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LINCOLN MEMORIAL UNIVERSITYCaylor School of Nursing

Nursing 124/125Fall 2010

LESSON PLAN: Fluid and Electrolytes

1. Explain the distribution of fluid and electrolytes in the body.2. Identify the compartments for water in the body.3. Identify ways adult human persons lose fluids and nursing measures to replace fluid loss.4. Recognize the mechanism and routes by which fluid is transported in the body.5. Identify the major electrolytes of the body and the primary function and purpose of the electrolytes.6. Identify common electrolytes and water imbalances, signs and symptoms of these imbalances and

nursing interventions to prevent and correct such imbalances.7. Accurately calculate intake and output.8. Describe the relationship between normal fluid intake and output.9. Identify common diagnostic tests regarding fluid and electrolyte balance.10. Identify stimuli which may affect fluid and electrolyte balance in different the young adult and older

adult.11. Utilize the Roy Adaptation Model (RAM) nursing process to develop a plan of care for the adult with

fluid and/or electrolyte imbalance.12. Identify the physiologic action, use, side effects, and nursing implications of medications utilized in

the pharmacologic management of fluid balance needs.13. Identify appropriate interventions for the adult receiving parenteral fluid therapy.14. Correctly calculate medication dosage and administration.15. Identify the various acid base disorders, causes and interventions.16. Describe the process of administering blood, assessing and evaluating

complications.

TOPICAL OUTLINE I. Review of Fluid and Electrolyte Balance Homeostasis- maintenance of this constant environment in the face of continual change. Fluid imbalance manifests as:

o Excesseso Deficitso Abnormal shifts among body compartments

Nurses’ Functions related to F&E Balance Daily weight is a major indicator of fluid status Recognize situations causing imbalances Intervene to prevent imbalances Carry out preventive/therapeutic measures prescribed and monitor response Monitor to prevent and recognize imbalances Alleviate effects of disturbances in comfort and safety Prevent imbalances in people at risk

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Fluid Approximately 60% of the typical adult is fluid Varies with age, body size, and gender

o 80% or greater in infants; decreases with ageo Less in elderlyo Less with obesity- fat cells contain little water

Adequate body water is necessary in: Maintenance of normal body temperature Elimination of waste products Making transportation within the body possible Acts as tissue lubricant

A. Distribution of Body FluidsDistribution of Body fluid Intracellular fluid (ICF)

o Found within body cellso 60-70% total bodyo Major electrolytes in ICF

Potassium Magnesium Phosphate

Extracellular Fluid (ECF)o Found outside the cello 30-40% total body fluido In constant motion

Interstitial fluid (between cells) Intravascular (plasma) Cerebrospinal fluid GI secretions

Extracellular Fluid (ECF) Highly determined by Na+ concentration Contains large amounts of Na+, Cl-, and HCO3- Normal movement occurs between capillaries and interstitial spaces If capillary of interstitial pressures are altered, fluid can shift abnormally

Fluid spacing Third spacing- occurs when fluid accumulates in areas that normally have little or no fluid

(peritoneum, edema with burns, etc)o It is lost- body is not able to use = imbalanceo What clinical manifestations will be seen?

Low BP Tachycardia Cold, clammy skin Decreased urine output Give albumin to pull out trapped fluid

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B. Electrolytes

1. Major Cations (Na+, K+, Ca+, Mg+)Sodium Main electrolyte in ECF Controls and regulates volume of body fluids Maintains water balance Primary regulator of ECF volume Important for nerve impulse generation and transmission Regulated by antidiuretic hormone, thirst, and angiotensin-aldosterone system

Potassium Major cation in ICF Vital in transmission of electrical impulses in the heart, nervous system, skeletal system, intestinal

and lung tissues Chief regulator of cellular enzyme activity 80% of potassium is lost through kidneys, if kidneys are not functioning properly could cause

increase in potassium

Calcium Plays a major role in transmitting nerve impulses, and helps regulate muscle contraction and

relaxation, including cardiac muscle. Plays a role in blood coagulation Excreted mostly through feces Serum calcium level is controlled by PTH and calcitonin, which is released from the thyroid.

