Transcript for:
Understanding Fluids and Electrolytes

in this video I'm going to cover the key Concepts you want to know about fluids and electrolytes let's start with the basics of cell membrane transport the human body likes to maintain a homeostatic environment to make sure that our fluids and solutes are equally balanced and to do this it has different types of transport processes that allow this to be achieved so in this review I'm going to be talking about the two types of diffusion known as simple diffusion and facilitated diffusion along with osmosis and active transport and hydrostatic pressure and oncotic pressure also known as colloidal osmotic pressure first let's talk about the processes that move substances within the cell specifically that cell membrane here you're going to see a phospholipid bilayer that is found within the cell membrane and this phospholipid by layer acts as this medium to really allow substances to flow in and out of the cell so here you see the circular yellow little balls those are known as the hydrophilic heads and then coming off those heads are the hydrophobic tails and they really just come together to help form this barrier that separates the extracellular part the outside of the cell from the intracellular part the inside of the cell and then scattered within this membrane are these Channel carrier proteins now one thing I want you to remember about this by layer is that it is very particular it only allows certain substances to go in through certain processes so really based on the size and if this solute is charged will depend on how it's going to enter or exit the cell so first let's talk about simple diffusion simple diffusion is just as its name says it's a very simple process because it requires no energy from the cell and it's a passive form of Transport so what happens with this process is that molecules H solutes are going to move from a high concentration to a low concentration so here we see outside of our cell a lot of solutes there's a high concentration of them and according to simple diffusion they are just going to easily diuse hence move through that phospholipid Bayer to the inside of the cell where there's not a lot of solutes until homeostasis has been achieved so this mass movement will continue until we have equilibrium where we have a balance of these solutes now an important thing to remember about simple diffusion is that only tiny non-charged molecules are going to be able to go straight through this phospholipid by layer so we're talking about things like oxygen carbon dioxide and so forth now if bigger charged polar molecules want to move in and out of the cell they need to do it through a different process known as facilitated diffusion and facilitated diffusion is very similar to simple diffusion but with facilitate diffusion it's going to use these special helper proteins that are found within that phospholipid membrane to move these solutes hence molecules to and from the cell so again these molecules hence solutes are going to go from a high concentration to a low concentration it's going to go down that concentration gradient it's a passive form of Transport requires no energy but it's going to allow big molecules that are charged and polar to move to and from the cell they just can't go straight through that phospholipid B layer so we can move glucose and ions to and from the cell now we have a different type of transport that's sort of going to do the opposite of what diffusion did because with diffusion we went from high to low concentration we were going down the concentration gradient it was a very simple process we didn't have to go against it but sometimes our body wants to move against this concentration gradient and wants to go from a low concentration to a high concentration and this is where active transport comes into play so with active transport there's going to be the movement of molecules hint solutes from a low concentration to a high concentration through these special proteins found within that phospholipid bilayer but it's going to use energy in the form of ATP so here we have our phospholipid bilayer notice on the inside of the cell we don't have a lot of solutes but on the outside of the cell we have a lot of them so with this transport process we want to go from low to high so we're going against that concentration gradient rather than just down the concentration gradient so when we go against it it requires effort a lot of energy so this is where we utilize ATP so in order to move this molecule from inside the cell to the outside of the cell it's going to flow through this special protein Channel but ATP is going to help energize this process and we're going to be able to flow to that higher concentration now let's take a look at osmosis so with OS is we're talking about the movement of water water is going to move through a semi-permeable membrane that is only permeable to water and nothing else and it's going to do this through a passive process it's a passive form of Transport requires no energy and the whole goal of Osmosis is to achieve homeostasis in the terms of water it water wants to shift around until we've equaled out the concentration of water inside and outside the cell and we've equaled out that solute concentration so whenever you're trying understand osmosis you can look at it one of two ways one way is that you can remember that water will move from a high water concentration to a low water concentration or water is going to move from a low solute concentration so the solutes hence the dissolved substances that are in that water are low and that water wants to move to a fluid hints water situation where the solutes are high it has a high osmolarity there's a lot of solutes in it so water is attracted to solutes hence water is attracted to sodium you got a lot of sodium on board it's going to draw a lot of water in so those are two ways you can look at osmosis and when we're talking about a cell we're talking about water moving in and out of the cell and it all really depends on that solute concentration whether it's High inside of the cell or outside of the cell so let's look at this illustration here on the outside of the cell or extracellular part of our cell there is a lot of water but there's not a lot of solute so it has a low osmolarity on that extracellular fluid but on our inside of the cell notice there's a lot of solutes but not a lot of water so it has a high osmolarity in there so according to osmosis effortlessly no energy needed that water wants to achieve some homeostasis it's really salty or high osmolarity inside of that cell so that water is going to be drawn through a semi-permeable membrane and it's going to go and enter into that cell until it's tried to equal out osmolarity inside outside of the cell and whenever that's achieved osmosis will cease now some problems that can arise whenever fluid does move in the Direction with osmosis because we have a cell that has such a high osmolarity is that too much water can go inside that cell and it can cause it to swell and rupture and the flip side can happen let's say that inside of the cell had a low osmolarity but the outside of the cell had a high osmolarity had a lot of solutes but and it didn't have a lot of water well too much water can leave that cell and go in the opposite direction to extracellular fluid and we could dehydrate that cell and shrink it now the neat thing about this osmosis process is that in healthcare we can actually use this to benefit our patient because sometimes patients come in with fluid volume deficit or fluid volume overload and they need certain fluids to help correct that imbalance and we can manipulate this osmosis process with those fluids based on the solute concentration of these fluids to help either rehydrate that cell or dehydrate that cell depending on what's going on with that patient so we just reviewed how certain transport processes move fluid and substances to and from that cell through that cell membrane now let's look at some processes that move fluid from the capillaries to the interstitium also known as a tissue Space by talking about hydrostatic and oncotic pressure hydrostatic pressure and oncotic pressure are two pressures that literally work the opposite of each other but they work beautifully together to help maintain fluid going across our capillary wall into our interstitium our tissue space with oncotic pressure it's going to pull water across that capillary wall and hydrostatic pressure is going to push water across that capillary wall so first let's talk about oncotic pressure so oncotic pressure pressure you may hear also referred to as colloidal osmotic pressure so if you also hear that term as well that's what it's talking about cuz sometimes that can get a little confusing and this is that pulling force on water created by proteins specifically the protein albumin which is known as a colloid and a cool thing about albumin is that a lot of it hangs out in our blood plasma and it is way way too big to pass through that capillary wall so it just hangs out there in that blood plasma in that intravascular space in high concentrations and whenever it does this by hanging out in high concentration it creates an osmotic pressure which pulls water through a process known as osmosis and we just talked about osmosis and we know that osmosis occurs because water loves to be where there's a high concentration of something hence solutes and in this case we're talking about albumin so there's a lot of albumin hanging out in this capillary wall which is going to result in water being pulled in so water is going to stay inside that capillary which is what we usually want so again just to drive home that point let's look at this illustration we have this example of a capillary and in white you see all these colloids hence album and the proteins hanging out within this vessel and it's highly concentrated so what it's going to do is it's going to pull water from that surrounding area that intertial area with the fluid in there and it's going to cause water to stay inside that vessel and the reason it's doing that is because there's a high concentration of that albumin inside that vessel it causes osmotic pressure to occur which is going to pull water in there and water is going to stay inside that vessel hence our capillary now sometimes problems arise in some patients where they don't have enough of this albumin in their blood plasma and they're experiencing a condition known as hypo albuminemia and this can happen in cases of liver or kidney failure because your liver makes albumin so you just don't have enough in your blood or the patients let's say had severe burn so we've dropped those levels so what do you think's going to happen if you don't have enough albumin in your blood plasma well your oncotic pressure is really going to be affected you're not going to have a lot of it because there's not enough of it hanging out in the blood to create that pressure so instead water is going to leave that blood plasma go into that interstital space face and we're going to experience swelling now let's talk about hydrostatic pressure so this is the opposite of oncotic pressure because it creates a pushing effect on water across that capillary wall and in other words really what hydrostatic pressure is is it's the pressure or force of a fluid inside a restricted space so inner body when we're trying to think of that the restricted space is going to be our blood vessels since our capillaries and that fluid is going to be our blood so what happen happens is that this pressure is created somewhere and it's created by our heart so our heart contractions create hydrostatic pressure and hydrostatic pressure varies throughout your circulatory system it's really high in the arteries and we need it to be high in the arteries because your arteries take that fresh oxygenated nutrient rich blood and needs to push it out throughout your body so we need hydroid pressure to be high but as we get closer to the Venus system it gets lower because the Venus system system's job is to take that used blood back to the heart so we can make it better again give it more nutrients so whenever you're looking at the capillary and you're trying to figure out where these pressures are highest on the end of the arterial part of the capillary is where the hydrostatic pressure is the highest versus where it's the lowest which is the Venus end of the capillary and the whole goal of hydrostatic pressure is that it needs to create a process known as filtration because we need to get this water and solutes out of the capillary into their intital fluid so it can go and do its thing and then come back to us so what hydrostatic pressure does is it's that pressure that pushes that water and solutes out of the capillary into the interstial fluid which is again known as filtration so as you can see with these two processes oncotic pressure and hydrostatic pressure how our body needs them to work we have one that's going to push out the water in the new nutrients which is hydrostatic pressure and then we have the other oncotic pressure which is going to pull it and keep it inside the vessels now let's take a look at hormones and fluid regulation the water in our body must be balanced we can't have too much or too little and if we do we start to have major problems so whenever an imbalance starts to occur we have hormones and certain systems in our body that will kick in to hopefully help correct those imbalances so in this lecture we're going to review those hormones and systems so I'm going to be talking about the renin Angiotensin aldosterone system known as Ras I'm also going to be talking about The Thirst mechanism and review those hormones known as anti-diuretic hormone which is known as ADH aldosterone and the N Tre uretic peptide hormones so first let's review the renin Angiotensin aldosterone system also known as Ras okay so let's say you have a patient who has fluid volume deficit so thinking back to lecture on fluid volume deficit we know that our patient has low fluid in their body and this can cause a low blood pressure and our body doesn't like a low blood pressure so whenever it senses this this rra system is going to kick in and the whole goal of the system is to increase your blood pressure and how it does this is it gets Angiotensin 2 involved which is a hormone that's also going to stimulate other hormones such as aldosterone and ADH that anti-diuretic hormone and those hormones are going to add more water to your blood to help increase blood volume hence increase blood pressure so how this system works is that your blood pressure drops that drop in blood pressure indicates to the body hey we have a loss of fluid so we've got to do something about this and this causes the kidneys to respond specifically the juxa glomerular cells inside that kidney and they are going to release a substance called renin and whenever renin is present in the blood circulation this causes the liver to respond and whenever the liver responds it is going to activate a substance called angiotensinogen and whenever angiotensinogen is there it actually turns into a substance called Angiotensin one so we have Angiotensin one but again the whole goal is to get Angiotensin 2 involved because that is that big major hormone that's going to actually cause some things to happen so we've got to get there now how do we get there from Angiotensin 1 to Angiotensin 2 well that is where Ace comes in a stands for Angiotensin converting enzyme and this helps turn Angiotensin 1 into Angiotensin 2 and now that we have Angiotensin 2 involved things are going to start getting interesting because now we'll be able to achieve our goal of increasing that blood pressure because Angiotensin 2 has major effects on the body one thing it does is it causes Vaso constriction so we're going to get narrowing of those vessels and when we narrow those vessels it's actually going to constrict the blood flow to the kidneys and limit its ability to excrete water which is what we want because we want that water to stay in the body right now so we can increase our blood volume hence increase our blood pressure in addition Angiotensin 2 is going to cause our adrenal cortex to release a hormone called aldosterone and aldosterone will cause the kidneys to keep sodium which will also cause us to keep water and again we want to do this because we're trying to increase our blood volume so whenever this happens your patient will have a temporary decrease in their urination which again is what we want and then another thing Angiotensin 2 does is it causes the posterior pituitary gland to release a hormone called ADH which again is antidiuretic hormone so how this works is it's going to cause the kidneys to keep water and whenever we keep water we're going to increase blood volume so think of it this way if you're familiar with how diuretics work we give patients diuretics to help them urinate extra fluid out of the body it's used to treat a lot of times fluid volume overload well if we're having a substance in our body called antidiuretic anti- means works against we're working against that concept so let that help you remember what ADH does ADH is going to cause your body to keep water water it has an antidiuretic effect and then lastly another thing Angiotensin 2 does is it stimulates the thirst mechanism so let's review how The Thirst mechanism regulates fluid in our body so whenever this mechanism is stimulated it's because again of low fluid in the body so whenever you have low fluid in the body think about your blood Plasma's osmolality how's it going to be it's going to be high because you're going to have a low amount of fluid in there but a lot of solutes so whenever we have a high blood plasma osmolality it's going to cause the hypothalamus to respond particularly The osmo receptors inside the hypothalamus and look at that word osmo receptor we have osmo and we're talking about osmolality so these receptors are very sensitive to how the blood Plasma's osmolality is that's how they respond is based on if it's high so whenever they respond they cause anti-diuretic hormone to be released ADH now ADH is also called vasopressin and ADH is actually made in the hypothalamus but it's stored and secreted in the posterior pituitary gland and this is when the third sensation is going to be experienced so the person is going to have this desire to drink fluid so once ADH is secreted it's going to cause the kidneys to respond they sense that ADH hanging out and it's particularly going to cause the nephrons within the kidneys to start doing some things a little bit differently so your nephrons are all those