FLUID AND ELECTROLYTE

BALANCE

Earl Francis R. Sumile, RN

Instructor, College of Nursing
University of Santo Tomas
 Water
Water constitutes over 50% of an individual’s weight
Infant- 70-80%
Adult 50-60%
Geriatric 45-55%
Water requirement= 2500cc/day; minimum of 1500 cc/day

Average daily water intake and output

of normal adult
water in food- 1000 Urine- 1500
water ingested- 1200 Feces-150
water from oxidation- 300 Lungs -350
2500 Skin-500
2550
Fluid compartments
1. Intracellular - within cells- 70% body
water
2. Extracellular - outside cells -30% body
water
a. interstitial- area around cells- 24%
body water
b. intravascular- area within body
vessels- 6% body water
Electrolytes (mEq)
• salts or minerals in body fluids
•contain electrically charged particles called ions
•principal source of osmotic forces which control volume or
location of fluid

Cations- positively charged; Na, K, Ca, Mg

Anions- negatively charged; CL, HCO3, PO4
Types of Solution
1. Hypertonic- exerts greater concentration of particles
outside than inside the cell; cells shrink
e.g. D51/2NS, D5 NS, D5 LR, 3%NS, 5%NS
2. Hypotonic- exerts lesser concentration of particles outside
than inside the cells; cells swell
eg. 1/2 NS, 1/4 NS, 1/3 NS, 2.5% Dextrose, D5W
3. Isotonic- same concentration of particles inside and outside
the cell; no change on size and shape of cells
eg. Normal Saline, Lactated Ringer’s
Care of Clients with
Burns
Earl Francis R. Sumile, RN
Instructor, College of Nursing
University of Santo Tomas
Burns
• wounds caused by excessive exposure to
thermal, electrical, chemical and
radioactive materials
•usually secondary to carelessness or
ignorance
Nursing Assessment
1. ABC’s
• Age
• Burn Location
• Coverage

2. Tetanus immunization
3. TBSA- Total Body Surface Area
a. Berkow formula
•calculated on the basis of the client’s age
•changes that occur in proportion of the head and legs to the rest
of the body as the individual grows
•arms and trunk have a fixed proportion throughout life

Eg. Head: 1yo = 19%; 1-4yo = 17%; 5-9yo =13%;

10-14yo = 11%; 15yo = 9%; adult = 7%
B. Lund and Browder Chart
• thought to be more accurate
•takes into account changes in % of burned surface at various
stages of development

C. Rule of Nine
• useful for immediate appraisal of the burned area
•body is divided into areas, each represents 9% of or multiples
of 9; inaccurate
Classifications of Burns:
1. Major- partial thickness> 25% or full thickness > 10%
2. Moderate- partial thickness 15-25% or full thickness <10%
3. Minor- partial thickness <15% or full thickness < 2%
Categories of burn depth:
1. Partial thickness
a. Superficial Partial Thickness (First degree)
depth: epidermis
cause: sunburn, splashes of hot liquid
sensation: painful
characteristic: erythema, blanching on pressure,
no vesicles
B. Deep Partial Thickness (second degree)
depth: epidermis and dermis
cause: flash, scalding or flame burn
sensation: very painful
characteristic: fluid filled vesicles, red, shiny, wet
after vesicle rupture
2. Full thickness (third and fourth degree)
depth: all skin layers and nerve endings, may
involve muscles, tendons and bones
cause:flame, chemicals, scalding, electric current
sensation: little or no pain
characteristic:wound dry, white, leathery, or
hard tissue

*eschar- leathery or hard tissue due to loss of blood supply

Nursing Management in Different Stages of Burns:
1. Emergent phase- remove person from source of burn
goals: relief of pain, minimize contamination, transport
a. Thermal- stop, drop and roll; flame off
b. Smoke inhalation- ensure patent airway
c. Chemical- remove clothing that contains chemical;
lavage with copious amounts of water
d. Electrical- shut off source of electricity; note entry or
exit wound
Nursing Interventions:
b. Ensure patent airway
c. Wrap in dry, clean sheet or blanket or prevent contamination
of wound
d. Provide warmth
e. Provide IV route if possible
f. Tetanus prophylaxis
g. Transport immediately
2. Shock Phase- 1st 24-48 hrs post burns
• Fluid shift from plasma to interstitial fluid= hypovolemia;
fluid also moves to areas that normally have little or no fluid
(third spacing)
• Dehydration, decreased BP, increased pulse, decreased
urinary output, thirst
• Hyperkalemia, hyponatremia, increased hematocrit,
metabolic acidosis, loss of HCO3 ions
3. Fluid remobilization or Diuretic phase (2-5 days post-burns)
b. Interstitial fluid returnsto vascular compartments
c. Increased BP, increased urinary output
d. Hypokalemia

