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Fluid and Electrolytes (24)
1. Identify normal and abnormal ranges of electrolytes
● Na+ (130-150 mEq/L)

▪ HYPOnatremia : <130 HYPERnatremia :

D/T: D/T:

● Prolonged low-sodium diet ● High salt intake—enteral or IV
● Decreased sodium intake ● Renal disease
● Fever ● Fever
● Excess sweating ● Insufficient breast milk intake in neonate
● Increased water intake without electrolytes (dehydration hypernatremia)
● Tachypnea (infants) ● High insensible water loss:
● Cystic fibrosis • Increased temperature
● Burns and wounds • Increased humidity
● Vomiting, diarrhea • Hyperventilation
● Nasogastric suction • Diabetes insipidus
● Fistulas • Hyperglycemia
● Adrenal insufficiency
● Renal disease
● Diabetic ketoacidosis (DKA)
● Malnutrition

S/S: S/S:

● Associated with water loss: ● Intense thirst
• Same as with water loss—dehydration, ● Dry, sticky mucous membranes
weakness, dizziness, nausea, abdominal cramps, ● Flushed skin
apprehension ● Temperature possibly increased → Fever
• Mild—apathy, weakness, nausea, weak pulse ● Hoarseness
• Moderate—decreased blood pressure, lethargy ● Oliguria
o Muscle Cramps ● Pulmonary Edema
o Confusion ● Nausea and vomiting
● Possible progression to disorientation, convulsions,
Laboratory findings: muscle twitching, nuchal rigidity, lethargy at rest,
hyperirritability when aroused
• Sodium concentration<130 ( may be normal if ● Laboratory findings:
volume loss) • Serum sodium concentration ≥150 mEq/L
• High plasma volume
• Urine Specific Gravity depends • Alkalosis


.5 ( See changes when >7) D/T: D/T: ● Starvation ● Renal disease ● Clinical conditions associated with poor food ● Renal failure intake ● Adrenal insufficiency (Addison disease) ● Malabsorption ● Associated with metabolic acidosis ● IV fluid without added potassium ● Too-rapid administration of IV potassium ● Gastrointestinal losses—diarrhea. chloride fistulas.5-5. SR/SW NURSING CARE: NURSING CARE: ● Determine and treat cause of sodium deficit ● Determine and treat cause of sodium excess ● Administer IV fluids with appropriate saline ● Administer IV fluids as prescribed→ NO SODIUM IVs concentration ● Measure fluid intake and output→ Weigh Daily ● Monitor fluid intake and output ● Monitor neurologic status ● Check BP frequently ● Ensure adequate intake of breast milk and provide ● Restrict Fluids lactation assistance with new mother-baby pair before hospital discharge. salt ● IV administration of insulin in DKA substitutes) ● Alkalosis NURSING ALERT SLIDE INFO POINTS IN LECTURE ..5 HYPERkalemia: >5.g. diabetes mellitus) ● Potassium-sparing diuretics ● Familial periodic paralysis ● Increased intake of potassium (e.g.5 mEq/L) ▪ HYPOkalemia: <3. vomiting. nasogastric suction ● Transfusion with old donor blood ● Diuresis Administration of diuretics ● Severe dehydration ● Administration of corticosteroids ● Crushing injuries ● Diuretic phase of nephrotic syndrome ● Burns ● Healing stage of burns ● Hemolysis ● Potassium-losing nephritis ● Dehydration ● Hyperglycemic diuresis (e. ● GIVE HYPERTONIC FLUIDS ● GIVE HYPOTONIC FLUIDS ● K+ (3.

