Transcript Signs and Symptoms

Chapter 41
Fluid, Electrolyte, and Acid-Base
Balance
Characteristics of Body Fluids
Fluid = Water that contains dissolved or suspended
substances such as glucose, mineral salts, and proteins.
Fluid amount = Volume.
Fluid concentration = Osmolality.
Fluid composition (electrolyte concentration)
Degree of acidity = pH
Scientific Knowledge Base : Location and
Movement of Water and Electrolytes
Intracellular Fluid
(ICF)
Extracellular Fluid (ECF)
= Fluid outside of cells
= Fluids within cells
 ~2/3 of total body water

~1/3 of total body water
 Three divisions:
– Interstitial
– Intravascular
– Transcellular
Hemoglobin
• The hemoglobin test measures the amount of
hemoglobin in blood and is a good measure of
the blood’s ability to carry oxygen throughout the
body. Norm Males: 13.2-17.3 g/dL
Females: 11.7-15.5 g/dL
Hematocrit
This test measures the amount of space
(volume) red bloods cells take up in the blood.
The value is given as a % of RBCs in a volume of
blood. For example, a hematocrit of 38 means
that 38% of the blood’s volume is made of RBCs.
Norm: Male: 39%-50%
Females: 35%-47%
Hematocrit
ECF Volume deficit
Hypovolemia
 Causes
 Abnormal fluid loss
 Diarrhea
 Fistula drainage
 Hemorrhage
 Polyuria
 Fever (↑ perspiration)
 Inadequate intake
 Osmotic diuresis
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ECF Volume deficit
Hypovolemia: Sign and Symptoms
Cardiovascular Changes
 Mild to moderate
Respiratory Changes
 ↑ respiratory rate
 ↑ HR (due to SNS)
 Peripheral pulses are weak,
difficult to find
 Change in position may
cause ↑ HR or ↓ BP
 Dizziness and lightheadedness
 Severe fluid volume
 ↓ BP in lying position
 Pulse: weak, thready
 Flattened neck veins
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ECF Volume deficit
Hypovolemia: Sign and Symptoms
Renal Changes
 UO below 500 mL/day
Neurologic changes
 Alteration in Mental
Status
 Restlessness
 Drowsiness
 Lethargy
 Confusion (more
common in the elderly;
may be first indicator of
fluid balance problem)
 Seizures, coma
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ECF Volume deficit
Hypovolemia: Sign and Symptoms
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Skin turgor is diminished
Skin may be warm and dry with mild deficit
Skin may be cool and moist with severe deficit
Skin may appear dry and wrinkled
Oral mucous membranes will be dry, sticky, pastelike coating
and the tongue may be furrowed
 Patient C/O thirst
 Eyes: soft, sunken
 Lab data:
 ↑ H & H; BUN;
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Nursing Care Plan
Therapeutic Interventions
 Restore fluid and electrolyte balance
 IVs and blood products as ordered; small, frequent drinks
by mouth
 Daily weights to monitor progress of fluid replacement
 Loss or gain of 2.2 lbs is equal to 1 L of fluid
 I & O, hourly outputs
 Two most important assessments: HR & Output
 Avoid hypertonic solutions
 Promote comfort
 Frequent skin care
 Position: change q hr to relieve pressure
 meds as ordered: antiemetics, antidiarrheal
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Nursing Care Plan
Therapeutic Interventions
 Prevent physical injury
 Risk for falls due to orthostatic hypotension,
dysrhythmia, muscle weakness, gait stability and level
of alertness.
 Frequent mouth care
 Dry mucous membrane due to dehydration
 Monitor IV flow rate
 Observe for circulatory overload (↑ pulse, ↑ HR)
 Pulmonary edema (SOB)
 Monitor vital signs
 BP should be rising, ↑ LOC: more alert
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ECF Volume excess
Hypervolemia
• Causes
– Excessive intake of fluids
– Abnormal retention of fluids
• Heart failure
• Renal failure
– Long-term corticosteroid
therapy
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ECF Volume excess
Hypervolemia: Signs and symptoms
Cardiovascular Changes
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↑ Pulse: full and bounding
Full peripheral pulses
Distended neck veins
↑ BP
Other Changes
-Urine; polyuria, nocturia
-Lab data
↓ Hematocrit, BUN
Respiratory Changes
 ↑ respiratory rate
 Shallow respirations
 ↑ dyspnea with exertion or
in the supine position
 Pulmonary congestion and
pulmonary edema
 SOB
 Irritative cough
 Moist crackles
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ECF Volume excess
Hypervolemia: Signs and symptoms
Neurologic changes
 Altered LOC
 Visual disturbances
 Skeletal muscle weakness
 Paresthesias
 Cerebral edema
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Headache
Confusion
Lethargy
Diminished reflexes
Seizures, coma
 Skin
 Edematous may feel cool
 Skin may feel taut and
hard
 Edema-eyelids, facial,
dependent (sacrum),
pitting, peripheral
extremities
 GI Changes
 Increased motility
 Enlarged liver
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Nursing Care Plan
Therapeutic Interventions
 Maintain oxygen to all cells
 Position: sim-Fowler’s or Fowler’s to facilitate
improved gas exchange.
