Fluidand

Electrolyte
Imbalance
among ELDERLY
CLIENTS

1. Dehydration
2. Hyponatremia
3. Hypernatremia
4. Hypokalemia
5. Hyperkalemia
 Dehydration is the most
common fluid and electrolyte
disturbance in older adults
Dehydration occurs when you

use or lose more fluid than

you take in, and your body
doesn't have enough water
and other fluids to carry out
its normal functions. If you
don't replace lost fluids, you
will get dehydrated.
 RISK FACTORS
a. More than 85 years of age
b. Female
c. Semi-dependent in eating
d. Functionally more independent
e. Few fluid ingestion opportunities
f. Inadequate nutrient intake
g. Alzheimers disease or other dementias
h. Four or more chronic conditions
i. Four medications
j. Fever
k. Vomiting and diarrhea
l. Individuals with infections
m. Individuals who have had prior episodes of
dehydration
n. Diuretics: thiazideloop and thiazide
COMMON CAUSES OF
DEHYDRATION INCLUDE:
vigorous exercise, especially in hot weather
intense diarrhea
Vomiting
fever or excessive sweating
Not drinking enough water during exercise or in
hot weather even if you're not exercising also
may cause dehydration. Anyone may become
dehydrated, but young children, older adults
and people with chronic illnesses are most at
risk.
 EXCESSIVE SWEATING
Excessive sweating.You
lose water when you
sweat. If you do vigorous
activity and don't replace
fluids as you go along, you
can become dehydrated.
Hot, humid weather
increases the amount you
sweat and the amount of
fluid you lose. But you can
also become dehydrated in
winter if you don't replace
lost fluids.
 DIARRHEA, VOMITING
Severe, acute diarrhea that is,
diarrhea that comes on suddenly
and violently can cause a
tremendous loss of water and
electrolytes in a short amount of
time. If you have vomiting along
with diarrhea, you lose even
more fluids and minerals.
Diarrhea may be caused by a
bacterial or viral infection, food
sensitivity, a reaction to
medications or a bowel disorder.
 FEVER

In general, the higher

your fever, the more
dehydrated you may
become. If you have a
fever in addition to
diarrhea and
vomiting, you lose
even more fluids.
 INCREASED URINATION
This may be due to
undiagnosed or uncontrolled
diabetes. Certain
medications, such as
diuretics and some blood
pressure medications, also
can lead to dehydration,
generally because they cause
you to urinate or perspire
more than normal.
MILD TO MODERATE DEHYDRATION
IS LIKELY TO CAUSE:
Dry, sticky mouth
Sleepiness or tiredness children are likely
to be less active than usual
Thirst
Decreased urine output
Dry skin
Headache
Constipation
Dizziness or lightheadedness
 Severe dehydration, a medical emergency, can cause:
Extreme thirst
irritability and confusion in adults
Very dry mouth, skin and mucous membranes
Little or no urination any urine that is produced will be darker than
normal
Sunken eyes
Shriveled and dry skin that lacks elasticity and doesn't "bounce back"
when pinched into a fold
Low blood pressure
Rapid heartbeat
Rapid breathing
Fever
serious cases, delirium or unconsciousness

