc. Consider replacingthese as needed.
(d)Provide therapy
Add up water and electrolyte needs from deficits and daily
requirements.
Continuing IV therapy considers:
7/27/2019 Fluid and Electrolite
69/82
ACID-BASE BALANCE
Governed by the regulation ofhydrgen ion
(H+) concentration in the body
pH = negative logarithm of the H+concentration
Acids - proton donors & give up H+
Bases - H+ acceptors
Acidic - inc. in concentration of H+
Basic - dec. in concentration of H+
HENDERSON -
7/27/2019 Fluid and Electrolite
70/82
HASSELBALCH EQUATION
Expresses that the
ratio of base to acid or
HCO3
- to H2
CO2
*
( 20: 1) determines the
pH
pH < 7.35
ACIDOSIS pH > 7.45
ALKALOSIS
7/27/2019 Fluid and Electrolite
71/82
7/27/2019 Fluid and Electrolite
72/82
ACID-BASE REGULATORY
7/27/2019 Fluid and Electrolite
73/82
MECHANISMS
CHEMICAL BUFFER SYSTEMS -
bicarbonate, phosphate, protein,
hemoglobin LUNGS - carbonic acid broken down into
CO2 & H2O
KIDNEYS - increasing or decreasingbicarbonate ions
7/27/2019 Fluid and Electrolite
74/82
Arterial Blood Gases (ABGs)
pH 7.35-7.45
PaCO2 35-45 mm Hg
Pa O2 80-100 mm Hg
O2 sat. 95-99%
HCO3- 22-26mEq/L
7/27/2019 Fluid and Electrolite
75/82
ACID-BASE PARAMETERS
ACID
pH 45 HCO3 7.45
PaCO2 26
7/27/2019 Fluid and Electrolite
76/82
Respiratory Acidosis*
pH < 7.35
PaCO2 > 45mm Hg
Due to inadequate alveolar ventilation
Tx aimed at improving ventilation
Respiratory Opposite
7/27/2019 Fluid and Electrolite
77/82
Respiratory Alkalosis*
pH > 7.45
PaCO2 < 35mm Hg
Due to alveolar hyperventilation &hypocapnia
Tx depends on underlying cause
7/27/2019 Fluid and Electrolite
78/82
Metabolic Acidosis*
pH < 7.35
HCO3 < 22mEq/L
Due to gain of acids or loss of base (likeexcessive GI loss from diarrhea)
May have associated hyperkalemia
Tx aimed at correcting metabolic defect
Metabolic Even
7/27/2019 Fluid and Electrolite
79/82
Metabolic Alkalosis*
pH > 7.45
HCO3 > 26 mEq/L
Due to loss of acid or gain of base (mostcommon is vomiting or gastric suction)
Hypokalemia may produce alkalosis
Tx aimed at underlying disorder
7/27/2019 Fluid and Electrolite
80/82
ABG ASSESSMENT*
36 yo pt. complains of
acute SOB, R sided
pleuritic pain
pH 7.50
PaCO2 29 mmHg
PaO2 60 mmHg
HCO3- 24 mEq/l
SaO2 78%
? Meaning ?
32 yo pt. with drug
OD & breathing 5
times / minute
pH 7.25
PaCO2 61 mmHg
PaO2 74 mmHg
HCO3- 26 mEq/l
SaO2 89%
? Meaning ?
7/27/2019 Fluid and Electrolite
81/82
ABGs*
70 year old diabetic
with hx of not taking
insulin
pH 7.26
PaCO2 42
HCO3 17
????
58 year old pt. With
CHF for 6 mos. &
placed on digoxin &
Lasix
pH 7.48
PaCO2 45
HCO3 26
????
7/27/2019 Fluid and Electrolite
82/82
HATURNUHUN
TERIMA KASIH
Top Related