Fluid & Electrolytes/Acid Base BalanceGoal: Reestablish & maintain normal balance -assess clients likely to develop imbalances -monitor clients for early manifestations -implement collaborative interventions
Necessary for cells to be able to carry out their work. Body fluids are in constant motionBody fluids maintain healthy living conditions for body cells
nutrients in foodnormal digestive processesnormal volume, composition, distribution, & pH of body fluids
Homeostasis involvesDelivery of essential elements such as oxygen and glucose to the cellsRemoval of wastes such as carbon dioxide from the cells
Intracellular fluid 40% total body weightEssential for normal cell functionProvides medium for metabolic processes
Extracellular fluid 20% total body weightInterstitial fluid: spaces between cellsIntravascular fluid (plasma-arteries, veins, capillaries)Transcellular fluidUrine, digestive secretions, perspirationCerebrospinal, pleural, synovial fluidsIntraocular, gonadal, pericardial fluids
82 year old women
Isotonic dehydration, the most common type of fluid deficit, is caused by loss of plasma volume. In this case, the client lost volume by excessive vomiting and diarrhea
Urine specific gravity >1.010 Urine volume decreased Serum sodium normal Serum hct & hgb increasedBUN normal or increased Serum osmolality normal
Orthostatic hypotension and flat neck veins
Increased sympathetic discharge
Rapid hydration of IVF
Distended hand and neck veins
All except diminished peripheral pulses, thirst, orthostatic hypotension
Restrict free water
ElectrolytesMaintain fluid balanceRegulate & maintain acid-base balanceContribute to enzyme reactionsEssential for neuromuscular activityMeasured in mEq/L of watermEq-measure of chemical binding power of the ion
Bacon, fresh fruit salad if it contains bananas, cantalope, kiwi, orange) potato, spinach, & dried fruit; salt subsitute
Deficit knowledge related to dietary intake of potassium as evidenced by dietary intake of potassium rich foods such as potatoes, bacon, and salt subsitute. Deficit knowledge related to lack of familiarity with information resources as evidenced by inaccurate follow through on instructions for medication and dietary intake of potassium rich foods
Loose diarrhea stools. Symptoms are a result of the excess potassium moving from ICF to ECF creating an stimulation of the bowel and resulting in diarrhea.
There is no need to clarify the order. GI s/s of hyperkalemia are increased motility, hyperactive bowel sounds and diarrhea. The kayxalate will reduce the potassium levels consequently the intestinal motility decreases if the enema is successful
Spironolactone is a potassium sparing diuretic and should be d/c.Teach diet, medications, and recognition of s/s of hyperkalemia. Importance of follow up care
Because of her symptoms and history knowing that dehydration can be characteristic of hypernatremia the sodium level is expected to be elevated. Assessment: CNS, neurovascular, and CV manifestations Treatment fluid replacement with isotonic solution (NaCl) Teaching sodium content in foods and beverages, safety measures (physiologic changes in the elderly, s/s of dehydration to report, prevention of dehydration and hypernatremia by drinking adequate water
High Ca can cause constipation, polyuria which causes increased thirst; cardiac arrestLow Ca Lethargy, coma
Heart rhythm-dysrhythmias, ECG changes possible HTN, cardiac arrest
Fluid & Electrolyte disorders Excess fluids result from excessive intake or decreased output, from any cause Fluid deficits result from poor intake or excessive output, from any cause Both occur from shifts that occur with various health disorders
Recent illness accompanied by fever, vomiting/diarrhea
Assessment: FVD Physical Assessment Weight Vital signs Peripheral pulses/capillary refill Jugular neck vein Skin color Temperature Turgor LOC/mentation Urine output
Fluid Management: FVD Isotonic Electrolyte solutions 0.9% NaCL/Ringer’s solution Expand plasma volume (↓ BP pt’s) Replace abnormal losses Total body water deficits D5W Dextrose is metabolized to carbon dioxide & water ->availability of free water for tissue needs
Fluid Imbalance Nursing Process: Patient Care Plan for Dehydration Osborn page 421
Ms. Hicks 39 year old female history of vomiting & diarrhea from the flu rapid pulse orthostatic hypotension urine output of 20 mL/hr skin turgor poor with tenting increased respiratory rate
Ms. Hicks Which type of dehydration do you suspect that this Ms. Hicks has? Explain your answer.
Ms. Hicks In evaluating the client’s laboratory values, would you expect the following values to be normal, elevated, or decreased? Urine specific gravity Urine volume Serum sodium Serum hct & hgb BUN Serum osmolality
Ms Hicks When assessing a patient with FVD, the nurse would expect to find: Increased pulse rate and BP Dyspnea and respiratory crackles Headache and muscle cramps Orthostatic hypotension and flat neck veins
Ms Hicks What compensatory mechanism responsible for the client’s rapid pulse?
Ms Hicks What immediate interventions are necessary to correct this client’s fluid volume imbalance?
Ms Hicks Admitted with hypovolemia. Which IV solution would the nurse anticipate administering? Ringer’s solution 10% dextrose in water 3% sodium chloride 0.24% sodium chloride
Ms Hicks What would be most important to monitor to determine the client’s response to corrective interventions?
Mr Hicks What assessment data would indicate that the client is having a negative response to fluid resuscitation?
Diuretics: Pt & Family Teaching Take in morning and afternoon Change position slowly Weigh daily Avoid salt shaker & processed foods Read food labels ↑ potassium foods (banana/orange juice) Potassium sparing diuretics do not use salt substitute
Pitting Edema Extravasation & accumulation of interstitial fluid in tissues Dependent areas of the body Leaves indentation when skin surface is pressed by a finger Reflects high right atrial pressure, for example, in heart failure More severe than non-pitting edema
Nursing Diagnosis: FVE Excess fluid volume Risk for Impaired Skin Integrity Risk for Impaired Gas exchange
Admitted to the hospital with a decreased serum osmolality and a serum sodium of 126 mEq/L.
