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Study Guide Fluids Class I Fluids in the Body-TBW(Total Body Water) 1. Percentages of body weight for different populations:
A. Adult male>adult female- Why does the male have more

fluid______________________________? B. Average Adult_____% C. Older adult_____% D. Newborn______%Why does the infant have a high percentage of water______________________________? Which of the groups above are at greatest risk for fluid and electrolyte imbalances?________________________________________________ Would an obese individual be more/less at risk for a fluid imbalance? Why?_________________________ 2. Body Fluid Compartments A. Intracellular holds_____ of TBW or _____% of TBW. B. Extracellular-______of TBW or_________% of TBW. a. Intravascular________of ECF or about_________L b. Interstitial_______of ECF or about______L. c. Transcellular ________L and is found in______________________________________________ _______________________________________________ If you lose this fluid from vomiting it can have serious consequences. What fluid is it________________? If more than 1/3 of body fluid is lost_____ ____________things can occur. Example:_______

3. Fluid Spacing Distribution of Water

A. First-spacing-_________ distribution of extra/intra cellular water. B. Second Spacing-_______ accumulation in interstitial fluid. C. Third-Spacing-___________accumulation in areas where there would normally be very little or none.

4.

Functions of Body Water A. ____________________________________________B. ____________________________________________ C. ____________________________________________ D. ____________________________________________ E. ____________________________________________

5.

Calculation of Body Fluid Imbalances A. 1L Water=2.2 pounds or 1Kg B. Daily Weight excellent indicator of overall fluid volume if done this way: ____________________,_______________________,_________ ______________________,_______________________________ _ C. If your patient has had a weight gain of 7 pounds in 3 days how many Liters of fluid are they retaining_______________?

6. Electrolytes
A. An electrolyte is a substance that splits into an_________ when placed in __________. B. Ions are ______________charged. C. Several pairs of oppositely charged ions are so closely linked that a problem with one ion causes a problem with another. D. Example:___________Do you know any others___________________?

7. Anions and Cations

A. Cations have a_________charge and include: _____,__________,__________,__________ B. Anions have a__________charge and include: _________________,___________,_______________. C. The ions that mainly live inside the cell are: _______,___________,__________ D. The ions that mainly live outside the cell are: _______,_______,________,_______.

8. Measurement of Electrolytes

A. Only the electrolytes in the__________ ____________ are measured. B. Most labs report results in_________ C. This is a measure of the ions__________ ____________. D. The MOST important thing for Nurses to know about measurement of electrolytes is what are the_______ _______ When they are out of ________. What effect will this have on the patient. 9. Normal daily body fluid intake A. Liquid=1500 B. Food=800 C. Water of oxidation=300 Total__________________ Other types of intake include:____________________________________? Normal daily Body Fluid Losses A. Skin=600 B. Lungs=400 C. Kidneys=1500 D. Intestines=100 Total_________________ A quick way to estimate water balance is to look at how much they have taken in and put out over 24 hrs. Important to look at trend. Intake should___________________output. List 2 symptoms that can occur in patients that would cause increased loss of fluid through skin and lungs. 1._________________ 2._________________ 10. Sensible Loss is______________________________. Insensible Loss is_____________________________ 11. Abnormal fluid losses: _________________________________ _________________________________ _________________________________ _________________________________ _________________________________

Types of Fluids
Solutions: liquids (__________) containing dissolved substances (__________) and classified according to concentrations (___________). 1. Isotonic-comparable to body fluids. A. The fluid in our body has about the same amount of _________as is found in .9 Normal saline solution. This is known as isotonic. B. If two fluids in adjacent compartments are equally __________________, they are in balance. Fluid in each compartment stays put. No imbalance means no net fluid_________. C. The blood in our body has a sodium content nearly equal to the Na found in what solution_______________? This solution would be called___________?

