Chapter 14: Fluid and Electrolytes: Balance and Disturbance

Fluid and Electrolyte Balance ‡ ‡ Fluid ‡ Approximately 60% of typical adult is fluid ± ‡ ‡ Varies with age, body size, gender Necessary for life, homeostasis Nursing role: help prevent, treat fluid, electrolyte disturbances

Intracellular fluid Extracellular fluid ± ± ± Intravascular Interstitial



Third spacing : loss of ECF into space that does not contribute to equilibrium

Electrolytes ‡ Active chemicals that carry positive (cations), negative (anions) electrical charges ± ± ‡ Major cations: sodium, potassium, calcium, magnesium, hydrogen ions Major anions: chloride, bicarbonate, phosphate, sulfate, and proteinate ions

Electrolyte concentrations differ in fluid compartments

Regulation of Fluid ‡ Movement of fluid through capillary walls depends on ± ± ‡ ‡ ‡ ‡ Hydrostatic pressure: exerted on walls of blood vessels Osmotic pressure: exerted by protein in plasma

Direction of fluid movement depends on differences of hydrostatic, osmotic pressure Osmosis: area of low solute concentration to area of high solute concentration Diffusion: solutes move from area of higher concentration to one of lower concentration Filtration: movement of water, solutes occurs from area of high hydrostatic pressure to area of low hydrostatic pressure

‡ Active transport: physiologic pump that moves fluid from area of lower concentration of one of higher concentration Active Transport ‡ ‡ ‡ Physiologic pump that moves fluid from area of lower concentration to one of higher concentration Movement against concentration gradient Sodium-potassium pump: maintains higher concentration of extracellular sodium. insensible losses Lungs GI tract Other Dietary intake of fluid. intracellular potassium Requires adenosine (ATP) for energy ‡ Routes of Gains and Losses ‡ Gain ± ± ‡ Loss ± ± ± ± ± Kidney: urine output Skin loss: sensible. food or enteral feeding Parenteral fluids .

renal.Gerontologic Considerations ‡ ‡ ‡ ‡ Reduced homeostatic mechanisms: cardiac. respiratory function Decreased body fluid percentage Medication use Presence of concomitant conditions Fluid Volume Imbalances ‡ ‡ Fluid volume deficit (FVD): hypovolemia Fluid volume excess (FVE): hypervolemia .

nausea. decreased skin turgor. hemorrhage. increased temperature. concentrated urine. cramps Laboratory data: elevated BUN in relation to serum creatinine. osmotic diuresis. muscle weakness. lassitude. thirst. inability to gain access to fluid Risk factors: diabetes insipidus. cool clammy skin due to vasoconstriction. rapid weak pulse.Fluid Volume Deficit ‡ Loss of extracellular fluid exceeds intake ratio of water ± ‡ Electrolytes lost in same proportion as they exist in normal body fluids Dehydration: loss of water along with increased serum sodium level ± May occur in combination with other imbalances ‡ Dehydration ± Causes: fluid loss from vomiting. UO. increased hematocrit ± Serum electrolyte changes may occur ‡ ‡ Medical management: provide fluids to meet body needs ± ± Oral fluids IV solutions Fluid Volume Deficit . coma. mental status Measures to minimize fluid loss Oral care Administration of oral fluids Administration of parenteral fluids . decreased intake. mucosa. adrenal insufficiency. sweating. diarrhea.Nursing Management ‡ ‡ ‡ ‡ ‡ ‡ I&O. oliguria. GI suctioning. VS Monitor for symptoms: skin and tongue turgor. third space shifts ± ‡ Manifestations: rapid weight loss. postural hypotension.