● Renal Dialysis may be required ● Evaluate acid-base status EXTRA NOTES: EXTRA NOTES: Peripheral line for glucose 20% ● Ca+ (8. premature ventricular • Flat P wave on ECG. Bananas. Oranges. & Tented). flaccid paralysis hyporeflexia ● Twitching ● Hypotension ● Hyperreflexia ● ardiac arrhythmias. SR/SW S/S: S/S: ● Muscle weakness. drowsiness ● Oliguria ● Irritability ● Apnea—respiratory arrest ● Fatigue . Spinach) ● Administer exchange resin.5 mEq/L) NURSING ALERT SLIDE INFO POINTS IN LECTURE . ● Determine and treat cause of potassium excess ● Monitor vital signs. ● Assess for adequate renal output before ● Administer IV fluids administration. administer potassium w/regular insulin) to facilitate movement of slowly. peaked T waves( Tall contractions. decreased ST segment. including ECG ● Administer supplemental potassium (IV. if prescribed. RAPID THREADY PULSE. paralysis. stiffness. widened QRS complex. offer high-potassium fluids and foods. ● Monitor vital signs. cramping. gallop rhythm ● Bradycardia ● Tachycardia or bradycardia Ileus ● Ventricular fibrillation and cardiac arrest ● Apathy. Anorexia ● Laboratory findings: ● Laboratory findings: • High serum potassium concentration • Decreased serum potassium concentration ≥5. potassium into cells ● Always monitor ECG for IV bolus potassium ● KAYEXALATE replacement. ● Muscle weakness.5 mEq/L ≤3. ● Evaluate acid-base status ● For oral intake.5 mEq/L • Variable urine volume • Abnormal ECG—notched or flattened T waves.5-10. including ECG. ● Administer IV insulin (10-20% glucose ● For IV replacement. increased PR interval NURSING CARE: NURSING CARE: ● Determine and treat cause of potassium deficit.

8.5 D/T: D/T: ● Inadequate dietary calcium ● Acidosis ● Vitamin D deficiency ● Prolonged immobilization ● Rapid transit through gastrointestinal tract ● Conditions associated with increased bone catabolism ● Advanced renal insufficiency ● Hypoproteinemia ● Administration of diuretics ● Kidney disease ● Hypoparathyroidism ● Hypervitaminosis D Hyperparathyroidism ● Alkalosis ● Hyperthyroidism ● Calcium trapped in diseased tissues ● Excessive IV or oral administration ● Increased serum protein (albumin) ● Cow’s milk—tetany of the newborn (inappropriate calcium/phosphorus ratio in whole milk for newborn) ● Exchange transfusion with citrated blood ● Inadequate parenteral administration in diseased status S/S: S/S: ● Neuromuscular irritability ● Constipation ● Tingling of nose. causing formation of kidney stones ● Cardiac arrest ● Laboratory findings: ● Laboratory findings: • Increased serum calcium levels or • Decreased serum calcium concentration (8. vomiting ● Laryngospasm ● Anorexia ● Generalized convulsions ● Dry mouth (thirst) ● Diarrhea . Numbness ● Behavioral Changes ● May be changes in clotting ● Muscle hypotonicity ● Positive Chvostek and Trousseau signs ● Bradycardia or cardiac arrest ● Hypotension ● Increased calcium concentration in urine. fingertips.8 mEq/L) or increased serum protein levels • Prolonged QRS complex or PR interval. SR/SW ▪ HYPOcalcemia: <8. NURSING ALERT SLIDE INFO POINTS IN LECTURE .5 (non-emergent) HYPERcalcemia: >10. toes ● Weakness. decreased serum protein levels 10. fatigue ● Tetany ● Nausea. ears.

vitamin D. ● Increase Dietary Calcium 2. ● Avoid cow’s milk in infants younger than 12 months. and changes in electrolyte concentration influence fluid movement. ● Renal Dialysis may be required ● Monitor serum protein levels. ● Monitor ECG. ● Monitor IV site. administer IV slowly and diluted. SR/SW • Prolonged QT interval shortened QT interval NURSING CARE: NURSING CARE: ● Determine and treat cause of calcium deficit. ● Thirst ▪ The impetus to ingest water is stimulated by increased solute concentration (osmolality) of extracellular fluid and/or diminished intravascular volume. calcium may cause vascular ● Administer Calcitonin to reduce Calcium irritation. ● Antidiuretic hormone (ADH) ▪ ADH is released from the posterior pituitary gland in response to increased osmolality and decreased volume of intravascular fluid. ● Administer oral calcium supplements as prescribed. ● Determine and treat cause of calcium excess. ● Monitor serum calcium levels. and parathyroid levels. Factors that influence electrolyte concentration ● Alterations in fluid volume affect the electrolyte component. ● Monitor serum calcium. it promotes water NURSING ALERT SLIDE INFO POINTS IN LECTURE .

