Ignatavicius: Medical-Surgical Nursing, 7th Edition

Chapter 13: Assessment and Care of Patients with Fluid and Electrolyte Imbalances
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HOMEOSTASIS

The body has many control mechanisms, called homeostatic mechanisms to prevent
fluctuations in fluid and electrolytes.

ANATOMY AND PHYSIOLOGY REVIEW: PHYSIOLOGIC INFLUENCES ON FLUID

AND ELECTROLYTE BALANCE

Body fluids are composed of water and particles dissolved or suspended in water.
The solvent is the water portion of fluids.
Solutes are the particles dissolved or suspended in the water.
When solutes express an overall electrical charge they are known as electrolytes.
Body function depends on keeping the correct balance of fluid and electrolytes within each
body fluid space.
Specific processes control normal fluid and electrolyte balance so the internal environment
remains stable even when the external environment changes.
These processes are filtration, diffusion, osmosis, and active transport.
They determine how, when, and where fluids and particles move across cell membranes.

FLUID BALANCE: BODY FLUIDS

A persons age, gender, and amount of fat affect the amount and distribution of body fluids.
o An older adult has less total body water than a younger adult.
o An obese person has less total water than a lean person of the same weight because
fat cells contain almost no water.
o Women of any age have less total body water than men of similar sizes and ages
related to more body fat.
Assessment is key in managing imbalances.
o Assess patients who have a sudden change in cognition for fluid and electrolyte
imbalances.
o Assess skin turgor on the forehead or the sternum of older patients.
o Use daily weights to determine fluid gains or losses.
o Ask patients about the use of drugs such as diuretics, laxatives, salt substitutes, and
antihypertensives that may alter fluid and electrolyte status.
o Correctly interpret laboratory electrolyte values.
o Assess any patient with a fluid or electrolyte imbalance for falls risk.
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o Monitor the cardiac and pulmonary status at least every hour when patients with
dehydration are receiving IV fluid replacement therapy.
o Assess the bowel sounds; heart rate, rhythm, and quality; and muscle strength to
evaluate the patients responses to therapy for an electrolyte imbalance.
Use a gait belt when assisting a patient with muscle weakness to walk or transfer.
Do not give oral fluids to an unconscious patient.
Offer or ensure that oral care is performed at least every 4 hours for patients with
dehydration.
The minimum amount of urine output per day to excrete toxic waste products, called the
obligatory urine output, is 400 to 600 mL.
Other normal water loss occurs through the skin, the lungs, and the intestinal tract.

HORMONAL REGULATION OF FLUID BALANCE

The endocrine system helps to control fluid and electrolyte balance.

o Three hormones that help control these critical balances are aldosterone, antidiuretic
hormone, and natriuretic peptide.

SIGNIFICANCE OF FLUID BALANCE

The human body requires a balance of body fluids, electrolytes, and acids and bases for best
function.
The most important fluids to keep in balance are the blood volume (plasma volume) and the
fluid inside the cells (intracellular fluid).
The most critical fluid balance to prevent death is maintaining blood volume at a sufficient
level for blood pressure to remain high enough to ensure adequate perfusion and oxygenation
of all organs and tissues.
Balance of both water and electrolytes is needed for this very vital function.
Activated angiotensinogen is angiotensin I, which is relatively weak. It is then acted on by
another enzyme known as angiotensin converting enzyme or ACE, which converts
angiotensin I into its most active form, angiotensin II.
Angiotensin II starts several different activities that all work to increase blood volume and
blood pressure.

DEHYDRATION

All patients are at risk for some degree of fluid imbalance because many health problems can
disrupt fluid intake or output.
In dehydration, fluid intake is less than what is needed to meet the bodys fluid needs,
resulting in a fluid volume deficit.
o Management of dehydration aims to prevent injury, prevent further fluid losses, and
increase fluid compartment volumes to normal ranges.
o Main strategies include assuring patient safety, fluid replacement, and drug therapy.

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o Ensure access to adequate fluids for patients who are unable to talk or who have
limited mobility.

FLUID OVERLOAD

Fluid overload, also called overhydration, is an excess of body fluid.

o Fluid overload may be either an actual excess of total body fluid or a relative fluid
excess.
o Interventions for patients with fluid overload ensure patient safety, restore normal
fluid balance, provide supportive care until the imbalance is resolved, and prevent
future fluid overload.
o Use a pump or controller to deliver intravenous fluids to patients with fluid overload.

ELECTROLYTE BALANCE AND IMBALANCES

Electrolyte imbalances can occur in healthy people as a result of changes in fluid intake and
output, which are usually mild and easily corrected.
o Severe electrolyte imbalances are life threatening.
o Electrolyte homeostasis balances the dietary intake of electrolytes with the renal
excretion or reabsorption of electrolytes.

SODIUM

The ECF sodium level determines whether water is retained, excreted, or moved from one
fluid space to another.
Serum sodium balance is regulated by the kidney under the influences of aldosterone,
antidiuretic hormone (ADH), and natriuretic peptide (NP).

HYPONATREMIA

Hyponatremia is a serum sodium level below 136 mEq/L.

o Sodium imbalances often occur with fluid volume imbalances because the same
hormones regulate both sodium and water balance.

