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Name: laxmi thapa & ravisha pokhrel
B.sc nursing 3rd yearCollege of medical
sciences, bharatpur
Help maintain body temperature and cell shape Helps transport nutrients gases and wastes
The desirable amount of fluid intake and loss in adults ranges from 1500 to 3500 mL each 24 hours. Ave= 2500 mL
Normally INTAKE = OUTPUTFLUID IMBALANCEFLUID IMBALANCE
• Changes in ECF volume = alterations in sodium balance• Change in sodium/water ratio = either hypoosmolarity or hyperosmolarity• Fluid excess or deficit = loss of fluid balance• As with all clinical problems, the same pathophysiologic change is not of
equal significance to all people• For example, consider two persons who have the same viral syndrome with
associated nausea and vomiting
It is an abnormally decreased or increased fluid volume or rapid shift from one compartment of body fluid to anotherHypovolemiaHypervolemia
• May occur as a result of:May occur as a result of:• Reduced fluid intakeReduced fluid intake• Loss of body fluidsLoss of body fluids• Sequestration (compartmentalizing) of Sequestration (compartmentalizing) of
body fluidsbody fluids PathophysiologyPathophysiology
DECREASED FLUID VOLUMEDECREASED FLUID VOLUME
Stimulation of Stimulation of thirst center in thirst center in hypothalamushypothalamus
Person complains of Person complains of thirstthirst
↑ ↑ ADH SecretionADH Secretion
↑ ↑ Water resorptionWater resorption
↓ ↓ Urine OutputUrine Output
Renin-Angiotensin-Renin-Angiotensin-Aldosterone System Aldosterone System
ActivationActivation
↑ ↑ Sodium and Sodium and Water ResorptionWater Resorption
↑ ↑ Urine specific gravity except Urine specific gravity except with osmotic diuresiswith osmotic diuresis
acute weight lossOliguriaLow bpSunken eyesDizzinessWeaknessDecreased skin turgorConcentrated urine
• Fluid Management• Oral rehydration therapy – Solutions
containing glucose and electrolytes. E.g., Pedialyte, Rehydralyte.
• IV therapy – Type of fluid ordered depends on the type of dehydration and the clients cardiovascular status.
• Diet therapy – Mild to moderate dehydration. Correct with oral fluid replacement.
Monitor & measures fluids at least every 8 hours and sometimes hourly
Monitor daily body weightMonitor vital signsObserve for weak, rapid pulse and
orthostatic hypotensionMonitor urine concentration by
measuring urine specific gravityAssess degree of oral and mucous
membrane moisture
To prevent hypovolemia, the nurse identifies patient at risk and takes measures to minimize fluid loss. For ex: the patient has diarrhoea, measures should be implemented to control diarrhoea and replacement fluid administered. This includes antidiarrheal medication and small volume of oral fluids at frequent intervals
It refers to an isotonic expansion of the ECF caused by abnormal retention of water and sodium in approximately the same proportion in which they normally exist in the ECF.
It is most often secondary to an increase in total body water.
Common Causes:Congestive Heart FailureEarly renal failureIV therapyExcessive sodium ingestionSIADHCorticosteroid
Signs/SymptomsIncreased BPWeight gainBounding pulseVenous distentionPulmonary edema
DyspneaOrthopnea (diff. breathing when
supine)crackles
Pharmacological therapyDiuretics such as thiazide diuretics and
loop diureticsThiazide diuretics: hydrochlorothiazideLoop diuretics: furosemide, torsemidePotassium supplement
I/O chart at regular intervals to identify excessive fluid retention
Breath sound are assessed at regular intervals in at risk patient particularly if parenteral fluid are being administered
Monitor the degree of edema in most dependent parts of body such as feet & ankles
If renal function is so severely impaired that pharmacologic agents cannot act efficiently, other modalities are considered to remove sodium and fluid from the body. Haemodialysis or peritoneal dialysis may be used to remove nitrogenous wastes and control potassium and acid base balance and to remove sodium and fluid. Continuous renal replacement therapy may also be required
IF it is important to detect FVE before the condition become severe. Intervention include promoting rest, restricting sodium intake , monitoring parenteral fluid therapy and administering appropriate medications
Regular rest periods may be beneficial because bed rest favours diuresis of fluid
Sodium and fluid restriction should be instituted as indicated
Fowlers position should be maintain to promote lung expansion
• Controls and regulates volume of body fluidsControls and regulates volume of body fluids
• Its concentration is the major determinant of ECF volumeIts concentration is the major determinant of ECF volume
