Valencia College
FLUID & ELECTROLYTE IMBALANCES
Valencia Community College
Nursing II – Student Outline
FLUID VOLUME DEFICIT
I. INTRODUCTION
A. Dehydration
B. Overview
1. Isotonic
2. Hypertonic
3. Hypotonic
page 212
COMMON CAUSES
Isotonic Dehydration
Hypertonic Dehydration
Hypotonic Dehydration
page 214
ASSESSMENT
History
Age
Height & Weight
Manifestations of Dehydration
- Cardiovascular
- Respiratory
- Integumentary
Table 15-1
ASSESSMENT Cont.
- Neurologic
- Renal
Psychosocial Assessment
Laboratory Assessment
- No single lab test result confirms or rules out dehydration.
- Diagnosis is based on lab findings & S/S.
Lab assessment cont.
Specific gravity
- Isotonic
- Hypotonic
- Hypertonic
Hematocrit
- Isotonic
- Hypotonic
- Hypertonic
Lab assessment cont.
- BUN
- Hematocrit
- ABG’s
- Urine sodium
- Serum osmolality
ANALYSIS
Priority Nursing Diagnosis
- Fluid volume deficit RT excessive fluid loss or inadequate fluid intake
- High risk electrolyte imbalances
- Decreased CO RT decreased plasma volume
- Constipation RT decreased fluid intake
NURSING INTERVENTIONS
Fluid management
- Diet therapy, oral hydration therapy, and drug therapy are used to correct fluid volume deficit (chart 15-4)
- Divide fluid replacement between the shifts
TYPES OF IV SOLUTIONS
Isotonic
Hypotonic
IV SOLUTIONS cont.
Hypertonic
Type IV fluid depends on:
- type fluid loss
- severity of the deficit
IV SOLUTIONS cont.
- serum electrolytes
- serum osmolality
- acid-base status
MEDICAL MANAGEMENT
Restoration of normal fluid volume and correction of acid-base & electrolyte imbalances.
Treat underlying cause
- examples:
NURSING INTERVENTIONS
I & O and specific gravity
(qh if volume deficit severe)
Monitor VS’s & hemodynamics
Administer & monitor fluids (PO & IV)
Weigh QD
Monitor for overcorrection
Monitor HCT and notify MD if decreases
Nursing Interventions cont.
Position (usually) supine with legs elevated
Monitor & report changes
Protect client from injury
Treat fever
Avoid vasodilation if possible
Evaluate capillary refill
Assess peripheral pulses
EXPECTED OUTCOMES
Reversal of Signs and Symptoms
OVERHYDRATION
(fluid overload)
Overview
- Isotonic
- Hypotonic
- Hypertonic
ASSESSMENT
Cardiovascular
Respiratory
Integumentary
Neuromuscular
Gastrointestinal
CAUSES
Decreased excretion of NA+ & H20
- decreased renal function
- heart failure
- cirrhosis
- cortico-steroids
CAUSES cont.
Increased sodium & water
- circulatory overload
IV fluids
- too much
- too fast
- wrong type
- increased PO fluids
- increased with increased fluid content
- excessive meds with increased sodium
MANIFESTATIONS
Weight gain
Edema
- generalized
- dependent
- eyelids
- pulmonary
- brawny
ASSESSMENT
Diagnostic tests
History
Assess for presence of, and changes in:
- physical findings & S/S
- Hemodynamic measurements
MEDICAL MANAGEMENT AND INTERVENTIONS
Restrict sodium
Restrict fluids
Medications
- diuretics (loop & osmotic)
- Digoxin
Dialysis
Diet – restrict fluid & NA+ intake as needed
NURSING INTERVENTIONS
Strict I & O
Daily weight
Assess K+ levels PRN
Check for edema
COMMON NURSING DIAGNOSES
ELECTROLYTE IMBALANCES
Potassium
- Major intracellular electrolyte (98%)
- Normal (3.5 – 5.0)
- 80% excreted by kidneys
- 20% excreted by bowel & sweat
POTASSIUM cont.