 Vital signs; q 4 hrs and PRN
 Tachycardia
 ↑ BP (overload) and ↓ BP (fluid deficit)
 Fluid restriction: I & O
 Promote excretion of excess fluid
 Meds as ordered: diuretics
 Monitor electrolytes, esp. Mg and K
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Nursing Care Plan
Therapeutic Interventions
 Obtain/maintain fluid balance
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Wt gain is the best indicator of fluid retention and overload
Weight daily; 2.2 lbs = 1 Liter (1000 ml)
Measure: all edematous parts, abdominal girth,
I & O: fluid restriction
Limit fluids by mouth, IVs per doctors orders
Strict monitoring of IV fluids
 Prevent tissue injury
 Skin and mouth care as needed
 Evaluate feet for edema and discoloration when client is OOB
 Observe suture line on surgical clients (Potential for evisceration
due to excess fluid retention)
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Functions of Sodium
• Regulates osmolality
– ICF: 14 mmol/L & ECF: 135-145 mmol/L
• Helps maintain blood pressure by balancing
the volume of water in the body
• Works with other electrolytes to promote
nerves, muscles and other body tissues to
work properly.
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Hypernatremia
Water loss: Causes
 Inadequate water intake
 Unconscious or cognitively
impaired individuals
 NPO status
 Excessive water loss
 ↑ insensible water loss
 High fever
 Diuretic therapy
 Watery diarrhea
 Disease states
 Uncontrolled diabetes mellitus
Water loss: Signs and Symptoms
• Restlessness, agitation,
twitching, confusion
• Seizures*, Coma
• Intense thirst
• Dry, swollen tongue
• Sticky mucous membranes
• Weight loss
• Weakness, lethargy
• Postural hypotension
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Hypernatremia
Na gain: Causes
 Na intake
 IV fluids: hypertonic NaCl,
excessive isotonic NaCl
 Hypertonic tube feeding with
out water supplement
 Use of Na containing drugs
 corticosteroids
 Diseases
 Renal failure
Na gain: Signs and Symptoms
• Restlessness, agitation,
twitching
• Seizures, Coma
• Intense thirst
• Flushed skin
• Weight gain
• Peripheral and pulmonary
edema
• ↑ BP
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Hyponatremia
• Dilutional (↑ ECF
Volume) Causes
– Use of hypotonic
irrigation solution
– Tap water enemas
– Excessive water gain
• Excessive hypotonic
IV fluid
 Dilutional (↑ ECF Volume)
Signs and Symptoms
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Headache, apathy, confusion
Nausea, vomiting, anorexia
Lethargy
Weakness
Muscle spasms, seizures, coma
Diarrhea, Abdominal cramps
Weight gain
↑ BP
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Hyponatremia
 Na Loss: Causes
 GI
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Vomiting
Diarrhea
NG suctioning
NPO Status
 Kidney
 Diuretic
 Skin
• Burns
• Wounds
• Excessive diaphoresis
 Na Loss: Signs and
Symptoms
 Irritability, apprehension,
confusion
 Dizziness
 Personality changes
 Tremors, seizures, coma
 Dry mucous membranes
 Postural hypotension
 Tachycardia, thread pulse
 Cold & clammy skin
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Functions of Potassium
• Maintains fluid balance in the cells
– Contributes to intracellular osmotic pressure
• Direct effect on excitability of nerves and
muscles
– Skeletal, cardiac, and smooth muscle contraction
• Regulates glucose use and storage
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Hyperkalemia
Causes
• Most cases of hyperkalemia occur in
hospitalized patients and in those undergoing
medical treatment.