2. Hypotonic-More water than solutes.

A. A higher/lower solute concentration than another solution. If

one solution contains only a little sodium and another solution contains more what is the first solution________________. As a result, fluid with the ________________solute(more water) would shift into the ____________solute solution(less water) until the two solutions had equal concentrations. B. If the vascular space fluid is hypotonic it would cause the fluid to shift into the____________and cause the cells to___________. What IV fluid is considered hypotonic______________________? What makes this solution hypotonic________________________? 3. Hypertonic-less water than solutes A. A higher/lower solute concentration than another solution. If one solution contains a large amount of sodium and a second solution contains hardly any. The first solution is________________? As a result, fluid from the__________solute solution would shift into the _______________________solute solution until the two solutions had equal concentrations.

If the vascular space is hypertonic what would the fluid in the cells do____________? This would make the cells__________? What IV fluid is considered hypertonic__________________? What makes this solution hypertonic____________________?

Fluid Movement 1. Diffusion

A. Solutes move from area of _____________concentration to area of ________________concentration. Diffusion is a form of ______________transport because no___________is required to make it happen. _________is an example of what moves by diffusion.

2. Active Transport
A. Solutes move from area of _________________concentration to area of_____________concentration. Energy comes from______________________. It is stored in all cells What solutes require ATP to move in and out of cells______________________________? Draw a picture of the Na/K+ Pump:

3. Osmosis
A. The ____________movement of fluid across a membrane.

Moves from a ________________solute concentration(more fluid) into an area of_________________solute concentration(less fluid). B. Osmosis stops when the two fluid on both sides of the membrane have__________solute concentration.

Pressures in the Vascular System A. Capillaries are the only part of the vascular system with __________thin enough to let solutes through. This movement of fluids in and out of the capillary

plays a critical role in the bodys fluid _______________. B. Movement of fluids through the capillaries at the arteriole end is known as_________________________. C. Capillary filtration results from blood____________against the capillary walls. It takes place at the ________ end of the capillary. This pressure is known as_______________pressure. The hydrostatic pressure forces fluids and solutes through the capillary wall. D. When the_________________pressure in the capillary is______________than the hydrostatic pressure in the___________space, fluids and solutes are forced out into the interstitial space. When the hydrostatic pressure inside the capillary is_________than the hydrostatic pressure outside of it, fluids and solutes move________into the capillary at the_______end of the capillary. This is known as________________. E. When fluid filters through a capillary, ___________remains behind in the diminishing volume of water. Albumin is a large particle that cannot pass through a capillary membrane unless there is damage to the capillary. As the concentration of____________inside the capillary______________, the pressure known as________________increases helping to pull the fluid back into the capillary via __________. This osmotic pulling force of albumin in the vascular space is called_____________________________pressure. As long as these pressures remain normal the amount of water that moves out of the vascular space___________the amount of water that moves back into the vascular space.

If any of these pressures are altered for whatever reason________will occur. REGULATORS OF FLUID BALANCE
A. Thirst Mechanism 1. Located in the_______________. Stimulated with increases in ________________and ____________. It makes us get up and go get a drink of water. 2. What about the confused elderly patient, the infant, or the unconscious patient? B. Na and Cl help to regulate the ___________content in the body. C. Kidneys Major organ for maintaining balance of fluid in the body. Kidneys filter approximately________liters of plasma a day. Rate, called the__________ ___________rate leads to 1-2L urine per day. Remaining 178L plasma is _______________________. ______________and___________ are either excreted or retained depending on bodys need. D. Heart If heart is weak/strong cardiac output will go up/down? When cardiac output goes up/down the vital organs will have increased/decreased perfusion? If the kidneys are not being perfused urine output will increase/decrease? E. Hormonal Influence-ADH 1. Stored and released by the________________gland. 2. When you think of ADH, think____________ONLY. 3. Its purpose is to restore____________________. 4. Stimulation of the pituitary to release ADH is from__________________blood volume or _______________serum osmolality. 5. ADH keeps fluids in balance all day long? F. Enzyme-Renin-Angiotensin 1. When the body loses _________and the BP drops (usually less than 90 systolic) kidneys release an enzyme called_____________. 2. A series of steps follow and renin is converted to Angiotensin II-powerful___________________.

