Fluid and Electrolytes

Fluid Volume Deficit

-aka hypovolemia

-if pt is in severe deficit, called shock***

-causes:

-loss of fluid from anywhere, surgery, trauma where blood is lost directly from the vascular space

-ex:is pt has an NG tube connected to suction and the container continues to fill up-that person
can also go into shock b/c they are losing fluid

-vomiting and diarrhea

-loss to third spacing-fluid is in a place that does you no good

-if someone is burned, where does all their fluid go?

-into the interstitial space and does not stay in the vascular

-thus these pts are so edematous

-ascites-fluid in the peritoneal (abdomen)-not in the stomach

-if you have a pt with ascites, you need to measure their abdominal girth everyday

-if the abdomen is getting bigger and bigger everyday, it is pushing up on the diaphragm and
now they are having trouble breathing

-remember ascites and importance of measuring abdominal girth and its importance on
impacting breathing

-pt with ascites usually is one with liver disease

-they have a large abdomen

-if you turn them from side to side, may hear the fluid shifting around

-they look like they are in FVE but remember the fluid is not in the right place!!!

-anytime you see fluid in the abdomen, need to check the BP b/c pt can become
hypotensive****

-if they have a lot of fluid in the abdomen, where did all that fluid come from-came from
vascular space: the larger their abdomen gets, their vascular volume is going down

-diseases with polyuria

-diabetes:

-these pts have a lot of particles (glucose particles) in their vascular space. Anytime there are a
lot of particles in the blood, the kidneys want to help you get rid of the particles

-the particles need to come out in volume called PID-Particle Induced Diuresis

-thus, in the process of losing the glucose molecules, they lost water as well
 -polyuria think SHOCK first*****

-if you have a pt in shock, they will not continue to put out urine

-normally when pt goes into shock, their urine output goes down

-they could go from polyuria to oliguria to anuria

-when this occurs-we are concerned with renal failure

-S&S of FVD

-weight will decrease

-decreased skin turgor

-dry mucus membranes

-decreased urine output for 2 reasons:

-kidneys are not being perfused or

-they are trying to hold onto the fluid, trying to compensate

-BP will go down; less volume less pressure

-these pts are at high risk for orthostatic hypotension aka postural hypotension

-requires safety precautions

-pulse increases

-heart is trying to pump what little volume is there

-pulse is weak and thready

-thready means when your in shock, the size of the artery is small like a thread

-respiratory rate will be increased

-the body perceives this decreased blood volume as hypoxia and increases the RR to improve
the hypoxia

-CVP-going down; less volume, less pressure

-peripheral veins and neck veins will be very tiny

-hard to start IV

-cool extremities

-when someone is going into shock, their skin gets cool and clammy due to peripheral
vasoconstriction in an effort to shunt blood to the vital organs

-urine specific gravity goes up-if pt has any urine output, it will be very concentrated

-Na, specific gravity and hematocrit numbers go up (will be very concentrated)****

Treatment
 -prevent any further losses

-replace volume

-if mild deficit-PO fluid

-if severe deficit- IV fluids

-safety precautions

-they are at high risk for falls related to changes in vital signs and mental status

-monitor IV fluid replacement very carefully to watch for overload

-ex: elderly pt admitted for dehydration. You are assisting with ambulation and pt complains of being
dizzy and light-headed. Should we be worried? Yes due to orthostatic hypotension.

-sequencing question-decide what is the safest order

1. have the client lie down for at least 3 min

2. assess the vital signs with the client lying

3. assess the vital signs with the client sitting

4. assess the vital signs with the client standing

5. record BP and pulse with position noted

-we will not delegate this procedure to an unlicensed assistant personal-this procedure requires
ongoing nursing judgement and assessment

IV fluids

-Isotonic solutions (or balanced solutions)

-go into the vascular space and stay there. Fluid does not move in and out of cells

-causes fluid volume to go up, causing increase in BP

-4 types:

-Normal Saline 0.9%

-Lactated Ringers

-D5W

-D5 ¼ NS

-when will we use isotonic solutions?

-if client lost fluids from nausea, vomiting, burns, sweating, hemorrhage, trauma

-NS is the basic solution used when administering blood

-Lactated Ringers best used for shock-it has more electrolytes

-what should we be cautious of?

 -do not use isotonic solutions in pts with HTN, cardiac disease, or renal disease. These solutions
can cause FVE, HTN, and hypernatremia

-ex: we will be putting NS 0.9% fluid into the vascular space-our body fluid can be also
considered 0.9%-thus it causes a build up in the vascular volume without shifting of the fluid out
or into the cells

-Hypotonic solutions

-solutions that go into vascular space and shift out to replace cellular fluid-will rehydrate but will not
cause hypertension (will not drive up the BP b/c they wont stay in the vascular space)

-types

-D2.5 W

-1/2 NS

-1/3 NS

-when will we use these?

-pt with HTN, renal disease, cardiac disease and needs fluid replacement b/c of vomiting, burns,
nausea, sweating, hemorrhage

-used for dilution with pt has hypernatremia and for cellular dehydration

-ex: if you have pt with vomiting and diarrhea with BP of 160/98: if you give them isotonic
solution, it can increase their BP and can an MI. thus in this situation, you will use a hypotonic
solution

-Alerts:

-watch for cellular edema b/c the fluid is moving out into the cell and can cause FVD or
decreased BP

-Hypertonic

-think packed with particles**

-volume expanders and will draw fluid into the vascular space from the cells

-types:

-D10W

-3% NS

-5% NS

-D5LR

-D51/2 NS

-D5 NS

-TPN

-Albumin
 -if I am giving pt a magnesium sulfate infusion, I am giving them a hypertonic solution and I need to
watch out for FVE and pulmonary edema

-uses:

-pts with hyponatremia or shifted large volume into a third space such as severe edema, burns,
ascites

-hypertonic solution will return the fluid volume from the cells back into the vasculature

-alerts:

-watch for FVE-need close monitoring in ICU setting, assessing their BP, pulse, CVP if they are
receiving 3% NS or 5% NS

Quick tips for IV solutions:

Isotonic Solutions: “Stay where I put it”

HypOtonic Solutions: “Go Out of the Vessel”

HypErtonic Solutions: “Enter the Vessel”