MODULE 10  Water lost through the skin and lungs is known as insensible loss

Lesson 45: Fluid and Electrolyte Imbalances because the individual is unaware of losing that water. Between 600
and 800 mL/day is lost through the skin and 400 to 600 mL/day
 Body Fluid through the lungs.
 Gastrointestinal loss accounts for 100 mL/day.
Description  About 1500 mL/day is lost through the kidneys.
 Body fluid transports nutrients to cells and carries waste products
from cells.  Maintaining Fluid and Electrolyte Balance
 Body fluid accounts for about 60% of the body's weight.
 A loss of 10% of body fluid in the adult is serious; loss of 20% is fatal.  A deficiency of fluids or electrolytes must be made up for normally,
 The largest single fluid constituent of the body is water. through intake of food and water; or by means of therapy, such as
intravenous (IV) infusions and medications.
 Body-Fluid Compartments  When the client has an excess of fluid or electrolytes, therapy is
directed toward helping the body eliminate that excess.
 To function normally, body cells must have fluids and electrolytes in  The kidneys play a major role in controlling fluid and electrolyte
the right compartments and in the right amounts; whenever an balance.
electrolyte moves out of a cell, another electrolyte moves in to take  The adrenal glands help control extracellular fluid volume by
its regulating the amount of sodium reabsorbed by the kidneys.
place.  Antidiuretic hormone (ADH) from the pituitary gland regulates the
 The intracellular compartment consists of the fluid inside cells. osmotic pressure of extracellular fluid by regulating the amount of
 The extracellular compartment comprises the fluid outside cells. water reabsorbed by the kidneys.
 The intravascular (plasma) compartment contains the fluid within
blood vessels.  Fluid-Volume Deficit
 Interstitial fluids are the fluid between cells and blood vessels.
 Compartments are separated by semipermeable membranes. Description
 Fluid-volume deficit is the term given to an insufficient amount of
 Fluid Imbalances body fluid.
 The goal of treatment is to restore fluid volume, replace electrolytes
Third-Spacing as needed, and eliminate the cause of the deficit.
 Extracellular fluid accumulates and is sequestered in an actual or  May be caused by inadequate intake of fluids.
potential body space (pericardial, pleural, peritoneal, joint cavities,  Use of diuretics can lead to a fluid deficit.
bowel, soft tissues) as a result of disease or injury.  Conditions that increase fluid loss (e.g., hemorrhage, excessive
 Trapped fluid represents a volume loss because it is unavailable for perspiration, vomiting, diarrhea, gastrointestinal suctioning or
normal physiological processes. drainage, third-space fluid shifts, ketoacidosis, diabetes insipidus)
 Assessing intravascular fluid loss is difficult; it may not be reflected increase the risk of fluid-volume deficit.
in weight changes or intake-and-output records and may not
become apparent until after organ malfunction occurs. Nursing Considerations
 Be aware of the signs and symptoms of fluid-volume deficit.
Edema  Increased temperature
 Edema is the excessive accumulation of fluid in interstitial spaces.  Thready, rapid pulse
 Localized edema occurs as a result of traumatic injury sustained  Decreased blood pressure and postural hypotension
during accidents or surgery, local inflammatory processes, or burns.  Increased rate and depth of respirations
 Generalized edema, also called anasarca, is an excessive  Dryness, poor turgor, and tenting of skin
accumulation of fluid in the interstitial space throughout the body as  Thirst
a result of a condition such as cardiac, renal, or hepatic failure.  Decreased urine output with increased specific gravity
 Diminished peripheral pulses
Intake and Output  Flat neck and hand veins
Intake  Altered level of consciousness
 Water enters the body by way of three sources: oral liquids, water in  Decreased central venous pressure
foods, and water formed by the oxidation of foods.  Provide oral rehydration therapy, if possible (IV fluid replacement if
 The average total amount of water taken into the body by all three the dehydration is severe).
sources is about 2300 to 2900 mL/day.  Correct the cause of the deficit.
