6784 FM.qxd 8/17/08 11:10 AM Page i PPOORRTTAABBLLEE FFlluuiiddss && EElleeccttrroollyytteess 6784 FM.qxd 8/17/08 11:10 AM Page ii STAFF The clinical treatments described and recom- mended in this publication are based on re- Executive Publisher search and consultation with nursing, medical, Judith A. Schilling McCann, RN, MSN and legal authorities. To the best of our knowl- edge, these procedures reflect currently accepted Editorial Director practice. Nevertheless, they can’t be considered David Moreau absolute and universal recommendations. For individual applications, all recommendations Clinical Director must be considered in light of the patient’s clini- Joan M. Robinson, RN, MSN cal condition and, before administration of new or infrequently used drugs, in light of the latest Art Director package-insert information. The authors and Mary Ludwicki publisher disclaim any responsibility for any ad- verse effects resulting from the suggested proce- Senior Managing Editor dures, from any undetected errors, or from the Jaime Buss, MSPH, ELS reader’s misunderstanding of the text. Editorial Project Manager © 2008 by Lippincott Williams & Wilkins. All Liz Schaeffer rights reserved. This book is protected by copy- right. No part of it may be reproduced, stored in Clinical Project Manager a retrieval system, or transmitted, in any form Jennifer Myering, RN, BSN, MS, CCRN or by any means—electronic, mechanical, pho- tocopy, recording, or otherwise—without prior Editors written permission of the publisher, except for Sharon R. Cole, Karl Schaeffer brief quotations embodied in critical articles andreviews and testing and evaluation materi- Copy Editors als provided by publisher to instructors whose Kimberly Bilotta (supervisor), schools have adopted its accompanying text- JaneBradford, Scotti Cohn, book. Printed in the United States of America. For information, write Lippincott Williams & HeatherDitch, ShanaHarrington, Wilkins, 323 Norristown Road, Suite 200, DonaPerkins, Irene Pontarelli, Ambler, PA 19002-2756. DorothyP.Terry, PamelaWingrod PORTFE010607 Designer Library of Congress Arlene Putterman Cataloging-in Publication Data Digital Composition Services Portable fluids & electrolytes. Diane Paluba (manager), p. ; cm. JoyceRossiBiletz, Donna S. Morris Includes bibliographical references and index. 1. Water-electrolyte imbalances—Handbooks, Manufacturing manuals, etc. 2. Water-electrolyte imbalances— BethJ.Welsh Nursing—Handbooks, manuals, etc. I. Lippincott Williams & Wilkins. II. Title: Portable Editorial Assistants fluids and electrolytes. Megan L. Aldinger, Karen J. Kirk, [DNLM: 1. Water-Electrolyte Imbalance— nursing. 2. Infusions, Intravenous—nursing. LindaK.Ruhf WY 150 P839 2008] Design Assistant RC630.P67 2008 616.3'992—dc22 Georg W. Purvis IV ISBN-13: 978-1-58255-678-9 (alk. paper) Indexer ISBN-10: 1-58255-678-4 (alk. paper) 2007007781 Judith Young 6784 FM.qxd 8/17/08 11:10 AM Page iii CCoonntteennttss Contributors and consultants v PART I Fluid & electrolyte balance 1 1 Fluid balance 2 2 Electrolyte balance 19 3 Acid-base balance 31 PART II Fluid & electrolyte imbalances 43 4 Fluid imbalances 44 5 Sodium imbalances 72 6 Potassium imbalances 89 7 Magnesium imbalances 108 8 Calcium imbalances 128 9 Phosphorous imbalances 148 10 Chloride imbalances 164 11 Acid-base imbalances 176 PART III Disorders affecting fluid & electrolyte balance 205 12 Heat syndromes 206 13 Heart failure 216 14 Respiratory failure 227 u iii 6784 FM.qxd 8/17/08 11:10 AM Page iv vi u CONTENTS 15 Excessive GI fluid losses 235 16 Renal failure 243 17 Burns 255 PART IV I.V. therapy 271 18 Introduction to I.V. therapy 272 19 Peripheral I.V. therapy 294 20 Central venous therapy 343 21 Total parenteral nutrition 398 Selected references 406 Index 407 6784 FM.qxd 8/17/08 11:10 AM Page v CCoonnttrriibbuuttoorrss aanndd ccoonnssuullttaannttss Katrina D. Allen, RN, MSN, CCRN Nursing Instructor, Faulkner State Community College, Bay Minette, Ala. Pamela C. Anania, APRN, MSN, NP-C Nursing Skills Lab Coordinator/Adjunct Faculty, Brookdale Community College, Lincroft, N.J. Penny Bennet, RN, BSN Charge Nurse Surgical Unit, Good Shepherd Health System, Longview, Tex. Colleen Davenport,RN, C, MSN Consultant, Renton, Wash. Shelba Durston, RN, MSN, CCRN Nursing Instructor, San Joaquin Delta College, Stockton, Calif. Staff Nurse, San Joaquin General Hospital, French Camp, Calif. Christine Kennedy, RN, MSN LPN Instructor, Eli Whitney Vocational School, Hamden, Conn. Jennifer M. Lee, RN, FNP, CCRN Staff Nurse, AnMed Health, Anderson, S.C. Pamela Moody,APRN-BC, MSN, PhD, NHA Nurse Practitioner Consultant, Alabama Department of Public Health, Tuscaloosa Dina Nicole Salvatore, LPN Charge Nurse, Windemere Nursing & Rehabilitation Center, Oak Bluffs, Mass. Donna Scemons, RN, MSN, FNP-C, CNS, CWOCN President, Healthcare Systems, Inc., Castaic, Calif. Bruce Austin Scott, APRN,BC, MSN Nursing Instructor, San Joaquin Delta College Staff Nurse, St. Josephs Medical Center, Stockton, Calif. u v 6784 FM.qxd 8/17/08 11:10 AM Page vi vi u CONTRIBUTORS AND CONSULTANTS Emily Sheff, RN, MS, APRN, BC RN Term Lecturer, Clinical Faculty, Massachusetts General Hospital, Boston College, Boston Elliot Stetson, RN, BC, MSN, CCRN Staff Nurse, Robert Wood Johnson University Hospital, New Brunswick, N.J. Allison J. Terry, RN, MSN, PhD Director of Center for Nursing Workforce Research, Alabama Board of Nursing, Montgomery Patricia Van Tine, RN, MA Nursing Faculty, Mt. San Jacinto College, Menifee, Calif. 