fluid imbalance

PRESENTED BY: -Ms. SUKHRAJ KAUR M.Sc. (N) IST YEAR

ACON, PATIALA

FLUID IMBALANCE

The basic type of fluid imbalances are isotonic and osmolar. Isotonic deficit and excess exist when water and electrolytes are gained and lost in equal proportions.

CAUSESFluid losses from GI tract

Loss of plasma

Loss of blood

Fever

Decreased oral

intake

Use of diuretics

FLUID VOLUME DEFICIT • It occurs when the fluid intake of the body is not sufficient to

meet the fluid needs of the body. • Fluid volume deficit (hypovolemia) should not be confused

with the term dehydration, which refers to loss of water alone with increased serum sodium levels. FVD may occur alone or in combination with other imbalances.

CAUSES• Acute weight loss • Decreased skin turgor • A weak, rapid heart rate • Decreased central venous pressure • Diarrhea, Nausea, Vomiting • Fever

CLINICAL MANIFESTATIONS• Weight loss• Thirst• Changes in pulse rate and Bp• Weak, rapid pulse• Decreased urine output• Dry mucous membrane  

TREATMENT / INTERVENTIONS (FVD)

• Diet therapy – Mild to moderate dehydration. Correct with oral fluid replacement. • Oral rehydration therapy – Solutions containing glucose

and electrolytes. E.g. Pedialyte, Rehydralyte.• IV therapy – Type of fluid ordered depends on the type of

dehydration and the client’s cardiovascular status.

NURSING INTERVENTIONS 

Conti...

• Administer medications as prescribed, such as antidiarrheal, antimicrobial, antiemetic, and antipyretic medications, to correct the cause and treat any symptoms.• Administer oxygen as prescribed. • Monitor electrolyte values and prepare to administer

medication to treat an imbalance, if present.

FLUID VOLUME EXCESS

• is also called Overhydration or fluid overload

COMMON CAUSES

• Congestive Heart Failure• Early renal failure• IV therapy• Excessive sodium ingestion• Corticosteroids

CLINICAL MANIFESTATIONS

TREATMENT/ INTERVENTIONS (FVE)

Drug therapy Diuretics may be ordered if renal failure is not the cause. Restriction of sodium and saline intake Weight

LABORATORY FINDINGS

Serum sodium level < 125 meq / L

Decrease hematocrit

MANAGEMENT ICFVE is treated by the addition of solutes to IV fluids. Use of D5%, 0.45% Nacl will help to correct ICFVE when the cause is water excess. Oral fluids such as water and soft drinks should be given in addition to water and ice chips. IV therapy should be monitored every hour.

Conti… Monitor vital signs and intake- output Every 1-8 hrs. Weight should be checked daily to measure fluid gain or loss. Administer prescribed antiemetic as needed to allow food and fluids to be ingested. Safety measures are necessary when the client displays behavioral changes.

NURSING INTERVENTIONS 

• Monitor cardiovascular, respiratory, neuromuscular, renal, integumentary, and gastrointestinal status.• Prevent further fluid overload and restore normal fluid

balance.• Administer diuretics; osmotic diuretics typically are

prescribed first to prevent severe electrolyte imbalances.

Conti…• Restrict fluid and sodium intake as prescribed. • Monitor intake and output; monitor weight.• Monitor electrolyte values, and prepare to administer

medication to treat an imbalance if present.

ELECTROLYTE IMBALANCES

HYPONATREMIA

Hyponatremia is a serum sodium level below 135 meq / L

ETIOLOGY

CLINICAL MANIFESTATION

MEDICAL MANAGEMENT

• Determine cause of hyponatremia and to correct it. • If client has hyponatremia due to fluid volume excess, intake

of fluids will be restricted to allow the sodium to regain balance. • If the serum sodium level falls below 125 meq / L, sodium

replacement is needed.

PHARMACOLOGIC MANAGEMENT

• For client with moderate hyponatremia 125 meq/ L I/V saline solution (0.9% Nacl) or lactated Ringer solution may be ordered. • When the serum sodium level is 115 meq / L or less, a

concentrated saline solution such as 3 % Nacl is indicated.