Magnesium 2nd most abundant cation in ICF Plays a role in carbohydrate and protein metabolism Important for neuromuscular function Also acts peripherally to produce vasodilation Predominantly found in bone and soft tissues Primarily excreted by kidneys Mostly absorbed through GI tract

2. Major Anions (Cl-, HCO3-, PO4-)

C. Movement of body fluid and electrolytes

1. OsmosisMovement of fluid from an area of lower solute concentration to an area of higher solute concentration

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2. DiffusionMovement of molecules and ions from an area of higher concentration to an area of lower concentration

3. Active transport Physiologic pump that moves fluid from an area of lower concentration to one of higher

concentration Movement against the concentration gradient Sodium-potassium pump maintains the higher concentration of extracellular sodium and

intracellular potassium Requires adenosine (ATP) for energy

Sodium-potassium pumpo Sodium concentration greater in ECFo Diffusion allows sodium to enter the cello Once inside the cell, the sodium-potassium pump actively moves the Na back to the ECFo Energy must be expended for Na+ and K+ to change places rapidly through the systemo Sodium-potassium pump maintains the higher concentrations

4. Filtration Movement of water and solutes from an area of higher hydrostatic pressure to an area of lower

hydrostatic pressure Capillaries filter fluid from intravascular space to interstitial space Kidneys filter plasma allowing excretion of water and waste products Must have two factors present

o Hydrostatic pressure = BPo Osmotic pressure

D. Routes of gains and losses

1. Gains – dietary, enteral, parenteralo Dietary intake of fluid and food or enteral feedingo Parenteral fluids

2. Losses - Sensible vs. insensible, kidneys, skin, lungs, GI tract, other Loss: sensible (measurable) and insensible (unmeasurable)

o Kidney: urine outputo Skin loss-sweatingo Lungso GI tracto Other- hemorrhaging

3. Intake and outputIntake

Intake primarily regulated by thirst mechanism Adult daily fluid intake is approximately 2600ml

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o 1300 ml from liquidso 1000 ml from foodso 300 ml from metabolism

Output Kidneys- approximately 1500ml each day, at least 30 ml/hr Skin

o Loss through sweat/perspiration, increased temperature or metabolismo Evaporation through skin/lungs with respiration

Lungs- approximately 300 ml/day (average adult) GI Tract- approximately 200 ml/day

4. Daily weightsDaily weights

Provide estimate of fluid volume status Best indicator of fluid balance What principles should be remembered?

o Same time of the day, everydayo Same scale, make sure scales are properly zeroedo Same amount of clothes

E. Regulation of body fluid and electrolytes

1. Kidneys Adjustments made in urine volume to balance fluid Excretion of metabolic waste and toxic substances Filters plasma Responds to ADH and aldosterone to regulate levels

2. Cardiac Increase HR and CO Atrial natriuretic factor (ANF)- lab test to identify BNP Released when left atrium of heart is stretched from volume overload Vasodilates and increases urinary excretion of Na+ and H20

3. Lungs Through exhalation, the lungs remove about 300ml of fluid daily

4. HormonesRegulation of Fluid

Renin-Angiotensin-Aldosterone System (RAAS)o A complex series of events triggered by decrease B/P and decreased perfusion to kidneyso Decrease BP = secretion of renin from kidneyso Renin combines with angiotensinogen to form Angiotensin Io Angiotensin I is converted in the lungs to Angiotensin IIo Angiotensin II stimulates the adrenal cortex to release aldosterone

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o Aldosterone results in Na+ and H2O retention = also causes increase in BP

Hormonal Effects on Fluid Balance ADH regulation – anti-diuretic hormone secreted from posterior pituitary gland when increased

serum osmolality (concentration) is increased.o Promotes water reabsorption

Atrial Natriuretic Peptide Hormone that is released by the atrium of the heart when it is stretched from fluid overload.

o Hormone blocks effects and excretion of aldosterone and renin

5. Thirst mechanismThirst mechanism- located in the hypothalamus

Activated by increased ECF osmolality (concentration)

