Student Preparation for Fluids and Electrolytes Lesson

1. Read all Nursing Alert boxes in chapter 14 of Brunner textbook

2. What is the relationship between fluid and body weight?

3. What is the best measure of fluid gains/losses?

4. Consider children, adults, and elderly adults:

• Who has more and who has less water?

• How does this impact fluid problems?

5. Consider adult males and adult females: who has more water?

6. Consider obesity versus normal weight: who has more water?

7. What is recommended amount of water for an adult?

(clue: answer is not just 8 glasses per day)

8. What is acceptable hourly urine output?

9. What does osmolarity/osmolality mean?

10. What is the difference between osmosis and diffusion?

11. What is hydrostatic pressure?

13. What is colloidal oncotic/osmotic pressure?

14. What is the difference in first, second, and third spacing of fluids?

15. What does ADH do? What stimulates its release? What happens after it is released?

16. What does renin do? What stimulates its release? What happens after it is released?

17. What does the lymphatic system have to do with fluid homeostasis?

18. What are the fluid compartments, and where is most of the body fluid?

19. See chart on IV Fluids:

• How are IV fluids described?
• What is used to determine that description?
• What are crystalloids?
• What are colloids?
• How do different IV fluids affect the body?

20. See chart on Electrolyte Imbalances

21. Be prepared to discuss this information on Monday, January 14, 2008.
FVD RT (can be intravascular, interstitial and/or intracellular)
• Decreased intake (elderly < thirst, fear incontinence, dementia)
• Increased fluid loss (<ADH, V/D, >diaphoresis, meds, blood loss, > glucose, hypertonic IV fluid/tube
feeding)
• Fluid shifts (decreased albumin)

FVD AMB or AEB : List what your physical assessment would show

List what labs would show:

• BUN
• Creatinine
• BUN: Creatinine ratio
• Serum osmolality
• Urine osmolality
• Hematocrit

FVD Plan—NOC : Fluid & electrolyte balance, AB balance, hydration, adequate nutrition (food/fluid), causes
corrected (must look for and treat problem)

FVD NIC: Fluid volume management

Goals for FVD Interventions and Eval

Client will: Rationales
1. Have moist mucous membranes
2. Have absence of orthostatic
hypotension <15 mm drop with
changes, < 15 increase in HR
3. Have balanced 24 hour I&O, at
least 30 mL/hour urine output
4. Have no further vomiting/diarrhea
(if this is RT)
5. Have BUN 10 – 20
6. Have BUN: Creatinine Ratio 10 –
20:1
7. Have serum osmolality 275 – 300
8. Have Na 135 – 145
9. Have Hct 40 - 50
10. Have no evidence of second or
third spaced fluids
11. Have no changes in mental status,
no seizure activity
12. Verbalize/demonstrate measures to
maintain balance
FVE RT
• Increased intake (oral or IV)
• Increased Na
• Increased fluid retention (CHF, renal failure)
• Fluid shifts (colloids, hypertonic IV)

AMB or AEB—List what your physical assessment would show

List what labs would show:

• BUN
• Srum osmolality
• Hematocrit
• Na

FVE Plan—NOC : Fluid & electrolyte balance, AB balance, hydration, adequate nutrition (food/fluid), causes
corrected (must look for and treat problem)