You recognize that dehydration or overhydration may accompany hypotonic conditions.
Mrs. Hsu A priority assessment for this client with FVE is: Mental status Weight Postural vital signs Urine output
Mrs Hsu In further assessing the client, what assessment data would indicate that the client has fluid volume excess? Distended hand & neck veins Decreased urine output Decreased capillary refill Increased rate and depth of respirations
Mrs. Hsu Increased, bounding pulse JVD Diminished peripheral pulses Presence of crackles Thirst Elevated blood pressure Orthostatic hypotension Skin pale & cool to touch Which of the following assessments would indicate that Mrs. Jones has fluid volume excess?
Mrs Hsu After determining the client is not dehydrated, which of the following interventions would be appropriate to correct this hypotonic overhydration? Administration of 0.9% NS Restriction of free water Administration of antihypertensives Restriction of potassium
Mrs. Hsu A patient is exhibiting sudden onset of crackles in the lungs, moist respirations, & rapid respiratory rate. Which intervention should be performed first? Weigh the patient Assess capillary refill Measure edema Reduce IV rate
Mrs Hsu What would you assess for evidence of a worsening hypotonic condition? Mental status Urine output Skin changes Bowel sounds
Potassium (K+) 3.5 to 5.5 mEq/L Major cation in the ICF Affects cardiac muscle concentration, electrical conductivity, & cell excitability Aids neuromuscular transmission of nerve impulses. Alteration in K+ balance will result in acid-base imbalance Regulation of protein synthesis Regulation of glucose use & storage
Assessment: Hypokalemia Health history Anorexia, nausea, vomiting, abdominal discomfort Muscle weakness or cramping Diuretic use Prolonged vomiting or diarrhea Diabetes, Addison or Cushing disease Current medications
Treatment: ↓ K+ Oral potassium supplements Oral: dilute liquid K+ in fruit or vegetable juice or cold water Never give K+ if pt is not voiding Chill to increase palatability Give with food to minimize GI effects Parental potassium supplements
Which foods in his diet contribute to his hyperkalemia?
Mr. Williams What would be a relevant nursing diagnosis for this client based on the client’s assessed data?
Mr. Williams C/O abdominal cramping and several very loose diarrhea stools since yesterday. What is the etiology of the client’s symptoms?
Mr. Williams Physician orders Kayexalate retention enema to be given stat. Should you clarify the physician’s orders before administering the enema?
Mr. Williams Will the physician continue the order for Spironolactone? Explain. What would be some teaching and learning priorities for d/c.
Sodium (Na+) 135-145 mEq/liter Normal physiologic function Maintains ECF volume Maintenance of ECF osmolality. Initiation of skeletal muscle contraction Initiation of cardiac contractility Transmission of neuronal impulses Maintenance of renal urine-concentration system
Sodium Imbalance Affect osmolality of ECF Affect water distribution between fluid compartments Low Na+ H2O is drawn into cells (swell) High Na+ H20 drawn out of cells
Signs & Symptoms Hyponatremia Muscle cramps, Weakness, fatigue Dulled sensorium, irritability, personality changes Hypernatremia Most serious effects are seen in the brain Lethargy, weakness, irritability can progress to seizures, coma, death
Point to Remember Pt’s with low Na+ will present with acute onset of confusion Risk for falls in the elderly
A patient receiving D5W at 100 mL/hr is most at risk for developing Hypernatremia Hyponatremia FVE FVD
Mrs. Hudson 77-year-old female Found confused, unable to get up to the bathroom Weak, anxious, confused to time & place P 110; B 108/58 Skin dry Urine Specific gravity 1.028 Deep tendon reflexes slightly reduced
Mrs. Hudson Would the client’s serum sodium be elevated, decreased, or normal? What would be your priority assessment plan?
What treatment would you expect this client to receive at this time?
What would be a teaching plan for this client?
Chloride (Cl-) 95 to 108 mEq/liter Formation of hydrochloric acid in stomach Cl- and Na+ levels usually change in direct proportion to one another. Works with Na+ to maintain ECF osmotic pressure & water balance
Calcium (Ca++)8.5 – 10.5 mEq/dl (4-5.5 mEq/L) Functions Enhances activity of enzymes or reactions Skeletal muscle contraction Cardiac contractility Helps activate steps in blood coagulation. Bone strength & density Regulation of neural impulse transmission
The most important assessment in a patient with hypercalcemia is Heart rhythm Urine output Trousseau’s sign Weight
The nurse evaluates teaching about calcium supplement therapy as effective when the patient states that she will take her calcium tablets All at one time in the morning With meals As needed for tremulousness With a full glass of water
Phosphorus 2.5 – 4.5 mEq/dl Vital for intracellular activities Activation of B complex vitamins Plays major role in acid-base balance through its action as a urinary buffer Cell division Plays essential role in muscle, RBC, neurological function Aids in carbohydrate, protein and fat metabolism
Magnesium (Mg++) 1.5-2.5 mEq/l Muscle contractility Carbohydrate and protein metabolism. Affects neuromuscular irritability & contractility of cardiac and skeletal muscle. Facilitates transport of Na+ and K+ across cell membranes. DNA & Protein synthesis
The nurse is caring for a patient with severe vomiting and diarrhea Nasogastric tube to low wall suction. The nurse realizes that this patient is at risk for which of the following electrolyte imbalances?