little structures within the kidney that really work to keep the kidney functioning and help create your urine so the ADH is going to act on two particular parts of that nephron it's going to affect the distal convoluted tubal and the collecting duct it's going to cause those structures of the nefron to actually reabsorb water so instead of taking water and putting it back into that nefron hence into the filtrate so it'll be urinated out instead it's going to cause your body to reabsorb that water and put it back into the bloodstream which is what we want because we're on a fluid volume deficit and we need water back into the body so water is going to be retained and whenever we retain this water it's going to help our plasma osmolality so instead of being so high and high of solutes we're going to add water back to it help water it down just a little bit and even out the water in the solute concentration so we can normalize the osmolality so we just reviewed hormones and systems in our body that help us correct a fluid imbalance where we don't have enough fluid in the body known as fluid volume deficit but how do we prevent those systems from doing their job too well where they add way too much fluid into our body and send us into fluid volume overload well we have a group of hormones that help prevent that they really keep those system and hormones in check and they're known as the natriuretic peptide hormones and one of these hormones is known as atrial natriuretic peptide also known as& and this hormone is secreted by heart cells when they is stretching of that atrial wall and remember the Atria are the top chambers of the heart then we also have what's called BNP and you may hear BMP a lot whenever you're taking care of a heart failure patient because these patients are in fluid volume overload and BNP stands for brain natriuretic peptide hormone and this is a hormone that is actually released by The Heart cells whenever there's a lot of ventricle wall stretching so whenever we have the RAS aldosterone ADH and thirst mechanism doing their thing they were adding water back into our blood system so whenever that water is added back in there it's going to go up and it's got to go into the heart because the heart job is to pump that extra fluid out throughout the body well when you're adding just too much your heart's going to start to sense that because it just wants to get it at a right point so it doesn't over stretch because it's over stretching those Atrium ventricles because that water that extra water in the blood is going there it's signaling hey we may be going into fluid volume overload so these hormones are secreted by those heart cells that make up the Atria and the ventricles and what these hormones are going to do is they're really cool they actually work against Angiotensin 2 because Angiotensin 2 was our big star of the RAS system that's what got aldosterone ADH that thirst mechanism all of that involved so it's going to stop the effects of aldosterone ADH and renin so we don't go into a fluid volume overload so it's like a check and balance type hormones that help us manage our fluid now let's dive a little deeper and look at the lab values you want to know so what are they well a CBC a complete blood count this tells tells us about the cells in our blood like our red blood cells white blood cells platelets all those important cells that help us maintain life in addition arterial blood gases abgs this tells us the acid base imbalance in our patients um especially if our patients having a respiratory or metabolic problem it can tell us how bad it is and if our treatment is working to help correct the problem another thing is metabolic panels this can be a basic like a BMP or comprehensive like a CMP and this tells us really important things like our patients fluid and electrolyte status how's our potassium our sodium our calcium glucose along with our patients renal function their bu and creatinin and if it's comprehensive it can tell us how that liver is performing as well another thing you want to know especially if your patients on anti-coagulants are their coag levels their coagulation levels like that PT INR a PT and this is going to tell us how our patients clotting what's their clotting time and if they're therapeutic on their medication and lipid panels This is assessing the patients cardiovascular risk for disease and we're looking at the LDL the HDL the total CH cholesterol and triglycerides and the last thing are those drug levels because patients many of our patients are on drugs that have this narrow therapeutic level like dexin Dilantin lithium and we want to know is it safe to give this drug what's their drug level now when you take the inlex exam and you're looking at those lab values and you're trying to determine is this normal or abnormal you need to know that inlex is going to give you something that is noticeably abnormal it's not going to be right on the line or close to the normal range and the reason for that is because lab ranges for the normal really vary depending on the lab and the text like for instance some things will say that a normal mag is 1.5 to 2.3 while another one may say it's 1.5 to 2.5 so inlex is going to give you something that's really abnormal and you're going to know it's abnormal so first let's start out talking about the complete blood count the CBC this tells us about the cells in our blood so what's a normal RBC range a red blood cell range it should be 4.5 to 5.5 million for white blood cells wbc's it should be 5,000 to 10,000 for platelets it should be 150,000 to 400,000 now some terms you want to be familiar with would be like thrombocytopenia what is that that is a low platelet count so if they say that to you you know that's going to be less than 150,000 or how about a patient with glucopenia that is a low white blood cell count so a count less than 5,000 now let's look at our hemoglobin and hematocrit levels this tells us about our red blood cells and we really use this when we're transfusing packed red blood cells we want to know that hemoglobin level really and it varies between the female and the male and I would remember the differences for a female a normal hemoglobin range is 12 to 6 16 G per deciliter a normal hematocrite is 37 to 47% and for a male a normal hemoglobin is 14 to 18 gram per deciliter and a normal hematocrit is 42 to 52% now let's look at coagulation levels if your patients's on an anti-coagulant you definitely want to know their coagulation levels for instance if they're on warrin you want to know their PTINR and if they're on heprin you want to know that a PTT so let's look at this PT INR PT stands for Prothrombin time in a normal PT level in someone who's not on any anti-coagulant should be 10 to 12 seconds an INR is calculated from the PT and INR stands for international normalized ratio and normally it should be less than one and this is for someone who's not taking any anti-coagulant specifically Warframe but how about they are taking taking Morphin what do we want the INR level to be so they're therapeutic so this drug is working to prevent blood clots we would want their i r to be between two to three so if it's less than two this cumin this warrin is not really achieving what we need so their dose would need to be increased if it was way greater than three they are at risk for bleeding so their dose would need to be decreased now let's look at this a this stands for activated partial thromboplastin time and this is used to for patients who are taking heprin a normal a in a patient who's not taking heprin is 30 to 40 seconds now they're taking heprin we need them to be within this certain range so they're therapeutic and this drug is working so we would want it to be 1 and 1/2 to 2 and 1/2 times this normal range which which ends up being about 60 to 80 Seconds now if they were less than 60 that would mean that we're not achieving what we need they're not therapeutic so their dose would need to be increased of heprin if they're greater than 80 seconds it's taking them way too long to clot so they really have too much Hein in their system so their dose would need to be decreased now let's switch and let's look at the metabolic panel again this is going to tell us about our fluid and electrolytes which will include glucose our re function and if it's comprehensive it's going to tell us how our liver is functioning as well so let's look at these ranges okay glucose a normal glucose is 70 to 100 migr per deciliter calcium level is 8.5 to 10.5 mg per liter chloride is 95 to 105 mil equivalents per liter magnesium is 1.5 to 2.5 mg per deciliter uh phosphorus is 2.5 to 4.5 mg per deciliter pottassium is 3.5 to5 mil equivalents per liter and a sodium is 135 to 145 mil equivalents per liter now how I remember those is that they're like multiples of five like everything is represented with five so if you can remember that it'll help keep you straight now let's look at our renal function our bu and creatinin will tell us that normal bu is 5 to 20 a normal creatinin is 6 to 1.2 mg per decler now we're getting into liver function so let's look at total protein that is 6.2 to 8.2 Gams per deciliter and then albumin this is another protein remember albumin played a huge role in regulating our oncotic pressure and it's 3.4 to 5.4 G per deciliter then we have these three enzymes that are found in the liver it's the Alp the alt and the A and if these are abnormal it could indicate liver disease or some type of other disease in the body so a normal Alp which stands for alkaline phosphatase is 40 to 120 units per liter then we have alt which stands for albolene transaminase and a normal range is 7 to 56 units per l and then the a which is aspartate trans aminase a normal is 10 to 40 units per liter then the last part of our metabolic panel is the Billy ruen and this substance is created when you have the breakdown of red blood cells and when red blood cells break down they release this reddish orangish color and a normal Billy Rubin level should be less than 1 millgram per deciliter but if your patient has an elevated one you will will notice that they will have this orangish yellowish Hue to their skin or this mucous membrane where all this Billy ruin has collected in the blood and has just leaked into the skin giving them that like pumpkin Hue appearance now let's look at the lipid panel this test is going to tell us about our patients's risk for cardiovascular disease and it's going to look at the LDL the HDL the total cholesterol and the triglycerides so LDL this stands for low density Li protein and we want this value to be low so we want it to be less than 100 mg per deciliter now the HDL which stands for high density lipoprotein we want this number to be high and we want it greater than 60 milligrams per deciliter so some people get these confused but how I remember it is that L for LDL stands for low so we want that number low and the HDL it stands for high so we want this number high now total cholesterol we want that less than 200 Mig per desit and then triglycerides less than 150 mg per deer now let's move on to arterial blood gases abgs I have a whole video on how to interpret abgs to know if it's respiratory metabolic problem if it's acidosis alkalosis compensation partial compensation and check out that video because it'll show you how to do the Tic Tac Toe method and really simplify how to get those answers but you want to know the normal ranges for those so a blood pH is 7.35 to 7.45 anything less than 7.35 is acidic anything greater than 7.45 is alkaline then we have a pco2 the normal range for that is 35 to 45 and I have switched them here because anything greater than 45 is acidic and anything less than 35 is alkaline then we have B carb hc3 the normal range is 22 to 26 and anything less than 22 is acidic and anything greater than 26 is alkaline then we have P2 which normal is 80 to 100% And then we have the oxygen saturation and a normal is about 96 95 to 100% now let's switch to the hemoglobin A1C test this test is really helpful and helping us determine the average glucose in a person over the last 3 months so it's great for patients who have diabetes so we can see their average glucose so what do we want this number to be well in a person who does not have diabetes we would want them to have a hemoglobin A1c of 4 to 6% but if they have diabetes we would like for their target hemoglobin A1c to be less than 7% now let's wrap up this lecture and let's talk about the most most common drug levels you may encounter on inlex so first up is dexin a normal dig level is .5 to2 nanog per milliliter then we have carbom mapine which is Tegretol normal level is 4 to 10 micrograms per milliliter Dilantin a normal level is 10 to 20 microgram per milliliter then theop normal level same as Dilantin is 10 to 20 micrograms per milliliter then we have barbital a normal level is 15 to 40 microG per milliliter lithium at5 to 1.2 milles per liter and then lastly valproic acid also known as depic Co it is 50 to 100 microgram per milliliter now we're going to review the electrolytes and balances that can occur we need a proper balance of fluid and electrolytes in our body in order to maintain life we don't need too much or too little we need a specific range in fact 70% of our body is actually made up of water and here you can see the function of the water in our body it's found in our brain in our muscles bones it helps transport nutrients and oxygen into the cell also our blood consists of 83% of water but this just isn't plain water it consists of many things and one thing it consists of are electrolyt so what are electrolytes well we're going to be talking about six main ones such as potassium sodium chloride calcium phosphate and magnesium so these are substances that once they enter the body and they are dissolved in water hence our blood they actually produce an electrical charge hence become ions and this is very important with electrical signaling in our body so some things that electrolytes do in our body are the following they help with contraction of muscles sending ner impulses creating bones balancing the fluids in our body like our cells via osmosis and maintaining the blood's acid base imbalance therefore whenever we have these imbalances of these electrolytes you're going to start to see certain abnormalities in these processes depending on if it's high or low for example with contraction of muscle in certain electrolyte imbalances you can start to see muscle spasms or your heart which is a muscle will start to demonstrate abnormal EKG findings and it's very specific to certain electrolytes and as we go through this lecture I will highlight that for you but now let's talk about how electrolytes are maintained in our body how do we keep them from being too low or too high well we get electrolytes majority from our food whenever we eat and drink and it goes into our body and majority of them are going to be absorbed in our gut so if you have a gut problem let's say an issue with your small intestine that can affect how you are absorbing certain electrolytes then it enters into our blood and you know that your blood has to be filtered by your kidneys and just remember the kidneys really if you have any kidney problems you're probably going to have an electrolyte problem and your kidney is made up of all these little functional units called nephrons and the nephrons in a sense what they do is they take your blood and they create filtrate out of it which in the end is going to be urine and it's like a little pipe I like to think of it as it runs through the kidney and the filtrate is going to go through certain sections of that pipe we call them tubules and certain electrolytes and water and other things are going to be taken out of the blood and put in the filtrate or it's going to stay in the blood and you're going to keep it in your body so whatever your body doesn't need as it tweaks these electrolytes you will urinate out as urine so think about it this way if you have any problem with the renal system you can affect the electrolytes hence a lot of times they're going to be really high so that's why many times patients who have high abnormal electrolytes will need to go for dialysis because that dialysis machine is going to replace what that kidney's nephrons should be doing in addition we can manipulate the kidneys and by giving them diuretic so a lot of times if we give too much of a diuretic we can cause these electroly imbalances so other ways our electrolytes can be affected is that if we have an exit route for them and this could be anything it could be trauma it could be where we've had a lot of blood loss or we've had Burns or the patient just really sick they're throwing up a lot through vomit or they have diarrhea maybe they have um suction NG suction we're sucking off too much of those gastric juices which are rich in many of our electrolytes or the patient has some type of disease process and you're going to see that a lot with the causes like problems with aldosterone or ADH the anti-diuretic hormone Etc now let's look at these electrolytes individually first I'm going to start with sodium so sodium is a really important electrolyte that loves to hang out outside of your cell so there is a higher concentration of sodium in the extracellular part compared to the intracellular part where there's a lower concentration now sodium plays a huge role in regulating the water inside and outside of our cell along with muscle contraction and nerve impulses so if you get an balance of this electrolyte you're going to start to see issues with these processes a normal sodium level is about 135 to 145 mil equivalents per liter so anything less than 135 is considered hyponatremia and anything greater than 145 is considered hyper nutria and you want to remember the higher the number or lower the number with these ranges you're going to start to see more profound signs and symptoms the worse off the patient is going to be whenever it's just a little bit over a little bit under it's going to be very mild so now I want you to see a visualization of how sodium really works in that extracellular area and affects the cell here we have hypernatremia conditions so in the blood there's a lot of sodium hanging out and you want to remember that water loves sodium so wherever there's a higher concentration of sodium that is going to pull water water wants to be there and think of it like this if you eat a lot of salty foods what do you start to Crave water so it's almost the same concept so we have lots of sodium in the blood the water that's in the cell is going to be pulled outside of the cell and this is going to cause the cell to shrink up now on the