II. Diagnosis

A. Common tests

1. CBC (complete blood count) Hematocrit- measures the percentage of red blood cells in whole blood

o Male Normal Range: 42-52o Female Normal Range: 35-47

2. Serum electrolytes Sodium 135-145 mEq/L Potassium 3.5-5.0 mEq/L Calcium 8.6-10.2 mg/dL Magnesium 1.3-2.5 mEq/L Phosphorus 2.5-4.5 mg/dL Chloride 97-107 mEq/L Carbon Dioxide 24-32 mEq/L Glucose 60-110 mg/dL Albumin 3.5-5.0 g/dL

3. Blood urea nitrogen (BUN) BUN- is made up of urea, the end product of metabolism of protein by the liver

o Normal BUN- 10-20mg/dL

4. Creatinine Creatinine- the end product of muscle metabolism. Indicator of renal function

o Normal creatinine- 0.7-1.4mg/dL

5. Osmolarity/osmolality Osmolality- measures the solute concentration per kilogram in blood and urine

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o Normal serum osmolality- 275 – 300 mOsm/kgo Normal urine osmolality- 250 – 900 mOsm/kg

6. Urine pH & specific gravity Specific Gravity- measures the kidney’s ability to excrete or conserve water

o Less reliable indicator of concentration than osmolalityo Normal urine specific gravity- 1.003 – 1.030

Urinary Sodium 75-200 mEq/day Urinary Potassium 26-123 mEq/day Urinary Chloride 110-250 mEq/day Urinary pH 4.5-8.0

III. General Risk Factors

A. Age related differences

1. Gerontological Reduced homeostatic mechanisms: cardiac, renal, and respiratory function Decreased body fluid percentage Medication use Presence of concomitant (History of other diseases) conditions

2. Pediatric Children are also at greater risk for fluid and electrolyte imbalance due to higher proportion of

water in the body.

IV. Utilize the RAM nursing process for fluid volume imbalances, which includes risk factors, assessment, analysis/nursing diagnosis and evaluation/expected outcomes.

A. Fluid volume deficit (FVD): hypovolemia/dehydrationFluid Volume Deficit

Dehydration- a decrease volume of water, but not a change in electrolytes Hypovolemia- deficiency in both water and electrolytes in the ECF. (more severe)

Causeso Abnormal fluid losses

Vomiting, diarrhea, and GI suctioning Diaphoresis, prolonged fever Diuretics, Diabetes Insipidus, Renal disease, Adrenal Insufficiency, ketoacidosis Hemorrhage

o Decreased intake of fluid Anorexia, nausea, inability to gain access to fluid

o Third Spacing Peritonitis, intestinal obstruction, ascites, burns

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o Risk Factors: diabetes insipidus, adrenal insufficiency, osmotic diuresis, hemorrhage, coma, and third space shifts

Assessment findingso Thirst, weight loss, dry mucus membraneso Decreased skin turgor, edemao Decreases UOP, oliguriao Increased HR, rapid and weak pulse, increased temperatureo Decreased B/P, postural hypotensiono Confusion, dizziness, fatigueo Cool, clammy skino Muscle weakness and crampso Flattened neck veins

Labso Na- elevatedo Serum osmolality- elevatedo BUN- elevatedo Urine specific gravity- elevatedo HCT- elevated

Nursing interventions for FVDo Assess for presence or worsening of FVD (Always think why?)o Administer oral fluids as toleratedo Provide TPN, IVF’s (isotonic or hypotonic)o Tube feedings PRNo Monitor patient response, mental statuso Monitor for signs of fluid volume overload, monitor I&Oo Skin and oral careo Evaluate interventions

B. Fluid volume excess (FVE): hypervolemiaFluid Volume Excess (FVE) Hypervolemia- excess retention of water and Na+ (Examples) Due to fluid overload or diminished homeostatic mechanisms Risk factors: heart failure, renal failure, and cirrhosis of the liver Contributing factors: excessive dietary sodium or sodium-containing IV solutions