Note:Unfortunately, thirst isn't always a reliable gauge of the body's need

for water, especially in children and older adults. A better indicator is
the color of your urine: Clear or light-colored urine means you're well
hydrated, whereas a dark yellow or amber color usually signals
dehydration
CALL YOUR FAMILY DOCTOR
RIGHT AWAY IF YOUR LOVED ONE:
Develops severe diarrhea, with or without
vomiting or fever
Has bloody or black stool
Has had moderate diarrhea for 24 hours or
more
Can't keep down fluids
Is irritable or disoriented and much sleepier
or less active than usual
Has any of the signs or symptoms of mild or
moderate dehydration
DEHYDRATION CAN LEAD TO SERIOUS
COMPLICATIONS, INCLUDING:
Heat injury
Swelling of the brain (cerebral edema)
Seizures
Low blood volume shock (hypovolemic
shock)
Kidney failure
Coma and death
Heat injuryIf you don't drink enough fluids when
you're exercising vigorously and perspiring heavily,
you may end up with a heat injury, ranging in
severity from mild heat cramps to heat exhaustion or
potentially life-threatening heatstroke.
Swelling of the brain (cerebral edema)
Sometimes, when you're getting fluids again after
being dehydrated, the body tries to pull too much
water back into your cells. This can cause some cells
to swell and rupture. The consequences are
especially grave when brain cells are affected.
 Seizures. Electrolytes such as potassium and
sodium help carry electrical signals from cell to
cell. If your electrolytes are out of balance, the
normal electrical messages can become mixed up,
which can lead to involuntary muscle contractions
and sometimes to a loss of consciousness.
Kidney failureThis potentially life-threatening
problem occurs when your kidneys are no longer
able to remove excess fluids and waste from your
blood.
 Low blood volume shock (hypovolemic shock).
This is one of the most serious, and sometimes life-
threatening, complications of dehydration. It occurs
when low blood volume causes a drop in blood
pressure and a drop in the amount of oxygen in your
body.

Coma and death. When not treated promptly and

appropriately, severe dehydration can be fatal.
 NURSING MANAGEMENT
A. Risk Identification
1. Identify acute situations: vomiting, diarrhea, or febrile episodes

2. Use a tool to evaluate risk: Dehydration Appraisal Checklist

B. Acute Hydration Management
1. Monitor input and output.

2. Provide additional fluids as tolerated.

3. Minimize fasting times for diagnostic and surgical procedures.

C. Ongoing Hydration Management
1. Calculate a daily fluid goal.

2. Compare current intake to fluid goal.

3. Provide fluids consistently throughout the day.

4. Plan for at-risk individuals

a. Fluid rounds.

b. Provide two 8-oz. glasses of fluid, one in the morning and the other in the evening

c. "Happy hours" to promote increased intake.

d. "Tea time" to increase fluid intake.

e. Offer a variety of fluids throughout the day.

5. Fluid regulation and documentation
a. Teach able individuals to use a urine color chart to monitor hydration status.

b. Document a complete intake recording including hydration habits.

c. Know volumes of fluid containers to accurately calculate fluid consumption.

 Try sipping water or sucking on
ice cubes.
Try drinking water or sports
drinks that contain electrolytes.
Do not take salt tablets. They
can cause a serious
complication.
Learn
what to eat if you have diarrhea
.
 MEDICAL MANAGEMENT: INITIAL REPLACEMENT (PHASE 1 ACUTE
RESUSCITATION)

Give 20 ml/kgNormal SalineorLactated Ringersover

10-15 minutes
May repeat bolus until circulation stable
May require up to 60 ml/kg within the first hour
Stabilization criteria include
NormalHeart Rate
Capillary Refill<2 seconds
Intact mental status
Adequate urine output
After fluid boluses until circulation stable
Administer 100 ml/kg of fluid
Option 1:Oral Rehydration Solution
Option 2: IntravenousNormal SalineorLactated Ringers
Initiate maintenance fluids
Option 1:Oral Rehydration Solution
Option 2: Continue intravenous hydration as below
 I
E M
T R
A
N
. O
2 YP
H
A
2. HYPONATREMIA
Sodium plays a key role in your body. It helps maintain
normal blood pressure, supports the work of your
nerves and muscles, and regulates your body's fluid
balance.
Hyponatremia is a condition that occurs when the level
of sodium in your blood is abnormally low. Sodium is
an electrolyte, and it helps regulate the amount of
water that's in and around your cells.
A normal sodium level is between 135 and 145
milliequivalents per liter (mEq/L) of sodium.
Hyponatremia occurs when the sodium in your blood
falls below 135 mEq/L.
 Risk factors
Age.Older adults may have more contributing factors for
hyponatremia, including age-related changes, taking certain
medications and a greater likelihood of developing a chronic
disease that alters the body's sodium balance.
Certain drugs.Medications that increase your risk of
hyponatremia include thiazide diuretics as well as some
antidepressants and pain medications. In addition, the
recreational drug Ecstasy has been linked to fatal cases of
hyponatremia.
Conditions that decrease your body's water
excretion.Medical conditions that may increase your risk of
hyponatremia include kidney disease, syndrome of inappropriate
anti-diuretic hormone (SIADH) and heart failure, among others.
Intensive physical activities.People who drink too much water
while taking part in marathons, ultramarathons, triathlons and
other long-distance, high-intensity activities are at an increased
risk of hyponatremia.
SYMPTOMS