4. Convalescent phase
g. Starts when diuresis is completed and wound healing begins
h. Dry, waxy-white appearance of full-thickness burn changing
to dark brown; wet, shiny, serous exudate in partial
thickness
i. Hyponatremia
Nursing Interventions:
2. Provide relief or control pain
3. Administer analgesic or narcotics (morphine sulfate) 30 mins
before wound care
4. Position burns to alignment
5. Monitor alterations in fluid-electrolyte balance
6. Monitor foley catheter output hourly (30 cc/hr)
7. Weigh daily
8. Administer water or colloids
9. Promote maximal nutritional status
10. Wound care done 1hr before meals
11. Prevent wound infection
• Biologic dressing- used to cover large denuded areas
• Grafts- autograft, allograft, xenograft or heterograft
3. Controlled sterile environment
4. Hydrotherapy not more than 30 mins to prevent electrolyte
loss
5. Sulfamylon, silvadene, silver nitrate, betadine, gentamycin
applied using sterile technique
6. Prevent GI complications
7. Provide client teaching and discharge plan
• Escharotomy- lengthwise incision through eschar to allow
expansion of skin as edema forms
• Fasciotomy- surgical incision done on underlying tissues or
muscles to explore for viability
Care of Client with Problems
Related to the Genitourinary
System

Earl Francis R. Sumile, RN

Instructor, College of Nursing
University of Santo Tomas
Renal functions: Homeostasis
2. Maintain constancy of internal environment by regulating
water and electrolyte content and acid base balance
3. Conserve appropriate amounts of essential substances vital
to normal cell function
4. Excrete waste products of metabolism, toxic substances, and
drugs in urine
5. Endocrine role- production of renin, erythropoietin and
prostaglandin
6. Metabolism of vitamin D
Manifestations of impaired renal function:
2. Abnormal urinary volume
c. Oliguria-< 500ml/24hr
d. Anuria- <250ml/ 24hr; renal shutdown, decrease filtartion
secondary to renal disease, hypotension, dehydration,
decreased renal blood flow
e. Polyuria- volume >2000ml/24hr
f. Pollakuria- abnormally frequent urination
g. Nocturia- frequent urination at night
h. Isosthernuria- kidneys cannot concentarte urine
i. Strangury- desire to pass urine but not received by micturition
j. Incontinence- true, false, paradoxical overflow; stress related
1. Abnormal urine color Abnormal constituents in urine
2. Abnormal constituents in urine
c. Albuminuria- presence of albuminin the urine secondary to
inflammation and damage to glomeruli
d. Hematuria- presence of blood (RBC) in urine

6. Azotemia- metabolic wastes accumulated in blood,

increased urea, craetinine and uric acid
g. Uremia- symptomatic elevation of metabolic waste products
in urine; a state or complex of symptoms reflecting failure of
kidneys to excrete metabolic wastes and excess substances
1. Fluid, electrolyte and pH imbalance- edema, metabolic
acidosis- failure of kidneys to excrete hydrogen ions with
increased sodium, phosphate and ammonia

3. Vital signs- increased BP in renal insufficiency; pulse weak,

dyspnea in pulmonary edema; kussmaul breathing in
acidosis; breath- uremic or ammoniacal odor in advanced
renal failure, fever

