Interactive Discussion

Fluid and Electrolytes

 Peritoneal Dialysis

 to remove toxic substances

and metabolic wastes and

 toreestablish normal fluid

and electrolyte balance.
 who are unable or unwilling
to undergo hemodialysis or
kidney transplantation

 diabetes or cardiovascular
disease, many older patients

 risk for adverse effects of

systemic heparin
 Peritoneal membrane serves as the
semipermeable membrane

 Diffusion
 (clearance)

 Osmosis

 Ultrafiltration
 high dextrose concentration
hypertonic)

 osmotic gradient

 higher the dextrose concentration

 greater the osmotic gradient

 more water will be removed

 Performing the Exchange

 a series of exchanges or
cycles

 Infusion (fill)

 Dwell

 Drainage of the dialysate

 infused by gravity

5 to 10 minutes is usually required

to infuse 2 to 3 L of fluid

 dwell/equilibration time (diffusion,

osmosis, & ultrafiltration)

 Drainage – tube is unclamped * solution

drains from the PC by gravity

 Usually completed in 10 – 20
minutes
 normally colorless or
straw colored

https://www.imedpub.com/articles-images/renal-medicine-cessation-
lercanidipine-1-2-10-g002.png
 Should not be cloudy

 Peritonitis

 mostcommon and serious

complication

 diffuse
abdominal pain and
rebound tenderness

 Hypotension & other signs of

shock
 Bloody drainage may be seen in
the first few exchanges

 some blood enters the abdominal

cavity following insertion

 stops in 1 to 2 days

 young, menstruating women

https://onlinelibrary.wiley.com/toc/1525139x/2019/32/1
What is the predominant way of removing toxins, nitrogenous
waste products, creatinine, and excess potassium during
peritoneal dialysis?

a. Osmosis

b. Negative pressure

c. Diffusion

d. Ultrafiltration
You have a patient that is receiving peritoneal dialysis.
What should you do when you notice the return fluid is
slowly draining?
a. Check for kinks in the outflow tubing
b. Raise the drainage bag above the level of the
abdomen
c. Place the patient in a reverse Trendelenburg
position
d. Ask the patient to cough
BURNS
 ELECTRICAL BURNS

 an electrical current passing through the body that leads

to damage to the skin
 Muscles & bones
 Acute kidney injury (AKI)- ???
 Dysrhythmia -???
 Bone fractures (cervical spine injuries)
A 65 year old male patient has experienced full-thickness
electrical burns on the legs and arms. As the nurse you
know this patient is at risk for the following: Select all
that apply:

A. Acute kidney injury

B. Dysrhythmia
C. Hyponatremia
D. Hypernatremia
E. Bone fractures
F. Fluid volume overload
What causes burn shock?
 Burn injury

Increase capillary permeability

Inhalation injury Shifting of fluid, electrolytes,

Severe upper airway edema & proteins to ISS
Loss of ciliary action
Severe mucosal edema
Bronchospasm Hypovolemia edema
atelectasis Paralytic ileus Burn shock

Curling’s ulcer
decreased CO & BP

Decreased renal tissue perfusion

Acute tubular necrosis
Acute kidney injury Hemoglobin & myoglobin occlude
the renal tubules
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What causes Curling’s ulcer?
 Decreased blood flow to the stomach along with

reflux of duodenal contents

 Large amounts of pepsin are also released

 Ischemia, pepsin, and acid leads to ulceration

Why is the patient is on NPO status
during the emergent phase?
 Quality & Safety Nursing Alert !

No food or fluid is given by mouth, and the patient is

placed in a position that will prevent aspiration of
vomitus, because nausea & vomiting may occur and
protection of airway is always a priority.
You are working on a burn unit and one of your acutely ill patient is
exhibiting signs and symptoms of third spacing. Base on this
change status, you should expect your patient s/sx of what
imbalance?

a. Metabolic alkalosis
b. hypermagnesemia
c. hypercalemia
d. hypovolemia
Fluid & Electrolyte Changes during Emergent/Resuscitative Phase

 Fluid accumulation phase

 burn shock (hypovolemic)