flip side hypon nutria we don't have a lot of sodium in the blood that extracellular part low amounts so the water is like Hey we're lonely so there's some inside the cell remember there's a lower concentration but there's some so that's going to cause the water and the extracellular part to be pulled inside the cell so what's going to happen the cell is going to start to swell now let's talk about the main causes of hyponatremia what can cause the sodium level in the blood to drop well not consuming enough sodium can do that along with giving a patient a medication called a diuretic diuretics are typically used when a patient has fluid volume overload they have too much water in their blood so we're going to manipulate their kidneys to pull that water off and they're going to urinate that out and the diuretic family that does that tends to be the thide so they influence the kidneys to really waste sodium and they're going to be wasting it in their urine and it'll drop our blood level also anything that's affecting our GI system because your gastric juices have a lot of sodium in them so vomiting or GI suction with an NG Tube that can waste the sodium level along with the potassium level as well diarrhea sweating which contains a lot of sodium And Addison's disease so let's do a quick review about Addison's disease this is where a patient has low aldosterone what is aldosterone well it plays a role with our blood pressure helping us maintain our blood pressure so normally it will cause the kidneys to keep water and sodium because that will increase your blood pressure but in exchange for that you're going to excrete potassium so if we have a low level of aldosterone how's that going to affect the water and sodium it's going to cause you to lose it so you're going to lose your sodium but on the flip side it's going to cause you to keep your potassium so that can cause that and also SI ADH which stands for syndrome of inappropriate anti-diuretic hormone secretion and this is where they secrete too much ADH which again is anti-diuretic hormone what does this do well whenever we're diur ing someone we're causing them to lose lots of fluid through their urinary system well if we anti that anti-diuretic hormone that's going to cause them to keep water not urinated as much so we're going to have more water in the body and in turn that's going to dilute the sodium some other conditions that can do that as well is whenever we have overload of fluid in the body like with congestive heart failure giving the patient um too much of a hypotonic solution or renal failure now let's look at the signs and symptoms associated with hyponatremia so to help you remember those signs and symptoms remember the word salt loss because we have a loss of sodium s is for seizures and stuper so stuper is where you have a decrease in Consciousness like confusion and this can be associated with the nerve transmission being affected along with depending on how severe it is those brain cells start to swell A is for abdominal cramping L for lethargic t for tendon reflexes diminish trouble concentrating L loss of urine and appetite o for orthostatic hypotension overactive bowel sounds s for shallow respirations and this happens late due to skeletal muscle weakness and then s is for spasm of muscles now let's talk about the main causes of hypernia what causes our body to keep too much sodium in our blood well if you have some issues with certain hormones like in Cushing syndrome our body is keeping too much cortisol so we have an over production of this and this remember from our other lectures plays a role with the stress process so some functions of cortisol would be to help us maintain our blood pressure with the inflammatory process so if we have too much of this we're actually going to keep too much sodium in our blood and we're going to waste too much pottassium so we'll have hypernia but hypokalemia in addition con syndrome can cause hyper nmia and this is also known as primary aldosterone ISM and this is where we have too much aldosterone being present in our body over here we had Addison's where we had low aldosterone so it's going to cause the opposite effect so with this remember the normal Ro role of aldosterone was to maintain our blood pressure with the water and sodium and excreting pottassium well if we have too much of this on board we're going to keep too much water and too much sodium hypernia and we're going to excrete our potassium and we can drop our levels and get hypo calmia in addition hypertonic Solutions giving a patient too much of a salty solution as I like to think of it in the blood and corticosteroids can do this if a patient is not drinking enough water that can concentrate the sodium in the blood or if they're losing too much water and a condition that can do this is like diabetes in cidus that can happen as well the patient is going to be urinating so so much with this condition in addition Burns can cause this and an increased intake of sodium can cause this condition as well now let's look at the signs and symptoms associated with hypernatremia and to help you remember those let's remember the phrase no fried foods for you and a lot of times fried foods are packed full of sodium so we know we're dealing with a lot of sodium here so the f is for fatigue they'll feel very tired ours for restless really agitated they're going to be confused because you're having Central Nervous changes I for increased reflexes this can progress to seizures and coma e for extreme thirst this is a huge sign remember this one and then D is for decreased urinary output and dry skin SL dry mouth now let's look at the electrolyte chloride so I want to do chloride after sodium because these two electrolytes really go together if there is generally a loss of sodium there's also going to be a loss of chloride and you're going to see a lot of overlapping causes and signs and symptoms so chloride is very important for helping maintain our acid base balance because of its relationship with bicarb also it plays a role in digestion because we need it in order to make hydrochloric acid and it plays a role with balancing the fluids in our body with the help of sodium a normal level is 95 to 105 mil equivalents per liter now chloride levels are maintained with the help of our kidneys they tweak our blood and decide okay how much chloride we need if we don't need a lot we're going to excrete it also it's excreted through the sweat and the GI juices so if you have some issue with the kidneys or sweating too much or GI juices chances are you can imbalance your chloride levels so let's look at hypochloremia so this is where we have low blood levels of chloride and some main causes are typically GI related where the patient is losing a lot of chloride through vomiting or their gastric juices like ction or if they have an iloy an ostomy also can cause hyponatremia because this is where a surgical procedure has been created to bring the small bowel on top of the skin so the patient is having effluent which is stool coming through that now this is really rich in sodium also chloride so if they have where they're putting out a lot of effluent that can cause these levels to drop also diuretics can cause it thyoides that was very similar to hypon nutria Burns and cystic fibrosis with cystic fibrosis these patients lose a lot lot of chloride especially through their sweat and patients who have fluid volume overload like heart failure sadh that's going to dilute the chloride and metabolic alkalosis can do this as well this is where we have a high level of bicarb and this is going to drop our chloride level and the reason it does this is because bicarbon chloride have this like opposite relationship especially in how they shift in and out of the red blood cell to help with proper gas exchange now the signs and symptoms of hypochloremia don't have their own specific ones compared to these other fluid and electrolytes they typically are going to be associated with whatever is causing this problem and if you can really remember the signs and symptoms of hyponatremia you can remember what hypochloremia is going to be because they really overlap so you may see dehydration signs and symptoms with an increase heart rate along with a decreased blood pressure fever vomiting diarrhea or being lethargic now let's look at hyper chloremia what can drive that chloride level up well it's going to be similar to the causes of hypernatremia because again sodium and chloride really go hand in hand so consuming too much sodium can drive the chloride level up like giving the patient too many hypotonic Solutions also the patient not drinking enough or losing too much water can de hydrate them raising that sodium level up along with the chloride decrease bicarb level whenever the bicarb drops that can increase the chloride because of their opposite relationship so losing too much with maybe having too much diarrhea also the con syndrome this is where they have the increased aldosterone so the patient is going to be retaining a lot of sodium but excreting pottassium and that can Elevate our chloride level medications like corticosteroids and then metabolic acidosis can do this as well may be a medication leading to this condition or some type of renal problem now the signs and symptoms of hyperchloremia are similar to hypernatremia and acidosis now let's look at the electrolyte pottassium so pottassium has an opposite relationship with sodium compared to how chloride had the similar one so chances are if you have a high sodium level you're going to have a low potassium level if you have a high potassium level you're going to have a l low sodium level and this is because you know pottassium is mainly found inside our cell there's a higher concentration there sodium the higher concentration was on the outside of the cell so they work together to help balance that fluid within the cell plus they play a huge role together with the Sodium pottassium pumps now the role of potassium is Big with muscle contraction and nerve impulse so if you have an imbalance of this electri you're going to start seeing issues with this a normal potassium is about 3.5 to 5 mil equivalents per liter so as you can see it's a very narrow range with a very important electrolyte so let's look at whenever we have hypokalemia so we have low potassium in the blood what are some main causes of this Loop Diuretics can cause this like fosmid it causes your kidneys to waste potassium so that's a big thing you got to watch on those patients corticosteroid can do this and if a patient has too much insulin the reason for this is because insulin makes potassium move inside the cell so if we're causing it to leave the blood and go inside the cell we're dropping our blood levels Cushing syndrome can cause this this was the high cortisol so again it decreases the potassium increases the sodium and we talked reason for that earlier starvation patients who have been under extreme conditions where they haven't been able to eat can cause this or losing too much potassium and this is again found richly in those GI juices they like vomiting or um GI suctioning through the NG tube now what are the signs and symptoms that you may see in a patient who has hypokalemia so we have a low potassium level in our blood remember that everything is going to be low but it's also going to be slow so remember the seven L's L represents low so the first L is that the patient is going to be very lethargic and they can be confused second L is for low shallow respirations third L is lethal cardiac dysmas they may have ST depression a shallow t- wve or a projecting uwave fourth L is lots of urine they can have frequent urination where the kidneys are just unable to concentrate the urine fifth L is leg cramps sixth L is limp muscles and they may have decreased deep tendon reflexes and then our last L is for low blood pressure and heart rate now what can cause hyper calmia where we have too much potassium in our blood well anything that really causes the potassium in the cell to move outside of the cell into the blood it's going to raise those blood levels so if a patient has severe burns this can occur along with tissue damage such as the condition like rabdo myisis this is where you have the breakdown of muscle tissue so whenever that muscle tissue is breaking down it's leaking potassium into the blood it's increasing it Addison's disease can do this and this is where we have decreased aldosterone so we're going to be um excreting our sodium but increasing keeping our potassium renal failure a lot of times whenever you have patients who have an elevated bu and creatinin you are going to definitely see that potassium level increase very high a lot of times they need dialysis to bring it down medications can do this as well like those pottassium sparing diuretics like spironolactone and ACE inhibitors can do this and incess now what are the signs and symptoms of hyperemia well to help us remember those signs and symptoms let's remember the word murder because if the potassium level gets too high in the end it's going to murder the patient so M is for muscle weakness U is for urinary output is going to be little or none this is very common in patients who have renal failure they're putting out like no urine R is for respiratory failure whenever it gets so high those Muses are going to just quit working and they're not going to be able to breathe D is for decreased cardiac contractility they're going to have a weak pulse low heart rate e for early on you're probably going to see muscle twitches and cramping and then R is for rhythm changes and I would remember this they are going to have tall peaked t- waves you can also sometimes see prolonged PR interval now let's talk about the electrolyte calcium this is an essential ion that plays a huge role in the health of our bones and our teeth along with muscle and Nerf conduction and clotting so in order to maintain a good level of calcium we have to have a diet that's rich in calcium so our gut plays a huge role with us absorbing calcium and once we absorb it what we really don't need to maintain that good blood level is going to be stored in our bones now our bones will monitor our blood levels and if those levels are low like in hypocalcemia what will happen is that the bones will actually start to release calcium into the blood but if this H keeps happening over and over it's going to make this bone really weak over time and the person can have osteoporosis break their bones now calcium is really regulated by three different things one vitamin D it's very important a person has vitamin D on board in order to absorb calcium also the parathyroid hormone pth and calcitonin play roll with this pth is produced by the parathyroid gland and calcitonin is produced by the thyroid gland so if you have destruction to these glands or maybe a patients had surgery we can alter calcium levels if we hurt these glands now normal calcium level is 8.5 to 10.5 mg per deciliter so let's talk about what happens whenever we get a really low level of calcium we start to experience hypocalcemia so what can cause this is decrease in the parathyroid hormone and typically this is going to happen with patients who've had surgery of this structure especially like a thyroid ectomy so you've had a patient who had who's had thyroid surgery check their calcium level because we could have damaged that gland a decrease intake of Cal calcium for some people this is very hard to keep their calcium levels maintained especially if they have lactose intolerance so they'll have to be very conscious about making sure they get enough calcium through other sources having a low vitamin D level can cause this as well because vitamin D plays a role with as absorbing calcium chronic kidney disease because the kidneys are wasting too much calcium bisphosphonates can cause this as well this is a medication that's actually used to help treat osteoporosis so to make those bones stronger and how it does this is it helps decrease the release of calcium but sometimes we need the release of calcium into the blood and if we don't get that we can have low levels also another group of medications include the aminoglycosides these are antibiotics they end in mein my C they cause the body to waste calcium via the kidneys and then some anti-convulsants like phenobarbitol and this affects the vitamin D levels in the body now what are the signs and symptoms of hypocalcemia well we know that our muscles and our nerves are definitely going to be affected so let's remember the word cramps C is for convulsions R is for reflexes hyperactive when you check those deep tendon they will be like that A is for arrhythmias they will have a prolonged QT interval if it's severely low enough M for muscle spasms and calves or feet this is known as tetany then P is for positive signs and these are signs that you can see in a patient who has a really low calcium l level so one of these signs that you definitely want to remember is called tro sign and this is where you can take a blood pressure cuff put it on the arm inflate it to a number greater than their systolic and leave it there for 3 minutes now if it's positive you will notice the hand will draw in toward the body and flexion will occur at the wrist thumb and mCP joints but the fingers will remain extended then another sign that you want to remember is called chabat stick sign and this is nerve hyperx ability of the facial nerve specifically that cranial nerve 7 and to elicit this response you're going to tap via the Meer muscle at the Jaws angle and the facial muscles on that same side that you tapped will contract momentarily so the lips will twitch and then s is for sensation of tingling and numbness known as paresthesia and this can be felt in the fingers and toes now what can cause hyper calcemia increasing the blood level of calcium well if you have an overactive parathyroid where you're having too much parathyroid hormone in the body because parathyroid hormone is going to cause the release of calcium if we have too much we're going to release way too much calcium in the blood next is increased vitamin D usage because vitamin D helps us increase our calcium helps us absorb it so we have too much that can increase it or using supplements with too much calcium in it if a patient has cancer that has spread to the bones this can affect calcium levels because it causes too much calcium to leak into the blood and then medications some main ones you can remember are like the thide diuretics can do this because it affects how the kidneys are absorbing calcium and then lithium can do this as well because lithium can affect the parathyroid hormone causing