5. Gastrointestinal- anorexia, nausea or vomiting, diarrhea,

hiccups in advanced renal failure

7. Headache- secondary hypertension and cerebral edema

1. Visual disturbances- papilledema and retinal
hemorrhages

3. Neurological- irritability, lethargic and drowsy,

disoriented to comatose; convulsion

5. Skin changes- yellowish brown discoloration dryness

or scaliness, pruritus and urea frost (uremic frost)
excreted by sweat glands

7. Hematological- dec erythropoeisis leading to anemia

and bleeeding tendencies- petechiae, purpura
Diagnostic Assessments
2. Urine examination or analysis
c. Routine- midstream first voided urine
d. Sterile or catheterized
e. 24 hours- collection starts at second voided urine
f. Residual
7. Blood examination or chemistry
h. CBC
i. BUN
j. Creatinine
k. Uric acid
l. Electrolytes
1. Radiologic
b. KUB (Kidneys, Ureters, Bladder)- identifies number and size
of kidney, ureters, bladder, tumors, malformation,. Calculi
c. IVP (Intravenous Pyelography)- fluoroscopic visualization of
kidney after dye injection via IV
d. Cystography or cystoscopy
Prep- NPO 6-8 hrs with premedications like nubain, valium
f. PSP (phenolsuphthalein)- checks the secretory ability of the
kidneys; urine expected to be red
7. Renal angiography
8. Percuatneous renal biopsy
Common Disorders:
2. Urolithiasis- presence of stones anywhere in the urinary tract;
often in men 20- 55yo; more in summer
Predisposing Factors:
d. Diet- large amount of calcium, oxalate, uric acid
e. Increased uric acid levels
f. Sedentary lifestyle, immobility
g. Family history of gout or calculi or hyperparathyroid
h. Genetic- xanthine, cystine stone
Signs and Symptoms:
b. Abdominal or flank pain
c. Renal colic
d. Hematuria
e. Cool moist skin
Nursing Interventions:
b. Strain all urine with gauze or strainer
c. Crush all clots
d. Force fluids 3000-4000cc/ day
e. Encourage ambiulation to prevent stasis
f. Relieve pain by analgesics or moist heat
g. I and O
Classification of Stones:
b. Acid stones- uric acid, cystine. Xanthine
c. Alkaline stones- phosphate, calcium, oxalate
Nursing Management:
2. Modified diet
c. Alkaline ash- for acid stones; vegetables, fruits, except
prunes, plums and cranberries
d. Acid ash- for alkaline stones; cranberries, prunes and plums,
meat fish, eggs, whole grain; limit milk
*avoid oxalates- tea, chocolate, spinach
*avoid purine- liver,brain, kidneys, shell fish, legumes
1. Allopurinol or zyloprim- decrease uric acid production;
enhance excretion of uric acid
2. Lithotripsy- crushing of stone
c. ESWL- Extracorporeal Shock Wave Lithotripsy
d. Electrohydraulic Lithotripsy
5. Surgery
f. Lithopalaxy
g. Pyelithotomy, Nephrolithotomy, Utero-lithotomy,
Cystolithotomy
1. Bladder Cancer- most common Ca in urinary tract; incidence-
men 50-70 yrs
Predisposing Factors: exposure to chemical especially, aniline dye,
cigarette smoking and chronic bladder infection
Nursing Management
d. Surgery
• Cystectomy
• Uterosigmoidostomy
• Ileal conduit
h. Radiation
i. Chemotherapy
1. Benign Prostatic Hypertrophy- hyperplasia and overgrowth of
smooth muscles and connective tissues of the prostate glaned;
most common problem of male reproductive system
Incidence: 50% men over 50; 75% men over 75
Cause: hormonal mechanism
Signs and Symptoms- nocturia, frequency, decrease force and
amount of urinary system, hesitancy, hematuria, increased
alkaline phophatase
Nursing mgt:
f. Antibiotics
g. Proscar
h. Prostacatheter
a. Surgery
• TURP Trans Urethral Resection of Prostate
• Suprapubic Prostatectomy
• Retropubic Prostatectomy
• Perineal Prostatectomy
Nursing Care in Cystolysis (CBI- Continuous Bladder Irrigation):
b. Maintain patency of the catheter system
c. Monitor appearance of urine; red to light pink (24hrs) to
amber or tea-colored (3days)
d. Monitor for signs of water intoxication; prevent water
intoxication by using saline solution
e. Avoid enemas and rectal temperature
f. Used prescribed medications like analgesics and
antispasmodics
g. After catheter removal, monitor output for signs of urinary
retention; monitor for continence; perineal exercise (kegal) if
with dribbling; encourage frequent voiding and increased
fluid intake
4. Renal Failure- state of total or nearly total loss of kidney
function
Acute Renal Failure- sudden inability of the kidneys to regulate
fluid and electrolyte balance and remove toxic products from the
body; reversible
Causes:
a. Pre-renal- factors interfering with perfusion and resulting in
decreased blood flow and glomerular filtrate,ischemia and
oliguria
b. Intra-renal- conditions that cause damage to nephrons
c. Postrenal- mecanical obstruction from tubules to urethra
Phases:
1. Onset- period precipitating event to development of oliguria
2. Oliguria ( to anuria)- urinary output less 400ml
3. Diuretic- gradual return of GFR and BUN level
4. Convalescent- renal function stabilizeswith gradual
improvement in 3-12 months
Signs and Symptoms:
a. oliguria to anuria
b. edema
c. anorexia
d. nausea or vomiting
e. lekocytosis
f. anemia
g. bleeding tendencies
h. drowsy
i. Muscle twitching and coma (uremic encephalopathy)
Nursing Management
a. Fluid and nutrition- limited fluids to 500ml to replace
obligatory loss from lungs or skin
b. Low protein diet
c. Rest
d. Precautions: side rails up
e. Mouth or skin care
f. Pharmacotherapeutics- diuretics
g. Dialysis
Chronic Renal Failure- progressive irreversible destruction of
kidneys that continues until nephrons are replaced with scar
tissues
Predisposing Factors: recurrent infections, exacerbations of
nephritis, urinary tract obstructions, diabetes, hypertension
Signs and Symptoms:
a. Electrolyte imbalance
b. Cardiovascular- hypertension,left ventricular hypertrophy,
CHF
c. Hematologic- anemia, decreased erythropoeitin, increased
hematocrit and bleeding tendencies
d. Gastro-intestinal- anorexia, nausea, vomiting
e. Respiratory- fluid overload, pulmonary edema: “uremic lung”
f. Orthopedic- increased Ca elimination, decreased serum Ca,
osteodystrophy or osteomalacia
g. Dermatological- excoriation or dry skin, uremic frost
h. Neurologic- peripheral neuropathy, burning feet; CNS
nystagmus, twitching, seizure
i.Reproductive-menstrual irregularities impotence, testicular
atrophy and decreased sperm count
j. Psychological- behavioral and personality changes
k. impaired immunologic system- increased susceptibility to
infection
Stages of CRF:
1. Renal impairment
2. Renal insufficiency
3. Renal failure
4. End stage of Renal disease
Nursing Management:
1. Conservative- assess uremia, mental function and supportive;
avoid undue fatigue
2. Advanced renal failure- oliguric or uremic phase
a. peritoneal dialysis
b. hemodialysis
c. kidney transplant
3. Dietary- early- no restriction
- advanced- low protein
Giordano or Giovanette diet- low protein with amino acids
Dialysis- removal by artificial means of metabolic wastes, excess
electrolytes and excess fluids