● Aldosterone ▪ Aldosterone is secreted by the adrenal cortex. thus promoting osmotic reabsorption of water.values of major electrolytes ● QUESTION #1 CHARTS 5. 3. it enhances sodium reabsorption in renal tubules. ● Bolus Fluid Formula ▪ 20 ml/kg ● Body Surface Area (BSA) formula ● Hourly Fluid Rate BODY WEIGHT AMOUNT FLUID PER HOUR 1-10 kg 4 ml/kg 11-20 kg 2 ml/kg >20 kg (remainder) 1 ml/kg ● Daily Maintenance Fluid Requirements (Not for IV ) BODY WEIGHT AMOUNT FLUID PER DAY 1-10 kg 100 ml/kg NURSING ALERT SLIDE INFO POINTS IN LECTURE . environmental factors. size. Calculate daily maintenance fluid requirements. and underlying disease.and hyper- values of electrolytes ● QUESTION #1 CHARTS 4. SR/SW retention in the renal system by increasing the permeability of renal tubules to water. Angiotensin also stimulates the release of aldosterone. hourly fluid rate. ● Renin-angiotensin system ▪ Diminished blood flow to the kidneys stimulates renin secretion. Apply appropriate interventions for the management of hypo. Recognize clinical manifestations of hypo. which reacts with plasma globulin to generate angiotensin. a powerful vasoconstrictor.and hyper. and bolus fluid rate ● Fluid requirements depend on hydration status.

Identify nursing considerations related fluid and electrolyte imbalances ● Question #1 CHARTS EXTRA BOOK/SLIDE NOTES ● For SIADH give Hypertonic fluids ● Hypertonic: More Salt o D5 0.45% NS o D5LR o D5NS ● Hypotonic: Less salt o 0.45%NS ● Isotonic: o LR o D5W o 0. and losses through urine and stool formation. SR/SW 11-20 kg 50 ml/kg >20 kg (remainder) 20 ml/kg 6. Increased Fluid requirements: Decreased Fluid Requirements: Fever (add 12% per rise of 1° C) HF DI. This contributes to greater and more rapid water loss during this age period. Burns After Surgery High. Diarrhea Mechanical Ventilation Postop Bowel Surgery Increased ICP ( Gastroschisis) Shock. DKA SIADH Vomiting .5% NS o 0. NURSING ALERT SLIDE INFO POINTS IN LECTURE .9%NS ● Maintenance water requirement is the volume of water needed to replace obligatory fluid loss such as that from insensible water loss (through the skin and respiratory tract). evaporative water loss.Output Kidney Failure Oliguric Renal Failure Tachypnea Phototherapy (Infant ) Radiant Warmer ( preterm infant) ● The infant loses a considerable amount of fluid in the first few days after birth and still maintains a larger amount of ECF than the adult until about 2 to 3 years of age.