the body to have too much calcium now what are the signs and symptoms that a patient has too much calcium in their blood well this patient is going to be extremely weak so W is for weakness of the mus muscles it'll be very profound e is for EKG changes and remember they can have a shortened QT interval A is for absent reflexes um they can also have altered mental status and abdominal distension from constipation and then K is for kidney stone formation so these patients are at risk for the development of kidney stones now let's talk about the electrolyte magnesium so this electrolyte likes to hang out inside the cell just like potassium did and it has a function in nerve and muscle which plays a role with with the sodium and potassium pump so with this pump you have ATP and what happens whenever magnesium binds with ATP because ATP needs it in order to function it's going to move three sodium ions out of the cell and two potassium ions into the cell therefore we need a proper balance of magnesium in order for this function to occur in addition it plays a role with our vessels maintaining our blood pressure and how our muscles contract and relax so with magnesium what happens with contraction you have calcium that's the big one that plays a role with that but in a nutshell magnesium competes with calcium for that binding spot so whenever relaxation is going to happen we have magnesium that allows that to happen so think about this if we didn't have enough magnesium if it allows us to have our muscles relaxed what's going to happen instead instead your muscles are going to to have spasms they're going to cramp and have contraction issues so magnesium is mainly absorbed in our gut specifically our small intestines so if we have issues with our gut as you're going to see with our Clauses we can have issues with balancing our magnesium levels and magnesium imbalances will more than likely present with other electrolyte imbalances like that of calcium and potassium so a lot of times if your calcium levels are low your magnesium levels will be low and vice versa now normal magnesium level is 1.5 to 2.5 milligrams per deciliter and if you can see that range it's very narrow so let's talk about low levels of magnesium in the blood this is known as hypomagnesemia and what can cause this is not consuming enough magnesium or we have some other electrolyte imbalances like we have issues with calcium or potassium or we have malabsorption disorders of that small intestine that can cause that or they are taking a PPI a proton pump inhibitor that can decrease the absorption of magnesium and patients who have alcoholism can have this as well now let's talk about the signs and symptoms of a low magnesium level so with this you want to remember the word twitch because everything in the patient is really going to be excited it's going to be hyperactive on the flip side whenever you have a high mag level everything is going to be really slow and not hyperactive so T is for truso sign and chotic sign and this is related to also having a low calcium level so hypocalcemia W is for weakness I is for increased deep deep tendon reflexes again everything's going to be hyperactive T is for torsades to plant and this is an abnormal heart rhythm that can lead to sudden cardiac death and it can be a lot of times seen in patients who have alcoholism and then another tea for this part is tetany those seizures and other ekj G changes that go with the calcium and the pottassium being decreased C is for calcium and potassium levels low they'll present together and then lastly is H for hypertension because magnesium helps with our blood pressure and having a low amount can make those vessels more likely to lead to hypertension now let's look at the main causes of what can Elevate the magnesium level in the blood known as hypermagnesemia well this condition is relatively rare it tends to happen when we're trying to correct a low magnesium level so we give them too much or you want to monitor a patient for this condition if they're an OB patient labor and delivery the patient has preclampsia and they're receiving magnesium sulfate so we want to monitor their mag levels to make sure we're not giving them too much and you're checking those deep tendon reflexes making sure they're there because if they're not there we may have a problem with our magnesium level also renal function can mess this level up as well causing us to keep too much magnesium now with this condition with the signs and symptoms everything in your body is going to be lethargic it's not going to be really hyperactive like over here so let's remember the word lethargic and typically with this condition you're only going to see it in severe cases mild cases may not present with signs and symptoms so L is for lethargic and may be profound e is for EKG changes with prolong PR and QT intervals and maybe a widen QRS com complex T is for tendon reflexes absent or grossly diminished H is for hypotension A is for arhythmia like bardia heart blocks R is for red and hot face they're going to have flushing GI issues is for G nauseum vomiting I is for impaired breathing due to skeletal muscle weakness and C is for confusion they can have neurological impairment now let's talk about our last electrolyte phosphate so phosphate plays a role in teeth and Bone building it's stored in the bones it's absorbed by the gut and excreted in the kidney so any issues with those structures we're going to have an imbalance of phosphate it's also regulated by the parathyroid gland because the parathyroid gland will tell the kidneys to inhibit inhibit reabsorption and then vitamin D influences how we absorb phosphate so are you seeing the parallels between calcium and phosphate they have some similarities so a normal phosphate level is anywhere between 2.5 to 4.5 milligram per deciliter so let's talk about if we have a low phosphate level in the blood this is known as hypo phosphatemia what can cause this over usage of aluminum base anti acids too much of this will block the guts absorption of phosphate low iner level also starvation and refeeding syndrome can cause this refeeding syndrome occurs when a patient has experienced severe starvation they haven't had any food and then whenever we give them food it can increase their blood sugar because that's what it normally does but because they've went under such extreme conditions in their body when this insulin is released because of this high blood sugar it's going to need phosphate to change glucose into energy so that is going to further deplete those phosphate levels leading to the low blood levels of phosphate also an overactive parathyroid can do this because if we have too much parathyroid activity we're going to majorly inhibit how the kidneys are reabsorbing phosphate hence we're really wasting it all and not getting it in our system and then low vitamin D levels can cause this as well because vitamin D plays a huge role in absorbing phosphate now let's look at the signs and symptoms of hypo phosphatemia and to help you remember the signs and symptoms let's remember the word bone because phosphate is huge with our bone health so B is for bone pain and fractures O is for Osteo malasia and this is where you have softening of the bones and whenever you have this especially in children it can affect their growth making them shorter and it can result in the Bowing of the legs how the bones are formed n is for neurostatus changes they can have irritability confusion seizures and then e is for arroy Destruction so phosphates play a huge role with our red blood cells so we can have our red blood cells being destroyed and this can lead to hemolytic anemia now let's look at elevated phosphate levels in the blood also known as hyperphosphatemia so over usage of phosphate containing laxatives like fleets enema can cause a high phosphate level so if a patient has renal failure you definitely want to watch using those too much vitamin D on board can cause it as well rabdo myol liis can cause this I mentioned this earlier this is where the muscles start to become damaged when they break down that contents of the muscle is going to go to the kidneys because your kidneys filter your blood and it's going to damage your kidneys and when your kidneys get damaged we're not going to be able to deal with phosphate like we should and we'll keep too much and have high levels and then hypoparathyroidism so an underactive parathyroid what's going to happen instead of normally being able to inhibit reabsorption of phosphate by the kidneys we're not going to have that instead we're going to keep more so that will Elevate the levels now the signs and symptoms of hyperphosphatemia can be similar to that in hypocalcemia so patients with high phosphate levels may be experienc in convulsions they may have hyperactive reflexes arrhythmias spasms in their muscles they may also have itching this is found in a lot of renal patients and they can have signs of tros and Chobot sticks now let's talk about the IV fluid types Ivy fluids also known as intravenous fluids are special fluids that we administer to the intravascular space which is part of the extracellular compartment space and administering Ivy fluids is a very common treatment that patients get whenever they come to the hospital and as a nurse our role revolves around administering these fluids to this space and we do that per the healthc care provider's orders and these fluids can be used to treat a wide variety of conditions really anything that's affecting these compartment spaces where we need to replenish that fluid let's say the patient's dehydrated they may need some fluids to help them with that or they're having electrolyte imbalance or an acid base imbalance we can use these fluids to help correct that therefore as a nurse you want to be familiar with the different types of IV fluids such as isotonic hypotonic and hypertonic you also want to know how they work once we administer them to the body and what you need to monitor for while your patients receiving these fluids but before we go over these different types of fluids I first want to go back and review the different body fluid compartments now the average adult body is made up of about 60 to 70% of water so that is a lot of fluid within our body and this fluid has to be stored somewhere and there are two main compartments that stores this fluid that I want you to remember the first compartment is known as the intracellular compartment and this is the fluid that's found within the cell and intra means within so remember this is the fluid inside of our cell as you can see here then we have the extracellular compartment and this is the fluid found outside of that cell an extra means Beyond or outside so we're talking about that fluid that is surrounding the cell and it is made up of the intravascular fluid which you can see here this is also referred to as the plasma then we have the intital fluid which you can see here in blue and it's just hanging out around our cells and then we have the transcellular fluid so now let's take a closer look at these body fluid compartments with the first being the intracellular space so again this was the fluid found inside of the cell and this space actually accounts for 2/3 of our body water so most of our fluid is inside of our cells and then there's the extracellular space which again is that fluid outside of the cell and it accounts for onethird of our body water and it includes the fluid compartments such as the interstial fluid compartment and the interstial fluid compartment is the fluid that surrounds the outside of our cells and this fluid plays a very very vital role in helping be a medium for electrolytes and other substances to move to and from the cell to the plasma with the assistance of the capillaries and the intravascular fluid compartment which again is known as the plasma is the fluid found inside the blood vessels which contain so many important substances like electrolytes blood cells and so forth and then lastly we have the trans cellular fluid compartment and this is actually the smallest compartment and this is the fluid that is found within certain body cavities like the spinal fluid the fluid that surrounds our heart and lungs and the joints now it's important to note that these compartments are really all interconnected with their own amount of water and electrolytes and they will work together to help maintain a homeostatic environment in our body and how they do this is that they will shift water electrolytes and other nutrients around so we can keep that balanced environment and they do this shifting through various process processes in the body with one of those processes being osmosis therefore in healthc care we can administer IV fluids let's say to this intravascular compartment to help expand it if we need to or shift fluids around these compartments via this process of osmosis to help us correct fluid imbalances or other problems that can occur within the intracellular and extracellular spaces so to help us understand how IV fluids do this let's talk about osmosis so osmosis is a process where water is going to move from a fluid of a higher water concentration to a fluid of a lower concentration in other words water is going to move from a fluid that has a low solute concentration to a fluid that has a higher solute concentration and it does this passively it doesn't need any energy or anything from the cell it actually does this on its own and it does it through a semi-permeable membrane which is only permeable to water molecules so let's illustrate this process by looking at this drawing here we have our semi-permeable membrane which is only permeable to water and on one side of the membrane we have a lot of water molecules but we don't have a lot of solutes and on the other side of the membrane we have not a lot of water molecules but a lot of solutes so according to osmosis what's going to happen is that water is going to move from a higher concentration of water to a lower concentration water or you can look at it this way water is going to move from the place where there's not a lot of solutes to a place that there are a lot of solutes now the big takeaway I want you to get from osmosis is that this process is highly influenced by a fluid solute concentration and depending on how concentrated that fluid is of the solutes will determine how osmosis is going to affect how water is going to shift from this EXT extracellular space to the intracellular space or vice versa so what is a solute a solute is a solid that has been dissolved in a liquid and there's many different substances out there that can become a solute in a liquid solution with one being like sodium and chloride so we can take sodium and chloride in their solid form put them in a liquid whenever we do that once they dissolve they become an electrolyte but there's still a solute in that fluid that we have now we can take that and we can administer it to the patient in their intervascular system now depending h on how much sodium and chloride we actually put in that fluid will determine how the process of osmosis is going to be affected in this extracellular and intracellular compartment so that leads me to osmolarity what is osmolarity osmolarity is the amount of solutes within a specific fluid volume so in other words it's the total solute concentration per liter of solution so depending on that IV fluid's osmolarity will depend on how well osmosis is going to work within the body to shift fluid around these compartments so we can term fluids as having a high osmolarity or a low osmolarity so whenever a fluid has a high osmolarity we're saying it has a lot of solutes in that fluid whenever something has a lot of solutes in it it has less water on the flip side if a fluid has a low osmolarity it has a low amount of solutes in it meaning it's going to have more water in it and in healthcare we can use osmolarity to our benefit to help treat patients who are sick and need fluids replaced based on what compartment we need to treat and shift fluids around we do this by administering various types of fluids that have different osmolarities or solute concentrations which will move water in or out of these compartments now let's talk about the different types of IV fluids and their tonicity so again there are three main types of IV fluids they are isotonic hypotonic and hypertonic and let the prefix and the suffix of these fluid names help you determine what type of fluid we're dealing with so the prefix ISO means equal and this means the fluid solute concentration matches or is equal to that of the blood plasma hypo means low and this means that the fluid solute concentration is lower than the blood plasma whereas hyper means high and this means that that fluid solute concentration is higher than the blood plasma and then when we look at the suffix tonic this is for tonicity and it tells us about the fluid's ability that will be entering that extracellular space hence that intravascular space how well it's going to move water in and out of that intracellular space hence inside the cell or not at all will it keep it equal or is it going to build up both parts and this is based on the concentration of electrolytes hence those solutes in the IV fluid so first is isotonic IV Solutions these have the same osmolarity as the blood so same concentration of solutes and with these fluids there's going to be an equal transfer of water so our cell is going to stay the same therefore we can just use these fluids to expand extracellular fluid volume hence our plasma now why would we want to expand the extracellular fluid well if the patient is experiencing a fluid loss in this space like through vomiting diarrhea they need some sodium and chloride back or they're experiencing hypovolemic shock Burns or maybe they're going to be having surgery and we know with surgery they're going to be losing a lot of blood like that extracellular fluid now some fluids that are considered isotonic are normal saline lactated ringer solution also called LR and 5% dextrose in water now there's an aster by this and I'll tell you about this fluid here in a second because although it is isoton IC it does work as a hypotonic solution once administered and some things you want to remember about isotonic Solutions is that with normal saline this replaces just water sodium and chloride and it is the only solution we use to administer with blood so you don't use any other solution only normal saline and with this type of solution you have to watch out for fluid overload especially in patients with kidney and heart failure because their heart and kidneys aren't working too great and if we put too much