Nausea and vomiting

Headache

Confusion

Loss of energy and fatigue

Restlessness and irritability

Muscle weakness, spasms or cramps

Seizures

Coma
CAUSES

Certain medications.Some medications, such as

some water pills (diuretics), antidepressants and pain
medications, can cause you to urinate or perspire more
than normal.
Hormonal changes.Adrenal gland insufficiency
(Addison's disease) affects your adrenal glands' ability
to produce hormones that help maintain your body's
balance of sodium, potassium and water. Low levels of
thyroid hormone also can cause a low blood-sodium
level.
 Heart, kidney and liver problems.Congestive heart
failure and certain diseases affecting the kidneys or
liver can cause fluids to accumulate in your body, which
dilutes the sodium in your body, lowering the overall
level.
Dehydration.Taking in too little fluid can also be a
problem. If you get dehydrated, your body loses fluids
and electrolytes.
The recreational drug Ecstasy.This amphetamine
increases the risk of severe and even fatal cases of
hyponatremia.
 Syndrome of inappropriate anti-diuretic
hormone (SIADH).In this condition, high levels of
the anti-diuretic hormone (ADH) are produced,
causing your body to retain water instead of excreting
it normally in your urine.
Chronic, severe vomiting or diarrhea.This causes
your body to lose fluids and electrolytes, such as
sodium.
Drinking too much water.Because you lose sodium
through sweat, drinking too much water during
endurance activities, such as marathons and
triathlons, can dilute the sodium content of your blood.
Drinking too much water at other times can also cause
low sodium.
 Complications

In acute hyponatremia, sodium levels drop rapidly

resulting in potentially dangerous effects, such as
rapid brain swelling, which can result in coma and
death.
MEDICAL MANAGEMENT / NURSING INTERVENTIONS

- Electrolyte management: Hyponatremia

- Cerebral edema management
- Delirium management
- Fluid monitoring
- Fluid management
- Seizure precautions
- Monitor level of consciousness
- Institute safety measures for seizures
- Administer IV isotonic solution (e.g. 0.9% NaCl) as
ordered
- Restrict free water intake (e.g. 1.2 L/24 hr)
- Monitor vital signs hourly and I&O (ECF excess,
restrict fluids and administer diuretics)
- Monitor serum sodium levels. Teach patient about
adequate intake of sodium, side effects of diuretics and
other causes for hyponatremia.
 rem
rn at
yp e
3. H
ia
 3.Hypernatremia

Hypernatremia:Increased blood
sodium levels. Can be caused by
excessive sodium levels but is more
often a result of low water levels in the
body. More detailed information about
thesymptoms,causes, andtreatments
of Hypernatremia is available below.
 causes:

diabetesinsipidus (caused by deficiency of

or insensitivity to ADH)
Diarrhea
Diuretic medication
Excessive salt intake
Excessive vomiting
Heavy respiration (e.g., exercise, exertion)
Severe burn
Sweating
 Symptoms of Hypernatremia

High blood sodium level

weakness
lethargy
irritability
edema
seizures
Neurologic damage
coma
 Medical Management /
Nursing Interventions:

- Electrolyte management: Hypernatremia

- Delirium management
- Fluid monitoring
- Fluid management
- Seizure precautions
- Monitor level of consciousness
- Institute safety measures for seizures
- Maintain body alignment and assist with movement
- Administer oral hygiene hourly
- Monitor vital signs
- Administer oral fluids or a parenteral hypotonic solutions
(e.g. 0.3% NaCl or D5W) as ordered.
- Monitor I&O
- Monitor daily weights
- Monitor laboraty findings.
- Teach patient about foods high in sodium and about
sodium-retaining drugs (cough medicines, cortisone, and
laxatives, with sodium).
4. hypokalemia
 Low potassium (hypokalemia) refers to a lower than
normal potassium level in your bloodstream. Potassium is
a chemical (electrolyte) that is critical to the proper
functioning of nerve and muscles cells, particularly heart
muscle cells.
Normally, your blood potassium level is 3.6 to 5.2
millimoles per liter (mmol/L). A very low potassium level
(less than 2.5 mmol/L) can be life-threatening and
requires urgent medical attention.