8 3. Vasoconstriction causes blood vessels to clamp_______in

your body and raise/lower the BP. This means that your vital organs are now going to be______________.

G. Aldosterone 1. A steroid hormone or more specifically, a _____________________. It is secreted normally by the ____________glands. 2. When the body loses a large amount of fluid or the body is under increased stress the adrenal glands release the hormone_________________. 3. Aldosterone regulates the reabsorption of _________and _______ and when this occurs aldosterone also causes _______________ to be excreted through the kidneys. H. Atrial Natriuretic Factor(ANF) 1. Cardiac hormone stored in cells of the ____________. 2. When atrial pressure is____________ANP is released. 3. Counteracts effects of renin by___________BP/reducing vascular blood volume 4. If the atria is stretched(CHF, CRF)leads to increased/decreased amounts of ANP being released. I. Intestines-85-95% of fluid absorption into vascular space comes from_________ ___________ and occurs in the _______intestines. J. Parathyroid Glands-Secrete_______________which makes serum calcium go up/down? K. Thyroid gland-When these hormones are released, blood flow increases/decreases. This increases/decreases circulation. What will occur_______________? L. Lymphatic system-Helps _________and_________get back into the vascular space.

Pediatric Considerations A. Approximately________% of their body weight is water. The

highest percent of their water is located in the__________. This is easy to lose which places the infant at high/low risk for a fluid imbalance.

B. Infants kidneys are immature/mature making it difficult for them to

concentrate and dilute urine. This means they will have a hard time conserving fluid.

Elderly Considerations A. As an individual ages the kidney function increases/decreases?

This can put the elderly at increased/decreased risk for a fluid imbalance because they can/cannot concentrate their urine as well when the intake has decreased. Heart-Decreased/Increased CO causes decrease/increase in kidney perfusion. Decrease/Increased thirst mechanism Decreased/Increased TBW Some will decrease/increase fluid intake as a result of incontinence.

B.

C. D. E. Osmolality A. This is looking at the concentration of a ___________. It is

determined by the number of dissolved__________per Kg of water. The particles are_____________. B. Which particle is the largest contributor to osmolality_____________________? C. Normal plasma level is____________? D. If the plasma level is greater than 295mOsm/kg it is known as_____________ or___________? E. If the plasma level is less than 275mOsm/kg it is known as__________ or ___________? F. How do you make a rough estimate of serum osmolality_____________________________? If the serum Na is 200 mEq what would you estimate the serum osmolality to be_______________? G. What other labs are important in helping to determine water imbalances in the body_________and_____________. H. Would these levels increase/decrease in dehydration? I. Would these levels increase/decrease in water excess?

Dehydration

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A. Dehydration is a result of not enough fluid intake to meet the

bodys need. This is also known as a_________ ________ ___________________________.

B. The 3 possible types of Dehydration include:

1. Isotonic-Water and electrolytes lost in______ amounts. 2. Hypertonic-Water loss is________than electrolyte loss. 3. Hypotonic-Electrolyte loss is___________than water loss.

C. Dehydration is a___________rather than a disease process.

There are many causes. D. Dehydration can be_________decrease in TBW by not drinking enough or too great a loss of fluid. E. Dehydration can also occur without an actual loss of TBW. This occurs when____________fluid in vascular space _______into the___________ ___________. This is known as __________________dehydration. An example of this type of dehydration would be from____________________. F. Older adults are at high risk for _________ _________ ___________ due to: ___________________________________________________ ___________________________________________________ ___________________________________________________

Isotonic Dehydration
A. Most common type B. Osmolarity of plasma remains____________while_____________is reduced. C. In this type of dehydration there is NO_______of fluid between compartments. D. Isotonic dehydration____________circulating blood volume also known as__________________. When the circulating blood volume is decreased will kidneys and other vital organs have decreased/increased perfusion? If there is decreased perfusion to the kidneys will the kidneys concentrate/dilute urine? Will the heart rate increase/decrease? Will the BP increase/decrease?

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E. Common causes of this type of dehydration include: 1. Hemorrhage 2. Vomiting/Diarrhea 3. Fistulas 4. Abscesses 5. Profuse diaphoresis 6. Third-Spacing-Burns 7. Long term NPO 8. Diuretic therapy 9. GI suction

Hypertonic Dehydration
F. Second most common type G. Osmolarity of plasma increases/decreases due to a _________loss of water than electrolytes. This increases the osmotic pressure and this causes water to move from the____ to the____. This shift results in cellular______________. When the fluid from the cells shifts to the plasma the plasma level will increase/decrease. Therefore you will not see compensatory mechanisms or____________ __________. H. Common causes: 1. Excessive sweating 2. Hyperventilation 3. Ketoacidosis a. Particle to water ratio is too high/too low? When this occurs in the body this causes the kidneys to excrete/retain the excess particles. b. Particles are depleted by the__________ through_______________. c.Will this increase/decrease the vascular space of water? d.Will the serum sodium/serum osmolarity be increased/decreased? Specific gravity: Increased/Decreased? 4. Prolonged fevers 5. Watery diarrhea 6. Diabetes Insipidus (DI) a. Caused by too much/too little ADH?

12 b. Causes of DI

include:______________________________ ____________________________________ ____________________________________? c. Will urine be concentrated or dilute? d. Will serum Na/Serum osmolarity be concentrated or dilute? 7. Tube Feedings that are not properly diluted 8. Individuals with impaired thirst mechanism/unconscious/impaired motor abilities G. Will the serum sodium/serum osmolality increase or decrease in hypertonic dehydration? Will the specific gravity of urine be concentrated or dilute? Will this make the number go up or down? What is the one disorder seen with this type of dehydration where urine will be dilute_________________? H. What organ in the body is affected first when the cells are dehydrated___________? I. What individuals are at highest risk for dehydration? ________________________________

Hypotonic Dehydration
A. Least common type B. Seen with__________loss of Na and K from ECF. The serum osmolarity decreases/increases. This decreases/increases the osmotic pressure of plasma compared to the fluid inside the cells. With the difference in pressure the fluid inside the vascular space will move inside the cell in an effort to__________. This results in a plasma volume___________ and causes the cells to_____________. C. The organ most sensitive to swelling cells is the__________therefore neuro changes can occur. D. Causes: 1. Fluid replacement with just water 2. Severe malnutrition 3. Chronic illness E. In hypotonic dehydration would the serum Na increase/decrease?

Signs and Symptoms A. Manifestations of Dehydration in General

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B. CV:
1. 2. 3. 4. 5. Respiratory: 1. 2. Neuro: 1. Lethargy to coma 2. Fever Renal: 1. Decreased urine output(except with DI) 2. Increased Specific gravity Integumentary 1. Skin dry and scaly 2. Turgor poor, tenting present 3. Mouth dry and fissured, pastelike coating present GI: 1. 2. 3. 4. Decreased motility Diminished Bowel sounds Constipation Thirst Increased pulse rate, weak and thready Decreased BP Orthostatic hypotension Flat neck and hand veins in dependent position Weight loss Increased RR Increased depth of respirations

Manifestations of hypotonic dehydration: Skeletal muscle weakness Manifestations of hypertonic dehydration:

Hyperactive DTRs Increased sensation of thirst Pitting edema

Treatment and Nursing Interventions A. Mild Isotonic Dehydration-Salt-free fluids- PO B. Marked-Severe

IV Solution Replacement Includes:

14 A. Water Deficit/Dehydration/Hyperosmolar Deficit-

Hypertonic/Isotonic/Hypotonic? B. Example of IV fluid that should be used is:________________________________. What is the rationale for using this solution_______________________________________? C. What could occur if the fluid is given too quickly________________________________________?

A. Water and Solute Deficit or Iso-osmolar DeficitB.

C. D. D. E.
F.

G. H. 1. 2.

Hypertonic/Isotonic/Hypotonic? Example of IV fluid that should be used is:________________________. What is the rationale for using this solution______________________? If the volume loss is due to blood loss then replacement should also include_______________. Monitor VS I and O-Include Urine/Stool Lab values that should be monitored: Serum Na, Serum Osmolality, Specific Gravity of Urine Daily WeightsSame_______Same______Same______Void prior to weighing. SINGLE MOST EFFECTIVE MEASUREMENT OF FLUID IMBALANCE. Mouth and skin care Teaching: Signs and symptoms to be aware of-orthostatic dizziness Fluid replacement with pedialyte/Gatorade

Hypervolemia-ECFVE Nursing Diagnosis: Fluid volume excess, edema, SOB, whatever signs and symptoms may be R/T body fluid overload secondary to heart failure(renal, liver, dysfunction) A. Hypervolemia means too much/too little fluid in the ECF? B. In this type of fluid excess there is No shift between compartments.
Why_____________________________?

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C. Why is it called Iso-osmolar

FVE_______________________________________________?

Causes of Iso-Osmolar Fluid Volume Excess A. Poorly controlled IV infusionsExcessive Na intake from IVs,(NS, LRs, blood or plasma replacement, Fleets enemas, Phospo-soda 1. If our kidneys are working properly our body will adjust the fluid overload. What will happen with decreased kidney function or the elderly__________________________________________

B. Renal Failure
1. If the kidneys are not functioning we will retain ____and_____? Where will the excess fluid go_______________

C. Congestive Heart Failure:

2. Heart is weak/strong? CO(Cardiac Output) will go up/down? 3. Kidney perfusion will go up/down? Urine output will go up/down? 4. Where will the excess fluid go_____________________or it could also go into the_______________________?

D. Aldosterone
a. What is aldosterone_____________________________? b. Normally when the blood volume goes down aldosterone is secreted and we retain/excrete Na and water? c. What if the body is making too much aldosterone? Name some disorders that produce too much aldosterone: a.__________________________________ b.__________________________________ E. Liver Disease 1. Ascites(third spacing)-Fluid moves from vascular space into the_____________________. What is the peritoneum__________________________________? The fluid in the peritoneum is physiologically useless. There is no exchange of particles. E. Burns

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a. During first 24-36 hours(Burn shock phase) fluid shifts from the ______________space to the________________space. Known as a third space shift. Causes edema. What has happened to the fluid in the vascular space__________________? What can occur____________?

Signs/Symptoms A. Initially-VS will increase/decrease? B. If the kidneys are healthy what will you see____________? C. CVP measurement will go up or down? D. RR will go up or down? E. If the heart begins to fail will the cardiac output go up or down? F. Renal perfusion will decrease/increase? G. If the cardiac output is decreased what will happen to the H. I. J. K. L. M.
BP____________? Pulse rate will increase/decrease? What will the character of the pulse be when you assess it _________and_______________. Respirations will be______________. Neck and hand veins will be_________________. CVP will increase/decrease? Edema will occur. Where is the fluid coming from_____________________? Where is it going to go____________or_________________. You will see edema in conditions like ____________ , __________, and________________. 1. Where will you see edema first in the bedfast patient___________? Why_________________? 2. If the patient can sit in the chair or ambulate where will the edema be_____________________? If it gets really bad it is called________________(generalized edema). You will see__________________edema(swollen eyelids.) 3. What is the difference between dependent edema and nondependent edema___________________________________________ ________________________________________________ ____________________________________________? 4. What scale do we use to measure pitting edema___________________________________________ ________________________________________________

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N.