fluid in there they can become overwhelmed and we can actually put too much fluid back into the extracellular space therefore you want to monitor their blood pressure make sure they're not hypertensive you also want to check their breathing and check those lung sounds make sure that you don't hear any crackles which could indicate pulmonary edema where we've had fluid build up in the lungs and then also look at their extremities especially those lower extremities make sure there's no edema present and because we are administering sodium and chloride you want to also check those sodium and chloride levels make sure that they're not increasing because this fluid could cause that if we give too much the next is 5% dextrose in water D5W this solution replaces water and glucose so as I pointed out earlier it starts out as isotonic but ends up as a hypotonic solution and why is this well in the solution is dextrose and when dextrose enters the body it will be used up by the body H metabolize but what's left over is not very concentrated it's really just free water so we have a low osmolarity and it becomes hypotonic therefore because of the components of this fluid it's not for fluid resuscitation situation it can actually increase the blood glucose too high causing hypoglycemia but it can help hyper nuta that is where we have too much sodium in the blood and what this fluid will do because it's hypotonic in the end it can help in a sense water down that blood hence decreasing our sodium level there and then lastly with LR this solution contains water pottassium sodium chloride calcium and lactate now this fluid contains lactate and lactate can actually help increase the blood's pH by converting to bicarbonate which is really helpful whenever we have acidotic conditions going on like mild cases of metabolic acidosis however it's not for patients with liver disease because our liver converts lactate to bicarbonate or for patients who are experiencing lactic acidosis because already in the body there's a high amount of lactic acid so we don't want to go and add more and because this fluid contains potassium you would want to monitor for hyperemia high potassium level in the blood especially if your patient has some type of renal insufficiency next are hypertonic IV Solutions and these Solutions have a higher osmolarity than the blood so they have a higher concentration of solutes in the fluid now because of this osmosis will cause water to leave the intracellular space hence it could shrink the cell which can help expand the extracellular space now why would this be beneficial well if we have a patient who has a severely low level of sodium so they're having severe hyponatremia where they don't have a lot of sodium in that blood or they have brain swelling which is cerebral edema now some solution that are considered hypertonic include 3% saline dextrose 10% in water dextrose 5% in normal saline and then dextrose 5% in half normal saline now some things you want to remember about these fluids whenever you're administering them is that you want to use them very cautiously because they have the risk of overloading that extracellular space because we're pulling fluid from inside the cell because remember a lot of fluid hangs out inside that cell to that extracellular space which which in the end could overload our system leading to pulmonary edema in addition because these Solutions are highly concentrated of let's say like saline they could cause hypernia so we'd want to check sodium levels of the blood and when you go to administer these Solutions you always want to check with your facility's protocol on how to properly administer hypertonic Solutions because some may recommend that all hypertonic Solutions have to be administered through a central line rather than a peripheral IV While others may say just 10% or higher concentrations have to be administered through a central line and the reason for this is because if hyperonic Solutions get in the surrounding tissue it can be very damaging to those cells and tissue so we have to watch out for extravasation and then lastly hypotonic IV Solutions so these Solutions have a lower osmolarity than the blood hence a lower concentration of solutes in the fluid and because of this osmosis will cause water to move from the extracellular space to the intracellular space which can swell the cell to the point where it may rupture now these fluids are going to help dilute the extracellular space and replenish the inside of the cell and why would this be beneficial well if there's too much solute concentration in the blood for example the patient has hyper nuta we can dilute that with these Solutions Plus it can help provide free water to help the kidneys excrete we waste and prevent dehydration and some hypotonic Solutions include Half normal saline 225% saline 33% saline and of course the 5% dextrose and water but again that started out as isotonic but once in the body it becomes hypotonic so it goes between both and some things you want to remember as a nurse about hypotonic Solutions is that they cause the cell to swell because fluid is leaving the extracellular fluid and going into the intracellular fluid which could cause brain swelling so you want to monitor for mental status changes low blood pressure hypo Valia and because we are giving some free water to the extracellular space we could give too much so that could really water down the sodium level so you want to monitor for hyponatremia and then monitor patients who are more fluid sensitive especially if they have heart failure and renal failure because they cannot handle the extra water so now let's look at the differences between crystalloids and colloids both of these Solutions are administered IV So to that intervascular space and both of these Solutions expand our plasma volume now whenever I say expand plasma volume what I'm talking about is that we are adding more fluid to that intervascular space so we're adding more fluid into our blood vessels so first let's take a look at colloid Solutions these Solutions can include natural and synthetic type solutions for instance a natural type of colloid is known as albumin whereas we can have synthetic type pipes which includes dextran hydroxyethyl starches and gelatin and how these fluids work is that they are going to pull water into that intravascular space now how do they do this well whenever you're administering a bag of colloids inside that bag you have very very large molecules so whenever those molecules go inside the intravascular system they are unable to actually Escape that capillary wall because they're just so big so because they can't escape that capillary wall high concentrations of them hang out inside the intravascular system so whenever we have a high concentration of something hanging out in there what's going to happen is that that's going to increase oncotic pressure another term for oncotic pressure is known as colloid or colloidal osmotic pressure and this results in water being pulled from around that blood vessel so from that interstial fluid so water is going to be pulled in inside that blood vessel hence or intervascular space and it's going to expand the volume hence the fluid inside that vessel and this is something we definitely want whenever our patient is experiencing hypothalamic shock severe burns or they've had some type of severe bleeding and because how these fluids work they are fast at expanding this plasma volume because they have such a great effect at pulling that water across that capillary wall into the intervascular space so the mount ministered so the mount of colloids we give the patient is usually equal to the amount of fluids that the patient has lost so we don't have to just throw in a bunch of colloids to this patient now there are some downsides to these fluids two things big things is that they can have allergic reactions and coagulation problems with these Solutions so we really have to monitor for that as the nurse plus they're not as easily accessible and they tend to cost more now let's compare this to crystalloid Solutions so crystalo they include hyperonic hypotonic and isotonic Solutions so in these bags of fluid we have fluid but we also have electrolytes and they are smaller molecules whereas with colloids those are big molecules typically like proteins but these are electrolytes therefore because they're smaller they don't hang out as long in that intravascular space and because of this the patient is going to need high amounts of these fluids in order to replace them amount of fluid they have lost so they really carry a huge risk with fluid volume overload and these fluids can work in a variety of ways depending on the tonicity of the bag of fluid for instance whenever we're dealing with hyperonic crystalloid Solutions we have a high tonicity so there's a high amount of solutes in that bag of fluid compared to the tonicity or the osmolarity of your blood plasma so when we throw a hyperonic solution into that intravascular space what it can do is that it can pull water from the cells and dehydrate them which sometimes we need to do that if we have like cells swelling like with cerebral edema however on the flip side hypotonic Solutions work in an opposite way they in this bag of fluid they have a lot of fluid but they don't have a lot of solute so it has a lower osmolarity hence tonicity than compared to your blood so whenever you throw those fluids into that intravascular space it can cause water to go inside of the cell which sometimes is what we need when that cell is de hydrated but sometimes it can cause problems because it can cause that cell to swell and rupture and then we have isotonic fluids and ISO just means equal so that bag of fluid its tonicity has the equal amount of solutes compared to your blood so it's the same type of tonicity so whenever we put that isotonic solution into the blood it doesn't really cause this mass movement of fluid in and out of the cell it really is just going to expand that intravascular space and all of this is happening because of Osmosis now some good things about crystalloid solutions that unfortunately colloid Solutions did not have is that crystalloid Solutions do not cause allergic reactions or coagulation problems plus they are easily accessible you can typically go in your clean hold and get whatever type of fluid you want based on what the doctor ordered and they tend to Cost Less which is really good for the patient next up is hypervolemia fluid volume excess is sometimes referred to as fluid volume overload overhydration hypervolemia or water intoxication so it has a lot of names and what's happening is that there is just too much fluid in our body and our body needs just the right amount of fluid in it in order to be able to function if it has too much or too little it's going to start to fail and you're going to start to see these certain signs and symptoms so with fluid volume overload where is all this flid fluid hanging out well whenever the system becomes overloaded this fluid likes to go into the different fluid compartments we have in our body so let's quckly review those fluid compartments so the first fluid compartment we have is called the intracellular compartment and this is the fluid found inside of the cell and there's actually a lot of fluid inside the cell it accounts for 2/3 of our body water then we have the extra cellular compartment and this is the fluid outside of the cell and accounts for about 1/3 of our body water and we can take that extracellular compartment and divide it into other sections for instance part of the extracellular compartment is the intital compartment and this is the fluid that is found around those cells so outside of the cells in between them then we have the intravascular compartment and this is our blood plasma as nurses we access this compartment a lot whenever we're starting IVs we are getting access to this compartment and many times the reason we're even accessing this intravascular compartment is because we need to give them fluids and then there's another part of the extracellular compartment known as the transcellular and this is a smallest part of all the extracellular compartments and it's the fluid that is found around certain joints and certain organs in our body like the heart and the lungs and all of these compartments are really interconnected they work together because they can shift fluid around as needed to help correct certain problems and they do this through various processes with one process being osmosis and osmosis is highly influenced by the osmolarity hence the solute concentration of a fluid and what happens in osmosis is that water is going to move from a fluid that has a low osmolarity hence a low concentration of solutes to a fluid that has a higher concentration of solutes hence a higher osmolarity so depending on where those solutes are hanging out will depend on where that fluid is going to move and these are all important Concepts that you want to be familiar with to help you understand the different types or causes of fluid volume overload so there are three types of fluid volume overload we have hypertonic hypotonic and isotonic so first let's talk about hypertonic fluid volume overload with this type of overload there's going to be the movement of water from the intracellular compartment to the extracellular compartment and this happens due to an increase of osmolarity hint the solute concentration in extracellular compartment which cause fluid hence our water to move from that intracellular compartment to the extracellular compartment so we're going to have an increased amount of water here in this extracellular compartment now when you're trying to think of the causes of this type of overload think of causes where we are introducing something in the body that has a high concentration of solutes hence in high osmolarity and this would happen if the patient ingested too much sodium because remember water loves sodium and whenever we have a lot of sodium on board in the body water just flows to it and whenever it flows to it we're going to increase our fluid volume in addition excessive administration of hypertonic IV Solutions can do this as well because what's happening is that we're administering these high osmolarity fluids hence they have a high solute concentration to that intravascular space which is part of that extracellular compartment and it's going to cause water to be pulled from the intracellular space the inside of the cell it's going to shrink it down but that fluid is got to go somewhere and it's going to go into extracellular space and we're going to overload that compartment then another type of overload is called hypotonic fluid volume overload and this is also sometimes referred to as water intoxication therefore we're increasing body water but not osmolarity we're actually going to dilute the solutes and with this we're going to have the movement of water from the extracellular space to the the intracellular space so you're going to have an intracellular compartment that's going to become overloaded along with the extracellular compartment so both compartments and when you're trying to think of the causes of this think of causes where free water is just being introduced into the body one way is through excessive intake of free water orally and a condition that can cause this is known as primary polydipsia and this is where the patient has a very strong compulsion to just drink water over and over so as they introduce all this water into their system they become water intoxicated and it will water down the extracellular compartment hence changing its osmolarity which is going to according to osmosis pull water into the intracellular compartment which will overload it as well siadh can also cause this as well and this stands for syndrome of inappropriate anti-diuretic hormone and this is where there is too much anti-diuretic hormone being released an anti-diuretic hormone is also Al referred to as ADH and whenever we have too much ADH on board what happens is that we are retaining way too much water in our body and we're going to have this same concept happen we're going to have fluid volume overload we're going to dilute everything really especially sodium in the extracellular compartment and then lastly we have isotonic fluid volume overload and this is sometimes referred to as hyper volia this is a very common type of overload that we see in patients and with this there there is no movement of water between those compartments like how we had with the other two because osmolarity is equal remember ISO means equal so we're not going to have the shifting of this fluid but we're going to have the overload of the extracellular compartment because we can have problems with major organs in our body that normally help us regulate our fluid volume for instance if we have heart failure or kidney failure it can lead to this type of overload or if we administer too much isot chronic IV solutions to the patient we can overload the cellular compartment in addition over usage of corticosteroids can lead to this because cortico steroids cause our body to retain sodium and water now let's talk about the signs and symptoms of fluid volume overload so to help you truly understand what you're going to be seeing in your patient you need to think about what is going on with my patient well we've already established that the patient is overloaded with fluid in their body fluid compartment and they are just oversaturated with fluid from head to toe so signs and symptoms are going to be based on how they're affecting that certain body system so first let's start with our head the neuro part so from a neuro standpoint you want to monitor for brain swelling because what happens is that those cells that make up your brain can start to expand and swell and this can lead to mental status changes and that is actually one of the earliest signs and symptoms that your patient is experiencing brain swelling so be monitoring for confusion in addition what can happen is that your patient can experience a headache or pressure in the head from that fluid overload now let's move down to the cardiovascular system so this system has a lot of fluid in it and it can become overwhelmed quite easily and how I like to think of this system being affected is the same concept with a water hose so your water hose is like your vessels in your body and if we have a lot of water connected to that water hose there's going to be a lot of pressure in it and almost the same is true for your body if you have a lot of fluid in that system you're going to have a very strong bounding pulse whenever you go to fill the patient's pulses