Function/Pathophysiology
- Helps maintain intracellular osmolality
- Is necessary in the regulations of skeletal, cardiac and smooth muscle activity
- Necessary for neuromuscular control
- An active part of many Intracellular enzyme reactions
- Influences acid – base balance
Potassium cont.
Hypokalemia
- < 3.5 mEq/L
- Potentially life threatening because every body system can be affected.
ASSESSMENT
History
- Age
- Drugs
- Other factors
Causes (table 16-1)
- inadequate K+ intake (NPO)
Physical Assessment/ Clinical Manifestations
Musculoskeletal
Respiratory
Cardiovascular
Neurological
Gastrointestinal
Page 228 (chart 16-1)
LABORATORY ASSESSMENT
Lab / Diagnostic values
- serum K+ < 3.5 mEq/L
- EKG changes:
- PVCs
- Flat or inverted T wave
- Depressed ST segment
INTERVENTIONS
Drugs
- Potassium supplements
- K+ chloride
- K+ gluconate
- K+ citrate
* Take with food
Drugs Cont.
Spironolactone (Aldactone)
- potassium sparing diuretic
Aldosterone antagonist (losss of Na+ & H2O and retention of K+
- Nursing Implications
strict I & O
check K+ level
Drugs cont.
- avoid foods rich in K+
- weigh daily
Triamterene (dyrenuim)
amiloride (midamor)
page 229
Diet Therapy
What are some good sources of potassium?
MANAGEMENT
INTERVENTIONS
- Treat underlying cause
- Replace K+
- Medications
PO (give with food)
IV
Management cont.
IV POTASSIUM
- Must be diluted
- Cannot be give IV push
- Should be administered with IV controller
EXPECTED OUTCOMES
HYPERKALEMIA
Serum K+ elevated ( greater 5.0 mEq/L)
Pathophysiology
Common Causes (table 16-2 page 231)
ASSESSMENT AND
MANIFESTATIONS
Chart 16 – 4 page 232
Cardiovascular
Respiratory
Gastrointestinal
LABORATORY
ASSESSMENT
Lab/ Diagnostic values
- serum K+ increase
- EKG changes
- usually do not occur until serum K+ reaches 7.0 mEq/L
DIETARY MANAGEMENT
Page 233 (chart 16-6)
Foods to avoid
Foods may eat
MANAGEMENT AND
INTERVENTIONS
Watch for S/S of overcorrection
History & physical exam
Lab/Diagnostic results
- Serum K+
- other electrolytes
- EKG changes
MANAGEMENT Cont.
Kayexalate
- Cation exchange resin
- usually given as retention enema
- May be given PO or via NGT
- Often combine with SORBITOL to induce diarrhea
- May bind with other cations in the GI tract & contribute to loss of magnesium & CA+
Page 233
MANAGEMENT Cont.
Restrict potassium
Medications
- Calcium gluconate
- IV glucose & insulin
- Sodium bicarbonate
INTERVENTIONS
Follow – up therapy
Teaching
Expected Outcomes
SODIUM IMBALANCES
Hyponatremia
- Serum NA+ less 135 mEq
Pathophsiology
Assessment (page 234 chart 16-7)
- Cerebral
- Cardiovascular
- Respiratory
ASSESSMENT cont.
- Neuromuscular
- Renal
- Gastrointestinal
CAUSES
page 234 table 16-3
Decreased sodium intake
Excessive losses
Sodium dilution
INTERVENTIONS
Drug Therapy
- IV saline infusions
- 3% to 5% saline
- osmotic diuretic (excretion H20 rather than sodium)
- Mannitol (osmitrol)
Drug cont.
Mannitol
- Nursing Implications
-Do not give lyte-free mannitol with blood.
-Use filter if giving concentrated mannitol.
DIET THERAPY
Increase oral NA+ intake
Restrict oral fluid intake
Table salt 2000 mg ( 1 tsp)
What are some food high in sodium?