diuretics Promote adherence to fluid restrictions. distended neck veins. positioning/turning ‡ ‡ ‡ ‡ ‡ Electrolyte Imbalances ‡ ‡ ‡ ‡ ‡ ‡ Sodium: hyponatremia. water intoxication. SIADH or losses by vomiting. hypermagnesemia Phosphorus: hypophosphatemia. patient teaching related to sodium and fluid restrictions Monitor. excess sodium administration. restriction of fluids and sodium.Nursing Management ‡ I&O and daily weights. other symptoms. diuretics . cirrhosis of liver Contributing factors: excessive dietary sodium or sodium-containing IV solutions Manifestations: edema. increased UO. renal failure.Fluid Volume Excess ‡ ‡ ‡ ‡ Due to fluid overload or diminished homeostatic mechanisms Risk factors: heart failure. avoid sources of excessive sodium. increased weight. hypertonic IV solutions Hyponatremia ‡ ‡ Serum sodium less than 135 mEq/L Causes: adrenal insufficiency. shortness of breath and wheezing Medical management: directed at cause. hyperphosphatemia Chloride: hypochloremia. heat stroke. including medications Promote rest Semi-Fowler s position for orthopnea Skin care. diarrhea. administration of diuretics ‡ Fluid Volume Excess . increased BP. hyperkalemia Calcium: hypocalcemia. pulse pressure and CVP. tachycardia. monitor responses to medications. hyperchloremia Hypernatremia ‡ ‡ Serum sodium greater than 145mEq/L Causes: excess water loss. hypernatremia Potassium: hypokalemia. edema. diabetes insipidus. abnormal lung sounds (crackles). assess lung sounds. sweating. hypercalcemia Magnesium: hypomagnesemia.

sticky mucosa. neurologic symptoms. poor dietary intake Manifestations: fatigue. dialysis Nursing management: assessment of serum potassium levels. muscle weakness and cramps. offer and encourage fluids to meet patient needs. paresthesias. dietary potassium restriction/dietary teaching for patients at risk Hemolysis of blood specimen or drawing of blood above IV site may result in false laboratory result Salt substitutes. monitor ECG and ABGs. IV for severe deficit Nursing management: assessment. provide sufficient water with tube feedings ‡ ‡ ‡ ‡ Nursing management: assessment and prevention. nausea. alterations of acid-base balance. restlessness. elevated temperature. anorexia.5 mEq/L). nausea. may occur with normal potassium levels with alkalosis due to shift of serum potassium into cells Causes: GI losses. decreased BP. weakness Note: thirst may be impaired in elderly or the ill Medical management: hypotonic electrolyte solution or D5W Nursing management: assessment and prevention. glucose intolerance. cation-exchange resin (Kayexalate). muscle weakness with potential respiratory impairment. abdominal cramping. dietary sodium and fluid intake. nursing care related to IV potassium administration Hyperkalemia ‡ ‡ Serum potassium greater than 5. neurologic changes Medical management: water restriction. paresthesias. assess for OTC sources of sodium. IV sodium bicarbonate . severe hypokalemia is life-threatening. hypoaldosteronism. medications. impaired renal function. decreased muscle strength. dietary potassium. anxiety. hyperaldosterism. headache. vomiting. effects of medications (diuretics. GI manifestations Medical management: monitor ECG. regular insulin and hypertonic dextrose IV. medications may contain potassium Potassium-sparing diuretics may cause elevation of potassium ‡ Should not be used in patients with renal dysfunction ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ . decreased salivation. DTRs Medical management: increased dietary potassium. monitor medication affects.0 mEq/L Causes: usually treatment related. acidosis Manifestations: cardiac changes and dysrhythmias. dry. lithium) ‡ Hypokalemia ‡ Below-normal serum potassium (<3. sodium replacement ‡ Manifestations: thirst. dry mucosa. swollen tongue. limitation of dietary potassium. F-2 agonists. potassium replacement. tissue trauma. IV calcium gluconate.‡ Manifestations: poor skin turgor. dysrhythmias. mix IVs containing K+ well. identify and monitor at-risk patients.

