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Chapter 14
Fluids and
Electrolytes
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Electrolyte Imbalances
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Hyponatremia
Lower than normal sodium in the blood serum
Can be actual deficiency of sodium or increase in
body water that dilutes the sodium excessively
Assessment
Symptoms: headache, muscle weakness, fatigue,
apathy, confusion, abdominal cramps, and orthostatic
hypotension
Take blood pressures with the patient lying or sitting
and then standing to determine if a significant drop
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Hyponatremia
Medical treatment
The usual treatment is restriction of fluids while the
kidneys excrete excess water
Diuretic: furosemide (Lasix)
Sodium replacement therapy
Nursing care
Administer prescribed medications and IV fluids
Measure fluid intake and output and assess mental
status
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Hypernatremia
Higher than normal concentration of sodium in the
blood
Very serious imbalance; can lead to death if not
corrected
Occurs when excessive loss of water or excessive
retention of sodium
Signs and symptoms
Thirst, flushed skin, dry mucous membranes, low urine
output, restlessness, increased heart rate, convulsions, and
postural hypotension
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Hypernatremia
Medical treatment
Oral or IV replacement of water to restore balance
A low-sodium diet often prescribed
Nursing care
Encourage patients with hypernatremia to drink water
Closely monitor the infusion of IV fluids
Teach patient to track daily I&O and to recognize the
signs and symptoms of fluid retention or depletion
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Hypokalemia
Low serum potassium
May result in gastrointestinal, renal, cardiovascular,
and neurologic disturbances
Can cause abnormal, potentially fatal, heart rhythm
Signs and symptoms
Anorexia, abdominal distention, vomiting, diarrhea, muscle
cramps, weakness, dysrhythmias (abnormal cardiac
rhythms), postural hypotension, dyspnea, shallow
respirations, confusion, depression, polyuria (excessive
urination), and nocturia
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Hypokalemia
Medical treatment
Potassium replacement by the IV or oral route
Nursing care
Monitoring at-risk patients for decreased bowel
sounds, a weak and irregular pulse, decreased reflexes,
and decreased muscle tone
Cardiac monitors may be used to detect dysrhythmias
Administer oral or IV potassium
Urine output should be no less than 30 ml/hr
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Hyperkalemia
High serum potassium
Patients at risk: decreased renal function, in metabolic
acidosis, taking potassium supplements
A serious imbalance because of the potential for life-
threatening dysrhythmias
Signs and symptoms
Explosive diarrhea and vomiting; muscle cramps and
weakness, paresthesia, irritability, anxiety, abdominal
cramps, and decreased urine output
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Hyperkalemia
Medical treatment
Correct the underlying cause
Restrict potassium intake
Polystyrene sulfonate (Kayexalate)
Intravenous calcium gluconate
Nursing care
Patients with low urine output or those taking
potassium-sparing diuretics must be monitored
carefully for signs and symptoms
Carefully monitor flow rate of IV fluids, which should
not exceed 10 mEq/hr through peripheral veins
Screen the results of laboratory studies
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Chloride Imbalance
Usually bound to other electrolytes; therefore,
chloride imbalances accompany other electrolyte
imbalances
Hyperchloremia
Usually associated with metabolic acidosis
Hypochloremia
Usually occurs when sodium is lost because chloride most
frequently bound with sodium
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Calcium Imbalance
Regulated by the parathyroid glands
Hypocalcemia results from diarrhea, inadequate dietary
intake of calcium or vitamin D, and multiple blood
transfusions (banked blood contains citrates that bind to
calcium), in addition to some diseases, including
hypoparathyroidism
Hypercalcemia results from a high calcium or vitamin D
intake, hyperparathyroidism, and immobility that causes
stores of calcium in the bones to enter the bloodstream
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Magnesium Imbalance
Hypomagnesemia: decreased gastrointestinal
absorption or excessive gastrointestinal loss, usually
from vomiting and diarrhea, or increased urinary
loss
Hypermagnesemia occurs most often with excessive
use of magnesium-containing medications or
intravenous solutions in patients with renal failure or
preeclampsia of pregnancy
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Acid-Base Disturbances
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Respiratory Acidosis
Respiratory system fails to eliminate the appropriate
amount of carbon dioxide to maintain the normal
acid-base balance
Caused by pneumonia, drug overdose, head injury,
chest wall injury, obesity, asphyxiation, drowning, or
acute respiratory failure
Medical treatment
Improve ventilation, which restores partial pressure of
carbon dioxide in arterial blood (Paco
2
) to normal
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Respiratory Acidosis
Nursing care
Assess Paco
2
levels in the arterial blood
Observe for signs of respiratory distress: restlessness,
anxiety, confusion, tachycardia
Intervention
Encourage fluid intake
Position patients with head elevated 30 degrees
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Respiratory Alkalosis
Low Paco
2
with a resultant rise in pH
Most common cause of respiratory alkalosis is
hyperventilation
Medical treatment
Major goal of therapy: treat underlying cause of condition;
sedation may be ordered for the anxious patient
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Respiratory Alkalosis
Nursing care
Intervention
In addition to giving sedatives as ordered, reassure the
patient to relieve anxiety
Encourage patient to breathe slowly, which will retain
carbon dioxide in the body
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Metabolic Acidosis
Body retains too many hydrogen ions or loses too
many bicarbonate ions; with too much acid and too
little base, blood pH falls
Causes are starvation, dehydration, diarrhea, shock,
renal failure, and diabetic ketoacidosis
Signs and symptoms: changing levels of
consciousness, headache, vomiting and diarrhea,
anorexia, muscle weakness, cardiac dysrhythmias
Medical treatment: treat the underlying disorder
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Metabolic Acidosis
Nursing care
Assessment of the patient in metabolic acidosis should
focus on vital signs, mental status, and neurologic
status
Emergency measures to restore acid-base balance.
Administer drugs and intravenous fluids as prescribed.
Reassure and orient confused patients
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Metabolic Alkalosis
Increase in bicarbonate levels or a loss of hydrogen ions
Loss of hydrogen ions may be from prolonged nasogastric
suctioning, excessive vomiting, diuretics, and electrolyte
disturbances
Signs and symptoms: headache; irritability; lethargy;
changes in level of consciousness; confusion; changes in
heart rate; slow, shallow respirations with periods of
apnea; nausea and vomiting; hyperactive reflexes; and
numbness of the extremities
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Metabolic Alkalosis
Medical treatment
Depends on the underlying cause and severity of the
condition
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Metabolic Alkalosis
Nursing care
Assessment
Take vital signs and daily weight; monitor heart rate,
respirations, and fluid gains and losses
Keep accurate intake and output records, including the
amount of fluid removed by suction
Assess motor function and sensation in the extremities;
monitor laboratory values, especially pH and serum
bicarbonate levels
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Metabolic Alkalosis
Intervention
To prevent metabolic alkalosis, use isotonic saline
solutions rather than water for irrigating nasogastric
tubes because the use of water for irrigation can result
in a loss of electrolytes
Provide reassurance and comfort measures to promote
safety and well-being