hypokalemia
 of potassium loss leading to low potassium include:
Excessive alcohol use
Chronic kidney disease
diarrhea
Excessive laxative use
Excessive sweating
Folic acid deficiency
Prescription water or fluid pills (diuretics) use
Vomiting
Some antibiotic use

Causes:
 Ileus
Constipation
Arrhythmias
Hypotention
Cardiac arrest
Polyuria
Hyperglycemia
Nausea and vomiting
Abdominal distention
Weakness
Mental depression
Thirst
tetany
Paralysis of the bowel wall
Muscle weakness

Symptoms of Hypokalemia
- Electrolyte management: Hypokalemia
- Dysrhythmias management
- Acid-base management: Metabolic alkalosis
- Administer potassium replacement therapy
as ordered.
* oral potassium should be diluted in 4-8 oz of
water or juice (decreased gastric mucosa
irritation)
* dilute IV potassium 20-40 mEq in 1L of IV
fluids (irritating to blood vessels and
myocardium)
* Never administer bolus IV potassium
- Monitor IV site for phlebitis and infiltration
- Protect form injury
- Monitor I&O hourly
- Monitior vital signs
- Monitor heart rate and rhythm
- Monitor patient closely for signs of digitalis
toxicity (premature atrial and ventricular
beats).
- Teach patient about potassium-rich fods and
how to prevent excessive loss (abuse of
laxative and diuretics)

Medical Management / Nursing Interventions:

 E M
AL
R K
PE A
Y I
5 .H
Hyperkalemia is the medical term that describes
a potassium level in your blood that's higher
than normal. Potassium is a nutrient that is
critical to the function of nerve and muscle
cells, including those in your heart.
Your blood potassium level is normally 3.6 to 5.2
millimoles per liter (mmol/L). Having a blood
potassium level higher than 7.0 mmol/L can be
dangerous and requires immediate treatment.

HYPERKALEMIA:
 Pseudohyperkalemia
oliguric renal failure
use of potassium-conserving diuretics in
patients with renal insufficiency, metabolic
acidosis
Addisons disease
crush injury
Burns
stored bank blood transfusion
and rapid IV administration of potassium .

CONTRIBUTING FACTORS
 Vague muscular weakness
tachycardia then bradycardia later on
dysrhythmias
flaccid paralysis
Paresthesias
intestinal colic
cramps
Irritability
anxiety.
ECG:tall tented T waves, prolonged PR interval and QRS duration, absent P
waves, ST depression.

CLINICAL MANIFESTATIONS:
 - Electrolyte management: Hyperkalemia
- Dysrhythmias management
- The medication Kayexalate may be administered orally, via nasogastric
tube or rectally.
- Restrict oral and parenteral potassium intake as ordered.
- Administer cation-exchange resins (Kayexalate) to reduce serum
potassium. Administer glucose and insulin parenteral solution to facilitate
movement of potassium into the cells as ordered.
- Assess for pain and provide comfort measures as indicated.
- Monitor I&O
- Monitor patient closely if receiving diuretics
- Monitor vital signs and heart rhythm hourly for ECG changes
- Institute safety measures when drawing blood:
* Leave tournique on for 1 to 2 minutes
* Draw blood from vein away from all infusions
- If the patient is to receive whole blood, indicate the blood bank requisition
the potassium level (blood 10 days or older has an elevated serum
potassium due to hemolysis of aging blood). Teach patient about potasium-
rich foods, potassium-containing salt substitutes, and potassium-
conserving diuretics.

