Fluid
Fluid
Imbalances
JERLYN JOY A. NARAG, RN, MSN
Fluid Volume Deficit
This is the loss of extracellular fluid volume that
exceeds the intake of fluid. The loss of water and
electrolyte is in equal proportion.
also called HYPOVOLEMIA
Fluid Volume Deficit
It can be called in various terms- vascular, cellular or
intracellular dehydration. But the preferred term is
hypovolemia.
DEHYDRATION refers to loss of WATER alone, with
increased solutes concentration and sodium
concentration
Pathophysiology of Fluid Volume Deficit
ETIOLOGIC fACTORS RISK FACTORS
a.Vomiting
a.Diabetes Insipidus
b.Diarrhea
b.Adrenal insufficiency
c.Prolonged GI suctioning
c.Osmotic diuresis
d.Increased sweating
d.Hemorrhage
e.Inability to gain access to
e.Coma
fluids
f.Third-spacing conditions like
f.Inadequate fluid intake
ascites, pancreatitis and burns
g.Massive third spacing
Pathophysiology
Factors decreased serum osmolality
decreased blood volume
decreased cellular hydration
cellular shrinkage
Prioritize wisely
Fluid Volume Excess
Refers to the isotonic expansion of the ECF
caused by the abnormal retention of water and
sodium
There is excessive retention of water and
electrolytes in equal proportion. Serum sodium
concentration remains NORMAL
also called HYPERVOLEMIA
Pathophysiology of Fluid Volume Deficit
ETIOLOGIC fACTORS RISK FACTORS
expansion of blood
volume
Prioritize wisely
Assessment
Physical Examination Increased weight gain
Increased Urine Output
Moist crackles in the lungs
Tachycardia
Distended neck veins
Increased CVP
Wheezes
Dependent Edema
Prioritize wisely
Laboratory Findings Albumin L 1.5
2g d
BUN and Hematocrit levels are LOW because of
dilution
Urine sodium and osmolality decreased (urine
becomes diluted)
CXR may show pulmonary congestion
Increased urea & nitrogen - Azotemia
Increased uric acid level - hyperuricemia
Prioritize wisely
Nursing Diagnosis Fluid Volume excess
Planning To restore the body fluids
Implementation Assist in medical Intervention
a. administer diuretics as
prescribed
b. Assist in hemodialysis
c. Provide dietary restrictions of
Prioritize wisely sodium and water
250mg day
Nursing Management
1.Continually assess the patient’s condition by measuring
intake and output, daily weight monitoring, edema
assessment and breath sounds
2.Prevent Fluid Volume Excess by adhering to diet
prescription of low salt- foods.
3.Detect and Control Fluid Volume Excess by closely
monitoring IVF therapy, administering medications, providing
rest periods, placing in semi-fowler’s position for lung
expansion and providing frequent skin care for the edema
Nursing Management
4. Teach patient about edema, ascites, and fluid
therapy. Advise elevation of the extremities,
restriction of fluids, necessity of paracentesis,
dialysis and diuretic therapy.
5. Instruct patient to avoid over-the-counter
medications without first checking with the
health care provider because they may contain
sodium
Prioritize wisely
Electrolytes
Electrolytes are charged ions capable of
conducting electricity and are solutes found
in all body compartments.
1. sources of electrolytes
foods and fluids ingested, medications;
IVF & TPN Solutions
2. Functions
Maintains fluid balance
Regulates acid-base balance
Needed for enzymatic secretion and activation
Needed for proper metabolism and effective
processes of muscular contraction, nerve
transmission
3. Types
CATIONS- positively charged ions; examples are
sodium, potassium, calcium
ANIONS- negatively charged ions; examples are
chloride and phosphates]
cell swelling
CELL SHRINKAGE
Water pulled from cells because of increased
extracellular sodium level and decreased cellular fluid
concentration
The Nursing Process in HYPERNATREMIA
Assessment
Clinical Manifestations
primarily neurologic
Presumably the consequence of cellular
dehydration.
Hypernatremia results in a relatively concentrated
ECF, causing water to be pulled from the cells.
The Nursing Process in HYPERNATREMIA
Assessment
Clinical Manifestations
Clinically, these changes may be manifested by:
- restlessness and weakness in moderate
hypernatremia
- disorientation, delusions, and hallucinations in
severe hypernatremia.
The Nursing Process in HYPERNATREMIA
Assessment
Clinical Manifestations
Dehydration (hypernatremia) is often overlooked
as the primary reason for behavioral changes in
the elderly.
If hypernatremia is severe, permanent brain
damage can occur (especially in children). Brain
damage is apparently due to subarachnoid
hemorrhages that result from brain contraction.
The Nursing Process in HYPERNATREMIA
Assessment
A primary characteristic of hypernatremia is thirst. Thirst is
so strong a defender of serum sodium levels in normal
people that hypernatremia never occurs unless the person
is unconscious or is denied access to water; unfortunately,
ill people may have an impaired thirst mechanism. Other
signs include dry, swollen tongue and sticky mucous
membranes. A mild elevation in body temperature may
occur, but on correction of the hypernatremia the body
temperature should return to normal.