 In a normal diet, an adequate amount of essential electrolytes is  Monitor electrolyte values and prepare to administer medication to
taken in; any unused electrolytes are excreted. treat imbalances if they exist.
Output  Implement safety precautions if the client is experiencing an altered
 Large quantities of water and electrolyte-containing liquids are level of consciousness or postural hypotension.
secreted into the gastrointestinal tract, but almost all of this fluid is  Evaluate the client's response to interventions.
reabsorbed.
 Severe diarrhea results in the loss of large quantities of fluids and
electrolytes.
 Normal kidneys can adjust the amount of water and electrolytes
leaving the body.
  Fluid-Volume Excess

Description
 In fluid-volume excess, there is a greater amount of fluid in the body Sodium Imbalances
than is needed to meet the body’s needs. Nursing Considerations
 The condition is also called overhydration or fluid overload. Assessment Findings: Hyponatremia
 The goals of treatment are restoration of fluid balance, correction of  Tachycardia; pulse may be thready and weak or bounding,
electrolyte imbalances, and elimination or control of the underlying depending on cause
cause of the overload.  Postural (orthostatic) hypotension or hypertension, depending on
 May be a result of renal failure, congestive heart failure, long-term cause
corticosteroid therapy, syndrome of inappropriate ADH, rapid  Shallow respirations
infusion of an IV solution, or excessive sodium ingestion.  Generalized muscle weakness
 Headache, apathy, confusion
Nursing Considerations  Nausea, abdominal cramps, diarrhea; hyperactive bowel sounds
 Vital sign assessment may reveal a bounding, rapid pulse; increased  Increased urine output with decreased specific gravity
blood pressure; and increased respiratory rate (shallow
respirations). Assessment Findings: Hypernatremia
 Other signs include dyspnea, moist crackles on auscultation of the  Heart rate and blood pressure changes in response to vascular
lungs, pitting edema in dependent areas (see image), ascites, volume status
distended neck and hand veins, altered level of consciousness, and  Signs of pulmonary edema if hypervolemia is present
increased central venous pressure.
 Presence or absence of edema, depending on fluid-volume changes
 Administer diuretics.
 Muscle twitching progressing to muscle weakness
 Restrict fluid and sodium intake as prescribed.
 Diminished deep tendon reflexes or an absence of these reflexes
 Monitor the client’s intake and output and weight.
 Altered cerebral function: agitation, confusion, seizures, lethargy,
 Monitor electrolyte values and prepare to administer medication stupor, coma
prescribed to treat an imbalance if one exists.
 Extreme thirst; dry skin and mucous membranes
 Evaluate and document the client’s response to interventions.
 Decreased urine output with increased specific gravity
 Sodium Imbalances
Interventions: Hyponatremia
Description  If a fluid-volume deficit (hypovolemia) is present, IV saline infusions
are administered to restore sodium content and fluid volume.
 Hyponatremia is the term given to a serum sodium level below 135
mEq/L (135 mmol/L).  If a fluid-volume excess (hypervolemia) is present, osmotic diuretics
are administered to promote the excretion of water rather than
 Hypernatremia is the term used to describe a serum sodium level
sodium.
exceeding 145 mEq/L (145 mmol/L).
 If the cause is inappropriate secretion of ADH, medications that
 Both conditions are commonly associated with fluid volume
antagonize ADH are administered.
imbalances and have a variety of causes.
 Instruct the client to increase oral sodium intake and educate the
Hyponatremia client about foods to include in the diet.
 Inadequate sodium intake  If the client is taking lithium carbonate, monitor the lithium level
 Vomiting or diarrhea closely, because hyponatremia can cause diminished lithium
 Excessive diaphoresis excretion, which may result in toxicity.
 Use of diuretics  Evaluate and document the client’s response to interventions.
 Gastrointestinal suctioning
 Wound drainage Interventions: Hypernatremia
 Renal disease  If the cause is fluid loss, prepare to administer IV infusions.