NIC: Fluid monitoring and management

Goals for FVE Interventions and Rationales Eval

Client will:
1. Have urine output at least
30 mL/hour
2. Achieve weight appropriate
for client
3. Have no edema, JVD
4. Have clear breath sounds
5. Have regular easy
respirations (no orthopnea,
dyspnea)
6. Have vital signs WNL for
client
7. Have BUN 10 – 20
8. Have BUN: Creatinine
Ratio 10 – 20:1
9. Have serum osmolality 275
– 300
10. Have Na 135 – 145
11. Have Hct 40 - 50
12. No mental status changes,
no seizure activity
13. Verbalize/demonstrate
knowledge regarding fluid
 and Na restrictions
14. Have no skin breakdown
HOW IV OSMOLALITY AFFECTS THE BODY
Hypotonic Solution
Osmolarity < 240
Physiologic Fluid shifts out of vascular
Effect compartment into the cells
and interstitial
compartments; Cells
swell
Indications Cellular dehydration Intravascular
(Many times the vascular dehydration (FVD)
bed gets into FVD first,
then the cells get
dehydrated as they send
water out to try to restore
homeostasis in serum
osmolarity. Therefore,
usually if there is FVD in
vascular compartment, the
cells will soon be in FVD
also. For this reason, you
may see orders to alternate
IV fluids between isotonic
and hypotonic--to restore
fluid volume in both
places)
Examples of .45%NS
these types of
IV fluids
Isotonic Solution Hypertonic Solution
240 - 340 > 340
Fluid stays in vascular Fluid shifts out of
compartment; no cells and interstitial
movement into or out of compartments into
cells; Cells aren’t vascular compartment;
affected Cells shrink
Intravascular
dehydration (FVD)
with intracellular
and interstitial
overload (FVE in
those areas); Useful
in restoring volume in
vascular bed and
drawing water out of
the cells and
interstitial spaces
NS D5NS
RL D5.45%NS
D5W (initially, but then D5RL
becomes hypotonic after D10W (10% dextrose
dextrose is used for in water)
cellular energy) 3%NaCl

ELECTROLYTE
Sodium (135 - 145 mEq/L)
Fluid balance, osmolality,
transmission of nerve impulses
Foods high: canned, cheese,
instant cereals, chips, etc.
Foods low: fresh or frozen fruits
and vegetables
Imbalances of Major Electrolytes
DEFICIT
Hyponatremia (<135)
Weakness
Cellular swelling, cerebral edema,
headache, seizure, stupor, coma, peripheral
edema, polyuria, absence of thirst,
hypothermia, tachycardia, hypotension, N/V
EXCESS
Hypernatremia (>145)
Irritability
Cellular shrinking may cause CNS
irritability, seizure, dry and flushed skin,
hypertension, thirst, hyperthermia,
tachycardia, weight gain, oliguria, anuria

Potassium (3.5 - 5.5 mEq/L) Hypokalemia (<3.5) Hyperkalemia (>5.5)

Transmission of nerve impulses to
muscles, acid-base balance
Foods high: OJ, bananas,
cantaloupe, raisins
Foods low: corn, sweet potatoes,
apples
Weakness
Cramps, decreased peristalsis, paralytic ileus,
metabolic alkalosis
Heart muscle so weak it becomes irritable
and has irregular rhythm; Beware of “dig
toxicity” if on digoxin.
Irritability
Muscle cramps, paresthesias, nausea,
explosive diarrhea, metabolic acidosis
Depressed conductivity of heart because of
excessive stimulation

Phosphate (2.8 - 4.5 mg/dl) Hypophosphatemia (<2.8) Hyperphosphatemia (>4.5)

Bone integrity, acid-base balance
Weakness Irritability
Foods high: dairy products
Similar S&S/ efffects as elevated Similar S&S/effects as decreased calcium
calcium (Inverse relationship) (Inverse relationship)

Calcium ( Total 9 - 11 mg/dl) Hypocalcemia (< 9) Hypercalcemia (>11)

Transmission of nerve impulses to
muscles; clotting, bone strength
Has a sedative effect on
neuromuscular system.
Foods high: dairy, cheese, canned
fish w/bones
Foods low: bananas, pasta, beef
Excitability/Irritability
Increased neuromuscular excitability,
pathological fractures, skeletal muscle
cramps, paresthesias, tetany,
laryngospasm, death!
Similar S&S/effects as elevated phophate
(Inverse relationship)
Weakness
Neuromuscular sedation, stupor to coma,
increased risk of bone fracture, vomiting,
constipation, kidney stones
Similar S&S/effects as decreased phosphate
(Inverse relationship)

Magnesium (1.5 - 2.5 mEq/L) Hypomagnesemia (<1.5) Hypermagnesemia (>2.5)

Transmission of nerve impulses;
promotes vasodilation in peripheral
Irritability Weakness
arteries and arterioles. Hypertension, tachycardia, seizures, tetany, Hypotension, bradycardia, respiratory
convulsions depression
Foods high: green vegetables, nuts,
bananas, PB, chocolate
Foods low: chicken, eggs, white
bread
For the most part, electrolytes come from eating and drinking them and absorption from small
intestine.

Sodium: Major contributor to serum osmolality (normal 135 – 145)

Hyponatremia
RT:
• Na loss (diuretics, prolonged vomiting, NG suction)
• Diet restrictions
• Water gain (dilutional hyponatremia due to >, or too much ADH-pituitary problem SIADH)

AMB : symptoms due to muscle/nerve weakness and cellular swelling

List what you would see on physical assessment

Nursing Diagnoses for hyponatremia:

• FVE
• Nutrition < body requirements
• High risk for injury RT confusion, weakness, seizure potential secondary to low sodium
• Altered thought processes

Plan/Goals/Outcomes for Hyponatremia

NOC: Fluid and electrolyte balance, nutritional balance, no injury, normal mental status

Interventions for hyponatremia

List what you will do
Hypernatremia

RT:
• Na gain (increased intake, hypertonic IV, increased aldosterone, steroids)
• Water loss in excess of Na loss (very watery diarrhea, burns, osmotic diuresis, too little
ADA (diabetes insipidus—very clear, watery urine), impaired thirst (cause)

AMB : symptoms due to muscle/nerve irritability and cellular shrinking

List what you would see on physical assessment

Nursing Diagnoses for Hypernatremia:

• FVD
• Nutrition > body requirements
• Altered oral mucous membranes
• High risk for injury RT confusion, weakness, seizure potential secondary to low Na
• Altered thought processes

Plan/Goals/Outcomes for Hypernatremia

NOC: Fluid and electrolyte balance, nutritional balance, No injury, normal mental status

Nursing Interventions for Hypernatremia

What will you do?
Potassium Normal 3.5 – 5.5
96% is inside cells
Generally, as Na increases, K decreases, and vv
Plays role in AB balance

Hypokalemia RT:
• Decreased intake (starvation, alcoholism, NPO and no K in IV fluids)
• GI losses>>>alkalosis from vomiting, NG suction, intestinal malabsorption
• Medications (K wasting diuretics, steroids, insulin)

AMB (overall weakness and cardiac irritability)

• Hypoactive bowel sounds and constipation, lethargy, apathy, mental dullness
• Cardiac dysrhythmias, flattened or inverted T wave, Dig toxicity if on Dig and K is low
• Muscle irritability (cramping of legs)

Nursing Diagnoses for hypokalemia

• Nutrition < body requirements RT decreased intake, alcohol intake, acid-base imbalance
• Constipation RT hypoactive peristalsis secondary to decreased serum potassium
• Risk for injury RT muscle weakness, cardiac dysrhythmias
• Pain RT muscle cramping
• Knowledge deficit RT potassium replacement needed with potassium wasting diuretics, etc.

Plan/Goals/Outcomes for Hypokalemia: Fluid and electrolyte balance, nutritional

balance, No injury, normal mental status

Nursing Interventions for Hypokalemia

What will you do?
Hyperkalemia
RT:
• Renal insufficiency or failure
• Traumatic injuries (ruptured cells releasing K)
• Acidosis (shock and decreased circulation leads to decreased perfusion to tissues, and glucose is used
without adequate oxygen and leads to lactic acidosis)
• Excessive intake (RL has K and other lytes)
• Serum drawn from IV line with K infusion
• Tourniquet too tight, Suction during blood draw, hemolyzed sample (be sure to match results to client)

AMB (cells become more irritable and them become weaker and paralyzed)
• Muscle cramps, hyperactive peristalsis and explosive diarrhea
• Heart muscle irritated at first, then becomes weak and contraction slows, cardiac output
decreases, cardiac arrest may occur)
• Tall T wave

Nursing Diagnoses for hyperkalemia

• High risk for injury RT muscle weakness, cardiac irritability secondary to elevated K levels
• Pain RT muscle cramping, bowel cramping
• FVD RT diarrhea secondary to muscle irritability due to elevated K levels
• Knowledge deficit of NURSE! (when we give out K meds and don’t even note labs)

