F LUID & E LECTROLYTES

I. P HYSIOLOGY
A. B ODY F LUIDS - as primary body fluid, water is most important nutrient of life
- humans can survive for only a few days without water

1. F UNCTIONS OF W ATER
 provide medium for transporting nutrients to cells, wastes from cells, and substances such as
hormones, enzymes, blood platelets, and red and white blood cells
 facilitate cellular metabolism an d proper cellular chemical functioning
 act as solvent for electrolytes and nonelectrolytes
 help maintain normal body temperature
 facilitate digestion and promote elimination
 act as tissue lubricant

2. B ODY F LUID C OMPARTMENTS

a. Intracellular fluid (ICF) - within cells

b. Extracellular fluid (ECF) - all fluid outside cells, including intravascular (plasma – liquid
component of blood) and interstitial (fluid that surrounds tissue cells and includes
lymph) fluids

total body water – total amt of water in body expressed as % of body weight

3. V ARIATIONS IN F LUID C ONTENT

- in a healthy person, total body water constitutes about 50 – 60% of body’s weight, depending on age,
lean body mass, and sex
- total body water differs by sex and person’s amt of fat cells
- fat cells contain little water while lean tissue is rich in water
- women tend to have proportionally more body fat than men, they also have less body fluid
than men
- decreasing % body fluid in older people is related to increase in fat cells

B. E LECTROLYTES
electrolyte – substance capable of breaking into electrically charged ions when dissolved in a solution

cations – ions that develop a positive charge anions – ions that develop a negative charge

1. S ODIU m (N A+) - chief electrolyte of ECF that moves easily between intravascular and
interstitial
spaces and moves across cell membranes by active transport
- influential in many chemical reactions in body, particularly nervous and muscle tissue cells
- controls and regulates volume of body fluids; maintains water balance throughout the body
- primary regulator of ECF volume and influences ICF
- participates in generation and transmission of nerve impulses
- essential electrolyte in sodium-potassium pump
- normal extracellular concentration: 135 – 145 mEq/L

2. P OTASSIUM (K +) – major cation of ICF working in reciprocal fashion with sodium (excessive intake of
sodium results in excretion of potassium, vice versa)
 - chief regulator of cellular enzyme activity and cellular water content
- plays vital role in such processes as transmission of electric impulses, particularly nerve,
heart, skeletal, intestinal, and lung tissue; protein and carbohydrate metabolism, and
cellular bldg.
- adequate qty. usually in well-balanced diet
- food sources include bananas, peaches, kiwi, figs, dates, apricots, oranges, prunes, melons,
raisins, broccoli, potatoes, meat and dairy products
- excreted primarily by kidneys, however, there are large amts in GI secretions and some in
perspiration and saliva
- normal range for serum: 3.5 – 5 mEq/L

3. C ALCIUM (C A+) – most abundant electrolyte, with up to 99% of total found in iodized form of bones
and
teeth
- close link between concentrations of calcium and phosphorus
- necessary for nerve impulse transmission and blood clotting
- catalyst for muscle contraction
- needed for vitamin B12 absorption and its use by body cells
- acts as catalyst for most cell chemical activities
- necessary for strong bones and teeth
- determines thickness and strength of cell membranes
- adult avg. daily requirement about 1 g, higher amts. according to body wt. required for
children and pregnant and lactating women
- 1,500 mg/day recommended consumption for older adults, particularly postmenopausal
women and men older than 65
- sources include milk, cheese, and dried beans, some present in meats and vegetables
- excreted in urine, feces, bile, digestive secretions, and perspiration

4. M AGNESIUM (M G 2+) – most cation found within body cells – heart, bone, nerve, and muscle tissues
- 2nd most important cation in ICF
- important for metabolism of carbohydrates and proteins
- important for many vital reactions involving enzymes
- necessary for protein and DNA synthesis, DNA and RNA transcription, and translation of
RNA
- maintains normal intracellular levels of potassium
- helps maintain electrical activity in nervous tissue and muscle membranes
- adult daily avg. requirement about 18 – 30 mEq, with children requiring larger amts.
- found in most foods, but especially in vegetables, nuts, fish, whole grains, peas and beans

