Interventions for Clients

with Fluid and Electrolyte imbalances

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Body Fluid Compartments

• 2/3 (65%) of TBW is intracellular (ICF)

• 1/3 extracellular water– 25 % interstitial fluid (ISF)

– 5- 8 % in plasma (IVF intravascular fluid)

– 1- 2 % in transcellular fluids – CSF, intraocular fluids, serous membranes, and in GI, respiratory and urinary tracts (third space)

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• Fluid compartments are separated by membranes that are freely permeable to water.

• Movement of fluids due to:– hydrostatic pressure

– osmotic pressure\

• Capillary filtration (hydrostatic) pressure

• Capillary colloid osmotic pressure

• Interstitial hydrostatic pressure

• Tissue colloid osmotic pressure

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Balance• Fluid and electrolyte homeostasis is

maintained in the body

• Neutral balance: input = output

• Positive balance: input > output

• Negative balance: input < output

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Solutes – dissolved particles• Electrolytes – charged particles

– Cations – positively charged ions

• Na+, K+ , Ca++, H+

– Anions – negatively charged ions

• Cl-, HCO3- , PO4

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• Non-electrolytes - Uncharged • Proteins, urea, glucose, O2, CO2

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Regulation of body water• ADH – antidiuretic hormone + thirst

– Decreased amount of water in body– Increased amount of Na+ in the body– Increased blood osmolality– Decreased circulating blood volume

• Stimulate osmoreceptors in hypothalamusADH released from posterior pituitaryIncreased thirst

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Result:increased water consumptionincreased water conservation

Increased water in body, increased volume and decreased Na+ concentration

Fluid Volume Excess

Occurs when the body retains both water and sodium in similar proportions to normal ECF. It is also called hypervolemia.

Common causes include:-- Excessive intake of sodium chloride- Administering sodium-containing infusions too rapidlyDisease processes that alter regulatory mechanisms such as heart failure, renal failure.

Edema Excess interstitial fluid.

Edema typically is most apparent in areas where the tissue pressure is low, such as around the eyes, and in dependent tissues (known as dependent edema), where hydrostatic capillary pressure is high.

Pitting edema: edema that leaves a small depression or pit after finger pressure is applied to the swollen area.

Electrolyte Imbalances

RISK FACTOR

Loss of sodium, as in:

Loss of GI .fluids

Use of diuretics

Gains of water, as in:

Excessive administration of

D5W

Water intoxication

Disease states associated with

SIADH (a form of

hyponatremia)

Pharmacologic agents that

may impair water excretion

Assessments

Anorexia

Nausea and vomiting

Lethargy

Confusion

Muscle cramps

Fingerprinting over sternum

Muscular twitching

Seizures

Coma

Serum Na below 135 mEq/L

Urine specific gravity <1.010

Nursing interventions-Monitor fluid losses and gains.-Monitor for presence of GI and CNS symptoms.- Monitor serum Na levels.- Check urine specific gravity.-If able to eat, encourage foods and fluids with high sodium content.-Be aware of sodium content of common-IV fluids.-Avoid giving large water supplements to-Patients receiving isotonic tube feedings.-Take seizure precautions when hyponatremia is severe

Hyponatremia

RISK FACTOR

Water deprivation

Increased sensible and

insensible water loss

Ingestion of large amount of

salt

Excessive parenteral

administration of sodium-

containing solutions

Profuse sweating

Diabetes insipidus

Assessments

Thirst

Elevated body temperature

Tongue dry and swollen,

sticky mucous Membranes

Severe hypernatremia

Disorientation

Hallucinations

Irritable and hyperactive

Focal or grand mal seizures

Coma

Serum Na above 145 mEq/L

Urine specific gravity

>1.015

Nursing interventions- Monitor fluid losses and gains.- Observe for excessive intake of high sodium foods.- Monitor for changes in behavior such as restlessness, lethargy, and disorientation.- Look for excessive thirst and elevated body temperature.- Monitor serum Na levels.- Check urine specific gravity.- Give sufficient water with tube feedings to Keep serum Na and BUN at normal limits.

Hypernatremia

RISK FACTORDiarrheaVomiting or gastric suctionPotassium-wasting diureticsPoor intake as in anorexia nervosa,alcoholism, potassium-freeparenteral .fluidsPolyuria

AssessmentsFatigueAnorexia, nausea, and vomitingMuscle weaknessDecreased bowel motilityCardiac arrhythmiasPolyuria, nocturia, dilute urinePostural hypotensionSerum K below 3.5 mEq/LECG changesT waves flattening and ST segment depression on ECG

Nursing interventions- Monitor for occurrence of Hypokalemia.- Prevent Hypokalemia by:- Encouraging extra K intake if possible- Educating about abuse of laxatives and diuretics-Administer oral K supplements if ordered.- Be knowledgeable about danger of IV potassium administration.

Hypokalemia

RISK FACTORDecreased potassium excretion:Oliguric renal failurePotassium-sparing diureticsHigh potassium intake, especiallyin presence of renal insufficiencyShift of potassium out of cells into the plasma(acidosis, tissue trauma, infection, burns)

AssessmentsVague muscle weaknessCardiac arrhythmiasParesthesias of face, tongue, feet, andhandsFlaccid muscle paralysisGI symptoms such as nausea, intermittent intestinal colic, or diarrhea may occurSerum K above 5.0 mEq/LPeaked T waves, widened QRS on ECG

Nursing interventionsMonitor for hyperkalemia, which is life threatening.Prevent hyperkalemia by:Following rules for safe administration of KAvoiding giving patients with renal insufficiency K-saving diuretics, K supplements,or salt substitutesCautioning about foods high in potassium content

Hyperkalemia

RISK FACTORSurgical hypoparathyroidismMalabsorption Vitamin D deficiencyAcute pancreatitisExcessive administration of citrated bloodAlkalotic states

AssessmentsTrousseau’s and Chvostek’s signsNumbness and tingling of fingers and toesMental changesSeizuresSpasm of laryngeal musclesECG changesCramps in muscles of extremitiesTotal serum calcium <8.5 mg/dL

Nursing interventionsTake seizure precautions when hypocalemia is severe.Monitor condition of airway.Take safety precautions if confusion is present.Educate people at risk for osteoporosis about need for dietary calcium intake.Discuss calcium-losing aspects of nicotine and alcohol use.

Hypocalcaemia

Hypocalcemia

Hypocalcemia

A positive Trousseau's signMuscular contraction including flexion of the wrist and metacarpophalangeal joints, hyperextension of the fingers and flexion of the thumb on the palm

A positive Chvostek's sign.Twitching or contraction of the facial muscles produced by tapping on the facial nerve at specific point

RISK FACTORHyperparathyroidismMalignant neoplastic diseaseProlonged immobilizationLarge doses of vitamin DOveruse of calcium supplementsThiazide diuretics

AssessmentsMuscular weaknessTiredness, lethargy , ConstipationAnorexia, nausea, and vomitingDecreased memory and attention spanPolyuria and polydipsiaRenal stonesCardiac arrestSerum calcium >10.5 mg/dL

Nursing interventionsIncrease mobilization when feasible.Encourage sufficient oral intake.Discourage excessive consumption of milk products.Encourage bulk in the diet.Take safety precautions if confusion is presentBe alert for signs of digitalis toxicity in Hypercalcaemia patients.Force fluids to prevent formation of renal stones.

Hypercalcaemia

Hypercalcemia

Hypomagnesemia Signs/symptoms Causes