Download Fluid Imbalances

Timby/Smith:
Introductory
MedicalSurgical
Nursing, 10/e
Chapter 16:
Caring for Clients with Fluid,
Electrolyte, and Acid-Base Imbalances
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Fluid and Electrolyte Balance
• Human body is 60% water
– Intracellular (mostly); Extracellular
• Average oral fluid intake-2500ml; primary sources of
body fluid is food and liquids
• Functions: Maintain or restore equilibrium in fluid
volume
• Translocation: Fluid and chemical exchange
– Electrolytes; Acids and bases; Fluid balance
• Physiologic processes
– Osmosis; Filtration; Passive and facilitated
diffusion; Active transport
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following
statement true or
false?
A function of fluid
and electrolyte
balance is to
maintain or
restore
equilibrium.
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Answer
True.
A function of fluid and electrolyte
balance is to maintain or restore
equilibrium, promoting
homeostasis.
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Fluid and Electrolyte Regulation
Distribution of body fluid at the cellular level, pg 182
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Fluid and Electrolyte Balance
• Osmosis
– Water movement through semi-permeable membrane;
Tonicity (concentration of substances); Osmotic pressure
(power to draw H2O toward an area of grater
concentration)
– Fluid distribution: Flows from dilute (low) to
concentrated (high); Figure 16-3 pg 183
• Filtration
– Movement: Fluid, dissolved substances through semipermeable membrane; Relocates: Water; Chemicals
• From high pressure to low pressure
– Affects kidney function; kidneys filter abt 180 L of fluid
from blood daily; all but 1 – 1.5 L is reabsorbed
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following
statement true or
false?
In osmosis, the fluid
flows from the dilute
to the concentrated.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
True.
In osmosis, the fluid flows from the
dilute to the concentrated.
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Fluid and Electrolyte Balance
• Passive Diffusion
– Movement: Dissolved substances
• High to low concentration
– Remains fairly static (post-equilibrium)
• Facilitated Diffusion
– Certain dissolved substances require assistance
• Carrier molecule
• To pass through semipermeable membrane
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Fluid and Electrolyte Balance
• Active Transport
– Energy source
– Adenosine triphosphate (ATP): Drives dissolved
chemicals; low-to-high concentration
• Sodium-potassium pump system
– Metabolic disorders: Diminish ATP
– Significant change in fluid volume
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Fluid-Electrolyte Regulation Mechanisms
• Maintain normal fluid volume and electrolyte
concentrations
– Urine formation; Thirst promotion
• Osmoreceptors
– Fluid volume regulation
– Located: Hypothalamus; Senses serum
osmolality
– Sensitive: Changes in blood volume and BP
– Baroreceptors (stretch receptors in aortic branch that
signals brain to release ADH when blood volume decreases
OR to inhibit release if blood volume is increased)
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following
statement true or
false?
The body is without
regulatory
mechanisms to
maintain fluidelectrolyte balance.
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Answer
False.
The body has several regulatory
mechanisms to maintain fluidelectrolyte balance, including thirst
and urine formation.