other Manifestations: tetany. dysrhythmias Medical management: IV calcium gluconate. bone loss related to immobility Manifestations: muscle weakness. constipation. Trousseau s sign. seizures. provide fluids containing sodium unless contraindicated. paresthesias. magnesium sulfate IV Nursing management: assessment. furosemide. patient teaching regarding magnesium containing OTC medications ‡ ‡ ‡ ‡ ‡ ‡ . calcium and vitamin D supplements. anxiety Medical management: IV of calcium gluconate. severe hypocalcemia is life-threatening. medications. weightbearing exercises to decrease bone calcium loss. athetoid movements. Chovstek's sign. depressed respirations. must be considered in conjunction with serum albumin level Causes: hypoparathyroidism. ECG changes. patient teaching related to diet and medications. biphosphonates Nursing management: assessment. renal failure. alkalosis. ensure safety. calcitonin. fluids of 3 to 4 L/d. hyperactive DTRs. vomiting. medications. patient teaching related to diet. tremors. and nursing care related to IV magnesium sulfate Hypomagnesemia often accompanied by hypocalcemia ± Need to monitor. evaluate in conjunction with serum albumin Causes: alcoholism. diabetic ketoacidosis. treat potential hypocalcemia Hypermagnesemia ‡ ‡ ‡ Serum level more than 2. phosphates. medications. alterations in mood and level of consciousness Medical management: diet.7 mg/dL Causes: renal failure.Hypocalcemia ‡ Serum level less than 8. nausea. IV NS of RL. hypothermia Manifestations: neuromuscular irritability. GI losses. muscle weakness. incoordination. fiber for constipation. rapid administration of citrated blood. sepsis. ECG changes. muscle weakness. anorexia. thirst. drowsiness. alcohol use. excessive administration of magnesium Manifestations: flushing. malabsorption. and nursing care related to IV calcium administration Hypercalcemia ‡ ‡ ‡ Serum level above 10. diet Nursing management: assessment. hypoactive reflexes. enteral or parenteral feeding deficient in magnesium. oral magnesium. contributing causes include diabetic ketoacidosis. ensure safety ‡ ‡ ‡ ‡ ‡ ‡ Hypomagnesemia ‡ ‡ Serum level less than 1. respiratory symptoms of dyspnea and laryngospasm.8 mg/dL. do not administer medications containing magnesium. pancreatitis. hypercalcemic crisis has high mortality. circumoral numbness. polyuria. nausea and vomiting. encourage ambulation. fluids. lowered BP.5 mg/dL. abnormal clotting. hemodialysis Nursing management: assessment. dysrhythmias Medical management: treat underlying cause. massive transfusion of citrated blood.5 mg/dL Causes: malignancy and hyperparathyroidism. abdominal and bone pain. loop diuretics. burns. ECG changes and dysrhythmias.

dehydration. hyperexcitability of muscles. phosphate-containing substances. signs of hypocalcemia ‡ ‡ ‡ ‡ ‡ ‡ Hypochloremia ‡ ‡ Serum level less than 96 mEq/L Causes: Addison s disease.‡ Dysphasia common in magnesium-depleted patients ± Assess ability to swallow with water before administering food or medications Hypophosphatemia ‡ ‡ Serum level below 2. reduced chloride intake. hypertension. gradually introduce calories for malnourished patients receiving parenteral nutrition Hyperphosphatemia ‡ ‡ Serum level above 4. medications. muscle weakness. soft-tissue calcifications. patient teaching related to diet. excess vitamin D. encourage foods high in phosphorus. hepatic encephalopathy. low potassium. metabolic acidosis. lethargy. severe diarrhea. excess phosphorus. calciumbinding antacids. irritability. weakness. vitamin D deficiency. dialysis Nursing management: assessment. chemotherapy Manifestations: few symptoms. coma Medical management: replace chloride-IV NS or 0. potassium.5 mg/DL Causes: renal failure. patient teaching related to high-chloride foods Hyperchloremia ‡ ‡ Serum level more than 108 mEq/L Causes: excess sodium chloride infusions with water loss. respiratory alkalosis. metabolic alkalosis Loss of chloride occurs with loss of other electrolytes. tissue hypoxia. sodium Manifestations: agitation. rapid. excessive sweating. diabetic ketoacidosis. LR. GI loss. diabetic ketoacidosis. medications Manifestations: tachypnea. loop diuretics. cognitive changes Normal serum anion gap Medical management: restore electrolyte and fluid balance. heat stroke. patient teaching related to diet and hydration ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ . diuretics Nursing management: assessment. NS IV. vitamin-D preparations. deep respirations. hyperparathyroidism. hypernatremia. weakness.5 mg/DL Causes: alcoholism. burns. avoid highphosphorus foods. confusion.45% NS Nursing management: assessment. muscle and bone pain. encourage high-chloride foods. head injury. hyperparathyroidism. avoid free water. major burns. increased susceptibility to infection Medical management: oral or IV phosphorus replacement Nursing management: assessment. hypoparathyroidism. low magnesium. symptoms occur due to associated hypocalcemia Medical management: treat underlying disorder. sodium bicarbonate. phosphate-binding gels or antacids. refeeding of patients after starvation. pain. seizures. respiratory alkalosis. diarrhea. hyperventilation. dysrhythmias. acidosis. fever. use of diuretic and antacids Manifestations: neurologic symptoms.