 Congestive heart failure  If the cause is inadequate renal excretion of sodium, prepare to
 Syndrome of inappropriate ADH secretion administer diuretics that promote sodium loss.
 Restrict sodium and fluid intake as prescribed.
Hypernatremia
 Evaluate and document the client’s response to interventions.
 Decreased sodium excretion, which can occur with the use
of corticosteroids or in conditions such as Cushing
syndrome, renal failure, and hyperaldosteronism
 Excessive oral sodium ingestion or excessive
administration of sodium-containing IV fluids
 Decreased water intake
 Increased water loss, which may occur with an increased
rate of metabolism, fever, hyperventilation, infection,
excessive diaphoresis, or watery diarrhea
  Potassium Imbalances Oral Supplements
 Potassium supplements given orally may cause nausea and
Description vomiting and should not be taken on an empty stomach.
 Hypokalemia is the term given to a serum potassium level below 3.5  If the client complains of abdominal pain or distension,
mEq/L. nausea and vomiting, or diarrhea, or if gastrointestinal
 Hyperkalemia is the term used to describe a serum potassium level bleeding occurs, oral potassium may have to be
higher than 5.1 mEq/L. discontinued.
 Potassium imbalances, which result from a variety of causes, can be  Liquid potassium chloride has an unpleasant taste and
life threatening because every body system is affected. should be taken with juice or another liquid.
IV Supplements
Hypokalemia  Never give potassium by way of IV push or the
 Excessive use of diuretics intramuscular or subcutaneous route.
 Vomiting, diarrhea  A dilution of no more than 1 mEq/10 mL (1 mmol/L) of
 Wound drainage, particularly that involving solution is recommended.
gastrointestinal wounds  After adding potassium to an IV solution, invert the bag to
 Renal disease ensure that the potassium is evenly distributed throughout
 Inadequate potassium intake the solution.
 Alkalosis  The maximal recommended infusion rate is 5 to 10 mEq/hr
 Hyperinsulinism (5 to 10 mmol/L); the health care provider may prescribe a
 Water intoxication rate higher than the recommended rate if the client’s
Hyperkalemia potassium level is extremely low, however, it should never
 Excessive potassium intake, orally or IV exceed 20 mEq/hr (20 mmol/L).
 Decreased potassium excretion, which may occur with the  Cardiac monitoring should be instituted in a client
use of potassium-sparing diuretics or in conditions such as receiving more than 10 mEq/hr, and the infusion should be
renal failure and adrenal insufficiency controlled with the use of an infusion device.
 Conditions that cause the movement of potassium to  Monitor the client for cardiac changes during potassium
intracellular fluid (e.g., tissue damage, acidosis, administration.
hyperuricemia, hypercatabolism)  Potassium infusion may cause phlebitis; the IV site is
assessed frequently for signs of phlebitis and infiltration
Nursing Considerations and the infusion is stopped immediately if either of these
Assessment Findings: Hypokalemia problems occurs.
 Thready, weak, irregular heart rate  Assess renal function before administering potassium;
 Weak peripheral pulses monitor intake and output during administration.
 Orthostatic hypotension  Institute safety measures for the client experiencing
muscle weakness.
 Shallow respirations
 If the client is taking a potassium-losing diuretic, it may be
 Diminished breath sounds on auscultation
discontinued; a potassium-sparing diuretic may be
 Electrocardiographic changes: ST-segment depression; shallow, flat, prescribed.
or inverted T wave; prominent U wave (see image)
 Muscle weakness, leg cramps, paresthesias, deep tendon Interventions: Hyperkalemia
hyporeflexia  Discontinue IV potassium (keep the catheter patent) and hold oral
 Nausea and vomiting, constipation, abdominal distension potassium supplements.
 Hypoactive bowel sounds or the absence of sounds  Initiate a potassium-restricted diet.