5. C HLORIDE (CI -) – chief extracellular anion, found in blood, interstitial fluid, and lymph and in minute
amts. in ICF
- acts with sodium to maintain osmotic pressure in blood
- plays a role in body’s acid-base balance
- has important buffering action when oxygen and carbon dioxide exchange in red blood cells
- essential for production of hydrochloric acid in gastric juices
- found in foods high in sodium, dairy products, and meat
- deficit leads to potassium deficit, and vice versa
- normal serum levels: 95 – 105 mEq/L

6. B ICARBONATE (HCO 3-) – anion that is major chemical base buffer within body
- found in both ECF and ICF
 - essential for acid-base balance; bicarbonate and carbonic acid constitute body’s primary
buffer system
- losses possible via diarrhea, diuretics, and early renal insufficiency
- excess possible via overingestion of acid neutralizers, such as sodium bicarbonate
- normal levels range between 25 – 29 mEq/L

7. P HOSPHATE (PO 4-) - major anion in body cells

- buffer anion in both ICF and ECF
- helps maintain body’s acid-base balance
- involved in important chemical reactions in body (necessary for many B vitamins to be
effective, helps promote nerve and muscle action, plays a role in carbohydrate
metabolism)
- important for cell division and transmission of hereditary traits
- avg. daily requirements similar to calcium
- found in most foods but especially in beef, pork, and dried peas and beans
- inversely proportionate to calcium - - increase in one results in decrease of the other
- normal range: 2.5 – 4.5 mEq/L

C. F LUID AND E LECTROLYTE M OVEMENT

- ECF provides nourishment to each body cell and receives cell’s waste products
- these exchanges are essential to life

1. O SMOSIS – through semipermeable membranes, water (pure solvent) is able to be transported

through cell walls
- major method of transporting body fluids
- through osmosis, water passes from an area of lesser solute concentration to an area of
greater solute concentration until equilibrium is established
- the greater the concentration of the two solutions, the greater the osmotic pressure
or drawing power of water

osmolarity – concentration of particles in a solution, or its pulling, power

isotonic – solution that has about the same concentration of particles (osmolarity) as plasma
- remains in intravascular compartment w/out any net flow across semipermeable membrane

hypertonic – solution has greater osmolarity than plasma

- water moves out of cells and is drawn into intravascular compartment, causing cells to shrink

hypotonic – solution has less osmolarity than plasma

- solution in intravascular space moves out and into intracellular fluid, causing cells to swell
and possibly burst

2. D IFFUSION – tendency of solutes to move freely throughout a solute; “coasting downhill”

- moves from area of higher concentration to an area of lower concentration until equilibrium is
established
- gases move by diffusion
- oxygen and carbon dioxide exchange in the lung’s alveoli and capillaries by diffusion

3. A CTIVE T RANSPORT – process that requires energy for movement of substances through a cell
membrane from an area of lesser solute concentration to an area of higher concentration
- adenosine triphosphate makes it possible for certain substances to acquire energy needed
 - energy requirements for active transport are affected by characteristics of cell membrane,
specific enzymes, and concentrations of ions
- “pumping uphill”
- substances include amino acids, glucose (in certain places only - - kidneys, intestines), and
ions of sodium, chloride, potassium, hydrogen, phosphate, calcium, and magnesium

4. F ILTRATION – passage of fluid through permeable membrane from area of high pressure to lower

colloid osmotic pressure (oncotic pressure) certain substances, such as plasma proteins, which
have high molecular weights on permeable membranes in the body

hydrostatic pressure – force exerted by fluid against container wall

- blood hydrostatic pressure is the pressure of plasma and blood cells in the capillaries - -
depends primarily on arterial blood pressure on arteriolar side of capillaries, and on
venous blood pressure on venular side of capillaries