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Fluid-Electrolyte Regulation Mechanisms
• Renin-Angiotensin-Aldosterone System
– Chain of chemicals
• Increase: BP; Blood volume
• Juxtaglomerular apparatus (Cells)
– Angiotensin II: Raises BP via vasoconstriction
– Aldosterone: causes kidneys to reabsorb Na
which in turn increases blood volume & BP
• Natriuretic Peptides: Hormone-like substances
– Works the opposite to renin-angiotensinaldosterone system; reduce blood volume =
urine release
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Fluid Imbalances
• Is a general term describing any of
several conditions in which the body’s
water/fluid is not in the proper volume or
location
• Common fluid imbalances:
- Hypovolemia
- Hypervolemia
- Third-spacing
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Fluid Imbalances: Hypovolemia
• Fluid imbalance: Fluid volume deficit
(Table 16-2, pg 185)
– Hypovolemia: Only blood volume low
– Dehydration: All fluid compartments deficient
• Pathophysiology and Etiology
– Inadequate fluid intake; Fluid loss in excess of
intake; Translocation
• Assessment Findings
– Thirst – earliest
– Hemoconcentration; Concentrated urine (high
specific gravity)
– Serum electrolyte levels normal
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Fluid Imbalances: Hypovolemia
• Medical Management
– Treat etiology (cause)
• Increasing oral intake volume
• IV fluid replacement
• Controlling fluid loss
• Nursing Management
– Gather assessment data
– Fluid deficit: Measures to restore balance
– Teaching plan: Prevent hypovolemia
– REVIEW: Nsg Care Plan 16-1 pg 187
– REVIEW: Nsg Guidelines 16-1 pg 188
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Fluid Imbalances: Hypervolemia
• High volume of water: Intravascular fluid
compartment
• Pathophysiology and Etiology
– Fluid intake > fluid loss
• Heart failure
• Renal disease
• Corticosteroid drugs
• Fluid retention
– Circulatory overload
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Fluid Imbalances:Hypervolemia
• Assessment Findings
– Weight gain; Elevated BP;
Dependent edema, Fig 16-7
pg 188
– Low blood cell count; Hemodilution;
Dilute urine (low specific gravity)
• Medical Management
– Treat etiology; Daily weight
– Restrict fluids; Medications: Diuretics
– Limit: Salt (sodium) intake
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Fluid Imbalances: Hypervolemia
• Nursing Management
– REVIEW: Nursing Process, pg 186-190
– Daily weight (same time/ same clothes, etc)
– Accurate I & O’s; Restrict fluids per Dr’s
order – maintain oral hygiene
– Monitor v/s; check for edema; administer
prescribed diuretics
– Limit: Salt (sodium) intake: Refer to Box
16-1, Foods high in Salt or Sodium
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following
statement true or
false?
The treatment for
hypovolemia and
hypervolemia are
the same.
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Answer
True.
While the steps taken during treatment
may differ, the treatment principle is the
same – you treat the cause (etiology).
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Fluid Imbalances: Third-spacing
• Fluid translocation to intracellular compartments
– Trapped, useless; Colloid loss
• Assessment Findings
– Hypovolemia symptoms (except weigh loss); Ascites;
Generalized edema
• Medical Management
– Restore circulatory volume
– Eliminate trapped fluid;
• IV solutions
• Blood products, albumin
• IV diuretic
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Electrolyte Imbalances
• Electrolytes
– Ions (including Bicarbonate; Protein; Organic acids)
– Extracellular fluid (more concentrated): Sodium,
Calcium; Chloride
– Intracellular fluid (more concentrated): Potassium;
Magnesium; Phosphate
– Imbalances; Identified – blood labs
• Electrolyte imbalances: Deficit or excess of electrolytes;
Electrolyte translocation
– Sodium; Potassium; Calcium; Magnesium of
particular concern
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Sodium Imbalances
• Hyponatremia: Sodium deficit (Na <135 mEq/L)
– Etiology
• Inadequate food intake; excessive water intake
• Administration of certain meds
• Profuse diaphoresis or diuresis
• Loss of GI secretions (Prolonged vomiting; GI
suctioning, etc)
– Assessment Findings
• Mental confusion; Elevated body temp;
Tachycardia; N/V; Personality changes; Coma
– Medical Management
• Treat underlying cause; Sodium administration
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Sodium Imbalances
• Hypernatremia: Sodium excess (Na > 145 mEq/L)
– Etiology
• Overabundance of orally consumed or IV
electrolytes
• Kidney Failure; Endocrine dysfunction
• Profuse watery diarrhea; Decreased H2O intake
• High fever
– Assessment Findings
• Dry, sticky mucous membranes; Decreased
urine output; Fever; Lethargy
– Medical Management
• Treat underlying cause; Restrict sodium
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Sodium Imbalances
• Nursing Management for Sodium Imbalances
– Assess sodium imbalances – EARLY detection!