 Bananas
Assessment Findings: Hyperkalemia
 Beef
 Slow, weak, irregular heart rate
 Dried fruits
 Decreased blood pressure
 Legumes
 Profound muscle weakness of the skeletal muscles that can lead to
 Milk
respiratory failure
 Oranges
 Electrocardiographic changes: tall, peaked T waves; widened QRS
complexes; prolonged PR intervals; flat P waves (see image)  Potatoes
 Muscle twitching, cramps, paresthesias, weakness of the arms and  Spinach
legs  Strawberries
 Abdominal cramping and diarrhea  Tomatoes
 Increased motility of the gastrointestinal tract and hyperactive  Whole grains
bowel sounds  Monitor the client’s renal function.
 Prepare to administer potassium-excreting diuretics if renal function
Interventions: Hypokalemia is not impaired.
 Administer potassium supplements orally or IV as prescribed.  If renal function is impaired, prepare to administer sodium
 Educate the client about foods that are high in potassium. polystyrene sulfonate, a cation-exchange resin that promotes
 Evaluate and document the client’s response to interventions. gastrointestinal sodium absorption and potassium excretion.
 Prepare for the IV administration of glucose with regular insulin to
move excess potassium into the cells.
 Prepare the client for dialysis and blood ultrafiltration if the  Paresthesias
potassium level is extremely high and other measures fail to reduce  Hyperactive deep tendon reflexes
it.  Trousseau sign (see image)
 When blood transfusions are prescribed for a client with a potassium  Chvostek sign (see image)
imbalance, the client should receive fresh blood, if possible;  Anxiety, irritability
transfusions of stored blood may increase the potassium level,
because the breakdown of older blood cells releases potassium. Assessment Findings: Hypercalcemia
 Teach the client about foods high in potassium and stress the need  Increased heart rate in early phase; in later phases, bradycardia that
to avoid salt substitutes and other potassium-containing substances. may lead to cardiac arrest
 Evaluate and document the client’s response to interventions.  Bounding, full peripheral pulses
 Increased blood pressure
 Calcium Imbalances
 ECG changes: shortened ST segment, widened T wave
Description  Anorexia, nausea, abdominal distension, constipation
 Hypocalcemia is the term used to describe a serum calcium level  Muscle weakness
below 8.6 mg/dL (2.15 mmol/L).  Diminished deep tendon reflexes or an absence of these reflexes
 Hypercalcemia is a serum calcium level exceeding 10 mg/dL (2.5  Disorientation, lethargy, coma
mmol/l).  Increased urine output leading to dehydration
 Calcium imbalances stem from a variety of causes.  Formation of renal calculi

Hypocalcemia Interventions: Hypocalcemia

 Inadequate intake of calcium or vitamin D  Administer oral or IV calcium supplements.
 Lactose intolerance  When administering IV calcium, warm the injection to body
 Malabsorption syndromes (e.g., Crohn disease) temperature before administration, administer it slowly, and
 Acute pancreatitis monitor the client for ECG changes and signs of infiltration; also
 Renal failure, polyuric phase watch for signs of hypercalcemia.
 Diarrhea
 Administer medications such as aluminum hydroxide, which reduce
 Wound drainage, especially that from a gastrointestinal
the serum phosphorus level and increase calcium absorption, as
wound
prescribed.
 Medications such as calcium chelators or binders
 Hyperphosphatemia  Administer vitamin D, which aids the absorption of calcium from the
 Hypoparathyroidism or hypothyroidism intestinal tract, as prescribed.
 Immobility  Provide a quiet environment to reduce environmental stimuli.
Hypercalcemia  Initiate seizure precautions.
 Excessive oral intake of calcium or vitamin D  Keep 10% calcium gluconate available for the treatment of acute
 Renal failure calcium deficit.
 Use of thiazide diuretics  Move the client carefully and watch for signs of pathological
 Hyperparathyroidism or hyperthyroidism fracture.
 Medications such as glucocorticoids or lithium carbonate  Instruct the client to consume foods high in calcium.
 Dehydration
 Milk, cheese, and low-fat yogurt
 Adrenal insufficiency
 Immobility
 Soy milk
 Rhubarb
Nursing Considerations  Sardines
 Spinach
 Tofu
 Evaluate and document the client’s response to interventions.