678401.qxd 8/17/08 11:32 AM Page 1 PPAARRTT II FFlluuiidd && eelleeccttrroollyyttee bbaallaannccee ◆ 1 678401.qxd 8/17/08 11:32 AM Page 2 FFlluuiidd bbaallaannccee 11 Fluids are vital to all forms of skin and the lungs. (See Sites in- life. In the human body, they volved in fluid loss.) help maintain temperature and A typical adult loses 100 to cell shape and also help trans- 200 ml/day through defecation. port nutrients, gases, and wastes. However, in a patient with severe Just about all major organs— diarrhea, losses may exceed including the skin, the lungs, and 5,000 ml/day. Insensible losses the kidneys—work together to from the skin, though fairly con- maintain the proper balance of stant, can vary depending on hu- fluid, or homeostasis. To main- midity levels and the person’s tain balance, the amount of fluid body surface area (BSA). gained throughout the day must AGE ALERT The BSA of an equal the amount lost. Maintain- infant is greater than that ing this equilibrium would be of an adult relative to respec- easy if all losses could be mea- tive weight. As a result, infants sured, but they can’t. typically lose more water from the skin than adults do. Respiratory rate and depth can affect the amount of fluid lost Fluid losses through the lungs. Tachypnea, Fluid losses may be measurable, for example, causes more water referred to as sensible losses, or to be lost; bradypnea, less. Fever immeasurable, referred to as in- increases insensible losses of flu- sensible losses. Sensible losses in- id from both the skin and lungs. clude losses from urination, defe- cation, and wounds. Insensible losses include losses from the ◆ 2 678401.qxd 8/17/08 11:32 AM Page 3 ◆ FLUID DISTRIBUTION 3 Sites involved in fluid loss Each day,the body gains and loses fluid through several different processes.This illustration shows the primary sites of fluid losses and gains as well as their aver- age amounts.Gastric,intestinal,pancreatic,and biliary secretions are almost com- pletely reabsorbed and aren’t usually counted in daily fluid losses and gains. DAILY TOTAL INTAKE 2,600 ML Liquids 1,500 ml Solid foods 800 ml Water of oxidation 300 ml DAILY TOTAL OUTPUT 1,200 TO 2,500 ML Skin and sweat 350 to 400 ml Lungs 350 to 400 ml Kidneys (urine) 400 to 1,500 ml Intestines (feces) 100 to 200 ml tween the two compartments Fluid distribution must remain relatively constant. The body holds fluid in two ba- In an adult, the total amount of sic areas, or compartments—in- intracellular fluid averages 40% side the cells and outside the of the person’s body weight, or cells. Fluid found inside the cells about 28 L. The total amount of is called intracellular fluid; fluid extracellular fluid averages 20% found outside the cells is called of the person’s body weight, or extracellular fluid. Capillary walls about 14 L. and cell membranes separate the Extracellular fluid can be bro- intracellular and extracellular ken down further into interstitial compartments. (See Understand- fluid, which surrounds the cells, ing fluid compartments, page 4.) and intravascular fluid or plas- To maintain proper fluid bal- ma, which is the liquid portion ance, the distribution of fluid be- of blood. In an adult, interstitial 678401.qxd 8/17/08 11:32 AM Page 4 ◆ 4 FLUID BALANCE Understanding fluid compartments This illustration shows the primary fluid compartments in the body:intracellular and extracellular.Extracellular compartments are further divided into interstitial and intravascular compartments.Capillary walls and cell membranes separate in- tracellular fluids from extracellular fluids. Intracellular Extracellular (intravascular) Extracellular (interstitial) fluid accounts for about 75% of with adults, infants have a the extracellular fluid, and plas- greater percentage of body wa- ma accounts for the remaining ter stored in interstitial spaces. 25%. About 80% of a full-term neo- Skeletal muscle cells hold nate’s body weight is water. much of the body’s water con- About 90% of a premature tent; fat cells contain little of it. neonate’s body weight is wa- Women, who normally have a ter. The amount of water as a higher ratio of fat to skeletal percentage of body weight de- muscle than men, typically have creases with age until puberty. a lower relative water content In a typical 154-lb (69.9-kg), than men. Likewise, an obese lean adult male, about 60% person may have a relative water (93 lb [42.2 kg]) of body content level as low as 45%. Ac- weight is water. (See Fluid cumulated body fat in these indi- changes with aging.) viduals increases weight without The body contains other flu- boosting the body’s water con- ids, called transcellular fluids, in tent. the cerebrospinal column, pleural AGE ALERT Fluid distribu- cavity, lymphatic system, joints, tion within the body and eyes. These fluids generally varies with age. Compared