Causeso Fluid shift- burns, protein administrationo Water intoxication- caused by excess water ingestion or from excess ADH secretions (heart

failure, cirrhosis, glucocorticosteroids)o Excessive sodium intake

Assessmento Weight gain, edema, skin pale and coolo Increased BP and pulse o SOB, crackles, increased RR (tachycardia), Pulmonary edemao Distended neck veins

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o Headache, altered LOC, weaknesso Polyuriao Third spacing

Labso Decreased BUN, Na, hematocrit, and specific gravity

Nursing Interventionso Assess for presence or worsening of FVEo I & Oo Daily weightso Na+ restricted and/or fluid-restricted diet as orderedo Teaching/learning regarding adherence to fluid restrictionso Short term goals and offer fluids every 1-2 hourso Oral hygieneo Avoid salty, dry, sweet foodso Evaluate if goals met and interventions usefulo Administering diuretics

FVE/Diuretics Diet- increase K for all except Aldactone Intake & Output, daily weight Undesirable effects: fluid and electrolyte imbalances Review BP and electrolytes Elderly- careful and evening does not recommended Take with or after meals in AM Increase risk of orthostatic hypotension Cancel alcohol and cigarettes

*See diuretics handout

General Nursing Interventions for F&E Imbalances 24 hour I & O Monitoring of VS Monitor for Neurologic changes Daily weights Monitor rates/types of IVF’s Provide supplementary water if receiving tube feedings Irrigate NG tube with saline not water

V. IV TherapyIV Catheter

PICC Line Line is entered peripherally (usually through the A.C.) to the heart (subclavian artery) Has to be done by physician or specially trained nurse Can have 1-2 ports, needs to be flushed with 10ml saline, Hep-lock 5ml Has to be flushed once per shift or before and after medication Always use a 10ml syringe

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Central Line Usually entered through jugular artery or subclavian Has 3 ports, has to be flushed with 5 ml saline, hep-lock 2 ml Always use a 10ml syringe (because of amount of pressure)

A. Site selection and initiationB. Complications

Fluid overload Air embolism Septicemia and other infections Infiltration and extravasation Phlebitis Thrombophlebitis Hematoma Clotting and obstruction

C. Isotonic, hypertonic and hypotonic fluids4 Classifications of IV fluids

Crystalloidso IV Fluids- D5W, lactated ringers

Colloidso Volume expanders

Hetastarch (can decrease HCT and PLT) Plasmanate (protein)

Bloodo Whole or PRBC (packed red blood cells)

Lipids

Types of Fluids Isotonic fluid- concentration of dissolved particles equal to ICF

o D5W- 5% dextrose in water Hypernatremia, fluid loss, and dehydration

o 0.9% NaCl- normal saline Hypovolemia, metabolic alkalosis, hypercalcemia

o Lactated Ringers- contains potassium and calcium in addition to sodium chloride Hypovolemia, burns, fluid lost as bile or diarrhea, and acute blood loss replacement

Hypotonic fluids- concentration less than ICFo 0.45 NaCl- half-strength normal saline

Hypertonic dehydration, Na and Cl depletion, and gastric fluid losso 0.25 NaCl- o D5 ½ NS

Hypertonic fluids- concentration greater than ICFo 3% NaCl

o 10% Dextrose (D10) o 50% Dextrose (D50)

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D. Blood transfusionsBlood Transfusions (Pg. 1107-1113)

Patient Historyo History of transfusions and reactions

Physical assessmento Respiratoryo Cardiaco Integumentary

Patient teaching Obtain consent Equipment: IV (20 gauge or greater for PRBCs), appropriate tubing, and normal saline solution Procedure to identify patient and blood product

Transfusion Reaction Types Febrile nonhemolytic reaction

o Most commono Chills followed by fevero Often begins 2 hours after transfusion starts- not life-threatening

Acute hemolytic reactiono Most dangerouso Fever, chills, low back pain, nausea, chest tightness, dyspnea, anxiety, acute renal failure, DIC,

death Allergic reaction

o Urticaria, itching, flushing

Nursing management of transfusion reactions Immediately stop transfusion Assess patient Notify physician of assessment findings Notify blood bank Return blood container and tubing to the blood bank If hemolytic transfusion reaction or bacterial infection- obtain blood and urine specimens. Document

according to facility protocol.