Interventions: Hypercalcemia
 IV infusions of solutions containing calcium are discontinued, as are
oral medications containing calcium or vitamin D.
 Thiazide diuretics may be discontinued and replaced with diuretics
that enhance calcium excretion.
 Medications that inhibit resorption of calcium from the bone may be
Assessment Findings: Hypocalcemia prescribed (e.g., phosphorus, calcitonin, biphosphonates, and
 Decreased heart rate prostaglandin synthesis inhibitors).
 Diminished peripheral pulses  Instruct the client to avoid foods high in calcium.
 Hypotension  Move the client carefully and watch for signs of pathological
 Electrocardiographic changes: prolonged ST interval, prolonged QT fracture.
interval  Monitor the client for flank or abdominal pain and strain the urine to
 Abdominal cramping, diarrhea check for urinary stones.
 Muscle twitching, cramps, tetany, seizures  Evaluate and document the client’s response to interventions.
  Magnesium Imbalances  Cauliflower
 Cooked rolled oats
Description  Green leafy vegetables (e.g., spinach and broccoli)
 Hypomagnesemia is the term given to a serum magnesium level  Low-fat yogurt
lower than 1.6 mg/dL (0.65 mmol/L).
 Milk
 Hypermagnesemia is the term used to describe a serum magnesium
 Peanut butter
level higher than 2.6 mg/dL (1.06 mmol/L).
 Peas
 A variety of conditions and disorders can result in magnesium
imbalance.  Pork, beef, chicken
 Potatoes
Hypomagnesemia  Raisins
 Malnutrition or starvation  Evaluate and document the client’s response to interventions.
 Malabsorption syndromes
 Vomiting or diarrhea Interventions: Hypermagnesemia
 Gastrointestinal suctioning  Oral and parenteral magnesium-containing medications are
 Large-volume urine output (e.g., that caused by diuretics) discontinued.
 Chronic alcoholism  Diuretics are prescribed to increase renal excretion of magnesium.
Hypermagnesemia
 IV calcium chloride or calcium gluconate may be prescribed to
 Renal failure
reverse the effects of magnesium on cardiac muscle.
 Excessive administration of magnesium (e.g., antacids,
laxatives, IV)  Instruct the client to restrict dietary intake of magnesium-containing
foods.
Nursing Considerations  Instruct the client to avoid the use of laxatives and antacids
Assessment Findings: Hypomagnesemia containing magnesium.
 Tachycardia  Evaluate and document the client’s response to interventions.
 Hypertension
 Phosphorus Imbalances
 Shallow respirations
 Electrocardiographic changes: tall T waves, depressed ST segments Description
 Hyperreflexia  Hypophosphatemia is the term used to describe a serum
 Tremors, seizures phosphorus level lower than 2.7 mg/dL.
 Trousseau sign  A decrease in the serum phosphorus level is accompanied by an
 Chvostek sign increase in the serum calcium level.
 Irritability and confusion  Hyperphosphatemia is the term for a serum phosphorus
concentration greater than 4.5 mg/dL.
Assessment Findings: Hypermagnesemia  An increase in the serum phosphorus level is accompanied by a
 Bradycardia decrease in the serum calcium level.
 Hypotension  The problems that occur in hyperphosphatemia are largely a result
 Respiratory insufficiency when skeletal muscles are involved of the hypocalcemia that results when the serum phosphorus level
 Electrocardiographic changes: prolonged PR interval, widened QRS rises.
complexes  Phosphorus imbalances may be traced to a variety of causes.