because we have a lot of fluid in there they are going to have a high blood pressure so hypertension in addition their jugular veins are going to be distended so they could have jbd which is known as jugular Venus distension and they can experience sinus tacac cardia then we can move out from this system to the respiratory system and our lungs can be majorly affected especially depending on how severe the fluid volume overload is because then fluid can start to leak into our lungs and cause pulmonary edema so you may see that the patient has shortness of breath with any simple activity they're having difficulty breathing you could also hear crackles in their lungs whenever you listen to them and here's an example of what crackles may sound like in addition the respiratory rate can be increased and they can have this dry hacking cough now this cough can actually become productive and if it becomes productive this is a really bad sign whenever they start to cough it will be this like foamy frothy blood tinge sputum that tells you that you need to get your patient treatment immediately because they're experiencing like flash pulmonary edema and then we start to see sign and symptoms peripherally where we're going to see swelling and edema in the upper and lower extremities and this edema can actually pit whenever you touch it which we're going to go over here in a moment in nursing interventions the skin will also feel cool to the touch because it can be so swollen that will diminish blood return causing it to feel cool and the abdomen can be swollen which we term acies because fluid can back up into our liver veins which can cause congestion in addition the patient can have nausea where there's just so much pressure in the belly and the patient is going to have weight gain and one thing you want to remember about weight gain that's helpful especially whenever you're monitoring the patient seeing how much fluid they're losing is that 1 kilogram which is 2.2 lbs is equal to about 1 liter of fluid so whenever we're diuresing them we definitely want to monitor their weight but whenever they're having fluid volume overload weight gain is one of those signs and symptoms they can't experience now let's talk about labs and Diagnostics what are you going to see as a nurse whenever your patient has fluid volume overload so remember your patient has a lot of fluid in their body so if we have a lot of fluid in other fluids of the body what is it going to do to the concentration of electrolytes or other important things in that blood it's going to dilute it so it's going to decrease it when we go and get our reports back we're going to see that certain labs are going to be decreased and the reason they're decrease is because we have way too much fluid watering down that blood and that urine so remember everything is going to be diluted which starts with a d and everything is going to be decreased so when we look at the Patients hemoglobin and hematocrite it will be decreased when we check the patient's sodium level it will be decreased it can be less than 135 Milli equivalents per liter in addition they're bu along with a decreased serum osmolality and this is the concentration of substances in the blood so because we have so much fluid in there it's going to be diluted and when we check the urine there's going to be a decreased urine specific gravity and osmolality test and these look and measure the solute concentration in the urine the urine specific gravity actually looks at the number and size of them and the osmolality looks at the number of them the electrolytes so again it's soluted and it's going to be low now if the patient has a really severe case of fluid volume overload we can look at a chest x-ray and we could see pulmonary edema where there's fluid in those lungs now let's talk about nursing interventions so treatment goals revolve around removing this extra fluid from the patient but we don't want to remove too much fluid from the patient because if we do we're going to flip them into fluid volume deficit and we don't want them to go there plus we don't want to remove too many electrolytes because we're going to be giving them diuretics and other things which could throw off our electrolyte balance so as a nurse we're going to play a vital role in helping administer treatments that removes this fluid but we also got to monitor those body systems how are they responding to us removing all this fluid and make sure that their electrolytes are staying Balan so what we're going to do is we're going to drain the water so remember the word drain to help you remember all those nursing interventions for this patient D is for diuretic so diuretics are medications we can administer to the patient and what happens is it causes them to urinate a lot and what they're going to do is they're going to urinate this extra fluid out and there's a wide variety of diuretics that can be used you can use Loop Diuretics osmotics or thyoides it really depends on the type of overload the patient is experiencing their renal function and the severity R is for restrict fluids and sodium so we don't want to be giving this patient all these fluids because it's literally going to counteract what we're trying to do for the patient so they're going to be on some type of fluid restriction it can be anywhere between 1 to 2 lers of fluid per day that they're restricted to if your patient does have this a lot of patients struggle with this you just want to remind them why we're doing it and then help them develop a plan of how they can space out their fluid throughout the day if they can cognitively do this with you in addition you want to restrict the sodium foods that they're consuming so chances are they're going to be on a low sodium diet and again patients don't like this a lot of times cuz if food taste plan but you want to explain to them why we're on this type of diet because sodium loves water sodium and water go together and if we're just throwing in a bunch of sodium we're going to be pulling a lot of water and we're not really solving our problem of fluid volume overload A is for assess daily weight and assessing a patient's weight is actually a great way to monitor their fluid status so again remember as you're weighing this patient you need to be doing it at the same time every day with the same skin SC so we can get the most accurate results and we want to see how those weights are trending we don't want our patient gaining more than 2 to3 lbs in a 24-hour period because that tells us what we're doing is not working they're actually gaining fluid and again you just want to remember that concept 1 kilogram which is equal to 2.2 lb equals one liter of fluid so if your patient's losing 1 kilog hey you removed around 1 liter of fluid and you also want to routinely be checking their edema is it decreasing so many of these patients are going to have pitting edema and you want to grade it and it's helpful to use the lower leg and press over the fibula or tibia region and here is a little guide to help you grade it one plus is like 2 mm of pitting 2 plus would be 4 mm of pitting 3 plus is 6 mm of pitting and then four plus which is pretty significant is about 8 mm of pitting and if your patient is very emitus in the extremities you want to know that that skin is very fragile and that can easily break down so you want to reposition these extremities and keep them dry and clean I is for intake and output strict measurements so you want to know everything that patient is taking in not only orally but through their IV flushes anything you give that patient and exactly what they're putting out this is a very important measurement because one reason you're giving them diuretics and you want to make sure that they're putting out enough urine because if they're not we may be over diuresing them and they're starting to get kidney problems and then we want to make sure that the patient's just not taking in too much fluid so it's really counteracting what we're doing and then lastly is in for sodium level monitored along with other electrolytes because we can again throw these patients into electrolyte imbalances our sodium could be naturally diluted because of the fluid volume overload and we want to make sure it doesn't get too severe or they're going into into hyponatremia plus we're going to be giving them diuretics for instance like Loop Diuretics and these like to waste pottassium so we want to make sure that they're not experiencing hypokalemia now let's look at hypo volia fluid volume deficit occurs in the body because there's not enough fluid in it to support its needs and functions now you may also hear fluid volume deficit referred to as hypovolemia or dehydration and dehydration can occur for many different reasons with one reason being that there is a loss of water or electrolytes in the body and we're specifically talking about the electrolyte sodium another reason it can happen is because the patient just isn't consuming enough water or electrolytes or the patient has had something happened in their body where water has shifted around within those fluid compartments for instance water has moved from the intravascular compartment to the interstial compartment which is referred to as third spacing so fluid volume deficit results in in a deficit of fluid within our fluid compartments and some fluid compartments can be more affected than others and this really depends on the type of dehydration that we're talking about so let's quickly review those fluid compartments so we have two fluid compartments we have intracellular and extracellular intracellular is the inside of the cell extracellular is the outside of the cell and it can be subdivided into three other compartments we have the interstital compartment which is the fluid that surr rounds the cell found in between the cell then we have the intravascular compartment and this is the fluid inside of our vessels we also refer to this as the plasma and then we have the transcellular compartment and this is the smallest compartment of them all and this is the fluid that is found within certain organs and Joints like your heart and your lungs and Etc and fluid Within These compartments can actually be shifted around through a process known as osmosis and this process is highly affected by the osmolarity of specifically that extracellular fluid so let's quickly review the different types of movements we can have based on osmolarity so if we have a hypertonic environment in that extracellular fluid so we have a high amount of solute concentration what that's going to do is it's going to pull fluid from the inside of that cell to the outside of the cell where the cell is going to shrink and become really dehydrated then we can have a hypotonic environment where the extracellular fluid is really diluted so it has a low osmolarity a low amount of solutes in it and what's going to happen is that water is going to move from that extracellular compartment to the intracellular compartment inside that cell and cause that cell to get really big and swell and eventually it could rupture then we can have an isotonic environment and this is where there's an equal amount of solutes on the inside of the cell and the outside of the cell so we have equal osmolarity so there's no drastic shifting of water from intracellular to extracellular or extracellular to intracellular it really just stays the same so with all those Concepts in your mind let's now take a closer look at the causes of fluid volume deficit and the different types of dehydration so the first type of dehydration is known as hypertonic and this is where there's mainly a loss of water rather than electrolytes hence our solutes which we're mainly talking about sodium this is also sometimes referred to as hypernia which means we have a high amount of sodium in the blood so when we're talking about hypertonic dehydration we're talking about things causing the extracellular compartment hence really our intervascular system to become extremely concentrated with solutes specifically sodium and we're going to have less fluid in there and that's what really hyperonic means it means that our extracellular fluid has a high osmolarity and again is really highly concentrated of these solutes so the result of this in these conditions is that water is going to move from the intracellular compartment to the extracellular compartment and our cell is going to shrink and become dehydrated so when we're thinking of causes of this type of dehydration let's think of causes that makes our blood more concentrated which would be like losing a lot of water and this is happening in cases of severe diarrhea or vomiting or with diabetes incipit and this is where the patient is passing a high volume of urine due to a low ADH level which is anti-diuretic hormone and when the patient has this it's literally just ridding their body of all of this fluid through the urine so we're not going to have a lot left in our blood hence we'll have a lot more solutes or sodium and then another cause is that the patient is just not taking in enough water and this can happen for many reasons maybe they don't have access to water or they're experiencing impaired thirst where they're not able to really recognize that they need to take in water so they easily become dehydrated and treatment for this type of dehydration is usually to rehydrate that cell and we can do that by administering hypotonic fluids because hypotonic fluids change the tone icity or the osmolarity of our extracellular fluid by adding more free water to it which is hence going to in a sense water down that high solute concentration and it's going to allow osmosis to pull water into that dehydrated cell and rehydrate it then we have hypotonic dehydration and this occurs when there's mainly a loss of electrolytes hence our sodium rather than water so it's the opposite of hypertonic dehydration and this is sometimes referred to as hyponatremia so a low sodium level in the blood and hypotonic means that that extracellular fluid has a low osmolarity so there's this low concentration of solutes particularly again sodium in that fluid and because of these conditions in this fluid it's going to result in water moving from the extracellular compartment to the intracellular compartment and the cell is going to swell and possibly rupture and the problem with this type of dehydration is that it can quickly deplete the intervascular compartment our plasma which can result in a low cardiac output and when you're trying to think of the causes of this type of dehydration think of causes that lead the body to lose electrolytes or conditions that dilute solutes and some things that can do this is administering too much of certain diuretics specifically like thides because thides waste too much sodium or too much free water replacement because this lowers the amount of solutes like you know with hypotonic Solutions so we have a loss of solute concentration and starvation or malnourishment can do this because the person is not consuming enough electrolytes and treatment for this type of dehydration could include administering hypertonic Solutions because these Solutions will go in there and help remove the fluid from those swollen cells because what it will do is it will change the osmolarity of the extracellular fluid which is going to through osmosis draw water out of that swollen cell and put it back into the extracellular compartment and then lastly we have isotonic dehydration and this is where we've had an equal loss of water and electrolytes and remember ISO means equal and with this there's no drastic shifting of water between those fluid compartments and this is actually the most common type of dehydration we see and the big problems that arise from this type of dehydration is that intravascular loss can happen and we're going to lose the ability to pump fluid throughout the body and this could quickly lead to hypovolemic shock causes for this type of dehydration include over usage of diuretics third spacing of fluids where water shifts from the intravascular space to the intital space the patient has experienced some type of trauma like they're bleeding out losing all that fresh nice blood in the body or they're experiencing vomiting diarrhea or excessive sweating now let's talk about the signs and symptoms you're going to see in a patient who has fluid volume deficit so we know the patient is going to be dehydrated so D is for dry mucous membranes when you look at their mucous membranes they're going to be sticky and very dry and uncomfortable to the patient if they can communicate that to you e is for early sign with this an early sign of dehydration is that they have an increased heart rate and when you go to fill that pulse it can feel very weak H is for hypotension so a low blood pressure and the reason they're having this is because they don't have a lot of fluid blood volume to pump throughout that system so when we get to measure that blood pressure it's going to be low and this can present as orthostatic hypotension and this is a form of hypotension that occurs when the patient goes from a supine or sitting position to a standing position and this can happen up to 3 to 5 minutes after that person changes the position so to have this the patient's systolic blood pressure that top number is going to decrease at least 20 mm of mercury or their diastolic blood pressure number that bottom number is going to decrease at least 10 mm of M Mercury and these decreases are from their Baseline blood pressure so as a nurse you want to make sure that you get a Baseline and you measure these blood pressures at these different positions why is for young babies whenever they're dehydrated how you can tell especially in severe cases is that they're going to have sunken font nails and these are like those soft spots on the young infant's head that they have because it helps facilitate vaginal birth delivery because those skull plates haven't fully fused together so normally they should not be sunken in and if they are sunken in this is an extremely bad sign then D is for decreased skin turg and what skin turg is is it's talking about skin elasticity so whenever we go to check their skin turer instead of just bouncing back real quickly it can tint it can be very sluggish it'll be decreased that's how we would refer to it now there's a certain patient population you can't really use this as a great indicator of dehydration and that's the older adults of geriatric population because as we get older so does our skin elasticity it's naturally going to decrease in itself so we want to check other signs and symptoms in those patients and then we have R for refill to the