- filtration pressure is the difference between colloid osmotic pressure and blood hydrostatic
pressure
- these pressures are important in understanding how fluid leaves arterioles, enters interstitial
compartment, and eventually returns to venules
- positive pressure in arterioles - - helping to force or filter fluids into interstitial space
- negative pressure in venules - - helping fluid enter venules

D. F LUID B ALANCE
- desirable amt of fluid intake and loss in adults ranges from 1500 – 3500 mL each 24 hrs., with most
people averaging 2500 mL/day
- individual’s health state as well as balance between actual intake and loss must be
considered
- intake should normally be approx. balanced by output or fluid loss
- may not always occur in a single 24-hr. period but should be achieved within 2 – 3 days

1. F LUID S OURCES
a. Ingested Liquids – makes up largest amt of water intake
- primarily regulated by thirst mechanism - stimulated by intracellular dehydration and
decreased blood volume

b. Water in Food – 2nd largest source of water - depends on diet

c. Water from Metabolic Oxidation – occurs during metabolism of food substances, specifically,
carbohydrates, fats, and proteins - source varies among different types of nutrients

2. F LUID L OSSES – through kidneys as urine, intestinal tract in feces, and skin as perspiration (sensible
losses)
- insensible losses include ex. of invisible amt of water lost from skin constantly through
evaporation and from the lungs exhaled as breaths
- losses vary according to person and circumstances
- any deviations from normal ranges for a balanced water intake and output should alert nurse
to potential imbalances

3. H OMEOSTATIC M ECHANISMS – almost every organ and system in the body helps fluid homeostasis
function automatically and effectively:
  kidneys (master chemists) selectively retain electrolytes and water and excrete
wastes and excesses
 cardiovascular system is responsible for pumping and carrying nutrients and water
 lungs regulate oxygen and carbon dioxide levels - - carbon dioxide is especially
crucial in maintaining acid-base balance
 adrenal glands secrete aldosterone which helps body conserve sodium, helps save
chloride and water, and causes potassium to be excreted
 thyroxine (from thyroid gland) increases blood flow leading to increased renal
circulation, resulting in increased glomerular filtration and urinary output
 parathyroid glands secrete parathyroid hormone, regulating level of calcium in ECF
 GI tract absorbs water and nutrients
 nervous system (acting as switchboard to inhibit and stimulate mechanisms)
regulates sodium and water intake and excretion

E. A CID -B ASE B ALANCE

- body fluids must maintain acid-base balance to sustain health and life
- acidity or alkalinity of solution is determined by concentration of hydrogen ions (H +)

acid – substance containing hydrogen ions that can be liberated or released

- strong acid dissociates (separates) completely and releases all hydrogen ions
- weak acid releases only a small number of hydrogen ions

base (alkali) – substance that can accept or trap hydrogen ions

- strong base binds/accepts H+ easily - weak base doesn’t accept H+ easily

pH – unit of measure used to describe acid-base balance

- expression of hydrogen ion concentration and resulting acidity or alkalinity of a substance
- scale ranges from 1 to 14
- neutral solution measures 7 (ex. pure water)
- as hydrogen ions increase the solution becomes more acid, pH is less than 7
- as hydrogen ions decrease the solution becomes more alkaline, pH is greater than 7

- normal blood plasma is slightly alkaline and has a normal pH range of 7.35 – 7.45
- when blood plasma pH exceeds normal range in either direction, signs and symptoms of
illness appear
- if deviation goes unabated, death results

acidosis – condition characterized by excess hydrogen ions in ECF in which pH falls below 7.35

alkalosis – lack of hydrogen ions and pH exceeds 7.45

1. C ARBONIC ACID -S ODIUM B ICARBONATE B UFFER S YSTEM – most important buffer system
- buffers either act like a base and bind or soak up free hydrogen ions or act like an acid and
release hydrogen ions when too few are present in a solution
- normal ECF has a ratio of 20 parts bicarbonate to 1 part carbonic acid
- exact quantities are unimportant as long as they remain a 20:1 ratio