•Participates in the generation and transmission of nerve Participates in the generation and transmission of nerve impulsesimpulses
• Eliminated primarily by the kidneys, smaller in feces Eliminated primarily by the kidneys, smaller in feces
• Salt intake affects sodium concentrationsSalt intake affects sodium concentrations
• Sodium is conserved through reabsorption in the kidneys, a Sodium is conserved through reabsorption in the kidneys, a process stimulated by aldosteroneprocess stimulated by aldosterone
• Normal value: 135-145 mEq/LNormal value: 135-145 mEq/L
Refers to the serum sodium concentration less than 135 mEq/L
Common with thiazide diuretic use, but may also be seen with loop and potassium-sparing diuretics as well
Occurs with marked sodium restriction, vomiting and diarrhea, SIADH, etc. The etiology may be mulfactorial
May also occur postop due to temporary alteration in hypothalamic function, loss of GI fluids by vomiting or suction, or hydration with nonelectrolyte solutions
Postoperative hyponatremia is a more serious complication in premenopausal women. The reasons behind this is unknown
Therefore monitoring serum levels is critical and careful assessment for symptoms of hyponatremia is important for all postoperative patients
Sodium loss from the intravascular compartmentSodium loss from the intravascular compartment
Diffusion of water into the interstitial spacesDiffusion of water into the interstitial spaces
Sodium in the interstitial space is dilutedSodium in the interstitial space is diluted
Decreased osmolarity of ECFDecreased osmolarity of ECF
Water moves into the cell as a result of sodium lossWater moves into the cell as a result of sodium loss
Water moves into the cell as a result of sodium lossWater moves into the cell as a result of sodium loss
Extracellular compartment is depleted of waterExtracellular compartment is depleted of water
CLINICAL SYMPTOMSCLINICAL SYMPTOMS
Muscle Weakne
ss
APATHY
Postural hypoten
sion
Nausea andAbdomi
nal Cramps
Weight Loss
In severe hyponatremia: mental confusion, delirium, shock and comaIn severe hyponatremia: mental confusion, delirium, shock and coma
Contributing FactorsExcessive diaphoresisWound DrainageNPOCHFLow salt dietRenal DiseaseDiuretics
Assessment findings: Neuro - Generalized skeletal muscle weakness.
Headache / personality changes.Resp.- Shallow respirationsCV - Cardiac changes depend on fluid volumeGI – Increased GI motility, Nausea, Diarrhea
(explosive)GU - Increased urine output
Plasma osmolality:2Na + glucose/18 + BUN/2.8
Interventions/TreatmentRestore Na levels to normal and prevent
further decreases in Na.Drug Therapy –
(FVD) - IV therapy to restore both fluid and Na. If severe may see 2-3% saline.
(FVE) – Administer osmotic diuretic (Mannitol) to excrete the water rather than the sodium.
Increase oral sodium intake and restrict oral fluid intake.
• A serum sodium level above 145 mEq/L is A serum sodium level above 145 mEq/L is termed hypernatremiatermed hypernatremia
• May occur as a result of fluid deficit or May occur as a result of fluid deficit or sodium excesssodium excess
• Frequently occurs with fluid imbalanceFrequently occurs with fluid imbalance• Develops when an excess of sodium occurs Develops when an excess of sodium occurs
without a proportional increase in body without a proportional increase in body fluid or when water loss occurs without fluid or when water loss occurs without proportional loss of sodiumproportional loss of sodium
• Risk Factors: excess dietary or parenteral Risk Factors: excess dietary or parenteral sodium intake, watery diarrhea, diabetes sodium intake, watery diarrhea, diabetes insipidus, damage to thirst center, too insipidus, damage to thirst center, too young, too old, those with physical or young, too old, those with physical or mental status compromise, and people with mental status compromise, and people with hypothalamic dysfunctionhypothalamic dysfunction
Increased Sodium concentration in ECFIncreased Sodium concentration in ECF
Osmolarity risesOsmolarity rises
Water leaves the cell by osmosis and enters Water leaves the cell by osmosis and enters the the extracellular compartmentsthe the extracellular compartments
Dilution of fluids in ECFDilution of fluids in ECF Cells are water depletedCells are water depleted
Suppression of aldosterone Suppression of aldosterone secretionsecretion
Sodium is exreted in the Sodium is exreted in the urineurine
CLINICAL SYMPTOMSCLINICAL SYMPTOMS
Dry, sticky Dry, sticky mucous mucous
membranesmembranes
Firm, rubbery Firm, rubbery tissue turgortissue turgor
Manic Manic excitementexcitement
TachycardiaTachycardiaDEATHDEATH
Assessment findings: Neuro - Spontaneous muscle twitches.