DIETARY MANAGEMENT

• A balanced diet is usually adequate for mild hyponatremia (126 to 135 meq/ L) • More severe hyponatremia may require sodium replacement • If the clients have hyponatremia due to excess fluids, a fluid

restricted diet may be prescribed. • Fluids may be restricted 800 to 1000 ml / day.

NURSING INTERVENTIONS• Monitor cardiovascular, respiratory, neuromuscular, cerebral,

renal, and gastrointestinal status of the patient.• If hyponatremia is accompanied by a fluid volume deficit

(hypovolemia), IV sodium chloride infusions are administered to restore sodium content and fluid volume.

Conti…• If hyponatremia is accompanied by fluid volume excess

(hypervolemia), osmotic diuretics are administered to promote the excretion of water rather than sodium.• Instruct the client to increase oral sodium intake and inform the client

about the foods to include in the diet.• If the client is taking lithium (Lithobid), monitor the lithium level,

because hyponatremia can cause diminished lithium excretion, resulting in toxicity.

HYPERNATREMIA

• Hypernatremia is a serum sodium level over 145 meq / L

ETIOLOGY

• Diabetes insipidus.• Excess NaCl IV fluid intake.• Accidental or international salt intake. • Canned vegetables.• Renal losses.

CLINICAL MANIFESTATIONS

LABORATORY FINDINGS 

Serum sodium > 145 meq /L.

MEDICAL MANAGEMENT• To decrease total body sodium and replace fluid loss either a

hypo-Osmolar electrolyte solution (0.2 % or 0.45 % Nacl) or D5% is administered.• Hypernatremia caused by sodium excess can be treated with

D5% and diuretic such as furosemide.

DIETARY MANAGEMENT

• Dietary restrictions of sodium are useful to prevent hypernatremia in high risk clients • Clients with renal disease may need to have their sodium

intake restricted to 500 to 2000 mg / day.

NURSING INTERVENTIONS

• Monitor cardiovascular, respiratory, neuromuscular, cerebral, renal, and integumentary status.• If the cause is fluid loss, prepare to administer IV infusions.• If the cause is inadequate renal excretion of sodium, prepare

to administer diuretics that promote sodium loss.• Restrict sodium and fluid intake as prescribed.

HYPOKALEMIAHypokalemia is a serum potassium level of less than 3.5 meq /L  

ETIOLOGY

CLINICAL MANIFESTATIONS

•  

LABORATORY FINDINGS 

Serum potassium <3.5 meq / L

MEDICAL MANAGEMENT

• Determining & correcting the cause of the imbalance. • Extreme hypokalemia requires cardiac monitoring.

PHARMACOLOGIC MANAGEMENT

• Oral potassium replacement therapy is usually prescribed for mild hypokalemia• Potassium is extremely irritating to gastric mucosa; therefore the

drug must be taken with Glass of water or juice or during meals• Potassium chloride can be administered intravenously for

moderate or severe hypokalemia & must be diluted in IV fluids.

Conti…• Administration of potassium by IV push may result in cardiac

arrests. Potassium can be given in doses of 10 to 20 meq/ hour diluted in IV fluid if the client is on heart monitor. • High concentration of potassium is irritating to heart muscle.

Thus correcting a potassium deficit may take several days.

DIETARY MANAGEMENT

• The administration of foods that are high in potassium help to correct the problem as well as prevent further potassium losses.• Common sources of food containing potassium – Cabbage,

Carrot, Cucumber, Mushrooms, Spinach, Tomato, Fruits- Banana, Guava, Orange.

NURSING INTERVENTIONS

• Monitor cardiovascular, respiratory, neuromuscular, gastrointestinal, and renal status, and place the client on a cardiac monitor.• Monitor electrolyte values.• Administer potassium supplements orally or intravenously, as

prescribed.• Liquid potassium chloride has an unpleasant taste and should be

taken with juice or another liquid.

