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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