VI. Utilize the RAM nursing process for electrolyte imbalances, which includes risk factors, assessment, analysis/nursing diagnosis and evaluation/expected outcomes.

A. HyponatremiaHyponatremia (sodium <135) Stimuli/causes

o Vomiting/diarrhea, NG tube suction, diureticso Adrenal insufficiency, burns, wound drainageo CHFo Administration of hypotonic IVF (too much)o Excessive water intake

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Behaviors/effectso With water excess-rapid weight gain, headache, confusion, nausea, vomitingo With Na+ loss- irritability, apprehension, confusion, tachycardiao =decrease serum osmolarity (blood concentration)o Fluid shift can cause cerebral edema (swelling of cells) and cause confusion

Nursing Interventionso Water restriction may be the only necessary treatmento If neuro changes, small amounts of hypertonic solutions (if sodium is dangerously low <120).

Listen for breath sounds when giving hypertonic, fluid shift will occur and need to monitor for fluid overload.

o Possibly Lasix administrationo Thorough nursing assessmento PREVENTION- teach pt. about dehydration

B. HypernatremiaHypernatremia (> 145) Stimuli/causes

o May occur with water loss or sodium gaino Primary protection- thirsto Usually doesn’t happen in the alert persono Can occur with hypertonic IVF’s or near drowning in salt watero Diabetes insipidus and heat stroke

Behaviors/effectso Intense thirst (may be impaired in elderly or ill)o Elevated temperatureo Dry, sticky mucus membraneso Firm rubbery turgoro Restlessness and weakness (moderate)o Confusion and hallucinations (severe)o SALT

S – skin flushed A – agitation (altered LOC) L - low grade temp T – thirst

Treatmento Depends on causeo I & Oo VSo Daily weighto Increase fluids – to help decrease the concentration, hypotonic solution or D5Wo Seizure precautions

C. HypokalemiaHypokalemia (<3.5) Stimuli/causes

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o Vomiting and Diarrheao Diureticso Dialysiso Hyperaldosteronismo Poor dietary intakeo Increased insulin- causes potassium to go back into cell

Behaviors/effectso Neurologic- fatigue, lethargy, confusiono Cardiovascular- dysrhythmias, vertigo, hypotension, slow weak pulse, increased risk of digoxin

toxicityo EKG- flat T wave, U wave, & or ST depressiono GI- anorexia, N/V, constipation, ileuso Respiratory- shallow respirationso Renal- polyuria, polydipsiao Fatigue, muscle weakness and crampingo Deep tendon reflexes

Nursing Interventionso Oral or IV administration of KCL

Don’t give if UOP <0.5ml/kg/hr IV- has to be mix in with at least 100 ml/fluid Cardiac monitoring Never exceed 20mEq/hour through peripheral line, no more than 40mEq/hr through

central line Never give IV push or IM!!! Best to give through PICC or central line, potassium is irritating to veins, may help to slow

infusion to decreases burning or put ice pack over IV site if patient complainso Increase dietary intake K+o Oral supplements- may taste bad, mix with juice for liquid formo Teach s/s hypokalemia and digoxin toxicity

D. HyperkalemiaHyperkalemia (>5.0)

Hemolysis of blood specimen or drawing of blood above IV site may result in false laboratory result

Salt substitutes and medications may contain potassium Potassium-sparing diuretics may cause elevation of potassium and should not be used in patients

with renal dysfunction

Stimuli/causeso Massive intake of K+, usually treatment relatedo Decreased renal excretiono Renal failureo Hypoaldosteronismo Tissue trauma- forces potassium out of cello Hyperglycemia and uncontrolled DMo Meds such as K+ sparing diuretics and Ace inhibitors

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Behaviors/effectso Cardiac- increased HR then decreased HR, arrhythmias (V-tach or V-fib), hypotensiono EKG- peaked T wave, wide QRSo GI- anorexia, nausea, diarrheao Neuromuscular- muscle weakness, cramps

