Fluid and Electrolyte Imbalances (Fundamentals Ch 57) Flashcards Preview

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Flashcards in Fluid and Electrolyte Imbalances (Fundamentals Ch 57) Deck (64)
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-minerals present in all body fluids
-regulate fluid balance and hormone production
-strengthen skeletal structures
-act as catalysts in nerve response, muscle contraction, and metabolism of nutrients


Fluid volume deficits (FVDs)

Isotonic FVD (hypovolemia)


Isotonic FVD

-loss of water and electrolytes from the ECF
-referred to as hypovolemia because intravascular fluid is also lost



-loss of water from body w/o loss of electrolytes
-this hemoconcentration results in increases in Hct, serum electrolytes, and urine specific gravity


Compensatory mechanisms for FVD

-sympathetic nervous system response of:
1) increased thirst
2) antidiuretic hormone (ADH) release
3) aldosterone release


Are older adults at increased risk for dehydration?

-due to decreased total body mass


Causes of isotonic FVD (hypovolemia)

1) abnormal GI losses--vomiting, ng suctioning, diarrhea
2) abnormal skin losses--diaphoresis
3) abnormal renal losses--diuretic therapy, diabetes insipidus, kidney disease, adrenal insufficiency
4) third spacing--peritonitis, intestinal obstruction, ascites, burns
5) hemorrhage
6) altered intake--impaired swallowing, confusion, NPO


Causes of dehydration

1) hyperventilation
2) prolonged fever
3) diabetic ketodacidosis
4) enteral feeding w/o sufficient water intake


Subjective and objective data of FVD

1) vital signs--hypothermia, tachycardia, thready pulse, hypotension, orthostatic hypotension, decreased central venous pressure, tachypnea, hypoxia
2) neuromusculoskeletal--dizziness, syncope, confusion, weakness, fatigue
3) GI--thirst, dry mucous membranes, dry furrowed tongue, N/V, anorexia, acute weight loss
4) renal--oliguria (decreased production of urine)
5) other clinical findings--diminished cap. refill, cool clammy skin, diaphoresis, sunken eyeballs, flattened neck veins, absence of tears, decreased skin turgor


Lab findings associated with FVD

1) Hct--increased in both hypovolemia and dehydration (unless FVD is due to hemorrhage)
2) serum osmolarity--dehydration--increased hemoconcentration osmolarity (greater than 300 mOsm/kg)- increased protein, BUN, electrolytes, glucose
3) urine sp. gravity and osmolarity--increased concentration (urine sp. gravity > 1.030)
4) serum sodium--dehydration--increased hemoconcentratin


Nursing care for FVD

1) assess respiratory rate, symmetry, effort
2) monitor SOB and dyspnea
3) check urinalysis, SaO2, CBC, electrolytes
4) administer supplemental O2 as prescribed
5) measure client's weight daily at same time of day using same scale
6) observe for N&V
7) assess & monitor VS (check for hypotension & orthostatic hypotension)
8) check neurological status to determine LOC
9) assess heart rhythm (may be irregular, tachycardic)
10) initiate & maintain IV access
11) place client in shock position ( on back with legs elevated)
12) fluid replacement: administer IV fluids as prescribed (isotonic solutions--Lactated Ringer's or 0.9% NaCl; blood transfusion)
13) monitor I&O--encourage as tolerated; notify provider of urine output less than 30 mL/hr
14) monitor LOC and ensure client safety
15) assess level of gait stability
16) encourage client to use call light for assistance
17) encourage client to change positions slowly
18) check cap refill
19) provide frequent oral care
20) prevent skin breakdown


Fluid volume excess (FVE)

-isotonic retention of water and sodium in abnormally high proportions


(hypoosmolar fluid imbalance)

-gain of more water than electrolytes
-hemodilution results in decreases in Hct, serum electrolytes, and protein


Compensatory mechanisms for FVE

1) increased release of natriuretic peptides--result in increased excretion of sodium and water by kidneys
2) decreased release of aldosterone


Causes of hypervolemia

1) chronic stimulus to kidneys to conserve Na and water (heart failure, cirrhosis, increased glucocorticosteroids)
2) abnormal kidney function w/ reduced excretion of Na and water (kidney failure)
3) interstitial to plasma fluid shifts (hypertonic fluids, burns)
4) age-related changes in CV and kidney function
5) excessive Na intake from IV fluids, diet, medications (Na bicarbonate antacids, hypertonic enema solutions)


Causes of overhydration

1) water replacement w/o electrolyte replacement (strenuous exercises w/ diaphoresis)
2) SIADH--excess secretion of ADH
3) head injuries
4) barbiturates
5) anesthetics


Subjective and objective data of FVE

1) VS--tachycardia, bounding pulse, hypertension, tachypnea, increased central venous pressure
2) neuromusculoskeletal--confusion, muscle weakness
3) GI--weight gain, ascites
4) respiratory--dyspnea, orthopnea, crackles
5) other clinical findings--edema, distended neck veins