2. P HOSPHATE B UFFER S YSTEM – active in intracellular fluids

- converts alkaline sodium phosphate (weak base) to acid in the kidneys
 3. P ROTEIN B UFFER S YSTEM – mixture of plasma proteins and globin portion of hemoglobin in red blood
cells
- tend to minimize changes in pH and serve as excellent buffering agents over a wide range of
pH values

F. D ISTURBANCES IN F LUID , E LECTROLYTE , AND ACID -B ASE B ALANCE

1. F LUID I MBALANCES – occur when body’s compensatory mechanisms are unable to maintain
homeostatic state
- involve either volume or distribution of water or electrolytes

a. Fluid Volume Deficit

- result from loss of body fluids, especially if fluid intake is simultaneously decreased
- 5% wt loss is considered pronounced deficit
- 8% wt loss or more is considered severe
- 15% wt loss is usually life-threatening

hypovolemia – deficit caused by deficiency in amt of both water and electrolytes in ECF
when water and electrolyte proportions remain near normal
- both osmotic and hydrostatic pressure changes force interstitial fluid into
intravascular space
- interstitial space is depleted, fluid becomes hypertonic, cellular fluid is drawn into
interstitial space, leaving cells without adequate fluid to function properly
- young children, elderly, and people who are ill are especially at risk

dehydration – decreased volume of water, but water is not decreased without electrolyte
changes also

hydration – union of a substance with water

- used to indicate normal water volume in the body

3rd space fluid shift – distributional shift of body fluids into potential body spaces such as
pleural, peritoneal, pericardial, or joint cavities; bowel; or interstitial space
- once trapped, fluid is not easily exchanged with ECF, deficit occurs
- fluid is trapped but not lost - - essentially unavailable for use
- may occur as a result of severe burn, bowel obstruction, or pancreatitis
- decreased body wt does not occur, nor can fluid loss be measured
- treatment is directed toward correction of cause

b. Fluid Volume Excess

hypervolemia – excessive retention of water and sodium in ECF in near-normal proportions
resulting in fluid volume excess

overhydration – above-normal amts of water in extracellular spaces

- common causes include malfunction of kidneys, causing inability to excrete
excesses, and failure of heart to function as a pump, resulting in
accumulation of fluid in lungs and dependent parts of the body
- when water is retained, so is sodium

edema – excessive ECF accumulated in tissue spaces

- because of increased extracellular osmotic pressure, fluid is pulled from cells to
equalize tonicity
 - by the time intracellular and extracellular spaces are isotonic, an excess of both
water and sodium is in ECF
- observed around eyes, fingers, ankles, and sacral space and later in or around body
organs
- may result in wt gain in excess of 5%; excess fluid remains in intravascular space –
concentration of solids in blood decreases

Grading Scale: 1+ = slight indentation; normal contours; fluid volume 30% above norm

2+ = deeper pit after pressing; lasts longer than 1+; fairly normal contours

3+ = deep pit; remains several seconds after pressing; skin swelling obvious
by general inspection

4+ = deep pit; remains for prolonged time after pressing, possibly minutes;
frank swelling

Brawny Edema = fluid can no longer be displaced secondary to excessive

interstitial fluid accumulation; no pitting; tissue palpates as firm or
hard; skin surface shiny, warm, moist

interstitial-to-plasma shift (hypervolemia) – movement of fluid from space surrounding

cells
to the blood
- compensatory response to volume or osmotic pressure changes of intravascular
fluid

2. E LECTROLYTE I MBALANCES – commonly involve deficit or excess of electrolyte

a. Hyponatremia – sodium deficit in ECF caused by loss of sodium or gain of water
- osmotic pressure changes result in ECF moving into cells causing prints from
examiner’s fingers to remain on pt’s skin over the sternum when pressure is
applied