Irregular contractions. Skeletal muscle wkness. Diminished deep tendon reflexes
Resp. – Pulmonary edemaCV – Diminished CO. HR and BP depend
on vascular volume. GU – Dec. urine output. Inc. specific
gravity Skin – Dry, flaky skin. Edema r/t
fluid volume changes.
Interventions/TreatmentDrug therapy Lowering of serum sodium level by
infusion of hypotonic electrolyte solutionDiuretics also may be prescribed to treat
sodium gainDesmopressin acetate to treat diabetes
insipidus if it is cause of hypernatremiaDiet therapy
Mild – Ensure water intake
The nurse should assess for abnormal looses of water or low water intake and for large gains of sodium as might occur with ingestion of OTC medication that have high sodium content
The nurse should obtain a medication history, because some prescription medications have a high sodium content
The nurse also notes the patients thirst or elevated body temperature and evaluates it in relation to other clinical sign and symptoms
The more K, the less Na. The less K, the more NaThe more K, the less Na. The less K, the more Na
• Plays a vital role in such processes such as transmission of Plays a vital role in such processes such as transmission of electrical impulses, particularly in nerve, heart, skeletal, electrical impulses, particularly in nerve, heart, skeletal, intestinal and lung tissue; CHON and CHO metabolism; and intestinal and lung tissue; CHON and CHO metabolism; and cellular building; and maintenance of cellular metabolism and cellular building; and maintenance of cellular metabolism and excitationexcitation
• Assists in regulation of acid-base balance by cellular Assists in regulation of acid-base balance by cellular exchange with Hexchange with H
•Sources: bananas, peaches, kiwi, figs, dates, apricots, Sources: bananas, peaches, kiwi, figs, dates, apricots, oranges, prunes, melons, raisins, broccoli, and potatoes, meat, oranges, prunes, melons, raisins, broccoli, and potatoes, meat, dairy productsdairy products
•Normal value: 3.5 – 5 mEq/LNormal value: 3.5 – 5 mEq/L
Serum level is below 3.5 meq/l (3.5 mmol/L) usually indicates a deficit in potassium store
= Action Potential= Action Potential
Nerve and Muscle ActivityNerve and Muscle Activity
Low Low Extracellular Extracellular
K+K+
Increase in Increase in resting resting
membrane membrane potentialpotential
The cell The cell becomes less becomes less
excitableexcitable
Sodium is retained in the body through resorption by the Sodium is retained in the body through resorption by the kidney tubuleskidney tubules
Potassium is excretedPotassium is excreted
Aldosterone is secretedAldosterone is secreted
Use of certain diuretics such as thiazides and furosemide, and corticosteroidsUse of certain diuretics such as thiazides and furosemide, and corticosteroids
Increased urinary outputIncreased urinary output
Loss of potassium in urineLoss of potassium in urine
Administration od 40- 80 meq/day of potassium is adequate in adult if there are no abnormal losses of potassium
Dietary intake of potassium in average adult is 50-100meq/day
When dietary intake is inadequate for any reason, oral or IV potassium supplements may be prescribed
The nurse needs to monitor for its early presence in patients at risk
Fatigue, anorexia, muscle weakness, decreased bowel motility, paraesthesia and dysrhythmias are signal that warrant assessing the serum potasium concentration
InterventionsAssess and identify those at riskEncourage potassium-rich foodsK+ replacement (IV or PO)Monitor lab valuesD/c potassium-wasting diureticsTreat underlying cause
Serum potassium level greater than 5meq/L
Less common than hypokalaemia , but it is usually dangerous