● When water is lost and sodium concentration becomes elevated. ● Predictors of fluid loss : o changing level of consciousness (irritability to lethargy) o altered response to stimuli o decreased skin elasticity and turgor o prolonged capillary refill (>2 sec) o increased heart rate→ EARLIEST SIGN o sunken eyes and fontanels ALERTS!!!! o In a child with a history of fluid loss and potential or actual dehydration. fluid shifts from area of LESSER concentration to HIGHER concentration. o Infants ingest and excrete a greater amount of fluid per kilogram of body weight than do older children. gear nursing assessment toward the possibility of impending shock INTRACELLULAR: EXTRACELLULAR: o K+ maintains Osmotic pressure o Na+ maintains most abundant Osmotic pressure o K+ Imbalances may be threatening o Remember: When either the ECF or ICF changes in concentration. ● Infant is less able to handle large quantities of solute-free water than is the older child and is more likely to become dehydrated when given concentrated formulas or overhydrated when given excessive free water or dilute formula. compensatory mechanisms in the kidney stop ADH secretion so water is retained. thus increasing the total body water content and returning sodium to a normal level ● Low BP in infants and young children is usually a late sign of shock. SR/SW ● The ECF diminishes rapidly from approximately 40% of body weight at birth to less than 30% at 1 year of age. o →Lower to Higher ● Dehydration ( FV Deficit): Water Intoxication (Excess): NURSING ALERT SLIDE INFO POINTS IN LECTURE . The thirst mechanism (not fully functional in infants) is also stimulated so water is replaced.

increased activity (basal metabolic o Hormone Imbalance rate) o CNS Infex • Impaired skin integrity—transudate from injuries o Administration of inappropriate prepared • Hemorrhage formula → Infants o Iatrogenic: • Overzealous use of diuretics • Improper perioperative fluid replacement • Use of radiant warmer or phototherapy o DKA o Extensive Burns o Massive Edema S/S: S/S: o Irritability o Thirst o Altered LOC→Somnolence o Dry Skin and mucous membranes o HA o Changing Sensorium (irritability to lethargy) o Vomiting. unconscious. hyperventilation. Diarrhea o Decreased response to stimuli o Generalized Seizures. nasogastric suction. Hgb o Increased /normal Creatinine o Variable urine volume o Variable serum electrolytes & urine volume NURSING ALERT SLIDE INFO POINTS IN LECTURE . • Plain water enemas psychotic. increased ambient o Congenital Heart Defect temperature. CVP o Postural Hypotension o Dyspnea o Mottled extremities o Hepatomegaly o Tachypnea o Weight Gain LABS: LABS: o Low urine specific gravity o Increased hematocrit . BUN. peripheral) o Increased HR→ Tachycardia • Pulmonary (moist rales or crackles) o Sunken eyes ( Sunken fontanels→infants) • Intracutaneous (noted especially in loose o Oliguria : Diminished UO areolar tissue) o Weight Loss o Fatigue o Elevated BP. fistula • Kidney disease (Renal Failure) o Disturbed body fluid chemistry: inappropriate ADH • CHF (MOST COMMON) secretion • Malnutrition o Excessive renal excretion: glycosuria (diabetes) o Loss through skin or lungs: o Acute IV overload • Excessive perspiration or evaporation—febrile o Too rapid reduction of glucose in DKA states.45% NS) • Neglect of intake by self or caregiver—confused. Serum Osmolality o Decreased serum electrolytes o High Urine specific gravity o Decreased hematocrit. intake diarrhea. SR/SW D/T: D/T: o Failure to absorb or reabsorb water o Water intake in excess of output: o Complete or sudden cessation of intake or • Excessive oral intake( Over hydration) prolonged diminished intake: • Hypotonic fluid overload (0. Coma o Decreased elasticity and turgor o EDEMA o Prolonged capillary refill ( >4→ severe) • Generalized (orbital . Hgb. or helpless o Failure to excrete water in presence of normal • Loss from gastrointestinal tract—vomiting.

9% NS o Diuretics o →20ml/kg IV bolus over 5-20 min o Fluid Restriction o Replace fluids 4-6 hrs (Mild 50ml/kg) o Weigh Daily o Monitor BP o Monitor K+ o Blood only if hemorrhaging o Implement seizure precautions o Weigh daily EXTRA NOTES: EXTRA NOTES: o In Hypertonic dehydration the skin has a smooth. Decreased GFR doesn’t allow for repeated excursion of water. NURSING ALERT SLIDE INFO POINTS IN LECTURE . so this leads to overload. 0. SR/SW TX/ NURSING CARE: TX/ NURSING CARE: o Replace Fluids (ISOTONIC)→ LR. o Infants unable to turn off fluid intake properly velvety feel before disturbed elasticity.