Interventionso Eliminate oral and parenteral K+o Increase elimination of K+ (diuretics, dialysis, or Kayexalate)o Increase fluid intakeo Force K+ from ECF to ICF by giving insulin IV along with glucose or by giving IV

NaHCO3(sodium bi-carbonate)o Calcium gluconate IV (emergent situation)o Monitor cardiac rhythm, VS, UOP, I & O, and fluid status

Potassium and Sodium supplementso Monitor for adverse side effectso Administer meds according to manufacturer’s guidelines

Dilute K+ in juice or water Most patients receiving diuretics will need K+ supplement unless K+ sparing diuretic

(Aldactone)o Know risks associated with IV K+o Check for drug-drug interactions

E. Hypocalcemia• Serum level less than 8.5 mg/dL must be considered in conjunction with serum albumin level• Causes: hypoparathyroidism, malabsorption, pancreatitis, alkalosis, massive transfusion of

citrated blood, renal failure, medications, other• Manifestations: tetany, circumoral numbness, paresthesias, hyperactive DTRs, Trousseau’s sign,

Chovstek's sign, seizures, respiratory symptoms of dyspnea and laryngospasm, abnormal clotting, and anxiety

• Medical management: IV of calcium gluconate; calcium and vitamin D supplements; diet• Nursing management: assessment as severe hypocalcemia is life-threatening, weight-bearing

exercises to decrease bone calcium loss, patient teaching related to diet and medications, and nursing care related to IV calcium administration

F. Hypercalcemia• Serum level above 10.5 mg/dL• Causes: malignancy and hyperparathyroidism, bone loss related to immobility• Manifestations: muscle weakness, incoordination, anorexia, constipation, nausea and vomiting,

abdominal and bone pain, polyuria, thirst, ECG changes, and dysrhythmias• Medical management: treat underlying cause, administer fluids, furosemide, phosphates,

calcitonin, and biphosphonates • Nursing management: assessment as hypercalcemic crisis has high mortality, encourage

ambulation, fluids of 3 to 4 L/d, provide fluids containing sodium unless contraindicated and fiber for constipation, and ensure safety

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G. Hypomagnesemia• Serum level less than 1.8 mg/dL; evaluate in conjunction with serum albumin• Causes: alcoholism, GI losses, enteral or parenteral feeding deficient in magnesium, medications,

rapid administration of citrated blood; contributing causes include diabetic ketoacidosis, sepsis, burns, and hypothermia

• Manifestations: neuromuscular irritability, muscle weakness, tremors, athetoid movements, ECG changes and dysrhythmias, and alterations in mood and level of consciousness

• Medical management: diet, oral magnesium, and magnesium sulfate IV • Nursing management: assessment, ensure safety, patient teaching related to diet, medications,

alcohol use, and nursing care related to IV magnesium sulfate• Hypomagnesemia is often accompanied by hypocalcemia

• Monitor and treat potential hypocalcemia• Dysphagia is common in magnesium-depleted patients; assess ability to swallow with

water before administering food or medications

H. Hypermagnesemia• Serum level more than 2.7 mg/dL• Causes: renal failure, diabetic ketoacidosis, and excessive administration of magnesium • Manifestations: flushing, lowered BP, nausea, vomiting, hypoactive reflexes, drowsiness, muscle

weakness, depressed respirations, ECG changes, and dysrhythmias• Medical management: IV calcium gluconate, loop diuretics, IV NS of RL, hemodialysis • Nursing management: assessment, avoid administering medications containing magnesium, and

provide patient teaching regarding magnesium-containing OTC medications

VII. Utilize the RAM nursing process for acid base imbalances, which includes risk factors, assessment, analysis/nursing diagnosis and evaluation/expected outcomes.Maintaining acid-base balance Normal plasma ph is 7.35 to 7.45: hydrogen ion concentration Major ECF buffer system; bicarbonate-carbonic acid buffer system Kidneys regulate bicarbonate in the ECF Lungs under the control of the medulla regulate CO2 and , therefore, carbonic acid in the ECF Other buffer systems

o ECF: inorganic phosphates and plasma proteinso ICF: proteins, organic and inorganic phosphateso Hemoglobin

