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Lilley: Pharmacology and the Nursing Process, 7th Edition

Chapter 29: Fluids and Electrolytes
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 Understanding fluid and electrolyte management requires knowledge of the extent and
composition of the various body fluid compartments.
 Approximately 60% of the adult human body is water distributed in the following
proportions! intracellular fluid 6"%# interstitial fluid $%%# and plasma volume &%.
 'otal body water (')*+ is divided into intracellular and extracellular compartments. ,luid
volume outside the cells is either in the plasma or between the tissues cells or organs.
 Intravascular fluid describes the fluid inside the blood vessels and extravascular fluid refers
to the fluid outside the blood vessels.
 -lasma or serum is the fluid that flows through the blood vessels (intravascular fluid+. 'he
interstitial fluid (./,+ is the fluid that is in the space between cells tissues and organs.
 'here is one big difference between the plasma and the ./,. -lasma has a protein
concentration (primarily albumin+ four times greater than that of the ./,. -rotein solutes have
a large molecular weight making them too large to pass through the walls of blood vessels.
 -rotein in the vessels exerts a constant osmotic pressure that prevents the leakage of too
much plasma through the capillaries into the tissues. 'his is called colloid oncotic pressure
and normally it is $0 mm 1g. 'he opposing pressure exerted by the interstitial fluid is called
hydrostatic pressure and normally it is 2" mm 1g3less than the colloid oncotic pressure.
 4ehydration leads to a disturbance in the balance between the amount of fluid in the
extracellular compartment and that in the intracellular compartment. 4ehydration may be
hypotonic resulting from the loss of salt# hypertonic resulting from fever with perspiration#
or isotonic resulting from diarrhea or vomiting.
 4eath often occurs when $0% to $%% of ')* is lost.
 Acid5base balance is also important to normal bodily functions and is regulated by the
respiratory system and the kidney.
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 'he choice of whether to use a crystalloid or a colloid depends on the patient6s condition.
 7rystalloids are fluids given by intravenous (.8+ in9ection that supply water and sodium to
maintain the osmotic gradient between the extravascular and intravascular compartments.
 7rystalloid solutions contain fluids and electrolytes that are normally found in the body but
do not contain proteins. 'he administration of large quantities of crystalloid solutions for
fluid resuscitation decreases the colloid oncotic pressure via a dilutional effect. 'hey can leak
from the plasma into the tissues and cells resulting in edema anywhere in the body.
 7rystalloids are distributed faster into the interstitial and intracellular compartments than
colloids making them better for treating dehydration than for expanding the plasma volume.
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 7rystalloid solutions are most commonly used as maintenance fluids to compensate for
insensible fluid losses replace fluids and manage specific fluid and electrolyte disturbances.
7rystalloids also promote urinary flow and are less expensive.
 1ypertonic solutions must be used very cautiously and given slowly because of the risk for
hypervolemia from over=ealous replacement.
 7olloids are large protein particles that increase the colloid oncotic pressure and cannot leak
from the blood vessels. 'hey are naturally occurring and consist of proteins (albumin+
carbohydrates (dextrans or starches+ fats (lipid emulsion+ and animal collagen (gelatin+.
 'he total protein level must be in the range of ".0 g>d?. .f this level falls below %.@ g>d?
fluid shifts from blood vessels into the tissues.
 7olloid oncotic pressure decreases with age and with hypotension and malnutrition.
 'he mechanism of action of colloids is related to their ability to increase the colloid oncotic
pressure. 7olloids increase the blood volume and are sometimes called plasma expanders.
 7linically colloids are superior to crystalloids because of their ability to maintain the plasma
volume for a longer time. 'hey can maintain the colloid oncotic pressure for several hours.
 7olloids are relatively safe agents although they have no oxygen5carrying ability and contain
no clotting factors unlike blood products. )ecause of this they can alter the coagulation
system through a dilutional effect which results in impaired coagulation and possibly
bleeding. 'hey may also dilute the plasma protein concentration which in turn may impair
platelet function. Aarely dextran therapy causes anaphylaxis or renal failure.
 'he three most commonly used colloids are %% albumin dextran 00 and hetastarch. 'hey all
have a very rapid onset of action as well as a long duration of action.