The Nursing Process in HYPERNATREMIA
Assessment test sn ousconfusedirritable
1 increased BP fluid retention
Physical Assessment E edema pitting
D decreased urine output
1.Restlessness, elevated body temperature
2.Disorientation F asFation
3.Dry, swollen tongue and sticky mucous membrane,
L lowgrade Fever
tented skin turgor T thirst
4.Flushed skin, postural hypotension
5.Increased muscle tone and deep reflexes
6.Peripheral and pulmonary edema
The Nursing Process in HYPERNATREMIA
Assessment
Subjective Cues Laboratory findings
1.Serum sodium level exceeds
1.Delusions and 145 mEq/L
hallucinations 2.Serum osmolality exceeds 295
2.Extreme thirst mOsm/kg
3.Behavioral 3.Urine specific gravity and
changes osmolality INCREASED or
elevated kidneys attempt to
conserve
The Nursing Process in HYPERNATREMIA
Nursing Diagnosis
1. Altered Cerebral perfusion
2. Fluid Volume deficit
Implementation
Assist in Medical Intervention
Administer hypotonic electrolyte solution slowly as
ordered Not level is reduced no faster than
0.5 1 meg t h
Administer diuretics as ordered
Desmopressin is prescribed for diabetes insipidus
The Nursing Process in HYPERNATREMIA
Implementation
Assist in Medical Intervention
Etiologic Factors
wound drainage
3.Nephrotic syndrome
4.Use of potassium-losing diuretics
5.Insulin therapy kt skeletal I hepatic
6.Starvation cells
7.Alcoholics and elderly
Pathophysiology depletion
Hypokalemia magnesium
Renal KT
loss
Etiologic Factors
treatmented
a
1.Iatrogenic, excessive intake of potassium
2.Renal failure- decreased renal excretion of
potassium
3.Hypoaldosteronism and Addison’s disease
4.Improper use of potassium supplements
1k sparring
diuretics
s
Pathophysiology Hyperkalemia
Other Factors
False hyperkalemia
1.Pseudohyperkalemia- tight tourniquet and
hemolysis of blood sample, marked
Trauma thecells
leukocytosis lysis of RBC to
leading
in
possible release
of its kt content
in blood
2.Transfusion of “old” banked blood kt
the
hyperkalemia
3.Acidosis b pH level
4.Severe tissue trauma expected kt
B
Pathophysiology herapy
Hypekalemia
increased potassium concentration
Possible ARRHYTHMIAS
The Nursing Process in HYPERKALEMIA
Assessment
Clinical Manifestations
By far the most clinically important effect of hyperkalemia
is its effect on the myocardium.
Cardiac effects of an elevated serum potassium level are
usually not significant below a concentration of 7 mEq/L
(SI: 7 mmol/L), but they are almost always present when
the level is 8 mEq/L (SI: 8 mmol/L) or greater.
As the plasma potassium concentration is increased,
disturbances in cardiac conduction occur.
The Nursing Process in HYPERKALEMIA
Assessment
Clinical Manifestations
The earliest changes, often occurring at a serum potassium
level greater than 6 mEq/ L (SI: 6 mmol/L), are peaked
narrow T waves and a shortened QT interval.
If the serum potassium level continues to rise, the PR
interval becomes prolonged and is followed by
disappearance of the P waves.
Finally, there is decomposition and prolongation of the QRS
complex. Ventricular dysrhythmias and cardiac arrest may
occur at any point in this progression.
The Nursing Process in HYPERKALEMIA
Assessment
Clinical Manifestations
Note that in Severe hyperkalemia causes muscle
weakness and even paralysis, related to a
depolarization block in muscle.
Similarly, ventricular conduction is slowed.
Although hyperkalemia has marked effects on the
peripheral neuromuscular system, it has little effect
on the central nervous system.
The Nursing Process in HYPERKALEMIA
Assessment
Clinical Manifestations
Rapidly ascending muscular weakness leading to
flaccid quadriplegia has been reported in patients with
very high serum potassium levels.
Paralysis of respiratory muscles and those required for
phonation can also occur.
Gastrointestinal manifestations, such as nausea,
intermittent intestinal colic, and diarrhea, may occur in
hyperkalemic patients.
The Nursing Process in HYPERKALEMIA
Assessment
Jeacresed M rate
Physical Assessment
1. Diarrhea Early muscle twitching
Late ascendingweakness
2. Skeletal muscle weakness
3. Abnormal cardiac rate Arrhythmias Tallapeaked
Twaves
Subjective Cues Flat Pwares
1. Nausea prolonged PR
interval
2. Intestinal pain/colic Wide QRScomple
3. Palpitations TummyTrouble
Ily 0 e
The Nursing Process in HYPERKALEMIA
Assessment
Laboratory findings
1. Peaked and narrow T waves
2. ST segment depression and shortened QT interval
3. Prolonged PR interval
4. Prolonged QRS complex
5. Disappearance of P wave
6. Serum potassium is higher than 5.5 mEq/L
7. Acidosis
The Nursing Process in HYPERKALEMIA
Implementation
Assist in Medical Intervention
Imbalances:
Metabolic acidosis= <22 mEq/L;
Metabolic alkalosis= >26 mEq/
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