• Those at greatest risk for hyperkalemia are
– Chronically ill patients
– Debilitated patients
– Older adult
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Hyperkalemia
Causes
Actual hyperkalemia
• Excess potassium Intake
– Excessive or rapid parenteral
administration
Relative hyperkalemia
• Shift of potassium Out of
Cells
– Acidosis
– Crushing injury
– Tissue catabolism (fever,
sepsis, burns)
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Hyperkalemia
Causes
• Failure to Eliminate Potassium
– Renal disease
– Potassium-sparing diuretics
– ACE inhibitors
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Hyperkalemia
Signs and Symptoms
Clinical Manifestations
 Irritability
 Abdominal cramping,
diarrhea
 Weakness of lower
extremities
 Irregular pulse
 Cardiac arrest if
hyperkalemia sudden or
severe
Electrocardiogram Changes
• Ventricular fibrillation
• Ventricular standstill
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Hypokalemia
Causes
• Potassium Loss
– GI losses: diarrhea,
vomiting, fistulas, NG
suction, NPO status
– Renal losses: diuretics,
– Skin losses: diaphoresis
– Dialysis
• Shift of Potassium into
Cells
– Alkalosis
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Hypokalemia
Causes
• Lack of Potassium Intake
– Starvation
– Diet low in K
– Failure to include K in parenteral fluids if NPO
– TPN
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Hypokalemia
Signs and Symptoms
Clinical Manifestations
 Fatigue
 Muscle weakness, leg
cramps
 Nausea, vomiting, paralytic
ileus
 Soft, flabby muscles
 Paresthesias, decreased
reflexes
 Weak, irregular pulse
Electrocardiogram Changes
• Ventricular dysrhythmias
(e.g., PVCs)
• Bradycardia
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Hypokalemia
Medical Management
 Administration of KCl supplements
 K may be given orally (K chloride, K gluconate,
K citrate) or IV
 KCl should be administered IV at a rate of 10 to
20 mEq/L over an hour. Rapid infusion could
cause cardiac arrest
 IV K solutions irritate veins and cause phlebitis.
Check IV site q 2 hrs. Discontinue IV if infiltrate to
prevent necrotic and slough of tissue
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Functions of Calcium
• Helps maintain muscle tone
• Contributes to regulation of blood pressure by
maintaining cardiac contractility
• Necessary for nerve transmission and
contraction of skeletal and cardiac muscle
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Hypercalcemia
Causes
 Increased Total Calcium
 Prolonged immobilization
 Thiazide diuretics
 Dehydration
 Renal failure
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Hypercalcemia
Signs and Symptoms
Clinical Manifestations
 Lethargy, weakness
 Depressed reflexes (DTR)
 Decreased memory
 Confusion, personality
changes, psychosis
 Anorexia, nausea, vomiting,
constipation
 Bone pain, fractures
Electrocardiogram Changes
• Ventricular dysrhythmias
• Hypertension
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Hypocalcemia
Causes
 Decreased Total
Calcium
 Chronic renal failure
 Loop diuretics (e.g.,
furosemide [Lasix])
 Chronic alcoholism
 Diarrhea
 Decreased Ionized
Calcium
 Excess administration of
citrated blood
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Hypocalcemia
Signs and Symptoms
Clinical Manifestations
 Easy fatigability
 Depression, anxiety, confusion
 Numbness and tingling in
extremities and region around
mouth
• Hyperreflexia, muscle cramps
• Chvostek’s sign & Trousseau’s
sign
• Laryngeal spasm
• Tetany, seizures
Electrocardiogram Changes
• Ventricular tachycardia
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Functions of Magnesium
• Cofactor in clotting cascade
• muscular irritability and contractions
• Maintains strong and healthy bones
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Hypermagnesemia
Causes
 Renal failure
 Diabetes Mellitus
 Clients who ingest large amounts of Mgcontaining antacids such as Tums, Maalox,
Mylanta, or laxatives such as MOM are also in
↑ risk for developing hypermagnesemia
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Hypermagnesemia
Signs and Symptoms
– Bradycardia and hypotension
– Severe hypermagnesemia: cardiac arrest
– Drowsy or lethargic
– Coma
– Deep tendon reflexes are reduced or absent
– Skeletal muscle contractions become progressively
weaker and finally stop
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Hypomagnesaemia
Causes
• Malabsorption disorders
– Inflammatory bowel disease (IBD)
– Bowel resection
– Bariatric population who undergoes gastric bypass surgery
• Alcoholism
• Prolonged diarrhea
• Draining GI fistulas
• Diuretics
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Hypomagnesaemia
Signs and Symptoms
• Confusion
• Hyperactive deep
tendon reflexes
• Tremors
• Seizures
• Neuromuscular changes
– Hyperactive deep
tendon reflexes
– Numbness and tingling
– Painful muscle
contractions
– Monitor for positive
Chvostek’s and
Trousseau’s signs
(hypocalemia may
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Case Study
• Susan Reynolds, a 42-year-old married
accountant, has just been admitted to the
acute care unit with a history of nausea,
loss of appetite, and vomiting and diarrhea
for 7 days. She feels her symptoms are
related to “bad food” she had on her recent
business trip. Past medical history includes
hypertension controlled by furosemide
(Lasix) 40 mg by mouth once a day and a
no-salt-added diet.