Contributing factors: Increase in K+ intakeRenal failureK+ sparing diureticsShift of K+ out of the cells
In non acute situations, restriction of dietary potassium and potassium containing medications may correct the imbalance
Administration either orally or by retention enema of cation exchange resins
EMERGENCY PHARMACOLOGIC THERAPYEMERGENCY PHARMACOLOGIC THERAPY If serum potassium level are dangerously
elevated, it may be necessary to adm. IV calcium gluconate
Monitor blood pressure
Patients at risk for potassium excess need to be identified and closely monitored for signs of hyperkalemia
Nurse should monitor I/O and observe for signs of muscle weakness and dysrythmias
Serum potassium level as well as BUN , creatinine, glucose & arterial blood gas values are monitored for patient at risk for developing hyperkalemia
InterventionsNeed to restore normal K+ balance:Eliminate K+ administrationInc. K+ excretion
LasixKayexalate (Polystyrene sulfonate)
Infuse glucose and insulinCardiac Monitoring
HYPOCHLOREMIA is a serum chloride level below 97meq/L (97mmol/L)
Irritability Tremors Muscle cramps Hyperactive deep tendon reflexes Slow shallow respiration Coma seizures
Correcting the cause of hypochloremia and contributing electrolytes and acid-base imbalances
Normal saline (0.9% sodium chloride) or half strength saline(0.45% sodium chloride) solution is administered by IV to replace the chloride
Monitor the patient I/O, arterial blood gas values and serum electrolyte levels
Changes in pts level of consciousness, muscle strength and movement and reported to the physician promptly
Vital signs are monitored and respiratory assessment is carried out frequently
Educate the pt about food with high chloride content which include tomato juice, banana, eggs, cheese etc
Serum level of chloride exceeds 107 meq/L
Hypernatremia, bicarbonate loss and metabolic acidosis can occur with high chloride levels
TachypneaWeaknessLethargyDeep and rapid respirationHypertensionDimnished cognitive ability If untreated it leads to:If untreated it leads to: Decrease in cardiac output, Decrease in cardiac output,
dysrhythmias and comadysrhythmias and coma
Correcting the cause of underlying cause of hyperchloremia and restoring electrolyte fluid and acid base balance are essential
Hypotonic IV solution may be administered to restore balance
Lactated ringers solution may be prescribed to convert lactate to bicarbonate in liver
Diuretics may be administered to eliminate chloride as well
Sodium chloride and fluid are restricted
Monitoring vital sign , arterial blood gas values and I/O is important to assess the patients status and the effectiveness of treatment
Assessment findings related to respiratory, neurologic and cardiac systems are documented and changes are discussed with physician
Educate about the diet
More than 90% of body’s calcium is located in the skeletal system
The normal total serum calcium level is 8.6-10.2 mg/dl (2.2 to 2.6 mmol/L)
The serum calcium value lower than 8.6mg/dl
Occurs in variety of clinical situation Older people and those with disabilities,
who spend on increased amount of time in bed have an increased risk of hypocalcaemia because bed rest increases bone resorption
Contributing factors:Dec. oral intakeLactose intoleranceDec. Vitamin D intakeEnd stage renal diseaseDiarrhea
Contributing factors (cont’d):Acute pancreatitisHyperphosphatemiaImmobilityRemoval or destruction of parathyroid gland
Numbness Tingling of finger, toes and circumoral
region Anxiety Hyperactive deep tendon reflex Bronchospasm diarrhoea
Assessment findings: Neuro –Irritable muscle twitches.
Positive Trousseau’s sign. Positive Chvostek’s sign.