capillaries is going to be sluggish so in severe cases of dehydration when we go to check that capillary refill it's going to be sluggish it can be greater than 3 seconds also attitude changes can occur where the patient becomes extremely rest rest less lethargic confused and it could progress to seizures so if you start to see mental status changes in a patient with dehydration this indicates you're dealing with a very severe case of dehydration because now it's affecting our neuro status which we really don't want it to get to that point and then another sign is thirst so the patient could just be extremely thirsty that's trying to replace those fluids that they have lost or those electrolytes now not all patients are going to have this for example geriatric patients as we get older so does our thirst response so we're not as responsive to that sensation of thirst also young patients may not even be able to communicate thirst to you so you definitely don't want to use that as a specific sign for those patients experience weight loss is another sign and symptom and actually measuring a patient's weight is a good way to tell us about their fluid status so we definitely want to make sure we're weighing our patients so you want to remember that 1 kilogram about 2.2 lb is equal to about one liter of fluid give or take so as your weight in your patient look at the trending of those weights if they're experiencing dehydration are they losing weight have they lost one kilogram that could mean that they've lost one liter of fluid and then we have lastly D for Diagnostics so let's go over the diagnostic results that you would be seeing in a patient with dehydration in the lab results you're going to see really depend on the type of dehydration that the patient has so you want to keep that in mind whenever we're going over these lab results but in a nutshell with fluid volume deficit what's happening is that we have a low amount of fluid so when we remove that fluid out of the body what we have left are those solutes so the concentration of them are going to be really high in our blood and in our urine so it's going to be increased all around which is the opposite of what we've seen in fluid volume overload everything was diluted so everything was decrease because we had so much water watering down those solutes therefore you're going to see an increase serum osmolality which is measuring the osmolality in the blood you're going to see an increase hemoglobin hematocrit increased bu increased sodium level and again if we were dealing with hypotonic dehydration that wouldn't be the case because remember we're actually going to be lowering our sodium level in that type so just keep that in mind and an increased specific urine gravity and osmolality but again this is not going to be the case with let's say patients who have diabetes and citus because that urine is going to be extremely diluted because they are passing High volumes of it from that low level of ADH now let's talk about nursing interventions for fluid volume deficit so the goal is that we want to replace that water and electrolytes that have been lost and treatment is going to revolve around finding the cause and treating the cause so let's say the patient is bleeding out somewhere well we want to find why they're bleeding stop that bleeding and trans fuse them some blood or let's say the patient has just been taking too many diuretics they have urinated all their fluid out what we want to do is stop those diuretics and Infuse some more fluid with electrolytes added to it to help correct that imbalance so as a nurse what we can do to help with this whole treatment of correcting fluid volume deficit is that we can provide daily weights so we want to weigh the patient at the same time every day with the same scale and we're looking at those weight are they trending up are they trending down now a fluid volume deficit we want to make sure that our patient isn't losing weight because that's one of those signs and symptoms so we're going to be looking at that weight making sure it's going up we also want to make sure that we are strictly measuring their intake and output so everything that they're taking in this includes IV fluids IV flushes anything that they take in orally or their tube feedings irrigations and so forth and we want to make sure we know exact ly what they are putting out of course this is urine but it also includes vomit any types of watery diarrhea or suction we want all that in our calculation and we particularly want to pay attention to that urinary output because this tells us how well our kidneys are working and if we are improving their hydration status so we want to calculate that out over that 24-hour period so you want to make sure that your patient's putting out at least 30 MLS per hour or5 MLS per per kilogram per hour which is based on their weight in addition we want to make sure that we are encouraging treatments that help hydrate the body so for instance oral hydration that's one of the easiest ways to help rehydrate your patient now not all patients can do this and in some cases they're so severely dehydrated that they're going to need that extra help with those IV fluids but we want to make sure that our patient has access to these fluids and that they're consuming healthy fluids to promote healthy hydration avoiding like teas and coffees and we're going to play a role with administering IV fluids per the doctor's orders so typically isotonic fluids are used but in different types of dehydration for example hypotonic dehydration we may want to administer hypertonic fluids and then in hypertonic dehydration hypotonic fluids may be used so it really depends on the type of dehydration your patient has on what fluids we're going to use and then also we want to make sure that we're looking at those electrolyte reports and checking the sodiums the potassiums and all those levels to make sure that they're within normal range now let's look at hypovolemic shock hypovolemic shock occurs when there is low fluid volume in the blood hence where the name hypo volic comes from hypo means low V means volume and emic means blood so we have low blood volume and we're specifically talking about the blood volume in the intravascular space and this space contains the volume of blood in a per person's circulatory system so if we deplete that volume of blood in a person's circulatory system what does that leave that heart to pump throughout the body not very much so what will happen the amount of blood that this heart pumps per minute is going to decrease and we're talking about cardiac output so if we decrease cardiac output the amount of blood that is going to the cells tissues and organs is going to dramatically decrease too so those cells are going to be deprived of of oxygen and when we do that cells start to die and then we start seeing signs and symptoms of shock now a person needs to lose about 15% or more of their volume for signs and symptoms of shock to occur now in the average human adult they have about 5 lers of blood so if a person loses one liter of that five lers they've lost 20% of their volume so whenever they lose that much they're going to start showing signs and symptoms of shock now let's talk about the causes of hypo volic shock so what can lead to a loss of fluid in the intervascular system well any conditions that really cause fluid to leave the body externally like there's some type of major injury so that person is just outwardly bleeding or there is some type of inside shift of fluid leaving that int vascular space so let's talk about the two types of hypovolemic shock first type is called relative hypovolemic shock and this is where you have an inside fluid shift from that intravascular system and this tends to be a little bit more concealed than the absolute type which we're going to talk about next you're not going to see just bright red blood leaving the body like how you could in absolute and you know that that patient's losing fluid this can be a little bit more concealed so this is where fluids or blood is collecting or leaking inside the body and this can occur with internal bleeding or where you have third spacing of fluid like with severe burns and this occurs due to increased capillary permeability and we talked in depth about this in our Burns video in addition long bone fractures they're very vascular can cause a lot of fluid loss in addition damage to organs like an acute pancreatitis you can see this when a patient develops colon or Turner sign and colon sign is where you have severe bruising around the belly button and Turner sign is where you have severe bruising on the flanks and that can indicate that the patient is having internal hemorrhage and that occurs with acute pancreatitis and another thing is like massive vasod dilation that occurs in sepsis the next type is absolute hypovolemic shock and this is where you have an outside fluid shift from the intravascular system and this is more noticeable compared to the relative type and um this is where fluid is leaving the body externally you can see it and this can occur with massive bleeding that's been experienced due to blood loss with surgery or some type of injury excessive fluid loss and this can be through the oral route with vomiting or the GU route urination or GI diarrhea or sweating with your skin and many times whenever that occurs it's being caused by some type of disease process the patient's really sick so they're just throwing up a lot or some type of endocrine disorder now let's talk about the pathophysiology of hypmic shock and tie in the signs and symptoms associated with this condition okay let's say we have a patient who's in hypmic shock and it's due to like either relative or an absolute cause but regardless what's happened is that their intervascular system their circulatory system has been depleted of fluid volume so what's going to happen is that you're going to get a decreased amount of fluid volume that is returning to this heart to be pumped so we have a low Venus return to the heart that intervascular system has been depleted of it so there's really nothing to drain back now whenever that happens it's going to affect cardiac preload now what is preload this is the amount that these ventricles stretch at the end of dle at the end of that filling phase of the heart so it's the in diastolic volume well if we don't have a lot of fluid volume draining back to that heart those ventricles really aren't going to stretch they don't have to stretch because the fluid volume just isn't there now cardiac preload is a determining factor in stroke volume and stroke volume is the amount of blood that this ventricle pumps each with each beat which should be anywhere between 50 to 100 MLS well when our stroke volume Falls it decreases cardiac output because remember cardiac output is heart rate times stroke volume and cardiac output is the amount that this heart pumps per minute and it should be anywhere between 8 to 4 lers but if we have a decrease in stroke volume that's going to decrease our cardiac output now when we get a decreased cardiac output this is going to decrease the amount of blood that's flowing to our organs and our tissu specifically to those cells so we're going to get decreased tissue profusion and what's that magical substance in the blood that sells love oxygen so when you decrease the amount of oxygen that is Flowing to these cells they're going to start struggling they attempt to try to save themselves at first by switching the way they metabolize from aerobic to anerobic but the problem with that is that you're going to get the built up the buildup of lactic acid which is going to throw off our pH of our blood entering into acidotic conditions and then the body is going to try to compensate and it's going to activate the sympathetic nervous system and the angio tensing the renin system it's going to be shunting blood all in an attempt to help save the body save those organs now the signs and symptoms of hypmic shock are affected by the percentage of fluid volume loss that patient has experienced so hypmic shock can be divided into four classes or four stages and to help you remember those stages slash classes remember the criteria numbers for each percentage loss so the numbers you want to remember are 15 that's class one 15 to 30 that's Class 2 30 to 40 That's class three and then the last class last stage is 40% okay so class one this is where the patient has lost less than 15% of their fluid volume and that's about 7 up to 750 mls in an adult now during this class slash stage the body can deal with this it can compensate enough to maintain cardiac output now because of that that your patient's really going to be asymptom atic with a fluid volume loss of less than this because remember at the beginning of the lecture I said that patients who have 15% or more are going to start showing those signs and symptoms of hypoy shock because the body really can't compensate for that and it has to turn on its sympathetic nervous system and all of that so in this class SL stage how do you expect our heart rate to be it's going to be less than 100 they're not going to have tacac cardia so um it's going to be within normal limits maybe a little bit on the high end maybe 80s or 90s blood pressure it's going to be within normal limit limits our body is maintaining our cardiac output respirations within normal limits we're not having any issues with decreased oxygen just yet because our body can deal with this blood loss mental status they're probably going to be normal they may have a l they may be a little anxious but nothing major their skin is going to be um warm um to the touch their capillary refill is going to be less than 2 seconds whenever we check that and their urinary output is going to be greater than 30 cc's an hour so kidneys are doing great that's where we want them next we have class two and this is where we've lost 15 to 30% of fluid volume so anywhere between 750 to, 1500 mls in an adult so with this because we've lost more fluid volume than compared to here our cardiac output is decrease the body cannot maintain its own cardiac output with this amount of fluid volume loss so it has to activate that sympathetic nervous system the body's receptors and the body's sense hey we can't do this so those barel receptors activate it and um that's in turn going to activate our renin Angiotensin system you're going to get shunting of blood away from nonvital organs so in a nutshell where you're going to have is Vaso constriction from those catacol amines from Angiotensin to and this is going to constrict vessels and this is going to increase Venus return to the heart which is going to increase our cardiac preload stroke volume um cardiac output and increase our blood pressure so we're going to be maintaining tissue profusion making our cells happy giving them oxygen also Al we're going to be increasing blood volume through some hormones under the influence of angiotensin too so we're going to have um ADH the anti-diuretic hormone on board that's going to cause us to retain water and aldosterone which is going to help us conserve sodium and water and all that in Hope of increasing blood volume volume in the blood which is going to increase the Venus return to the heart preload stroke volume and cardiac output so our signs and symptoms are going to really be around what what's going on because our body here is compensating with its built-in system so how do we expect our heart rate to be it's going to be increased because of the effects of the catac colomines on the heart so we're going to have some tacac cardia going on it'll be mild it's going to be less than 120 so less than 120 our blood pressure is going to be decreased from where that patient normally is but they're not going to be hypotensive just yet because this system is working to maintain our cardiac output but it'll be slightly decreased our respiratory rate is going to be increased a little bit just mildly from everything that's going on we've dropped in our oxygen so the bodies increasing respiratory to take in some more oxygen to help increase that level urinary output well what's going on with her ADH and aldosterone it's causing us to keep water so our urinary output is going to to decrease so instead of being the normal where we want at 30 MLS per hour it's probably going to be between 20 to 30 so it's going to decrease skin now we're diverting blood away from non-vital organs the skin is one of them so instead of our skin being warm and flesh it's going to be cool and clammy from where blood is being diverted capillary refill the same concept there instead of being less than 2 seconds it's going to be increased so greater than 2 seconds peripheral pulses because we're shifting blood away from those extremities they're going to start becoming diminished and how we feel them and mental status instead of just having being normal or maybe just a little bit anxious they're going to start to have some mild anxiety going on next is class three and this is where the patient has lost 30 to 40% of their fluid vol volume and this is anywhere between, 1500 to 2,000 MLS of fluid now because it is this much the body can no longer compensate so compensatory mechanisms are going to fail they're not going to be able to do it and our cardiac output is just really it has fell because they've lost so much blood in that circulatory system that the heart doesn't really have much to pump out maintain profusion so you're going to see those cells that make up those organs and tissues you're going to see malfunctioning of our body system so we're ending up having failure so our heart rate is going to be significantly high it's going to be greater than 120 we're going to have tardia tacac cardia their blood pressure they're going to have severe hypotension because we don't have the body being able to maintain blood pressure so we're going to have some hypotension going on respiratory rate is going to be majorly increased they're hitting respiratory failure territory so they need mechanical ventilation intubation possibly to help assist them urinary output is going to be low aluria so it's definitely going to be less than 30 cc's an hour we're getting in the renal failure territory where bu creatinin is going to be increased you're going to start seeing buildup of waste in the blood liver is going to be failing to help rid us of those toxins in addition profusion to the brain because our blood pressure is just so low mean arterial pressure is going to drop and so brain isn't going to be able to be profused so you're going to start seeing some major mental status changes here you're going to see confusion um