Hypernatremia – surplus of sodium in ECF that can result from excess water loss or an
overall excess of sodium

b. Hypokalemia – potassium deficit in ECF

- extracellular potassium level falls, potassium moves from cell creating intracellular
potassium deficiency
- sodium and hydrogen ions are retained to maintain isotonic fluids
- influences normal cellular functioning, pH of ECF, and functions of most body
systems
- skeletal muscles are generally 1st to demonstrate signs/symptoms
- typical signs include muscle weakness and leg cramps

Hyperkalemia – excess of potassium in ECF

- can be hazardous - - transmission of stimuli through heart muscle is slowed or
prevented, and cardiac arrest eventually occurs if not corrected

c. Hypocalcemia – calcium deficit in ECF

- if prolonged, calcium is taken from bones, resulting in osteomalacia, characterized
 by soft and pliable bones
- common signs include numbness and tingling of fingers, muscle cramps, and tetany

Hypercalcemia – excess of calcium of ECF

- emergency situation leading to cardiac arrest

d. Hypomagnesemia – magnesium deficit where potassium level also drops because the
kidneys tend to excrete more potassium when magnesium supplies are poor
- hypomagnesemia and hypokalemia often occur together

Hypermagnesemia – magnesium excess that can occur in end-stage renal failure when
kidneys fail to excrete magnesium and excessive amts are administered
therapeutically

e. Hypophosphatemia – below-normal serum concentration of inorganic phosphorus

- many factors may lower serum levels while total-body phosphorus stores are normal

Hyperphosphatemia – above-normal serum concentrations of inorganic phosphorus

3. A CID -B ASE I MBALANCE

- arterial blood gases (ABGs) are common lab test used in assessment acid-base imbalance
- venous blood results are only specific for particular extremity or area where blood is
drawn and do not provide information on how well lungs are oxygenating
blood
- pH of plasma indicates balance or impending acidosis or alkalosis
- carbon dioxide (PaCO2) is influenced almost entirely by respiratory activity
- when low, carbonic acid leaves body in excessive amts
- when high, there are excessive amts of carbonic acid in body
- imbalances occur when carbonic acid or bicarbonate levels become disproportionate

a. Respiratory Acidosis – primary excess of carbonic acid in ECF

- any decrease in alveolar ventilation that results in retention of carbon dioxide
- lungs are source of problem and are unable to participate in compensation
- high PaCO2 because of alveolar hypoventilation

b. Respiratory Alkalosis – primary deficit of carbonic acid in ECF

- result of increased alveolar ventilation and consequent decrease in carbon dioxide
- increase in respiratory rate and depth causes loss because carbon dioxide is
excreted faster than normal
- deficit of carbon dioxide depresses or ceases respirations
- lungs are source of problem and are unable to participate in compensation
- low PaCO2 because of alveolar hyperventilation

c. Metabolic Acidosis – proportionate deficit of bicarbonate in ECF

- result of increase in acid components or excessive loss of bicarbonate
- lungs attempt to increase carbon dioxide excretion by increasing rate and depth of
respirations
- kidneys attempt to compensate by retaining bicarbonate and excreting move H+
- if attempts are unsuccessful, body may lose consciousness and death can occur

d. Metabolic Alkalosis – primary excess of bicarbonate in ECF

 - result of excessive acid losses or increased base ingestion or retention
- body attempts to compensate by retaining carbon dioxide
- respirations become slow and shallow with periods of no breathing at all
- kidneys excrete potassium and sodium with excessive bicarbonate and
retain H+ in carbonic acid

II. A SSESSMENT
- imbalances can seriously compromise the patient’s health status and may prove life-threatening
- nursing assessment is directed toward:
 identifying patients at high risk for fluid, electrolyte, and acid-base imbalance
 determining that a specific imbalance is present and identifying the nature of the imbalance
along with severity, etiology, and defining characteristics
 determining effectiveness of plan of care