Resp. – Resp. failure d/t muscle tetany.CV – Dec. HR., dec. BP, diminished
peripheral pulsesGI – Inc. motility. Inc. BS. Diarrhea
Interventions/TreatmentDrug Therapy
Calcium supplements Vitamin D
Diet Therapy High calcium diet
Prevention of Injury Seizure precautions
Status of airway is clearly monitored Safety precaution to be taken if
confusion is present Educate the patient about
hypocalcemia, and calcium containing foods like milk, yogurt, cheese, sea fruit, legumes, fruits
Avoid overuse of laxatives and antacids
serum calcium value greater than 10.2 mg/dl
It is a dangerous imbalance when severe infact, hypercalcemic crisis has a mortality rate as high as 50% if not treated promptly
Contributing factors:Excessive calcium intakeExcessive vitamin D intakeRenal failureHyperparathyroidismMalignancyHyperthyroidism
Muscular weakness Constipation Anorexia Nausea & vomiting Dehydration Hypoactive deep tendon reflexes Calcium stones
Assessment findings:Neuro – Disorientation, lethargy, coma, profound
muscle weaknessResp. – Ineffective resp. movementCV - Inc. HR, Inc. BP. , Bounding peripheral pulses,
Positive Homan’s sign. Late Phase – Bradycardia, Cardiac arrestGI – Dec. motility. Dec. BS. ConstipationGU – Inc. urine output. Formation of renal calculi
Interventions/TreatmentEliminate calcium administrationDrug Therapy Isotonic NaCL (Inc. the excretion of Ca)DiureticsCalcium reabsorption inhibitors
(Phosphorus)Cardiac Monitoring
Increasing patient mobility and encouraging fluids
Encourage to drink 2.8 to 3.8L of fluid daily
Adequate fiber in diet is encouraged Safety precaution are implemented
It is indicated by value below 2.5 mg/dl
Contributing Factors:MalnutritionStarvationHypercalcemiaRenal failureUncontrolled DM
Paresthesia Muscle weakness Bone pain & tenderness Chest pain Confusion Cardiomyopathy Seizures Tissue hypoxia
Assessment findings: on lab analysis, serum phosphate level is less than 2.5 mg/L
Serum magnesium may be decreased due to increased urinary excretion of magnesium
X-ray may show skeletal changes of rickets
MANAGEMENTTreat underlying causeOral replacement with vit. D IV phosphorus (Severe)Serum phosphate level should be closely
monitoredDiet therapy
Foods high in oral phosphate
Identify the patient at risk for hypophosphatemia
Close monitoring of patient Vital signs and monitor serum
phosphorous level Check the level of consciousness Health education
Serum phosphorus level that exceeds 4.5mg/dl (1.45 mmol/L)
Tetany Tachycardia Anorexia Nausea & vomiting Muscle weakness Hyperactive reflexes
Administration of vit.D such as calcitriol which is available both oral ( Rocaltrol) & parenteral ( Calajex, paricalcitol forms)
Calcium binding antacids Administration of amphojel with meals Restriction of dietary phosphate, forced
diuresis with loop diuretics volume replacement with saline
Surgery may be indicated for removal of large calcium and phosphorus deposits
Dialysis may also lower phosphorus
The nurse monitor patient at risk for hyperphosphatemia
If low phosphorus diet is prescribed, patient is instructed to avoid phosphorus rich food such as hard cheese, cream, nuts, meats etc
Nurse instruct patient to avoid phosphate containing laxatives and enemas
Monitoring for chnages in urine output
HYPOMAGNESEMIAHYPOMAGNESEMIA Refers to below normal serum Refers to below normal serum
magnesium concentration 1.3mg/dl magnesium concentration 1.3mg/dl (0.62 mmol/L)(0.62 mmol/L)
It is frequently associated with It is frequently associated with hypokalemiahypokalemia
Contributing factors:MalnutritionStarvationDiureticsAminoglcoside antibioticsHyperglycemia Insulin administration
Neuromuscular irritability Mood changes Anorexia Vomiting Increased bp Increased deep tendon reflex insomnia
Assessment findings:*Neuro - Positive Trousseau’s sign. Positive Chvostek’s sign. Hyperreflexia. Seizures*CV – ECG changes. Dysrhythmias. HTN*Resp. – Shallow resp.*GI – Dec. motility. Anorexia. Nausea
Mild magnesium deficiency can be corrected by diet alone
Magnesium salt can be administered orally in an oxide or gluonate form
Vital signs must be assessed frequently Calcium gluconate must be readily
available to treat IV.mgso4
Observe for its sign and symptom Safety precaution are institued Due to dysphagia, patient should be
screened Health education
Serum magnesium level higher than 2.3 mg/dl
It is a rare electrolyte abnormality because kidney efficiently excrete magnesium
Contributing factors: Increased Mag intakeDecreased renal excretion
Flushing Hypotension Muscle weakness Drowsiness Depressed respiration Cardiac arrest diaphoresis
Assessment findings:serum magnesium level is greater than 2.3mg/dlcreatinine clearance decreases to less than 3.0ml/min
ECG finding: prolonged PR interval : tall T waves : widened QRS
Administration of magnesium Ventilatory support IV calcium gluconate Administration of loop diuretics and
sodium chloride Administration of lactated ringers IV
solution
Risk for hypermagnesemia are identified and assessed
Monitor vital signs, noting hypotension and shallow respiration
Observe for decreased deep tendon reflex and changes in level of consciousness
Caution is essential when preparing and medicating magnesium containing fluid parenterally