increased respiratory rate and depth. decreased blood pressure.45: hydrogen ion concentration Major extracellular fluid buffer system. potassium shifts back into cell. plasma proteins ICF: proteins.Maintaining Acid-Base Balance ‡ ‡ Normal plasma pH 7-35-7.45 High bicarbonate >26 mEq/L Most commonly due to vomiting or gastric suction . dysrhythmias.35 Low bicarbonate <22 mEq/L Most commonly due to renal failure Manifestations: headache. bicarbonate-carbonic acid buffer system Kidneys regulate bicarbonate in ECF Lungs under control of medulla regulate CO2. if decrease is slow. hyperkalemia may occur as potassium shifts out of cell As acidosis is corrected. organic. drowsiness. correct imbalance ± ‡ ‡ ‡ ‡ Bicarbonate may be administered ‡ With acidosis. inorganic phosphates Hemoglobin ‡ ‡ ‡ Metabolic Acidosis ‡ ‡ ‡ ‡ Low pH <7. potassium levels decrease Monitor potassium levels Serum calcium levels may be low with chronic metabolic acidosis ± Must be corrected before treating acidosis Metabolic Alkalosis ‡ ‡ ‡ High pH >7. carbonic acid in ECF Other buffer systems ‡ ‡ ‡ ECF: inorganic phosphates. patient may be asymptomatic until bicarbonate is 15 mEq/L or less Correct underlying problem. decreased cardiac output. shock. confusion.

7. body may compensate. sometimes loss of consciousness Correct cause of hyperventilation ‡ Arterial Blood Gases ‡ ‡ ‡ pH 7.45 PaCO2 35 .(40) . tachycardia. feeling of fullness in head ‡ ‡ Potential increased intracranial pressure Treatment aimed at improving ventilation Respiratory Alkalosis ‡ ‡ ‡ ‡ High pH >7. inability to concentrate. restore fluid volume with sodium chloride solutions ‡ Respiratory Acidosis ‡ ‡ ‡ ‡ Low pH <7.35 .4) . numbness and tingling.26 mEq/L ± ‡ Assumed average values for ABG interpretation PaO2 80 to 100 mm Hg . supply chloride to allow excretion of excess bicarbonate. symptoms of hypokalemia Correct underlying disorder. may be asymptomatic ± Symptoms may be suddenly increased pulse. respiratory rate and BP. respiratory depression.± ‡ ‡ May also be due to medications.35 PaCO2 >42 mm Hg Always due to respiratory problem with inadequate excretion of CO2 With chronic respiratory acidosis.(24) . mental changes.(7. especially long-term diuretic use Hypokalemia will produce alkalosis Manifestations: symptoms related to decreased calcium.45 mm Hg HCO3¯ 22 .45 PaCO2 <35 mm Hg Always due to hyperventilation Manifestations: lightheadedness.

extravasation Phlebitis Thrombophlebitis Hematoma Clotting. other infections Infiltration. obstruction .‡ ‡ Oxygen saturation >94% Base excess/deficit ±2 mEq/L IV Site Selection Complications of IV Therapy ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Fluid overload Air embolism Septicemia.

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