Conti…Oral potassium supplements may cause nausea and vomiting

and they should not be taken on an empty stomach; if the client complains of abdominal pain, distention, nausea, vomiting, diarrhea, or gastrointestinal bleeding, the supplement may need to be discontinued.

• Instruct the client about foods that are high in potassium content.

HYPERKALEMIA

Hyperkalemia is an Elevated potassium level over 5.0 meq/L.

ETIOLOGY • Retention of Potassium – Renal insufficiency, renal failure,

decreased urine output, potassium sparing diuretics. • Excessive release of Cellular Potassium - severe traumatic

injuries. Severe burns, severe infection, metabolic acidosis. • Excessive IV infusions or Oral administration of potassium.

CLINICAL MANIFESTATIONS

•  

LABORATORY FINDINGS

Serum potassium > 5.0 meq/L

Serum creatinine > 1.5 mg/dl

BUN > 25 mg/dl

MEDICAL MANAGEMENT • When serum potassium level is 5.0 to 5.5 meq/L restrict of

potassium intake. • If potassium Excess is due to metabolic acidosis, correcting the

acidosis with sodium bicarbonate promotes potassium uptake into the cells. • Improving urine output decreases elevated serum potassium

level.

DIETARY MANAGEMENT • When hyperkalemia is severe, immediate actions are needed to

be taken to avoid severe Cardiac disturbances. • The administration of foods that are high in potassium help to

correct the problem as well as prevent further potassium looses. • Common sources of food containing potassium – Cabbage,

Carrot, Cucumber, Mushrooms, Spinach, Tomato, Fruits- Banana, Guava, Orange.

NURSING INTERVENTIONS• Monitor cardiovascular, respiratory, neuromuscular, renal, and

gastrointestinal status; place the client on a cardiac monitor.• Discontinue IV potassium and hold oral potassium

supplements.• Prepare to administer potassium-excreting diuretics if renal

function is not impaired.

Conti…• Initiate a potassium-restricted diet.• If renal function is impaired, prepare to administer sodium

polystyrene sulfonate (Kayexalate).• Prepare the client for dialysis if potassium levels are critically

high.• Prepare for the IV administration of hypertonic glucose with

regular insulin to move excess potassium into the cells.

Conti…• Monitor renal function.• Teach the client to avoid foods high in potassium.• Instruct the client to avoid the use of salt substitutes or other

potassium-containing substances.

HYPOCALCEMIA

• Hypocalcemia is serum calcium below 4.5 meq/L or 8.5 mg/dl

ETIOLOGY

• Malabsorption of fat in intestine. • Metabolic alkalosis• Renal failure with hyperphsophatemia, acute pancreatitis,

Burns, Cushing‘s disease, hypoparathyrodism. • Medications – Magnesium sulfate.

CLINICAL MANIFESTATIONS• Neuromuscular: Tetany symptoms: Twitching around

mouth, tingling and numbness of fingers, facial spasm, convulsions. • Respiratory: Dyspnea, laryngeal spasm. • Gastrointestinal: increased peristalsis, diarrhea.• Cardiovascular: Dysrhythmias, palpitations  

MEDICAL MANAGEMENT

• Determining & correcting the cause of hypocalcemia. • Asymptomatic hypocalcemia is usually corrected with oral

calcium gluconate, calcium lactate or calcium chloride. • Administer calcium supplements 30 minutes before meals for

better absorption and with glass of milk because vitamin D is necessary for absorption of calcium from the intestine.

DIETARY MANAGEMENT • Intravenous calcium chloride or calcium gluconate (10%) is

given slowly to avoid hypertension, bradycardia & other arrhythmias. • Chronic or mild hypocalcemia can be treated in part by

having the client consume a diet high in calcium: e.g: Cheese, milk, spinach.

NURSING INTERVENTIONS• Monitor cardiovascular, respiratory, neuromuscular, and

gastrointestinal status; place the client on a cardiac monitor.• Administer calcium supplements orally or calcium intravenously.• When administering calcium intravenously, warm the injection

solution to body temperature before administration and administer slowly, monitor for electrocardiographic changes, and monitor for hypercalcemia.