– Monitor: Laboratory findings - serum potassium
– Monitors oral and IV fluid therapy closely
– Accurate I & O’s
– Assess vital signs q 1 to 4hrs
– Client education
• Review dietary restrictions: Nutrition Notes
16-1, pg 191
• Review: Pharmacy Considerations, pg 191
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Potassium Imbalances
• Hypokalemia: Potassium deficit (K+ <3.0 mEq/L)
– Potassium-wasting diuretics (Lasix, Hyrdodiuril);
Loss of fluid from the GI tract; Large
corticosteroid doses
• Assessment Findings
– Fatigue; N/V; Cardiac dysrhythmias;
Paresthesias; Leg cramps
• Medical Management
– Treat underlying cause; Potassium
sparing diuretic substitution
– Potassium-rich foods; Oral potassium
supplement
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Potassium Imbalances
• Hyperkalemia: Potassium excess (K+ >5.5 mEq/L)
– Severe renal failure; Severe burns; Overuse of
potassium supplements; Potassium-sparing
diuretics; Addison’s disease
• Assessment Findings
– Diarrhea, Nausea; Muscle weakness;
Paresthesias; Cardiac dysrhythmias (Tall T wave)
• Medical Management
– Treatment dependent on cause, severity:
Decrease potassium-rich foods; Kayexalate
– IV-insulin; Peritoneal dialysis; Hemodialysis
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Potassium Imbalances
Top left: Normal tracing
Top right: Serum potassium level
below normal results in U wave
Lower Right: High potassium on ECG
produces a tall T wave
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Potassium Imbalances
• Nursing Management for Potassium Imbalances
– Assess potassium imbalances
– Monitor: Laboratory findings - serum potassium
– Consults with the physician: Prolonged IV fluid
therapy without added potassium
– Client education
• Potassium-excreting medications
• Pharmacy Considerations: pg 193
• Food sources: Vegetables, dried peas and
beans, wheat bran, bananas, oranges (and
juice), melon, prune juice, potatoes, milk
• Supplements
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Calcium Imbalances
• Hypocalcemia: Calcium deficit (Ca++ < 8.8 mg/dL)
– Vitamin D deficiency; Hypoparathyroidim;
Severe burns; Acute pancreatitis;
Corticosteroids
• Assessment Findings
– Tingling in extremities, around mouth;
Abdominal and muscle cramps; Trousseau’s
sign; Mental changes; Positive Chvostek’s sign;
Tetany (Figure 16-9, pg 193)
• Medical Management
– Mild: Oral calcium, Vitamin D
– Severe: Calcium salt (IV)
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Calcium Imbalances
• Hypercalcemia; Calcium excess ( Ca++ >10 mg/dL)
– Parathyroid gland tumors; Paget’s disease;
Hyperparathyroidism; Chemotherapeutic agents;
Specific malignancies; Prolonged immobilization
• Assessment Findings
– Polyuria; Constipation; N/V; Thirst; Mental changes
• Medical Management
– Treat underlying cause when possible;
Oral fluid intake; Limit calcium
consumption
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Calcium Imbalances
• Nursing Management for Calcium Imbalances
– Assess closely for neurological manifestations:
tetany, seizures, spasms
– Monitor: Laboratory findings; watch for signs of
bruising or bleeding
– Consults with the dietician: limit Ca intake w/
increased Ca; increase w/low CA
– Client education
• Take medications as ordered
• Pharmacy Considerations: pg 194
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Magnesium Imbalances
• Hypomagnesemia: Magnesium deficit (Mg++< 1.3 mEq/L)
– Conditions: Excessive diuresis; Prolonged gastric
suction; Chronic alcoholism; Severe burns and renal
disease
• Assessment Findings
– Cardiac dysrhythmias; Paresthesias; Leg and foot
cramps; Hypertension; Mental changes; Positive
Chvostek’s, Trousseau’s signs
• Medical Management
– Dietary; Severe: Magnesium sulfate (IV)
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Magnesium Imbalances