Discussion
• What is Mrs. Reynolds at risk for?
• What will you assess?
• How does Lasix factor into this situation?
– What lab should be monitored when
administering this medication?
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• Mrs. Reynolds’ electrolytes are out of balance
due to the vomiting and diarrhea. Lasix
therapy compounds this issue because Lasix is
a diuretic that causes fluid loss.
• Reference: Pg. 887
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Case Study (cont’d)
• Mrs. Reynolds’ physician has admitted her
for observation and has obtained a blood
sample for electrolyte levels, CBC, and an
ECG. Orders include nothing by mouth, an
IV infusion of 0.9% saline at 125 mL/hr,
intake and output (I&O) recordings, and
vital signs every 4 hours, in addition to daily
weights.
• What assessment activities do you
anticipate Robert will perform?
What should Robert Assess?
• Ask Mrs. Reynolds to describe her nausea and what
accompanying signs and symptoms she is experiencing.
• Conduct an examination of GI and urinary function.
• Assess Mrs. Reynolds’ vital signs.
• Assess Mrs. Reynolds’ skin and mucous membranes for
indicators of dehydration.
• Evaluate Mrs. Reynolds’ laboratory values and ECG
results.
• Reference: Pg. 895
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Nursing Knowledge Base
• Use the scientific knowledge base in clinical decision
making to provide safe, optimal fluid therapy.
• Apply knowledge of risk factors for fluid imbalances
and physiology of normal aging when assessing older
adults, knowing that this age group is at high risk for
fluid imbalances.
• Ask questions to elicit risk factors for fluid, electrolyte,
and acid-base imbalances.
• Perform clinical assessments for signs and
symptoms of these imbalances.
Nursing Process: Assessment
• Nursing history
– Age: very young and old at risk
– Environment: excessively hot?
– Dietary intake: fluids, salt, foods rich in
potassium, calcium, and magnesium
– Lifestyle: alcohol intake history
– Medications: include over-the-counter (OTC)
and herbal, in addition to prescription
medications
Nursing Process: Assessment (cont’d)
• Medical history
– Recent surgery (physiological stress)
– Gastrointestinal output
– Acute illness or trauma
• Respiratory disorders
• Burns
• Trauma
– Chronic illness
• Cancer
• Heart failure
• Oliguric renal disease
Physical Assessment
• Daily weights
– Indicator of fluid status
– Use same conditions.
• Fluid intake and output (I&O)
– 24-hour I&O: compare intake versus output
– Intake includes all liquids eaten, drunk, or
received through IV.
– Output = Urine, diarrhea, vomitus, gastric
suction, wound drainage
• Laboratory studies
Case Study (cont’d)
• Mrs. Reynolds states that she has no appetite, is
nauseous, and has been vomiting and has had diarrhea for
7 days.
• Bowel sounds are hyperactive in all four quadrants. The
patient has had only two loose stools since midnight. She
voids with difficulty, with dark yellow urine. Her 24-hour
intake was 1850 mL; her output was 2200 mL (of which
urine was only 1000 mL).
• Temperature 99.6° F; pulse 100 bpm; BP 110/60 mm Hg
with no changes when standing
What’s wrong?
• The assessment findings indicate that Mrs.
Reynolds is dehydrated.
• Reference: Pg. 895
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Case Study (cont’d)
• Mrs. Reynolds’ laboratory results:
– Hematocrit 44% (suggesting hypovolemia)
– Potassium 3.6 mEq/L and sodium 138 mEq/L
(both low normal because of prolonged
vomiting and diarrhea)
– Electrocardiogram (ECG) showed normal sinus
rhythm.
Nursing Diagnosis
??????
??????
??????
Possible nursing diagnoses for Mrs.