MEDICAL MANAGEMENT / NURSING

INTERVENTIONS
 Pediatric
Fluid and
Electrolyte
Imbalances
Pediatric Fluid Imbalance
Dehydration
Dehydrationamong children pose a great danger. The
body surface of a child compared to an adult must be
maintained well enough since it has a thin gap between
being well hydrated from dehydrated. Children lose fluids
easier than adults. Their capability to access to fluids are
also the barriers in maintain enough fluids. They depend
more on their caregivers to give this type of basic need,
therefore it is very important to educate and encourage
them to be vigilant against dehydration.
Dehydration can be caused by numerous factors such as
from the inability of the child to take in fluids or secondary
to an illness commonly from vomiting and diarrhoea
making dehydration apparent only on a late stage.
 3 Types Classification of Dehydration :

a. Isotonic dehydration
b. Hypotonic dehydration
c. Hypertonic dehydration
a. Isotonic dehydration

Isotonic dehydration is an equal loss of water

and sodium. Isotonic means that
thenumberof particles contained on one side
of a permeable membrane is the same as on
the other side, thus there is no fluid shift in
either direction. The amount of intracellular
and extracellular water remains in balance.
This can be caused by a complete fast,
vomiting, and diarrhea.
b. Hypotonic dehydration
Hypotonic dehydration is the loss of water
and sodium at the same time but lack of
water than sodium, serum sodium lower
than the normal range of extracellular fluid
was hypotonic body status to reduce the
secretion of antidiuretic hormone, so that
the water in the renal tubular reabsorption
decrease in urine output to increase from an
increase in extracellularosmotic pressure.
c. Hypertonic dehydration
Hypertonic dehydration is the loss of water
and sodium at the same time, but the lack
of sodium than water, it is higher than the
normal range of serum sodium, extracellular
fluid status was hypertonic. When lack of
water than sodium, the increase in
extracellularosmotic pressure, increased
secretion of antidiuretic hormone, renal
tubular reabsorption of water
increased,reducedurine output.
 Causes of Dehydration

Viral infection A child with dehydration from a viral

infection may have fever, diarrhes, vomiting and decreased
appeptite. These are also reasons for dehydration to quickly
occur.
Mouth sores-Mouth sores are painful making the child
irritable and unable to drink fluids as he used to be. The
challenge for the caregiver here is to maintain adequate fluid
despite the sores. The sores exposes the child to greater
danger of infection on the skin and systematically.
Hot environment An environment that has a higher
temperature can make the child sweat more than the usual.
He or she may even drink more however the fluid loss is still
hard to catch up.
Rare conditions These rare conditions arecystic fibrosis
or celiac sprue. The childs body could not absorb the
desired amount of fluid making them dehydration unless
given fluids intravenously.
 Clinical
Manifestations

Clinical Mild Fluid Moderate Severe Fluid

Manifestations Deficit Fluid Deficit
Deficit

Mental
Status/General
Appearance *
Infants and Thirsty, alert, Thirsty, restless Lethargic,
young children restless or somnolent
lethargic but
Older children irritable to
and adults touch
Thirsty, alert, Usually
restless Thirsty, alert conscious,
apprehensive
Clinical Mild Fluid Moderate Severe Fluid
Manifestations Deficit Fluid Deficit
Deficit

Radial pulse Normal rate and Rapid and weak Rapid, feeble,
strength sometimes
impalpable
Heart Rate Normal or mild Tachycardia Severe
tachycardia tachycardia
that may
progress to
bradycardia
Respirations Normal Normal to rapid Deep and rapid

Normal Slightly Severely sunken

Fontanel & Eyes depressed

Systolic blood Normal Orthostatic Severe

pressure hypotension hypotension
Clinical Mild Fluid Moderate Fluid Severe Fluid
Manifestations Deficit Deficit Deficit

Skin elasticity Pinch retracts Pinch retracts Pinch retracts

immediately slowly very
slowly (>3 sec)

Tears * Present Present or absent Absent

Mucous Moist Dry Very dry

membranes *
Urine output Normal Oliguria Oliguria or anuria
Body weight loss 35 69 10
(%)