HYPERNATREMIA

Hypernatremia is a serum sodium level over 145 mEq/L.

o Drug and nutrition therapies decrease high serum sodium levels.
o Interventions used when sodium levels become life threatening include hemodialysis
and blood ultrafiltration.

POTASSIUM

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Keeping the large difference in potassium concentration between the ICF and the
extracellular fluid (ECF) is critical for excitable tissues to depolarize and generate action
potentials.
Other functions of potassium include regulating protein synthesis and regulating glucose use
and storage.

HYPOKALEMIA

Hypokalemia is a serum potassium level below 3.5 mEq/L which can be life threatening
because every body system is affected.
o Drug and nutrition therapies help restore normal serum potassium levels.
o Assess the respiratory status of all patients with hypokalemia.
o Follow facility policy for cardiac monitoring in presence of hypokalemia.
o Do not give intravenous potassium at a rate greater than 20 mEq/hr.
o Never give potassium supplements by the intramuscular, subcutaneous, or IV push
routes.
o Use a pump or controller when giving intravenous potassium-containing solutions.
o Assess the IV site of a person receiving IV solutions containing potassium hourly and
document its condition.
o Immediately stop the infusion of potassium-containing solutions if infiltration is
suspected.

HYPERKALEMIA

Hyperkalemia is a serum potassium level greater than 5.0 mEq/L.

o Even slight increases above normal values can affect excitable tissues, especially the
heart.
o Assess all patients with hyperkalemia for cardiac dysrhythmias and ECG
abnormalities, especially tall T waves, conduction delays, and heart block.

CALCIUM
This mineral is important for maintaining bone strength and density, activating enzymes,
allowing skeletal and cardiac muscle contraction, controlling nerve impulse transmission, and
allowing blood clotting.
Calcium enters the body by dietary intake and absorption through the intestinal tract.

HYPOCALCEMIA

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Hypocalcemia is a total serum calcium level below 9.0 mg/dL.

o Because the normal blood level of calcium is so low, any change in calcium levels has
major effects on function.
o Use a lift sheet to move or reposition a patient with chronic hypocalcemia.

HYPERCALCEMIA
o Hypercalcemia is a total serum calcium level above 10.5 mg/dL.
o Small increases have severe effects on all systems.
o Interventions for hypercalcemia aim to reduce serum calcium levels through drug
therapy, dialysis, rehydration, and cardiac monitoring.
PHOSPHORUS

Phosphorus is needed for activating vitamins and enzymes, forming adenosine triphosphate
(ATP) for energy supplies, and assisting in cell growth and metabolism.
It also functions in acid-base balance and calcium homeostasis.

HYPOPHOSPHATEMIA

Hypophosphatemia is a serum phosphorus level below 3.0 mEq/L.

o Body functions are not usually affected even with rapid, wide changes in serum
phosphorus levels, but may be with chronic hypophosphatemia.
o Drugs that promote phosphorous loss are discontinued and oral replacement along
with a vitamin D supplement may correct moderate deficiency.

HYPERPHOSPHATEMIA

Hyperphosphatemia is a serum phosphorus level above 4.5 mEq/L.

o Management of hyperphosphatemia entails the management of hypocalcemia since
hypocalcemia results when serum phosphorus levels increase.

MAGNESIUM

Magnesium is critical for skeletal muscle contraction, carbohydrate metabolism, adenosine

triphosphate (ATP) formation, vitamin activation, and cell growth.
Extracellular magnesium regulates blood coagulation and skeletal muscle contractility.

HYPOMAGNESEMIA

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Hypomagnesemia is a serum magnesium level below 1.2 mEq/L.

o Avoid administering magnesium sulfate by the intramuscular route.
o Since hypocalcemia often occurs with it, interventions also aim to restore normal
serum calcium levels.
o Avoid administering magnesium sulfate by the IM route.

HYPERMAGNESEMIA

Hypermagnesemia is a serum magnesium level above 2.1 mEq/L.

o In severe hypermagnesemia, excitable membranes may not respond to any stimulus.
o All oral and parenteral magnesium are discontinued.

CHLORIDE

Imbalances of chloride usually occur as a result of other electrolyte imbalances and are
corrected by interventions for correcting other electrolyte or acid-base problems.

PATIENT EDUCATION

Explain the purpose of fluid restriction to the patient and the family to ensure cooperation
and prevent misunderstanding.
Encourage all patients to maintain a fluid intake minimum of 3 liters per day unless another
condition requires fluid restriction.
Teach all people to increase fluid intake when exercising, in hot or dry environments, or
during conditions that increase metabolism such as fever.
Instruct patients who exercise heavily (athletes) to take scheduled fluid replacement breaks.
Instruct patients at risk for fluid imbalance to weigh themselves on the same scale daily, close
to the same time each day, and with about the same amount of clothing on each time, and to
monitor these daily weights for changes or trends.
Instruct caregivers of older adults who have cognitive impairments or mobility problems to
schedule offerings of fluids at regular intervals throughout the day.
Teach patients to determine electrolyte content of processed foods by reading labels.
Determine the patients food preferences and dislikes when planning an electrolyte restricted
diet.
Teach patients who are prescribed to take diuretics to take the drugs as prescribed.
Teach patients who are taking digoxin or diuretics to measure their pulse for rate, rhythm,
and quality.
Include the person who prepares the patients meals when teaching about dietary electrolyte
restrictions.

Copyright 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.