 Muscle weakness
 Diminished deep tendon reflexes or absence of these reflexes Hypophosphatemia
 Insufficient phosphorus intake: malnutrition and starvation
 Drowsiness and lethargy progressing to coma
 Hyperparathyroidism
 Renal failure
Interventions: Hypomagnesemia
 Use of aluminum hydroxide– or magnesium-based
 Because hypocalcemia frequently accompanies hypomagnesemia, antacids
interventions are also aimed at restoring the normal serum calcium  Hyperglycemia
level.  Malignancy
 Initiate seizure precautions.  Respiratory alkalosis
 IV magnesium sulfate is administered in severe cases; check the Hyperphosphatemia
serum magnesium level frequently. (Note that pain and tissue  Renal failure
damage may result when magnesium is administered by way of the  Increased intake of phosphorus, including dietary intake
IM route.) and overuse of phosphate-containing laxatives or enemas
 Monitor the client for diminished deep tendon reflexes, suggesting  Hypoparathyroidism
hypermagnesemia, during administration of magnesium.  Tumor lysis syndrome
 Oral preparations of magnesium may cause diarrhea and increase
magnesium loss. Nursing Considerations
 Instruct the client to increase intake of foods that contain Assessment Findings: Hypophosphatemia
magnesium.  Dysrhythmias
 Avocado  Shallow respirations
 Canned white tuna  Muscle weakness
 Rhabdomyolysis  Fluid-volume excess occurs when fluid intake
 Diminished deep tendon reflexes or fluid retention exceeds the body's fluid
 Irritability and confusion needs.
 Seizures  Sodium imbalances are commonly associated
with fluid-volume imbalances.
Assessment Findings: Hyperphosphatemia
 Potassium imbalances are potentially life
 Similar to those noted in hypocalcemia
threatening because every body system is
Interventions: Hypophosphatemia affected.
 Medications that cause hypophosphatemia are discontinued.  Potassium chloride is never given by way of IV
 Prepare to administer oral phosphorus, along with a vitamin D push or the IM or subcutaneous route.
supplement.  The Trousseau and Chvostek signs are seen in
 IV phosphorus is usually prescribed only when the serum hypocalcemia.
phosphorus level falls below 1 mg/dL and when the client has  During the administration of magnesium,
serious clinical manifestations. It is administered slowly because of monitor the client for diminished deep tendon
the risks associated with hyperphosphatemia. reflexes, which are indicative of
 Assess renal function before administering phosphorus. hypermagnesemia.
 Move the client carefully and be alert for signs of pathological
 A decrease in the serum phosphorus level is
fracture.
accompanied by an increase in the serum
 Instruct the client to avoid aluminum hydroxide– and magnesium-
based antacids. calcium level; conversely, an increase in the
 Instruct the client to increase the intake of phosphorus-containing serum phosphorus level is accompanied by a
foods while decreasing the intake of calcium-containing foods. decrease in the serum calcium level.
 Dairy products
 Fish
 Legumes
 Nuts
 Pork, beef, chicken
 Whole-grain breads and cereals
 Evaluate and document the client’s response to interventions.

Interventions: Hyperphosphatemia
 Institute measures for the management of hypocalcemia.
 Administer phosphate-binding medications that increase fecal
excretion of phosphorus by binding phosphorus from food in the
gastrointestinal tract. (These should be taken with or immediately
after meals.)
 Instruct the client to avoid phosphate-containing medications,
including laxatives and enemas.
 Instruct the client to decrease intake of foods that are high in
phosphorus.
 Evaluate and document the client’s response to interventions.

 Priority Points to Remember!

 Total body fluid accounts for about 60% of body weight.
 A loss of 10% of body fluid in the adult is serious; a loss of 20% is
fatal.
 To function normally, body cells must have fluids and electrolytes in
the right compartments and in the right amounts.
 Whenever an electrolyte moves out of a cell, another electrolyte
moves in to take its place.
 Third-spacing is the accumulation and sequestration of trapped
extracellular fluid in an actual or potential body space as a result of
disease or injury; trapped fluid represents volume loss and is
unavailable for normal physiological processes.
 Edema is an excessive accumulation of fluid in the interstitial spaces.
 Fluid-volume deficit is a dehydration in which the body's fluid intake
is not sufficient to meet the body's fluid needs.