Blood Products
 'he mechanism of action of blood products is related to their ability to increase the colloid
oncotic pressure and hence the plasma volume# they also have the ability to carry oxygen.
 )lood products are used to treat a wide variety of clinical conditions# the blood product used
depends on the specific indication.
 )ecause there is a risk for transfer of infectious disease although remote their use needs to
be based on careful clinical evaluation of the patient6s condition.
 )ecause these products come from other humans they can be incompatible with the
recipient6s immune system. 'hey can also transmit pathogens from the donor to the recipient.
 )lood must not be administered with any solution other than normal saline.
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 'he principal electrolytes in the extracellular fluid are sodium cations (Ba
+ and chloride
anions (7l
+. 'he ma9or electrolyte in the intracellular fluid (.7,+ is the potassium cation
+. Fther important electrolytes are calcium magnesium and phosphorus.
 <lectrolytes are controlled by the renin5angiotensin5aldosterone system antidiuretic hormone
system and sympathetic nervous system. *hen these neuroendocrine systems are out of
balance adverse electrolyte imbalances commonly result. -atients who receive diuretics are
at risk of electrolyte abnormalities.
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 Hyperkalemia is defined as a serum potassium level exceeding %.% m<q>?. /ymptoms
include muscle weakness paresthesia paralysis cardiac rhythm irregularities that can result
in ventricular fibrillation and cardiac arrest.
 Hypokalemia is defined as a serum potassium level of less than @.% m<q>?. /ymptoms
include anorexia hypotension lethargy mental confusion nausea and muscle weakness.
?ate symptoms include cardiac dysrhythmias neuropathies and paralytic ileus.
 A number of life5sustaining physiologic functions require potassium. ;uscle contraction the
transmission of nerve impulses and the regulation of heartbeats are a few.
 -otassium is also essential for the maintenance of acid5base balance isotonicity and the
electrodynamic characteristics of the cell. .t plays a role in many en=ymatic reactions and is
essential in gastric secretion renal function tissue synthesis and carbohydrate metabolism.
 -otassium replacement therapy is indicated in the treatment or prevention of potassium
depletion in patients whenever dietary measures prove inadequate. -otassium salts used for
this purpose include potassium chloride potassium phosphate and potassium acetate.
 'he adverse effects of oral potassium are primarily limited to the gastrointestinal (H.+ tract
including diarrhea nausea and vomiting. H. bleeding and ulceration are more significant.
 'he parenteral administration of potassium usually produces pain at the in9ection site.
 /odium is the ma9or cation in extracellular fluid and is involved in the control of water
distribution fluid and electrolyte balance and osmotic pressure of body fluids. /odium also
participates along with both chloride and bicarbonate in the regulation of acid5base balance.
 1yponatremia is a condition of sodium loss or deficiency and occurs when the serum levels
decrease less than 2@% m<q>?. 1yponatremia is manifested by lethargy hypotension
stomach cramps vomiting diarrhea and sei=ures.
 1ypernatremia is the condition of sodium excess and occurs when the serum levels of
sodium exceed 20% m<q>?. 1ypernatremia symptoms include edema hypertension red
flushed skin# dry sticky mucous membranes# increased thirst# temperature elevation# and
decreased or absent urination.
 /odium is primarily administered for the treatment or prevention of sodium depletion when
dietary measures have proved inadequate. /odium chloride is used for this purpose.
 1ypertonic saline (@% Ba7l+ sometimes used for severe hyponatremia is a high5risk
treatment because if it is given rapidly or at too high a dose it can cause central pontine
myelinolysis (osmotic demyelination syndrome+ that can lead to irreversible brainstem
 'he oral administration of sodium chloride can cause gastric upset consisting of nausea
vomiting and cramps.
 7onivaptan (8aprisol+ is a nonpeptide dual arginine vasopressin (A8-+ 82A and 8$ receptor
antagonist that inhibits the effects of A8- also known as antidiuretic hormone on receptors
in the kidneys. .t is indicated for the treatment of hospitali=ed patients with euvolemic
hyponatremia or low serum sodium levels at normal water volumes.
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 Assess the patient6s medical history including diseases of the H. renal cardiac and>or
hepatic systems.
 Assess fluid volume and electrolyte status (through laboratory testing and measurement of
urinary specific gravity vital signs and intake and output+ and document the findings.