• Hypermagnesemia: Magnesium excess (Mg++ > 2.1 mEq/L)
– Renal failure; Excessive antacid or laxative use
• Assessment Findings
– Flushing, warmth; Hypotension; Lethargy;
Bradycardia; Depressed respirations; Coma
• Medical Management
– Decrease magnesium intake; Discontinue
parenteral replacement; Hemodialysis
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Magnesium Imbalances
Hypermagnesemia: Magnesium excess (Mg++ > 2.1 mEq/L)
• Nursing Management for Magnesium Imbalances
– Monitor vital signs closely
– Client education
• REVIEW Pharmacy Considerations, pg 195
• REVIEW Stop, Think & Respond, pg 195
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Acid-Base Balance
• Chief acid: Carbonic acid (H2CO3) - Lungs
• Chief base (alkaline): Bicarbonate (HCO3) - Kidneys
– Acid, base content: Influence pH; pH values (7
is neutral)
– Normal plasma pH (7.35-7.45) maintained by
• Chemical regulation; Organ regulation
• Figure 16-10, pg 195
• Chemical Regulation
– Add Hydrogen ions: Increases acidity
– Eliminate Hydrogen ions: Promotes alkalinity
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Acid-Base Balance
• Chemical Regulation (Cont’d)
– Major chemical regulator of plasma pH
• Bicarbonate–carbonic acid buffer system
• Oxygen Regulation
– Lungs, kidneys facilitate: Ratio of bicarbonate to
carbonic acid
• Lungs: Regulate carbonic acid levels by releasing or
conserving CO2: (quickly by breathing faster or slower)
• Kidneys: regulate bicarbonate ion retention or
excretion (slower process)
– Compensation: Regulatory processes
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Acid-Base Imbalances
• Life-threatening
• Acidosis: Excess acids OR Excess loss of bicarbonate
• Alkalosis: Excess bases OR Excess loss of acids
– Four sub-types of acid-base imbalances
• Metabolic Acidosis: Increase in acids or decreased
bicarbonate
– Occurrence: Shock; Cardiac arrest; Starvation;
Diabetic ketoacidosis; Renal failure
– Assessment Findings: Kussmaul’s breathing; N/V;
Headache; Confusion; Lethargy; Dangerous cardiac
dysrhythmias
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Acid-Base Imbalances
• Metabolic Acidosis (Cont’d)
– Diagnostic Findings: ABG values; Decreases in
pH
• Medical Management
– Eliminating cause
– Replacing lost fluids and electrolyte
– Severe cases: IV bicarbonate
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Acid-Base Imbalances
• Metabolic Alkalosis: Increased plasma pH; Rapid
decrease in extracellular fluid volume
– Causes: Diuretic therapy; Prolonged gastric
suctioning; Vomiting; Hypokalemia
• Assessment Findings
– Circumoral paresthesias; Confusion; N/V;
Carpopedal spasm; Hypertonic reflexes; Tetany
– ABGs; Compensatory respiratory mechanisms
• Medical Management
– Eliminating cause; Sodium chloride solutions
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Acid-Base Imbalances
• Respiratory Acidosis: Excess carbonic acid
– Causes: Pneumo-hemothorax; Pulmonary edema; Asthma;
Atelectasis; Pneumonia; COPD; Cystic fibrosis
• Assessment Findings
– Extreme respiratory insufficiency; Decreased expiratory
volumes; Cyanosis; Behavioral changes due to CO2
accumulation
– ABG values; Compensatory mechanism
• Medical Management
– Individualized treatment dependent upon cause, acute or
chronic
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Acid-Base Imbalances
• Respiratory Alkalosis: Carbonic acid deficit from deficient
CO2 due to rapid breathing
• Assessment Findings
– Increased respiratory rate; Lightheadedness;
Numbness, tingling of hands and feet; Circumoral
paresthesias; Sweating; Panic
– Kidney excretes bicarbonate ions: HCO3 falls
– ABG values
• Medical Management
– Treat cause: (Temporary) Breathe into paper bag
and rebreathe expired air; Sedation
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Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins