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Most important nutrient of life; humans can only survive for a few days without it
Main need for the bodys life-supporting functions
90-93% of body fluids
Water
Solvent in which body salts, nutrients, and wastes are dissolved and transported
Protection of the blood volume (intravascular compartment) is the single most important aspect of fluid balance
homeostasis, even at the expense of creating other electrolyte imbalances
Fluid Balance
Even small fluctuations in the amount of water in the body can have harmful or fatal consequences
Functions of Water in the Body
Review of Basics
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Electrolyte Composition of Body Fluids
Body fatLess water, because fat cells contain very little water
Infants
Elderly
Patients with
Fever
Tracheostomy
Cerebral injury
Swallowing difficulties
Burn patients
Obese
Females
Apathetic, confused, very ill (debilitated)
Unconscious, comatose
Each Day
Water Balance
Exits body
Intake should equal output and average around 2,600 ml for an adult
Measurable:
Oral fluids
Rehydration fluids
Enteral feedings
Parenteral fluids
Enemas
Irrigation fluids
Not measurable:
Solid foods
Metabolic water (water produced through oxidation)
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Oral Rehydration Therapy
Fluids like soda, tea, fruit juices, and water are not appropriate for oral rehydration (dont contain proper
electrolytes; too much sugar)
Rehydration solution (homemade recipe): 8 tsp of table sugar, 1/2 tsp of salt, 1/2 tsp of sodium bicarbonate
(baking soda), and 1/3 tsp of potassium chloride to 1 L of water
Enteral Feedings: Use GI System
Enteral Feedings
IV Therapy: Parenteral
Parenteral: any fluid or medication administered by means other than alimentary tract (i.e., intravenous,
intramuscular)
Types of IV Solutions
NS (0.9% saline), LR
Expands vascular volume
Assess for hypervolemia (bounding pulse, SOB)
Types of IV Solutions
Plasma Expanders
Lung vaporization
15-20 ml/ kg/ day
Nasogastric Suction
Thirst mechanism
Kidneys
GI tract
Insensible loss
Skin, lungs
Hormone regulators
Kidneys
GI Tract
Skin
Lungs
Insensible
ADH = WATER
Dilutes blood
Renin-Angiotensin-Aldosterone System
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Increased excretion of potassium
Atrial Natriuretic Peptide (ANP)
Aldosterone antagonist
Urine
Minimum amount of urine needed daily to dissolve and excrete toxic waste products (400 - 600 ml/ 24)
S.G. 1.032: maximally concentrated, 1200 mmol/L
If 24 output < 400-600 ml:
Wastes are retained
Lethal electrolyte build-up (especially K+)
Toxic nitrogen build-up
Metabolic acidosis
Urine Terms
ml/ 24
Method to calculate specific 24 hour fluid needs (do this for your care plans)
30 ml/ kg
Example: 150-pound woman
150 2.2 = 68.18
68.18 X 30 = 2,045.4
24-hour fluid needs (150-lb woman): 2,045.4 mL
Exception: Cardiac or Renal patients
Hydration
Health History.
Health History
Nutritional history
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Daily Weights
Intake
Oral fluids
Parenteral fluids
Tube feedings
Catheter irrigants
Output
Urine output
Liquid feces
Vomitus
NG drainage
Wound drainage
Draining fistulas
Vital Signs
Signs and symptoms of ECF volume excess and deficit are reflected in changes in:
BP
Heart rate
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Respiratory rate
Temperature
Pulse Quality
A normal pulse can be felt with moderate pressure of the fingers and can be obliterated with greater pressure
Easily obliterated
Fluid volume deficit
Rapid, weak, thready
Fluid volume deficit
Bounding
Fluid volume excess
Lung Status
Pulmonary edema
Skin Turgor
A decrease in skin turgor is indicated when the skin (on the back of the hand, sternum, or forehead) is pulled up
for a few seconds and does not return to its original state
Mucous Membranes
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Tongue
Rough, dry, red
Dry, fissured tongue
Absence of salivation
Fluid volume deficit
Lips: cracked
Hand Veins
Normally, hand veins fill and become engorged when the hands are lower than the level of the heart
Collapsed hand veins in a dependent position indicate deficient fluid status
Edema
Edema
Dependent edema
Peripheral edema
Periorbital edema: significant fluid retention
Cool to touch, taut, shiny
Good skin care
Elevate extremities
Edema
Pitting vs nonpitting
Generalized vs localized
Anasarca: severe generalized edema, over entire body
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Abnormal fluid shifts into transcellular space (pericardial, pleural, peritoneal spaces; joint cavities, bowel;
abdomen)
Physiologically useless
Causes:
Tissue damage
Hydrostatic pressure
Colloid osmotic pressure (low albumin)
Blocked lymph drainage
Ascites
Fluid Retention
Daily weights
1 liter
Third-spacing
Neck Veins
Neck veins are normally distended when a client is in the supine position
Should be < 4 cm
Jugular vein distention in a sitting position
Fluid volume excess
HOB 45
Vertical distance from sternal angle to highest level of pulsation of internal jugular vein
Normal: 0 4 cm
CVP = 4 + this height
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Increased CVPhypervolemia
Client Goals
The client will reestablish normal ECF volume, water, and/or electrolyte balance
The client will demonstrate knowledge regarding how to promote future ECF volume, water, and electrolyte
balance
The client will remain free of complications from fluid or electrolyte imbalance
Fluid Balance & Implementation
Nursing interventions:
Vital signs
Strict I & O
Maintain IV access
Client teaching
Collaborative interventions:
Treat cause of illness
Assess and reassess patient response to treatment
Client Teaching
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Diuretics and other medications can increase the risk of fluid and electrolyte imbalance
Teaching is important to ensure client compliance and to help prevent any problems that can occur with treatment
Fluid Imbalances
Dehydration
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Degrees of Dehydration
Mild dehydration
2%, 1-2 liters
Symptoms: thirst
Moderate
5%, 3-5 liters
Symptoms: marked thirst; dry MM; dry skin; poor skin turgor; temp; tachycardia; tachypnea; SBP 10-15;
oliguria
Degrees of Dehydration
Severe
8%, 5-10 liters
Symptoms: flushed skin; SBP 60 or ; behavioral changes
Fatal
22-30 liters
Isotonic dehydration
With equal sodium and fluid loss
ECF isotonic
Contraction of the extracellular fluid space only
Hypotonic dehydration
Greater sodium loss than water
ECF hypotonic
Contraction of the extracellular fluid and expansion of the intracellular fluid
Hypertonic dehydration
Water lost exceeds sodium loss
ECF hypertonic
Expansion of the extracellular fluid and contraction of the intracellular fluid
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Isotonic Dehydration
ISO = SAME: there is no gradient, no fluid shifts, no movement of fluid between compartments
Involves loss of isotonic fluids from the ECF only (blood and interstitium)
Common Causes:
Hemorrhage
Decreased fluid intake
Loss of isotonic fluids (GI, renal, & skin)
Excessive vomiting
Gastrointestinal suction
Diarrhea
Diuretic therapy
Excessive urine loss
Severe wound drainage
Excessive diaphoresis
Weight loss
Hypotension and Orthostatic Hypotension
Rapid, weak pulse
Oliguria: dark, concentrated, scanty urine
Poor skin turgor
Dry skin, MM
Urine SG
Changes in LOC (irritable to lethargic)
H & H (except in hemorrhage), serum protein, and BUN
Severe: can lead to SHOCK
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Hypovolemic Shock
Shock: failure of the heart and blood vessels (circulatory system) to maintain perfusion (enough oxygen-rich
blood) to the vital organs of the body (hypoxia)
Healthy adult can compensate well up to 15% blood loss (500-750 ml)
Loss of compensation occurs at 30-40% blood loss (1500-2000 ml): at risk for irreversible organ damage,
exsanguination, death
Dehydration due to diarrhea, vomiting, or heavy perspiration can also lead to the development of hypovolemic
shock
Assessment of Shock
Hypotension
Rapid, weak pulse
Cold, moist, clammy skin
Rapid respirations
Decreased urinary output
Thirst
Changes in LOC
Early: apprehension and restlessness
Late: lethargy to coma
Goal: increase ECF volume and pressure, in order to increase tissue perfusion
Monitor VS frequently
Maintain airway, O2
HOB flat, legs elevated 45 degrees
Keep warm
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Water-loss hypernatremia
Deficit of ICF and expansion of ECF
Occurs when water loss from ECF is greater than electrolyte (sodium) loss
Hyperosmolarity is present (Na+ > 145)
Fluid pulled from the cells into the blood stream, leading to cellular shrinkage
Hypertonic Dehydration
Hypertonic Dehydration
Hypertonic Dehydration
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Thirst
Fair skin Turgor
Warm, doughy skin
Parched mucous membranes
Increased serum sodium (>150 mEq/L)
Increased serum Osmolarity
Increased urine specific gravity (>1.030)
Decreased urine output
Signs of shock are usually not present
Changes in LOC (lethargy, hyperirritability)
Be aware that rapid administration of hypotonic IV fluids can cause swelling of the brain cells, and increased
intracranial pressure
Hyperventilation, pure water loss with high fevers, and watery diarrhea
Prolonged NPO, excessive hypertonic fluids, sodium bicarbonate, or tube feedings with inadequate water
Hypotonic Dehydration
Relatively uncommon
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Hypotonic Dehydration
Chronic illness
Chronic renal failure
Malnutrition
Hypotonic fluid replacement
Seen in heat exhaustion / heat stroke
Hypotension
Tachycardia
Very poor skin turgor
Cold, clammy skin
Changes in LOC (lethargic to comatose, convulsions)
Na+ < 120 mEq/L
K+
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Outcomes