Bicarbonate Major chemical base buffer Found in both ECF and ICF Essential for acid-base balance Alkalosis- ph over 7.4 Acidosis- ph under

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Arterial Blood Gases pH 7.35 (7.4) to 7.45 PaCO2 35 (40) to 45 mm Hg HCO3ˉ 22 (24) to 26 mEq/L (assumed average values for ABG interpretation) PaO2 80 to 100 mm Hg Oxygen saturation >94% Base excess/deficit ±2 mEq/L

Acid Base (ROME)R- respiratoryO- opposite

pH PCO2 alkalosis

pH PCO2 acidosis

M- metabolicE- equal

pH HCO3 alkalosis

pH HCO3 acidosis

A. Metabolic acidosisMetabolic Acidosis Low ph <7.35 Low bicarbonate <22 meq/l Most commonly due to renal failure Manifestations: headache, confusion, drowsiness, increased respiratory rate and depth, decreased

blood pressure, decreased cardiac output, dysrhythmias, shock; if decrease is slow, patient may be asymptomatic until bicarbonate is 15 mEq/L or less

Correct the underlying problem and correct the imbalance; bicarbonate may be administered With acidosis, hyperkalemia may occur as potassium shifts out of the cell As acidosis is corrected, potassium shifts back into the cell and potassium levels decrease Monitor potassium levels Serum calcium levels may be low with chronic metabolic acidosis and must be corrected before

treating the acidosis

B. Metabolic alkalosisMetabolic Alkalosis High pH >7.45

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High bicarbonate >26 mEq/L Most commonly due to vomiting or gastric suction; may also be caused by medications, especially

long-term diuretic use Hypokalemia will produce alkalosis Manifestations: symptoms related to decreased calcium, respiratory depression, tachycardia, and

symptoms of hypokalemia Correct underlying disorder, supply chloride to allow excretion of excess bicarbonate, and restore

fluid volume with sodium chloride solutions

C. Respiratory acidosisRespiratory Acidosis Low pH <7.35 PaCO2 >42 mm Hg (mostly higher than 45) Always due to a respiratory problem with inadequate excretion of CO2 With chronic respiratory acidosis, the body may compensate and may be asymptomatic; symptoms

may include a suddenly increased pulse, respiratory rate, and BP; mental changes; feeling of fullness in the head

Potential increased intracranial pressure Treatment is aimed at improving ventilation

D. Respiratory alkalosisRespiratory Alkalosis High pH >7.45 PaCO2 <35 mm Hg Always due to hyperventilation Manifestations: lightheadedness, inability to concentrate, numbness and tingling, and sometimes loss

of consciousness Correct cause of hyperventilation

REQUIRED READINGS: Kee, J., Hayes, E., & McCuistion, L. (2009). Pharmacology a nursing process approach (6th

ed.). St. Louis, MO: Mosby. Ch. 15.

Smeltzer, S., Bare, B., Hinkle, J. & Cheever, K. (2008). Brunner and Suddarth’s textbook of medical – surgical nursing (11th ed.). Philadelphia: Lippincott Williams & Wilkins.Ch. 14 & Ch. 33 pp. 1103-1113.

Silvestri, L. A. (2005). Saunders comprehensive review for NCLEX-RN (4thed.). Philadelphia, PA: W.B. Saunders Company. Chapter 9 Fluid and Electrolytes p. 87, Questions 1-20 Chapter 10 Acid-Base Balance p. 107, Questions 1-10 Chapter 14 Intravenous Therapy p. 158, Questions 1-15 Chapter 15 Administration of Blood products p. 173, Questions 1-12

Wissmann, J. (2000-2007). Adult medical-surgical nursing RN edition 7.1. Current mastery series review module. Assessment Technologies Institute. Unit 3 (pp. 233-240) &

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Unit 4.

Wissman, J. (2000-2007). Fundamentals of nursing edition 6.1. Current mastery series review module. Assessment Technologies Institute. Unit 5 (Ch. 73 & 74).