Plan/Goals/Outcomes for Hyperkalemia: Fluid and electrolyte balance, nutritional balance,

No injury, normal mental status, no discomfort, no diarrhea

Nursing Interventions for Hyperkalemia

What will you do? Look at Kayexalate, renal dialysis, and insulin & glucose as therapies
Calcium (Normal Total serum Ca is 9 – 11, ionized is 4.5—5.5 )
99% of body calcium is found in bones and teeth
About 1/2 of Ca is bound to protein
Nerve impulses and muscle contractions like all the others & plays role in blood clotting
Has an inverse relationship with phosphorous

Hypocalcemia
RT:
• Decreased dietary intake
• Decreased absorption in small intestine
• Vitamin D deficiency
• Increased phosphorous levels (inverse relationship)
• Excessive losses secondary to loop diuretics
• Binding to necrotic areas in autodigestion of pancreas
• Hypofunction of parathyroid glands
• Decreased ionization of calcium secondary to alkalotic conditions
• Hypokalemic conditions that result in alkalosis

AMB (due to neuromuscular hyperexcitability)

What will you see on physical assessment? (paresthesias, Chvostek’s, Trousseau’s)

Nursing Diagnoses for hypocalcemia

• Nutrition < body requirements for calcium RT decreased intake, impaired absorption
• Nutrition > body requirements for phosphorous causing decreased calcium levels
• Risk for injury RT increased neuromuscular irritability
• Pain RT muscle spasms
• Risk for injury RT bone fractures due to increased losses from bones secondary to
decreased oral intake or due to hyperfunction of parathyroid glands,
• Knowledge deficit RT balanced nutrition, intake of Calcium supplements

Plan/Outcomes for hypocalcemia: Calcium levels WNL, Balanced nutrition, No

neuromuscular irritability, no discomfort, no respiratory distress, adequate clotting, no
fractures

Nursing Interventions for Hypocalcemia

What will you do?
 How are oral calcium supplements best given?
How should IV calcium be given?

Hypercalcemia
RT:
• Increased intake of calcium and vitamin D
• Hyperfunction of parathyroid gland
• Prolonged immobility
• Altered cell growth (cancer): bone resorption and paraneoplastic syndrome
• Decreased phosphorous levels
• Acidotic conditions where ionization of calcium is increased

AMB (most symptoms due to sedation to nerves and muscles)

What will you see on physical assessment?
Nursing Diagnoses with Hypercalcemia
• Risk for injury RT pathological fractures,
RT cardiac dysrhymias,
RT treatment with thiazide diuretics,
RT mental confusion
• Knowledge deficit or altered health maintenance RT excessive ingestion of calcium products
• Nutrition < BR RT decreased intake secondary to nausea, vomiting, constipation due to elevated calcium
• FVD RT decreased intake secondary to nausea, vomiting, and increased urine output due to elevated
Calcium levels

Plan/Outcomes: Fluid and electrolyte balance, no fractures, no cardiac dysrhythmias, no changes in mental
status, no pain, no renal damage

Nursing Interventions for Hypercalcemia:

What will you do?
Magnesium Normal is 1.5 – 2.5
Promotes vasodilation of peripheral arteries and arterioles

HYPOMAGNESEMIA
RT:
• Malnutrition (starvation, anorexia, alcoholism)
• Malabsorption
• Prolonged loss from GI or GU
• Prolonged NPO with IV/TPN without magnesium

AMB:
What will physical assessment reveal?

Nursing Diagnoses with Hypomagnesemia (Same as others)

Plan/Outcomes with Hypomagnesemia: No evidence of NM irritability, BP WNL, HR

regular rhythm and rate

Nursing Interventions for Hypomagnesemia:

What will you do?
Hypermagnesemia
RT:
• Impaired renal secretion (Renal insufficiency or failure)
• Excessive intake of Mg antacids or laxatives (Maalox, MOM)
• Excessive intake of IV magnesium (pregnancy)

AMB:
What will physical assessment reveal?

Nursing Interventions for Hypermagnesemia

What will you do?