HYPERNATREMIA
Pathophysiology
- Serum sodium level over 145 mEq/L
- Caused by or can cause changes in fluid volume
Causes (page 236 table 16-4)
ASSESSMENT
Central Nervous System
Neuromuscular
Cardiovascular
INTERVENTIONS
Drugs
- IV D5W
- Loop diuretic
- Lasix (furosemide)
- Bumex (bumetanide)
- Edecrin (ethacrynic)
Drugs cont.
Nursing Implications
- Strict I & O
- weigh daily
- check K+ level
- assess for edema
DIET THERAPY
Adequate water intake
Collaborate with dietitian
CAUSES
Excessive sodium intake
Decreased extracellular water
- increased water loss
- decreased water intake
MANIFESTATIONS
Lab / Diagnostic values
Signs / Symptoms
- Thirst
- Renal
- CV
- Neuromuscular
- Skin / mucous membranes
MANAGEMENT
Assessment
Lab / Diagnostic values
History & physical exam
Presence of, and changes in S/S
Indications of overcorrection
MANAGEMENT cont.
Interventions
- Treat underlying cause
- Restrict sodium in food, beverages & meds
Hypernatremia with water loss
- Hypotonic saline IV
(DANGER OF LOWERING TOO QUICKLY)
- DDAVP ( desmopressing acetate) if diabetes insipidus)
TEACHING
NURSING DIAGNOSES
CALCIUM IMBALANCES
Hypocalcemia ( less 9.0 mg / dL)
Etiology
- Actual
- Increase calcium excretion
- Relative calcium deficits
- Endocrine Disturbances
ASSESSMENT
Central nervous system
Neuromuscular
Cardiovascular
Gastrointestinal
INTERVENTIONS
Drugs
- IV volume expanders (0.9% NS)
- CA+ Carbonate
- CA+ Citrate
- CA+ Gluconate
- CA+ Lactate
Oral medications
Drugs cont.
IV medications
- CA+ Acetate
- CA+ Chloride
- CA+ Gluconate
Administer slowly
Monitor EKG
Assess IV site
DIET
High calcium diet
Collaborate with dietitian
NURSING DIAGNOSES
High risk for injury RT pressure
HYPERCALCEMIA
Serum calcium level greater than 10.5 mg/dL
CAUSES
- Actual CA+ excesses
- Decreased CA+ excretion
- Relative CA+ excesses
- Hemoconcentration
ASSESSMENT
Page 241 chart 16 – 13
Cardiovascular
Neuromuscular
Intestinal
Renal
INTERVENTIONS
Drug Therapy
- Loop diuretic
- Calcium binders
- Mithracin (plicamycin)
- penicillamine (Cuprimine)
- Inhibit CA+ resorption from bone
- phosphorus
- calcitonin (calcimar)
DRUGS cont.
Prostaglandin synthesis inhibitors
- ASA
- NSAI (non-steriodial antiinflammatory drugs)
DIALYSIS
MAGNESIUM
Hypomagnesemia
- Serum Magnesium ( levels below 1.2 mg/dL
- Pathophysiology
- Causes (page 243 table 16-8)
ASSESSMENT
Neuromuscular
Central nervous system
Gastrointestinal
INTERVENTIONS
HYPERMAGNESEMIA
Serum level exceeds 2.0 mg /dL
ASSESSMENT
Cardiac
- bradycardia
- peripheral vasodilation
- hypotension
- EKG changes
Central nervous system
- drowsy / lethargic
- coma
ASSESSMENT cont.
Neuromuscular
- Deep tendon reflexes reduced or absent
- muscle weakness
Respiratory muscle weakness can lead to respiratory failure & death.
INTERVENTIONS
Goal
- Reduce Mg level
- Correct underlying problem
Drugs
Loop diuretics ( Lasix)
Avoid drugs that increase Mg (antacids, laxatives or enemas)
PSYCHOSOCIAL
INTERVENTIONS
INTERVENTIONS cont.
Diet Therapy
- Limit meat
- nuts
- legumes
- fish
- vegetables
- whole-grain cereal products
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