 Plasma shift into the interstitial

fluid/ISC

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 What are the electrolyte imbalances
that occur during the emergent phase?
What is the acid-base imbalance that
occur during the emergent phase?
 a. Elevated hematocrit levels
A major goal for the client during
the first 48 hours after a severe b. Urine output of 30 to 50 ml/hr

bum is to prevent hypovolemic c. Change in level of

shock. The best indicator of consciousness
adequate fluid balance during
d. Estimate of fluid loss through
this period is:
the burn eschar
 a. Elevated hematocrit levels
A major goal for the client during
the first 48 hours after a severe b. Urine output of 30 to 50 ml/hr

bum is to prevent hypovolemic c. Change in level of

shock. The best indicator of consciousness
adequate fluid balance during
d. Estimate of fluid loss through
this period is:
the burn eschar
● Hypovolemia is a decreased in circulatory volume. This causes a
decrease in tissue perfusion to the different organs of the body.
Measuring the hourly urine output is the most quantifiable way of
measuring tissue perfusion to the organs. Normal renal perfusion
should produce 1ml/kg of BW/min. An output of 30-50 ml/hr is
considered adequate and indicates good fluid balance
 Clinical Manifestations

 singed nasal hair, soot in the airway injury/compromised

mouth/nose, coughing, voice edematous airway
changes, crackles, wheezes
decreased urine output diminished kidney perfusion

darkened appearance of renal damage/ ATN

urine (myoglobinuria)
 Glycosuria

decreased/ absent bowel paralytic ileus

sounds
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 Clinical Manifestations

 Coffee- ground emesis hypernatremia ???

 occult blood in the stool

hyperkalemia ??? hypocalcemia ???

Hypovolemia??? metabolic acidosis???

hyponatremia ??? respiratory acidosis???

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Hypovolemia can occur as a result of fluid losses and fluids moving
from the vascular space to the interstitial space.
Hyponatremia can result from increased loss of sodium and water
from the cells. Large amounts of sodium become trapped in
edematous fluid during the fluid accumulation phase.
Hypernatremia can occur as a result of the aggressive use of
hypertonic sodium solutions during fluid replacement therapy.
Hypocalcemia can occur because calcium travels to the damaged tissue
and becomes immobilized at the burn site.

Metabolic acidosis can develop as a result of the accumulation of acids

released from the burned tissue. It can also occur as a result of decreased
tissue perfusion from hypovolemia.

Respiratory acidosis can result from inadequate ventilation, as happens in

inhalation burns.
Why is glycosuria a common finding in the early post-burn hours?
Why is glycosuria a common finding in the early post-burn hours?

-results from the release of liver glycogen stores

in response to stress.
 Priority Nursing Diagnoses

 Impaired gas exchange

 Ineffective airway clearance
 Fluid volume deficit
 Hypothermia
 Acute pain
 Anxiety

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 Capillaries begin to regain their integrity

Increased urine output Fluid returns to the vascular

compartment

Increased GFR
Increased fluid volume

Increased cardiac output

Increased renal tissue perfusion

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Fluid & Electrolyte Changes in the Acute Phase
 hemodilution

Hypokalemia?

Hypervolemia?

Hyponatremia?

metabolic acidosis?
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Hypokalemia can develop as potassium shifts from the extracellular fluid
back into the cells.

Hypervolemia can occur as fluid shifts back to the vascular compartment.

Excessive administration of I.V. fluids may exacerbate the condition.

Hyponatremia may occur when sodium is lost during diuresis.

Metabolic acidosis can occur when loss of sodium results in the depletion
of bicarbonate
Metabolic acidosis can occur when loss of sodium results in the
depletion of bicarbonate

Decreased hematocrit?

 blood cell concentration is diluted as fluid enters the

intravascular compartment;

 loss of red blood cells at burn site.

 Rehabilitation/Convalescent Phase

 after the fluid accumulation & remobilization

phases have resolved

 optimal level of physical & psychosocial

adjustment

 healing or reconstruction of the burn wound

 anemia ?

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 Management

 Airway, breathing , & circulation

 endotracheal (ET) intubation

 administration of high concentrations of oxygen

 positive – pressure ventilation

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 Management

 100% humidified oxygen (mild pulmonary injury)

 encouraged to cough

 bronchial suctioning (severe situations)

 bronchodilators & mucolytic agents (severe

situations)

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 Management

 Fluid resuscitation – greater than 20% TBSA

 IV fluid administration

 50 mEq of sodium bicarbonate per liter of IV fluid?

