Beruflich Dokumente
Kultur Dokumente
Degree of acidity = pH
Scientific Knowledge Base : Location and
Movement of Water and Electrolytes
– Interstitial
– Intravascular
– Transcellular
Hemoglobin
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ECF Volume deficit
Hypovolemia: Sign and Symptoms
Cardiovascular Changes Respiratory Changes
Mild to moderate ↑ respiratory rate
↑ HR (due to SNS)
Peripheral pulses are weak,
difficult to find
Change in position may
cause ↑ HR or ↓ BP
Dizziness and light-
headedness
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 Neurologic changes
UO below 500 mL/day 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
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 Respiratory Changes
↑ Pulse: full and bounding ↑ respiratory rate
Full peripheral pulses Shallow respirations
Distended neck veins
↑ BP
↑ dyspnea with exertion or
in the supine position
Other Changes Pulmonary congestion and
-Urine; polyuria, nocturia pulmonary edema
-Lab data SOB
↓ Hematocrit, BUN Irritative cough
Moist crackles
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ECF Volume excess
Hypervolemia: Signs and symptoms
Neurologic changes Skin
Altered LOC Edematous may feel cool
Visual disturbances Skin may feel taut and
Skeletal muscle weakness hard
Paresthesias Edema-eyelids, facial,
Cerebral edema dependent (sacrum),
pitting, peripheral
Headache extremities
Confusion
Lethargy
Diminished reflexes GI Changes
Seizures, coma 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
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 Water loss: Signs and Symptoms
Inadequate water intake • Restlessness, agitation,
Unconscious or cognitively twitching, confusion
impaired individuals
NPO status • Seizures*, Coma
Excessive water loss • Intense thirst
↑ insensible water loss • Dry, swollen tongue
High fever
• Sticky mucous membranes
Diuretic therapy
Watery diarrhea • Weight loss
Disease states • Weakness, lethargy
Uncontrolled diabetes mellitus • Postural hypotension
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Hypernatremia
Na gain: Causes Na gain: Signs and Symptoms
Na intake • Restlessness, agitation,
IV fluids: hypertonic NaCl, twitching
excessive isotonic NaCl • Seizures, Coma
Hypertonic tube feeding with
out water supplement • Intense thirst
Use of Na containing drugs • Flushed skin
corticosteroids • Weight gain
Diseases • Peripheral and pulmonary
Renal failure
edema
• ↑ BP
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Hyponatremia
• Dilutional (↑ ECF Dilutional (↑ ECF Volume)
Volume) Causes Signs and Symptoms
Headache, apathy, confusion
– Use of hypotonic Nausea, vomiting, anorexia
irrigation solution Lethargy
Weakness
– Tap water enemas
Muscle spasms, seizures, coma
– Excessive water gain Diarrhea, Abdominal cramps
• Excessive hypotonic Weight gain
IV fluid ↑ BP
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Hyponatremia
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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 Relative hyperkalemia
• Excess potassium Intake • Shift of potassium Out of
– Excessive or rapid parenteral Cells
administration – 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 Electrocardiogram Changes
Irritability • Ventricular fibrillation
Abdominal cramping, • Ventricular standstill
diarrhea
Weakness of lower
extremities
Irregular pulse
Cardiac arrest if
hyperkalemia sudden or
severe
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Hypokalemia
Causes
• Potassium Loss • Shift of Potassium into
– GI losses: diarrhea, Cells
vomiting, fistulas, NG – Alkalosis
suction, NPO status
– Renal losses: diuretics,
– Skin losses: diaphoresis
– Dialysis
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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 Electrocardiogram Changes
Fatigue • Ventricular dysrhythmias
Muscle weakness, leg (e.g., PVCs)
cramps • Bradycardia
Nausea, vomiting, paralytic
ileus
Soft, flabby muscles
Paresthesias, decreased
reflexes
Weak, irregular pulse
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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 Electrocardiogram Changes
Lethargy, weakness • Ventricular dysrhythmias
Depressed reflexes (DTR) • Hypertension
Decreased memory
Confusion, personality
changes, psychosis
Anorexia, nausea, vomiting,
constipation
Bone pain, fractures
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Hypocalcemia
Causes
Decreased Total Decreased Ionized
Calcium Calcium
Chronic renal failure Excess administration of
Loop diuretics (e.g., citrated blood
furosemide [Lasix])
Chronic alcoholism
Diarrhea
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Hypocalcemia
Signs and Symptoms
Clinical Manifestations Electrocardiogram Changes
Easy fatigability • Ventricular tachycardia
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
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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 Mg-
containing 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 • Neuromuscular changes
• Hyperactive deep – Hyperactive deep
tendon reflexes tendon reflexes
– Numbness and tingling
• Tremors
– Painful muscle
• Seizures 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.
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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?
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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 potassium-
wasting diuretic
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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.
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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.”
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