Lab findings associated w/ FVE

1) Hct--hypervolemia: decreased Hct; overhydration: decreased Hct = hemodilution
3) serum osmolarity--overyhdration: < 280 mOsm/kg
4) serum Na--hypervolemia: Na within expected range (136-145 mEq/L)
5) electrolytes, BUN, creatinine--hypervolemia&overhydration: decreased
6) ABGs--respiratory alkalosis (decreased PaCO2, increased pH)


Nursing care for FVE

1) assess respiratory rate, symmetry, effort
2) assess breath sounds in all lung fields (may be diminished w/ crackles)
3) monitor for SOB and dyspnea
4) check ABGs, SaO2, CBC, CX-ray results (may indicated pulmonary congestion)
5) position client in semi-Fowler's
6) measure client's weight daily
7) monitor and document edema (pretibial, sacral, periorbital)
8) monitor I&O
9) implement prescribed fluid and Na intake restrictions
10) administer supplemental O2 as needed
11) reduce IV flow rates
12) administer diuretics as prescribed (osmotic, loop)
13) monitor and document circulation to extremities
14) reposition client at least q 2 hr
15) support arms and legs to decrease dependent edema as appropriate


Clients at greatest risk for electrolyte imbalances

1) infants and children
2) older adults
3) clients who have cognitive disorders
4) chronically ill clients


Sodium (Na+)

-major electrolyte found in ECF
-present in most body fluids or secretions
-essential for maintenance of acid-base and fluid balance, active and passive transport mechanisms, and irritability and conduction of nerve and muscle tissue
-136-145 mEq/L



-serum Na+ level < 136 mEq/L
-a net gain of water or loss of sodium-rich foods
-delays and slows depolarization of membranes
-water moves from ECF to ICF, causes cells to swell (cerebral edema)


Causes of hyponatremia

1) deficient ECF volume
2) abnormal GI losses--vomiting NG suctioning, diarrhea, tap water enemas
3) renal losses--diuretics, kidney disease, adrenal insufficiency, excessive sweating
4) skin losses--burns, wound drainage, GI obstruction, peripheral edema, ascites
5) increased or normal ECF volume--excessive oral water intake, SIADH
6) edematous states--heart failure, cirrhosis, nephrotic syndrome
7) excessive hypotonic IV fluids
8) inadequate Na+ intake (NPO status)
9) age-related risk factors--older adults greater risk due to incidences of chronic illnesses, use of diuretic medications, and risk for insufficient Na+ intake


Subjective and objective data of hyponatremia

1) physical assessment findings--vary with a normal, decreased, or increased ECF volume
2) VS--hypothermia, tachycardia, rapid thready pulse, hypotension, orthostatic hypotension
3) neuromusculoskeletal--headache, confusion, lethargy, muscle weakness w/ possible respiratory compromise, fatigue, decreased deep tendon reflexes (DTRs), seizures, coma
4) GI--increased motility, hyperactive bowel sounds, abdominal cramping, anorexia, nausea, vomiting


Lab findings associated with hyponatremia

1) serum Na+ -- decreased < 136 mEq/L
2) serum osmolality--decreased < 280 mOsm/kg



-serum sodium > 145 mEq/L
-serous electrolyte imbalance--can cause significant neurological, endocrine, and cardiac disturbances
-causes hypertonicity of serum--causes shift of water out of cells, making them dehydrated


Risk factors for hypernatremia

1) water deprivation (NPO)
2) heat stroke
3) excessive Na+ intake--dietary, hypertonic IV fluids, hypertonic tube feedings, bicarbonate intake
4) excessive Na+ retention--kidney failure, Cushing's syndrome, aldosteronism, some meds (glucocorticosteroids)
5) fluid losses--fever, diaphoresis, burns, respiratory infection, diabetes insipidus, hyperglycemia, watery diarrhea
6) age-related changes--decreased total body water content and inadequate fluid intake related to altered thirst mechanism
7) compensatory mechanisms--increased thirst and increased production of ADH


Subjective and objective data of hypernatremia

1) VS--hyperthermia, tachycardia, orthostatic hypotension
2) neuromusculoskeletal--restlessness, disorientation, irritability, muscle twitching, muscle weakness, seizures, decreased LOC, reduced to absent DTRs
3) GI--thirst, dry mucous membranes, dry and swollen tongue red in color, increased motility, hyperactive bowel sounds, abdominal cramping, nausea
4) other clinical findings--edema, warm flushed skin, oliguria


Lab findings associated with hypernatremia

1) serum Na+-- increased, > 145 mEq/L
2) serum osmolarity--increased, > 300 mOsm/kg


Nursing care for hypernatremia

1) report abnormal lab findings to provider
2) fluid loss--based on serum osmolarity (administer hypotonic IV fluids-0.225% NaCl)
3) Excess sodium--encourage water intake, discourage Na+ intake and administer diuretics (loop diuretics)
4) monitor LOC and ensure safety
5) provide oral hygiene and other comfort measures to decrease thirst
6) monitor I&O, alert provider if urinary output inadequate