agitation until it progresses to um the next stage where they'll be actually lifeless and a coma their skin is going to be cool clammy but even take it a step further it can be modeled and um their pulses are going to be absolutely poor their peripheral pulses and the last stage we have is class 4 and this is where the patient has lost 40% or more of their fluid volume so greater than 2,000 MLS and this is where death is near we need to get this patient some very very very fast treatment Dynamic treatment if possible to help prevent that and what you're going to see with this is just all these vital signs that we're talking about they're going to be significantly abnormal so you're going to have major tacac cardia greater than like 140 severe hypotension um major respiratory failure they're going to be anuric they're not going to be producing any urine there's like hardly any fluid to even produce fluid for urine off of mental status like I said they're going to be lifeless and in a coma so in a nutshell whenever you're looking for signs and symptoms like for your exams for hypo hypovolemic shock you need to be looking at that heart rate how's it going to be it's going to be high it's going to be T cardic how's the blood pressure going to be hypotensive respitory rate it's going to be increased um their urinary output is going to be decreased their skin profusion it's going to be cool clammy capillary refill is going to be down mental status is going to be confused so be keeping all that in mind and whenever a patient whenever they have like hemodynamic monitoring whenever they start getting in these classes of hypmic shock they're going to have that hemodynamic monitoring so whenever we're looking at Central Venus pressures how do you think that that number is going to be it's going to be low this is where you measure the pressure over here in this right atrium we don't have any fluid hardly even in the heart so the pressure there is going to be low and if you looked at a pulmonary capillary wedge pressure over here which looks at the filling pressure in the left atrium it's going to be low as well because we're depleted of our fluid volume so remember those two numbers and it's different whenever we talked about cardiogenic shock remember I talked about the CVP being high that Central Venus pressure and that pulmonary capillary wedge pressure being high because cardiogenic shock we don't have a loss of fluid volume our harsh is weak and that fluid volume the pressure of is actually increasing we have fluid volume overload so those numbers would be high in cardiogenic shock now let's talk about nursing interventions for hypovolemic shock okay what are some treatment goals first because that really dictates where we're going with our nursing interventions one thing of course is replacing fluid to this intravascular system we can increase the Venus return to the heart we can increase preload stroke volume and increase cardiac output and we get better tissue profusion so fluids ordered by The Physician are really going to help this patient and as a nurse we will be giving those fluids and monitoring them and it can vary it depends on what class or stage of hypmic shock that patient is in and um you can use various fluids like crystalloids colloids blood blood products and we'll be talking about all those here in a moment and of course correcting the underlying cause of the reason why that patient is losing so much fluid from the inas vascular system so if they're having a massive bleed somewhere they need to have surgery repair that to stop the bleeding so nursing wise we're looking at a lot of things we're looking at circulation profusion oxygenation and we're going to put our nursing interventions and goals for that patient around that so oxygenation wise we want to make sure that they're getting oxygen because O2 is a problem here because those cells are being deprived so we want to make sure that they're not entering into respiratory failure so they may need in mechanical ventilation plac on oxygen circulation wise are they actively bleeding they are you want to hold firm direct pressure call rapid response get someone there to help you fast because you need a team to help you with this patient condition simultaneously you're going to be doing all this you're going to be looking at signs and symptoms of adequate profusion is this patient going into hypovolemic shock so you're going to pull from those signs and symptoms that they are and very simple you can look at their skin cool and clammy that would be bad uh look at their mental status how are they acting what's their blood pressure their heart rate remember blood pressure will be low they can be um Tac cardic will be heart rate will be high urinary output what are they putting out and looking at all those things in addition you want to make sure that you have Ivy access we need access to that intravascular system so we can give them fluids and drugs whatever we need to get that cardiac output up replace that fluid so you need at least two IV sites and they need to be a large canula there and those large veins those anticubital veins AC's at least 18 gauge or higher you're going to be giving rapid fluids fast and other medications so we want to make sure that they're nice and working in addition they may need a fully catheter so you can monitor that urinary output precisely collect that instead of depending on the patient to use the bathroom which they're probably going to be so sick they can't do that and we want to be able to collect that and many patients who have severe hypovolemic shock they're not responding to the fluids going to have Central lines hemodynamic monitoring which will help us monitor the cardiac output and how well we're replacing those fluids and we can look at some numbers so whenever you have a patient in hypovolemic shock severe hypovolemic shock how again is that Central Venus pressure going to be it's going to be low how's that pulmonary capillary wedge pressure going to be it's going to be low but we're giving them fluid so one thing whenever you give fluids you have to make sure you're not giving them too much where we're going to actually flip them into cardiac um fluid overload so if we were giving them too much fluid how would those numbers start presenting Central Venus pressure can start becoming elevated um the pulmonary capillary wedge pressure can be start becoming elevated as well because putting too much fluid in the heart it's too much so it's increasing the pressure over here right atrium so CVP pressure and the filling pressure in the left atrium for pulmonary capillary wedge pressure so you want to look at those things now position wise what's a good position for these patients we want a position that's going to increase cardiac output Venus return to the heart so one position is modified Trendelenburg this is where the patient is suine with their feet SL legs elevated at that 45° doing that is going to increase Venus return and help us increase cardiac output a bit lab wise we have to monitor what's going on with the patient so Physicians will be ordering this and we'll want to be either collecting that um looking at those labs coming out hemoglobin hematocrit looking does this patient need blood products depends on protocols but usually less than 8 to seven for hemoglobin they'll need some blood transfusions abgs arterial blood gases remember these patients can go into acidotic conditions we want to be looking at that looking at lactate levels because our cells are switching from aerobic to Anor robic we're going to get the buildup of lactic acid livers may not be working building up more toxins or kidneys looking at electrolytes cbc's looking at bu creatinin telling us our renal function now let's talk about our fluid types used for the treatment of hypoy shock okay first thing we're going to talk about are crystalloids and colloid Solutions these are two types of volume expanders use for hypmic shock and again this varies depending on the patient's status volume loss of what will be used so first let's talk about crystalloids okay crystalloids what is a crystalloid well normal saline or lactated ringers and how they work is that they add more fluid to the intervascular system system and this is going to increase preload because it will increase How much fluids coming back to the heart and stroke volume and the cardiac output so with this you have to watch for fluid volume overload like I was talking about earlier and um you can look for many things just simply listening to their lungs you hear fluid in the lungs with crackles they having difficulty breathing um are they having elevated CVP pressures or pulmonary wedge capillary pressures or just looking for edema in legs are do they have jugular Venus distension things like that can point to that they're retaining too much of the fluid and one thing about crystalloid Solutions I want you to remember is that these Solutions are able to diffuse through the capillary wall so less fluid remains in the intravascular system compared to colloid Solutions now normal saline or lactated ringers are most commonly used number one they're really cheap easy to access and how they're given is by remembering the 3:1 Rule and what this rule says is for every mL of approximate blood loss 3 MLS of a crystalloid solution is given so let's say a patient has lost 750 mls of blood how much of a crystalloid solution would they give well according to that rule it would be 2250 MLS because we're going to be giving 3 MLS of a crystalloid solution for every mL of blood loss another fluid type is colloids and an example of this is like albumin or hetastarch and what colloids are they consist of large molecules examples like proteins that can't diffuse through a capillary wall so in the long term more fluid stays in that intravascular system for a longer period of time compared to those crystalloids how however colloids are more expensive to use and patients can have anaphylactic reactions so again just with crystalloid Solutions as well you would want to monitor for fluid overload now as a nurse it's really important to remember if you are giving large amounts of fluids like these crystalloids colloids it's very important that you warm them um before giving them because this will prevent hypothermia and we don't want a patient to go into into hypothermia CU hypothermia Alters the way clotting enzymes work so we want to keep the patient warm keep the fluids warm um but we don't want the patient sweating so remember that whenever you're giving large amounts of fluids the last fluid type we're going to talk about of course is blood and blood products this can include packed red blood cells platelets or fresh frozen plasma now packed red blood cells are going to help replace the fluid that has been lost and it's going to do another thing that really our crystalloids and colloids couldn't do it's going to provide the patient with hemoglobin and hemoglobin will carry oxygen to those deprived cells so that is one benefit of that now um it may be used when the patient is not responding to crystalloid fluid challenge has experienced severe bleeding or severe hypovolemic shock and some other type of blood products use are like platelets and these would be used for patients who are having uncontrolled bleeding due to thrombocytopenia so they need some platelets to help with that also a fresh frozen plasma this is for when patients need clotting factors now anytime you're giving any type of blood blood products you always want to monitor for transfusion reactions with these products and I have a whole video on um the nurses role with blood transfusions if you want to check that out as well now let's review intake and output first let's start out talking about intake okay what does this include this includes fluids taken in the body so this can be via the mouth a tube or an IV or central line but first let's talk about liquids consumed taken in by the mouth okay this includes any liquids that are liquid at room temperature that's what we're going to include in our calculation so this will include things like juice water ice chips and things you want to remember about ice chips is that they melt to half their volume so if you give them 8 oz of ice chips you're going to really record it as 4 oz cuz it's going to melt down to 4 oz any drinks like tea coffee soda you will include gelatin desserts like jello milk broths ice cream frozen treats like popsicles sorbet and nutrition supplements like insure or boost now what about pudding do you include that in the calculation or not unfortunately the consensus on this is not the same across the board I will say no you don't include pudding I've never included it as a nurse wasn't taught to and the late the latest inlex guide by Kaplan says that you don't include pudding in the calculation because it's a semi liquid however some students I've talked to they said that the professor told them to or their book told them to so if you have any doubts or questions always ask your professor before the exam and go by what they tell you but for this video we're not going to include pudding when we work our practice problems okay some other miscellaneous things that's included in this intake calculation are to feedings like the tube feeding that you would feed them through their peg tube whatever type of tube they have also don't forget the free water flushes that they'll receive as well and any type of IV fluid centraline fluids this can include tpn lipids blood prop products any Med infusions or flushes and next IV flushes don't forget those and any irrigant like continuous bladder irrigation things like that now let's talk about output okay this is anything that's taken out of the body that leaves the body and majority of your calculation for output will be urine and it also includes things like emesis vomit liquid stool like diarrhea or from an omey bag especially in il oomy since those stools tend to be a lot more liquid any wound drainage that you can measure that's like in a drain like a wound back JP drain a tube chest tube anything like that suction that you can suction from the respiratory system gastric system you'll want to include now one thing that we don't include that but you want to be aware of it as a nurse is the insensible loss things we really can't measure and this comes from the skin or the lungs and according to M's medical diction AR you can lose about 600 milliliters per day through these routes so whenever you are assessing those eyes and nose you want to take that into consideration because remember if that intake is less than that output or the output is more than the intake there is a risk of dehydration on your patients part because they're losing so much fluid more than they're taking in compared to if the intake was more than the output or another way of saying it the output's less than the intake they're retaining fluid they're at risk for fluid overload because they're just ingesting or receiving all this fluid but they're not really urinating it out so they're at risk for retaining it now let's solve a problem okay this particular problem wants to know what's the patient's total intake during your 12-hour shift so whenever you look at these problems you got to pay attention to a couple things because they try to throw you off okay number one you have to make sure you're in including the right thing in your intake calculation which is why we went over that whole list of what's included number two a lot of problems will give you the calcul like will give you the intake in ounces and you have to convert that to milliliters because we record intake and output in milliliters and it's really easy how you do that you take all the ounces and you multiply that by 30 and that will equal your milliliters another thing is that you want to make sure you pay attention whenever you are adding up those ounces and don't add in like 10 cc's to your ounce calculation until you have converted it because it can throw off your numbers so let's see what our problem says okay at 8:00 our patient had 8 oz of orange juice which we will include orange juice they had 6 ounces of yogurt we don't include that and they had a 10cc iy flush now CC's and milliliters are the same that equal one m one C equal 1 ml so we're going to include that so to help me keep them organized I'm going to have their own little columns which also equals milliliters so we had 8 oz of orange juice and we had a 10 CC flush okay at 10:00 they had 8 O of coffee which will include with 1 oz of cream liquid creamers we include so we'll include that so eight and one okay at 12 they had 12 oz of soda which will include they had two 12 O popsicles don't let that mess you up they had two of them so what would it be we're not going to record 12 we're going to record 24 so 24 oz they had 3 o of pudding which we're not including and then they had 4 o of broth which we include and then it 1300 they had 6 o of soda which we include and then at 1600 they had 8 O of ice chips now what did we say about ice chips we only record it in half because it will melt down to that so we'll record that as four and then the last last part it says from 1,400 to 19900 they had Ivy fluids running at 50 CC's an hour so 50 milliliters an hour so they had this running for 5 hours so 50 * 5 equals what 250 okay now we're ready to add okay so we're going to add up all of our ounces so all that added together equals 67 but we're still in ounces and we got to get to milliliters so we'll multiply 67 by 30 and that equals 20110 okay now we have to work this part over here so 10 + 250 = 260 okay and then we add it all together so 20110 + 260 equal 2,270 m and that's that was their total intake for your shift now let's calculate output okay this problem may be something similar that you may see on an exam and it says a patient had a turp and is receiving continuous bladder irrigation during your 12-hour shift the patient FY collects 5,320 milliliters the patient received 2500 milliters of bladder irrigation what is the patient's urinary output now whenever we look at this at first it's like I don't know they had all this fluid of irrigation going to their bladder and it's mixed with their urine so what exactly is their true urinary output and it's so easy to solve so what you'll do is you'll take the whole amount that was collected in that Foley bag because remember in the Foley bag it has urine and irrigation solution in it so it was a total of 5,320 and then you're going to subtract how much of bladder irrigation was instilled in that bladder so subtract 2500 and what do you get you get 2,820 milliliters so that is the patient's true urinary output