Principles:
-Diffusion, Osmosis, Ultrafiltration
Purposes:
1. To remove excessive amounts of drugs or toxins in poisoning
2. To check serious electrolyte or acid base imbalance
3. To maintain kidney function when renal shutdown occurs
4. To temporarily replace kidney function in patients with acute
renal failure and permanently replace in chronic renal failure
Peritoneal Dialysis- introduction of specially prepared dialysate
solution into the abdominal cavity where the peritonem acts as a
semipermeable membrane between the dialysate and blood in the
abdominal vessels
Nursing Interventions:
a. weight, VS every 15 mins then every hour
b. Patient voids
c. Warm dialysate solution to body temperature
d. Assist in trocar insertion
e. Inflow time, Dwell time and Drain time
f. Observe character of dialysate flow
Complications:
• Peritonitis
•Respiratory Difficulty
•Protein loss

Types of Peritoneal Dialysis

• CAPD- Continuous Ambulatory Peritoneal Dialysis
•CCPD- Continuous Cycle Peritoneal Dialysis
•IPD- Intermittent Peritoneal Dialysis
Hemodialysis- shunting of blood from client’s vascular system
through an artificial dialyzing system and return of dialyzed
blood to client’s circulation
Dialysis coil- acts as a semipermeable mebrane
Access Routes:
• AV shunt or cannula
• AV fistula
• Femoral or subclavian cannulation
Nursing Interventions:
1. Auscultate for bruit and palpate thrill- check patency
2. Check bleeding
3. Observe arm precaution
4. Avoid restrictive clothing or dressings over site
Complications:
1. Hypovolemic Shock
2. Dialysis disequilibrium syndrome
Renal transplant pre-requisites
1. Evaluation of patient’s medical immunologic, psychological
and social status
2. Should be identical- ABO and HLA compatible
Contraindications:
1. Acute infection
2. Malignancy
3. COPD
4. Liver disorder
5. DM
6. Atherosclerosis
Pre-op care:
1. Dialysis to make patient non-toxic
2. Treat all complications
3. Immunosuppressive drug to start 24hrs before transplant;
immuran, prednisone, sandimmune
4. Transplanted kidney placed on thigh, usually iliac fossa
Post-op care:
1. Reverse isolation
2. Monitor renal functions
3. Respiratory, therapy, deep breathing and coughing
exercises
4. Aseptic wound care
5. Oral hygiene
6.NGT to prevent paralytic ileus
7. Early ambulation
8. Health adjustment process
9. Lifetime-immune suppressive drugs
Complications:
• Acute rejection
• Chronic rejection