A. C OMPARISON OF I NTAKE AND O UTPUT

- intake should include all fluids taken into the body
volume deficit - when intake is substantially less than output

- output should include urine, vomitus, diarrhea, drainage (fistulas, suction, lesions), perspiration
- prolonged hyperventilation should be noted
volume excess – when intake is substantially more than output

B. U RINE V OLUME AND C ONCENTRATION

- factors that can alter urinary output must be accounted for:
 amt of fluid intake
 losses from skin, lungs, and GI tract
 amt of waste products for excretions
 renal concentrating ability
 blood volume
 hormonal influences
- low urine volume with high specific gravity = volume deficit
- low urine volume with low specific gravity = renal disease
- high urine volume = volume excess

C. B ODY W EIGHT
- believed to be more accurate indicator of fluid gained and lost
- use same scale ea. time at the same time ea. day (in morning, before breakfast, after
voiding) wearing the same or similar dry clothing
- use a bed scale if patient is unable to stand
- rapid variations in wt. reflect changes in body fluid volume
- 2% loss of total body wt (TBW) = mild volume deficit
- 2% gain of TBW = mild volume excess
- 5% loss of TBW = moderate volume deficit
- 5% gain of TBW = moderate volume excess
- 8% loss of TBW = severe volume deficit
- 8% gain of TBW = severe volume excess

D. S KIN AND T ONGUE T URGOR

- skin over sternum, inner aspect of thighs, or forehead is pinched; with children over the abdominal
are and on medial aspect of thighs
 - with volume deficit skin flattens more slowly after pinch and may remain elevated for many
seconds
- can vary with age, nutritional state, and even race and complexion
- severe malnutrition can cause depressed skin turgor
- tongue turgor is not affected appreciably by age and is useful assessment for all age groups
- with volume deficit, additional longitudinal furrows and tongue is smaller
- sodium excess causes tongue to look red and swollen

E. D EGREE OF M OISTURE IN O RAL C AVITY

- dry mouth may be result of volume deficit or mouth breathing
- dryness of membrane = volume deficit
- dry sticky mucous membranes = sodium excess

F. T EARING AND S ALIVATION

- decrease normally with age
- absence in a child = volume deficit
- obvious with 5% loss of TBW

G. A PPEARANCE AND T EMPERATURE OF S KIN

- metabolic acidosis can cause warm, flushed skin

H. F ACIAL APPEARANCE
- severe volume deficit = pinched and drawn facial expression
- volume deficit of 10% = decreased intraocular pressure, eyes appear sunken and feel soft to touch

I. E DEMA
- measurement of extremity or body part with millimeter tape is more exact method of measurement
- edema not usually apparent until retention of 5 – 10 lbs of excess
- excess of interstitial fluid accumulating predominantly in lower extremities of ambulatory pts. and
presacral region of bed-ridden pts
- pitting edema not evident until at least 10% increase in wt
- may be localized (thrombophlebitis) or generalized (heart failure, cirrhosis)
- presence of periorbital edema or pedal edema should prompt investigation in other body parts

J. V ITAL S IGNS
1. B ODY T EMPERATURE – fever increases loss of fluids; important for early detection and interventions
- elevations probably related to lack of available fluid for sweating
- decrease temperature with volume deficit uncomplicated by infection
- elevation between 101 – 103 increases fluid requirements by 500 mL/day
- above 103 increases it by 1000 mL/day

2. P ULSE – tachycardia is the earliest sign of decreased vascular volume associated with volume deficit
- irregular pulse with potassium imbalances and magnesium deficit
- pulse volume is decreased in volume deficit and increased in volume excess

3. R ESPIRATIONS – deep, rapid respirations may be compensatory for metabolic acidosis or disorder
causing respiratory alkalosis
- slow, shallow respirations may be compensatory for metabolic alkalosis or disorder causing
respiratory acidosis
- moist crackles = volume excess
 4. B LOOD P RESSURE – check while pt is lying down, sitting and standing
- a systolic fall greater than 15 mm Hg from lying to sitting or standing position = volume deficit