 Histamine blockers & antacids?

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 Management

 50 mEq of sodium bicarbonate per liter of IV fluid?

 assist in alkalinizing the urine

 Histamine blockers & antacids?

 reduce gastric acidity & ulceration

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 Fluid Resuscitation

Under-resuscitation Over- resuscitation

Shock, ischemic Heart failure &

complications , & multiple pulmonary edema
organ dysfunction syndrome
(MODS)

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 Management of Burn Injury

Emergent/resuscitative

Acute/intermediate

Rehabilitation

Assessment & management (overlap)

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 Fluid Resuscitation

Lactated Ringers (LR) (initial)

crystalloid of choice

pH & osmolality

resemble human plasma

lactate metabolized into bicarbonate

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 Fluid Resuscitation
ABA (2011) Formula for adults:

Adults within 24 hours post thermal or chemical

burn

2 ml LR x patient’s weight in kilograms x %TBSA

For adults with electrical burns

4 ml LR x patient’s weight in kilograms x %TBSA

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 Fluid Resuscitation

Parkland formula (total fluid requirement in 24 hours)

4ml x TBSA (%) x body weight (kg)

 50 % given in first 8 hours

 50 % given in next 16 hours

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 Fluid Resuscitation

Example: for a 68-kg (150-lb) person with 27%

body surface area burns

4 ml × 68 kg × 27 = 7, 344 ml over 24 hours

Give one-half of the total over the first 8 hours

after the burn

remainder over the next 16 h

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 Fluid Resuscitation

1st 24°

1st 8° = 50%

2nd 8° = 25%

3rd 8° = 25%

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 Fluid Resuscitation

1st 8° = 50% = 3, 672 ml

2nd 8° = 25%= 1, 836 ml

3rd 8° = 25% = 1, 836 ml

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 Extent of Body Surface Area Injured

 Rule of nines

 anatomic regions

 9 % of the TBSA

 add the corresponding percentages

 calculate initial fluid

replacement needs
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 If a person’s injured due to a burn, a doctor may assess
them quickly. For example, if they were burned on each hand
and arm as well as the front trunk portion of the body, using
the rule of nines, they’d estimate the burned area as 36
percent of a person’s body.

 both hands and arms= 18; anterior trunk = 18

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● A 30 year old female patient
has deep partial thickness
burns on the front and back of a. 921 mL/hr

the right and left leg, front of b. 938 mL/hr

right arm, and anterior trunk.
The patient weighs 63 kg. Use c. 158 mL/hr
the Parkland Burn Formula:
d. 789 mL/hr
What is the flow rate during the
FIRST 8 hours (mL/hr) based
on the total you calculated?
● A 30 year old female patient
has deep partial thickness
burns on the front and back of a. 921 mL/hr

the right and left leg, front of b. 938 mL/hr

right arm, and anterior trunk.
The patient weighs 63 kg. Use c. 158 mL/hr
the Parkland Burn Formula:
d. 789 mL/hr
What is the flow rate during the
FIRST 8 hours (mL/hr) based
on the total you calculated?
● Front and back of right and left ● Remember during the FIRST
leg (36%) 8 hours 1/2 of the solution is
infused, which will be 14,742
● front of right arm (4.5%) divided by 2 = 7371 mL.

● anterior trunk (18%) which ● 7371 divide by 8 equals 921

equals 58.5% mL/hr

● 4 x 58.5 x 63 = 14,742 mL
● A client is brought to the a. 36%
emergency unit with third-degree
burns on the posterior trunk, right b. 54%
arm, and left posterior leg. Using
the Rule of Nines, what is the total c. 45%
body surface area (TBSA) that
has been burned? d. 27%
● A client is brought to the a. 36%
emergency unit with third-degree
burns on the posterior trunk, right b. 54%
arm, and left posterior leg. Using
the Rule of Nines, what is the total c. 45%
body surface area (TBSA) that
has been burned? d. 27%
● Based on the rule of nines, with posterior trunk equals 18%, right

arm equals 9%, and the left posterior leg equals 9%. Therefore, a

total of 36%.