Reynolds include:
1. Risk for electrolyte imbalance
2. Fluid volume deficit
3. Impaired oral mucous membrane
4. Deficient fluid volume related to excessive
diarrhea, vomiting, and use of potassiumwasting diuretic
Reference: Pg. 900
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Case Study (cont’d)
• Nursing diagnosis: Deficient fluid volume
related to excessive diarrhea, vomiting, and
use of potassium-wasting diuretic
GOALS
– Mrs. Reynolds’ fluid volume will return to normal
by time of discharge.
– Mrs. Reynolds will achieve normal electrolyte
balance by discharge.
– What are 3 other goals?
• 1.
• 2.
• 3.
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Planning
• Goals and outcomes
• Setting priorities
• Collaborative care
Expected Outcomes
?????????????
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Case Study (cont’d)
• Fluid balance
–
–
–
–
Urine output will equal intake of ~1500 mL in 2 days.
Mucous membranes will be moist in 24 hours.
Skin turgor will return to normal within 24 hours.
Daily weights will not vary by more than 2 lbs over the next 2
days.
• Electrolyte and acid-base balance
– Serum electrolyte and blood counts will be within normal limits
within 48 hours.
– Mrs. Reynolds will not have any nausea or vomiting in 24 hours.
Nursing Interventions
• Interventions for electrolyte imbalances
– Support prescribed medical therapies
– Aim to reverse the existing acid-base
imbalance
– Provide for patient safety
Interventions & Rationales
?????????
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Interventions
• Administer IV fluids (0.9% normal saline) at 125 mL/hr.
– 1. Replacement of body fluid restores blood volume and normal
serum electrolyte levels; an isotonic solution expands the body’s
intravascular fluid volume without causing a fluid shift from one
compartment to another.
• Provide patient with an additional 480 mL of
noncaffeinated oral fluids every 8 hours.
– 2. Pepto-Bismol is an antidiarrheal to inhibit GI secretions,
stimulate absorption of fluid and electrolytes, inhibit intestinal
inflammation, and suppress the growth of Helicobacter pylori.
Interventions and Rationales
1.
Maintain accurate I&O measurements.
a.
I&O documents hydration and fluid balance for directing
therapy.
2. Weigh Mrs. Reynolds daily; monitor trends.
a. Daily weights provide reliable data of fluid balance.
3. Teach Mrs. Reynolds and family about specific dietary
modification (potassium-rich foods).
a.
Furosemide (Lasix) is a potassium-wasting diuretic. The body
does not store potassium, thus requiring dietary supplements
rich in potassium.
Reference: Pg. 903
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Implementation
• Health promotion
– Fluid replacement education
– Teach patients with chronic conditions about risk factors and signs
and symptoms of imbalances.
• Acute care
– Enteral replacement of fluids
– Restriction of fluids
– Parenteral replacement of fluids and electrolytes
• Total parenteral nutrition
• Crystalloids (electrolytes)
• Colloids (blood and blood components)
Implementation
• Restorative care
– Home intravenous therapy
– Nutrition support
– Medication safety
• Medications
• OTC drugs
• Herbal preparations
Case Study (cont’d)
• Nursing actions:
– Monitor electrolyte levels and daily weights.
– Inspect oral mucous membranes; assess skin turgor.
– Evaluate I&O trends during next 48 hours.
• Findings
– Serum electrolyte levels: potassium 4.0 mEq/L and sodium 140
mEq/L
– Mucous membranes remain dry; skin turgor normal
– Mrs. Reynolds’ 24-hour intake is 2800 mL, and output is 2200 mL
with 1800 mL urine. Urine specific gravity is 1.025, and weight has
returned to 143 lb.
Evaluation
1. Are the goals met?
2. How do we know?
Evaluation
• Robert is encouraged by Mrs. Reynolds’ progress. He discusses
sources of potassium in the diet and writes this documentation
note:
• “Denies nausea and reports feeling better. No diarrheal stool since
yesterday afternoon around 3 p.m. On inspection, oral mucosa
remains dry, without lesions or inflammation. Skin turgor is normal.
Bowel sounds are normal in all four quadrants, abdomen soft to
palpation. IV of 0.9% normal saline is infusing in left cephalic vein
in forearm at 40 mL/hr per MD order. No tenderness or
inflammation at IV site. Is able to identify five food sources for
potassium to include in diet. Is resting comfortably, out of bed in a
chair, ate all of breakfast. Will continue to monitor.”
• Reference: Pg. 914
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