 7onfirm orders with authoritative resources (e.g. current drug reference guides Physician’s
Desk Reference textbooks drug inserts+ or speaking with a pharmacist.
 After verifying all prescriber orders assess the solution or product the patient and the .8
site. Assess the following for .8 infusions of fluids and>or electrolytes! the solution to be
infused infusion equipment infusion rate of the solution concentration of the parenteral
solution related mathematical calculations laboratory values (e.g. sodium chloride
potassium+ and parenteral compatibilities.
 Aemember that you are responsible for making sure that the drug therapy administration
process3beginning with the assessment phase of the nursing process and through to
evaluation3is accurate and safe and meets professional standards of care.
 <ach form of dehydration is treated differently. 7arefully assess intake and output as well as
skin turgor urine specific gravity and blood levels of potassium sodium and chloride.
 1ydrating and hypotonic solutions include 0.$%% Ba7l and 0.0%% Ba7l>4
 .sotonic solutions (e.g. 0.G% Ba7l Inormal salineJ and lactated Ainger6s solution+ are used to
augment extracellular volume in patients experiencing blood loss and>or severe vomiting.
 1ypertonic solutions (e.g. @% or %% sodium chloride+ are used for replacement of fluids and
electrolytes in specific situations.
 'he skin and mucous membranes also reflect a patient6s hydration status# assess skin turgor
and>or rebound elasticity of skin over the top of the hand and other areas over the body.
4ocument the findings as KimmediateL rebound or KdelayedL rebound. 7ount the number of
seconds that the patient6s skin stays in the pinched5up position with normal return being
immediately or within @ to % seconds.
 Administer albumin with caution because of the high risk for hypervolemia and possible
heart failure. ;onitor intake and output weights heart and breath sounds and lab values.
 8enous access is an issue with parenteral potassium supplementation because the vein can be
irritated if infiltration occurs or if the solution has not been mixed thoroughly.
 4uring the infusion of blood components constantly assess for the occurrence of fever and
blood in the urine both being indicative of a reaction requiring immediate attention.
 4uring replacement therapy serum electrolyte levels need to remain within normal ranges
and not exceed these ranges.
 *ith parenteral dosing monitor infusion rates as well as the appearance of the fluid or
solution# potassium and saline solutions are clear and albumin is brown clear and viscous.
 ,requently monitor the .8 site for evidence of infiltration.
 Aemember that elderly and>or pediatric patients have an increased sensitivity to these
solutions and fluids.
 ,or the patient who is at risk for hypokalemia provide educational materials and patient
teaching to encourage consumption of certain foods high in potassium.
 1yperkalemia is treated with sodium polystyrene sulfonate (Eayexalate+. .t is used only
under very specific situations and under very close monitoring of the patient and his or her
serum potassium sodium calcium and magnesium levels.
 Potassium is ne1er gi1en "y *, push or *, "olus or in an undiluted 2orm3 -otassium
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administered in this manner is associated with cardiac arrest.
 Always carry out .8 infusion of albumin and other colloids slowly and cautiously and
carefully monitor the patient to prevent fluid overload and potential heart failure.
 *ith administration of blood products measurement of vital signs and frequent monitoring
of the patient before during and after infusions are critical to patient safety.
 )lood products must be given only with normal saline (0.G% sodium chloride+. 'he solution
of 4
* results in hemolysis of red blood cells if infused together.
 A transfusion reaction may include apprehension restlessness flushed skin increased pulse
and respirations dyspnea rash 9oint or lower back pain swelling fever and chills (a febrile
reaction beginning 2 hour after the start of administration and possibly lasting up to 20 hours+
nausea weakness and 9aundice.
 <ncourage patients receiving any type of fluid or electrolyte substance colloid or blood
component to immediately report unusual adverse effects to their prescriber including chest
pain di==iness weakness and shortness of breath.
 'he therapeutic response to fluid electrolyte and blood or blood component therapy includes
normali=ation of fluid volume and laboratory values including A)7 and *)7 counts
hemoglobin level hematocrit and sodium and potassium levels.
 ,requently monitor for adverse effects of any of these drugs and>or solutions and check for
distended neck veins# shortness of breath# anxiety# insomnia# expiratory crackles# frothy
blood5tinged sputum# and cyanosis (indicative of fluid volume overload+.
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