O. P. Q.

________________________________________________ ____________________________________________ 5. What is the single most important thing we must be so careful of in our patients with edema_______________? What is the rationale________________________________________ _______________________________________________ 6. With edema what will the appearance of the skin be _________, _________, and __________? 7. In patients with CHF where else can we see edema______________? 8. This is called__________________. It is a medical emergency. 9. It occurs because the left ventricle is weak/strong and weakened ventricle is not able to pump all of the blood and so it backs up into the__________of the lungs. 10. What symptoms would you see in a patient with pulmonary edema________, __________, and_______. 11.The hallmark of Pulmonary Edema is____ _____ ______. 12.Where do you need to place your stethoscope on this patient for proper assessment of their lungs___________ and _____________. Weight-Patients must be weighed___________. If a patient gains weight over a 24 hour period is this fat/water gain? How are we going to weight this patient? Same_________Same________Same________Void first. Neck vein engorgement-Jugular veins will remain __________ in a semi-fowlers position. Hand veins will be _______________. Liver disease-Fluid will be seen in the_________________. What do you need to do everyday to assess fluid increases in this patient__________________________. In fluid volume excess the Hct will be Increased/Decreased. Serum Na will increase/decrease? Serum osmolality will increase or decrease? Specific Gravity: Increase/Decrease?

Treatment/Interventions A. Restriction of sodium and fluid intake B. CHF-3 Ds include:__________, ____________,

and_____________. 1. What is an example of a loop diuretic_____________?

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2. What do we need to be concerned about when patients are using diuretics_______________? 3. What is an example of a potassium-sparing diuretic_________________________? What do we need to be concerned with in patient on this diuretic_____________? 4. Bedrest and oxygen C. Focused assessment-includes: 1. Mental status 2. VS 3. Lungs 4. Edema 5. Weight(more than a 2lb weight gain in 24 hrs signals need for more diuretic therapy). 6. I and O 7. Monitor labs-Na, K(hypokalemia can lead to digoxin toxicity) 8. Fowlers position, supplemental oxygen 9. Teaching1. Na content of foods 2. Meds/Side effects 3. How to weigh themselves properly and track changes

Water Intoxication(hypo-osmolar FVE) A. Excess fluid moves from ECF to ICF when fluid in ECF is
hypotonic B. The cells are hypertonic to the fluid in the ECF C. This causes a shift of the water from the ECF into the ICF D. Result is swelling of the Cells. Known as Water intoxication or Hypo-osmolar FVE E. Causes of Water Intoxication: 1. SIADH: Where does ADH live________________? What is the action of ADH___________________? If we are making too much ADH what will happen______________________________________________? Will the serum Na and serum osmolarity be elevated or decreased? The specific gravity will be increased or decreased? Name some causes of SIADH: ____________________________ ____________________________ ____________________________

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____________________________ 3. Psycho-genic Polydipsia-person drinks _________amounts of___________________even when they are not needed. 4. Rapid infusions of hypotonic fluids 5. Excessive use of tap water as NG tube irrigant or enema

Signs and Symptoms of Water Intoxication A. Signs of Low Serum Na: This is a result of increased ICP due to
cellular swelling: 1. HA and personality changes seen first 2. Confusion, irritability, lethargy 3. Nausea and vomiting 4. Cramping 5. Muscle weakness 6. Twitching, 7. Thirst 8. SOB 9. Late signs of ICP: Pupillary and vital sign changes(bradycardia, widened pulse pressure), seizures, coma

Lab findings in Water Intoxication: A. Serum Na will be <125mEq/L

B. Serum Osmolality<280 mOsm/kg

Treatment for Water Intoxication A. Avoid use of Hypotonic fluids-IV and PO

B. Restriction of oral and IV fluids C. Use of Hypertonic IV fluids in severe cases: 3%NS

Nsg Interventions A. Frequent neuron checks

B. VS/I and O C. Weigh Daily D. Institute Seizure precautions

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