Conti…

• Administer medications that increase calcium absorption. i.e. Vitamin D aids in the absorption of calcium from the intestinal tract.• Initiate seizure precautions.• Keep 10% calcium gluconate available for treatment of acute

calcium deficit.

• Instruct the client to consume foods high in calcium. 

HYPERCALCEMIA

Hypercalcemia is a serum level over 5.5 meq/L or 11 mg/L  

ETIOLOGY • Metastatic malignancy-lung, breast, Ovarian, Prostatic,

bladder, leukemia, Kidney. • Hyperparathyroidism. • Thiazide diuretic therapy. • Prolong immobilization. • Excessive intake of calcium supplements and vitamin D.

CLINICAL MANIFESTATIONS • Gastrointestinal: Anorexia, Vomiting, Constipation,

Neuromuscular: Mild to moderate hypercalcemia state –weakness, Severe hypercalcemic state-Extreme lethargy• Cardiovascular: Dysrhythmias, Electro-cardiographic

Changes: Shortened ST Segment and lengthened QT interval.• Musculoskeletal: Bone pain, fracture.

LABORATORY FINDINGS

Arterial blood gasses- PH < 7.45

Serum Calcium > 5.5 meq/L (> 11.5 mg/dl)

HCO3> 26 meq/L

MEDICAL MANAGEMENT• Treatment consists of correcting the underlying cause. • Intravenous normal saline (0.9% Nacl) given rapidly with

furosemide to prevent fluid overload, Promote urinary calcium excretion. • Corticosteroid drugs decrease calcium levels by competing

with vitamin D thus resulting in decreased intestinal absorption of calcium.

Conti…

• If the cause is excessive use of calcium or vitamin D supplements or calcium containing antacids these agents should be either avoided or used in reduced dosage. • A newer form of drug therapy is etidronate di-sodium. This

drug reduces serum calcium by reducing normal and abnormal bone reabsorption of calcium and secondarily by reducing bone formation.

NURSING INTERVENTIONS• Monitor cardiovascular, respiratory, neuromuscular, renal, and

gastrointestinal status; place the client on a cardiac monitor.• Discontinue IV infusions of solutions containing calcium and

oral medications containing calcium or vitamin D.• Discontinue thiazide diuretics and replace with diuretics that

enhance the excretion of calcium.

Conti…

• Administer medications as prescribed that inhibit calcium resorption from the bone, such as phosphorus, calcitonin, bisphosphonates, and prostaglandin synthesis inhibitors (aspirin, nonsteroidal anti-inflammatory drugs).• Prepare the client with severe hypercalcemia for dialysis if medications

fail to reduce the serum calcium level.• Instruct the client to avoid foods high in calcium. 

CONCLUSION

Fluids are essential for life. Homeostasis is sustained by very many processes. As nurses, one of our main responsibility in dealing with most kind of patient is the maintenance of fluid volume and electrolyte balance. Thus it is very essential to know regarding the fluid and electrolyte balance and imbalances.

SUMMARIZATION FLUID IMBALANCE CAUSES TYPES OF FLUID IMBALANCE ELECTROLYTE IMBALANCE HYPONATREMIA HYPERNATREMIA HYPOKALEMIA HYPERKALEMIA HYPOCALCEMIA HYPOCALCEMIA CONCLUSION BIBLIOGRAPHY

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advanced nursing practice. First edition. Banglore: Emmess; 2012.P. p 212- 223

• Silvestri anne linda. saunders comprehensive review for the NCLEX- RN EXAMINATION Fifth edition. America: Elsevier 2011 .p 245-249

Conti…

• Suddhartha & Brunner. Medical-Surgical Nursing, 10th edition - Pp- 256- 260, 261- 272• Potter A Patrica, Perry Griffin Anne. Fundamentals of

nursing. 7th edition. Noida: Elsevier;2009. Pp- 967-972.