K. N ECK V EINS AND C ENTRAL V ENOUS P RESSURE (CVP) – position pt in semi-Fowler’s position (head 30 – 40°
angle) with neck straight and constricting clothing removed
- provide adequate lighting and measure levels of distention on neck or above manubrium
- low CVP may indicate a) decreased blood volume, b) drug-induced vasodilation
- high CVP may indicate a) increased blood volume, b) heart failure, c) vasoconstriction
- more accurate measurements by hemodynamic monitoring

L. N EUROMUSCULAR I RRITABILITY
- to test for Chvostek’s sign, facial nerve should be percussed anterior to ear lobe
- to test for Trousseau’s sign, blood pressure cuff is inflated for 3 minutes
- deep tendon reflex is elicited and may be hyperactive with hypocalcemia, hypomagnesemia,
hypernatremia, and alkalosis
- muscle being tested should be slightly stretched and patient relaxed
- deep tendon reflex may be hypoactive with Hypercalcemia, hypermagnesemia, hypokalemia, and
acidosis
- reflex graded as: 0 = no response +1 = somewhat diminished but present
+2 = normal +3 = brisker than avg.; possibly indicative of disease
+4 = hyperactive

III. P LANNING / N URSING D IAGNOSIS

E XCESS F LUID V OLUME
- may result from greatly increased intake or decreased excretion

D EFICIENT F LUID V OLUME

- may result from decreased intake, increased excretion, fluid shifts, and special needs in
strenuous exercise, extreme heat or dryness, and conditions that increase metabolic
rate

R ISK FOR I MBALANCED F LUID V OLUME

- maintain approximate balance between intake and output

- maintain urine specific gravity within normal range
- practice self-care behaviors to promote fluid, electrolyte, and acid-base balance
- maintain adequate intake
- respond appropriately to signals of impending imbalance
- when imbalance exists:
 relate relief of symptoms after implementations and treatment
 exhibit signs and symptoms of restored balance or homeostasis
 identify signs and symptoms of recurrence of imbalance

IV. I MPLEMENTING
- interventions include dietary modifications, modification of intake, medication admin., IV therapy,
blood and blood products replacement, and TPN

A. P REVENTING F LUID I MBALANCES

- adequate intake and well-balance, nutritious diet with appropriate adjustments are essential
- general measures to help prevent fluid imbalances:
  be familiar with events that can lead to fluid imbalances, and observe pt carefully
- loss of fluid because of illness can cause serious and life-threatening problems
 note pt’s present intake, learn previous eating/drinking patterns
 note whether pt experiences excessive thirst or little or no thirst
 be aware of excessive losses of fluids, attempt to prevent
 consider ways medical regimen may lead to imbalances
 learn whether pt has been “treating” him/herself that may threaten fluid balance (enemas,
laxatives, antacids, OTC drugs that promote urination)
 consider conditions with destructive effects as threats to balance (immobilization, trauma,
burns, surgical procedures, exposure to toxic agents)
 teach pts to observe for imbalances and report them promptly (rapid wt gains/losses, swollen
fingers, feet, and ankles, puffy eyelids, muscle weakness, chg in skin sensations, scanty
or profuse urine)
 be aware of normal physiologic chgs associated with aging (dehydration)

B. D EVELOPING D IETARY P LAN

- initiate teaching that involves both pt and person preparing meals
- provide pt with written list for reference
- evaluate pt’s understanding of teachings (describe 24-hr diet plan)

1. Modifying Fluid Intake – increase, decrease, or modify in terms of types ingested

- identify appropriate fluid modification
- determine whether pt understands rationale, is motivated to follow modification, and is
capable of adhering to the plan
- develop and implement plan of care based on preceding information

V. E VALUATION