CLINICAL OBJECTIVES:1. Assess hydration status.2. Accurately calculate intake and output on an adult with compromised or ineffective responses to

fluid and electrolyte balance.3. Correctly calculate IV flow rate.4. Identify signs and symptoms of fluid and/or electrolyte imbalance.5. Develop teaching/learning strategies for the adult with fluid and/or electrolyte imbalance to

promote adaptation.6. Using the Roy Adaptation Model nursing process, develop a plan of care for the adult with

fluid/electrolyte imbalance and acid base imbalance.7. Participate in administering blood.

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DiureticsUsed for treatment of hypertension (HTN), edema, congestive heart failure (CHF), renal dysfunction

Diuretic class Mechanism of action General information Contraindications Side effects/adverse effects

Nursing considerations

Thiazide diuretics

Hydrochlorothiazide o Esidrixo HydroDIURIL

Chlorothiazide o Diurilo Chlorthalidoneo Quinethazone

Inhibit reabsorption of salt (Na+ and Cl-) in the distal renal tubule thereby increasing excretion of salt and water

Orally Generally mild

side effects Effective for

long-term use Can be primary

treatment for HTN

Allergy and allergy to sulfonamides

F/E imbalance Gout Diabetes Renal disease Liver disease Pregnancy/lactation

Dizziness, vertigo, weakness

Nausea, vomiting, anorexia

Dry mouth Orthostatic

hypotension Polyuria, nocturia Photosensitivity Muscle weakness or

cramps

Administer early AM to decrease sleep disturbance.

Give with food or milk to decrease GI disturbance

Stand slowly – safety precautions

Monitor electrolyte levels (esp. K+)

Add K+ rich foods or supplement

Monitor I & O, daily weight, and hydration

Home care - Patient report weight change of more than 3lb/day

Photosensitivity – wear sunscreen, sunglasses, and protective clothing

Increased risk of dig toxicity with hypokalemia

Loop Diuretics

Furosemide (Lasix)o Usual dose 20 – 80 mg

Bumetanide (Bumex) Ethacrynic acid (Edecrin) Torsemide (Demadex)

Inhibits reabsorption of salt in the proximal and distal renal tubules and the loop of Henle

Potent, rapid-acting diuretic

Can be given PO, IM, or IV

Used often with thiazides fail or patient needs rapid diuresis

Same as thiazides Same as thiazides Glycosuria Thrombophlebitis Blood dyscrasias Ototoxic (can cause

irreversible hearing loss – especially when given rapid IV push)

Rash

Same as thiazides IV administration

o Slow IV push (10 – 20mg/min)

Check compatibility with other meds and IVF

Protect from light Use within 24 hours

after dilution Assess patient

frequently for s/s of

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F/E imbalancePotassium-Sparing Diuretics

Spironolactone (Aldactone) Triamterene (Dyrenium)

Blocks the effects of aldosterone in the renal tubule, causing loss of Na+ and H2O and retention of K+

Used especially if hypokalemia is a problem

Also used to treat patient with high aldosterone levels

Allergy hyperK+ renal disease lactation use cautiously with

ACE inhibitors

dizziness, drowsiness, headache

diarrhea, cramping rash

similar to thiazides avoid high K+ foods avoid salt substitutes for GI problems,

administer after meals

Osmotic Diuretics

Mannitol (Osmitrol)

Hinders reabsorption of water in the kidneys leading to loss of water and sodium chloride)

renal disease intracranial bleeding dehydration CHF

Dizziness Nausea, anorexia Dry mouth, thirst Diuresis Dizziness

Given IV only Do not refrigerate –

causes crystallization Use IV filter with

tubing Foley catheter (F/C)

may be inserted to manage and monitor diuresis

Monitor patient’s hydration status,

Smeltzer, S. C., Bare, B. G., Hinkle, J. L., Cheever, K. H. (2008). Brunner & Suddarth’s Textbook of medical-surgical nursing.

(11th ed.). Philadelphia: Lippincott Williams & Wilkins.

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