Estimated fluid 3050 6090 100

deficit
(mL/kg)
 Isotonic dehydration When a child has decreased
urination, low blood pressure, tachycardic and cold
and clammy extremities. The consciousness of a
child may also be affected.
Hypertonic or Hypernatraemic dehydration The
child becomes irritable and sometimes seizures
are present. The sodium concentration in the body
is more than 165 mmol/L making the child
disoriented as well as the nervous system is now
affected.
Hypotonic or Hyponatraemic Dehydration The
child has a low sodium level due to excessive
urination. The excess fluid loss makes the child
weak. Seizures are also noted to happen in
Electrolyte Causes Clinical ECG Findings Management
Imbalance S&Sx
Hyponatremi Vomiting/diarrhea Lethargy N/A Treat
a NG suction Muscle underlying cause
Na intake cramps Frequent neuro
Na < 135 fever N/V assessments
mEq/L excessive diaphoresis Fluid
water intake Disorientation replacement (if
burns & wounds Seizures applicable)
renal disease Coma 3% saline
DKA Monitor Na
Malnutrition levels

Hypernatremi Irritability/agit N/A Treat underlying

a Na intake ation cause
renal disease Dry, sticky Frequent neuro
Na > 145 fever mucous assessments
mEq/L insensible water membranes Strict I&O
loss Flushed skin Slow correction
Diabetes insipidus Lethargy/conf of fluid deficit (if
Hyperglycemia usion applicable)
Seizures Monitor Na
Coma levels
Muscle
weakness
Muscle
twitching
Intense
thirst
Electrolyte Causes Clinical ECG Findings Management
Imbalance S&Sx

Hypokalemia K intake Muscle Muscle Determine &

Starvation weakness, weakness, treat cause
K Malabsorption cramping, cramping, Monitor ECG
+ syndromes stiffness, stiffness, Frequent
< 3.5 mEq/L GI losses paralysis, paralysis, neuromuscular
Diuresis hyporeflexia hyporeflexia assessments
Nephritis Hypotension Hypotension K
Alkalosis Lethargy Lethargy +
Irritability Irritability replacement
Tetany Tetany Monitor acid-
N/V N/V base status
Abdominal Abdominal
distention distention
Paralytic Paralytic ileus
ileus Irregular, weak
Irregular, pulse
weak pulse

Hyperkalemia Muscle Tall, peaked T Determine &

K intake weakness waves treat cause
K Renal disease/failure Ascending Widened QRS Monitor ECG
+ Adrenal insufficiency paralysis Prolonged PR Administer IV
> 5.5 mEq/L Metabolic acidosis interval fluids
Severe dehydration Hyperreflexia Ventricular D/C K+
Burns Confusion arrythmias containing
Crushing injuries Apnea Asystole fluids/meds
Hemolysis N/V Ca Glu
Diarrhea 100mg/kg
Electrolyte Causes Clinical ECG Findings Management
Imbalance S&Sx

Hypocalcemia dietary Ca NM Prolonged QT Treat/control

Vitamin D deficiency irritability interval cause
Ca < 8mg/dL Renal insufficiency Tingling Monitor ECG
iCa < 1.15 Diuretics sensation IV calcium
Hypoparathyroidism Chvosteks supplements
Alkasosis sign Monitor Ca &
serum protein Trousseaus Mg levels
sign
Tetany
Muscle
cramps
Lethargy
Seizures
Hypotension
Hypercalcemi Lethargy Shortened QT Treat underlying
a Acidosis Stupor interval cause
Prolonged Coma Bradycardia Monitor ECG
Ca > 10.5 immobilization Seizures Cardiac arrest IV fluids
mg/dL Kidney disease Anorexia Loop diuretics
iCa > 1.34 Hyperparathyroidism N/V
Excessive Constipation
administration NM
hypotonicity
Electrolyte Causes Clinical ECG Findings Management
Imbalance S&Sx

Hypomagnes intake (NPO) NM PVCs Treat cause

emia Malabsorption excitability V-tach IV Mg
syndromes Tetany V-fib replacement
Mg < 1.4 renal excretion Confusion Monitor ECG
mEq/ Dizziness Neuromuscular
Headache assessments
Seizures
Coma
Respiratory
depression
HR
Hypermagnes Lethargy Prolonged PR Treat cause
emia Chronic renal disease Muscle Prolonged QRS Monitor ECG
GFR/ excretion weakness Prolonged Qt Administer Ca
Mg < 1.4 ECF deficit swallow AV block Glu
mEq/L administration of gag IV hydration
Mg HR Dialysis
containing drugs BP