Fluid and Electrolyte Imbalances

Diagnosing Fluid and Electrolyte Imbalances

• Baby Angela was taken to the ER due to irritability, difficulty breastfeeding, and 3 days of diarrhea.
• Her respiratory rate was elevated and her fontanels were sunken.
• Lab results: pH 7.39, PaCO2 27 mmHg, and HСОЗ 19 mEq/L.

Oral/Enteral Fluid Replacement

• Oral replacement is possible if the client isn't vomiting and hasn't experienced excessive fluid loss.
• The client needs an intact GI tract along with gag and swallow reflexes
• Oral replacement is not possible in GI obstruction.

Fluid Restriction

• Patients with hyponatremia require a restricted water intake
• Those with severe ECV excess may have both sodium and fluid restrictions.
• Explain the reason for fluid restrictions to the patient, family, and visitors, including the permitted oral fluid amount.
• Ice chips, gelatin, and ice cream are fluids.
• Patients should decide the amount of fluid to drink with each meal, between meals, before bed, and with medications, along with preferred fluids, unless contraindicated.
• 1 oz (30 mL) of liquid helps patients swallow a number of pills frequently.
• In acute care, half the total oral fluids are allotted between 7 AM and 3 PM, when patients are more active and take oral medications.
• Offer the remaining fluids during the evening and night shifts.
• Patients on fluid restriction require frequent mouth care to moisten mucous membranes and maintain comfort.

Parenteral Correction/IV Therapy

• IV fluids are colloids and crystalloids.

IV Fluid Types

• Hypotonic solutions
• Isotonic solutions
• Hypertonic solutions

Intravenous Fluids: Hypotonic

• Hypotonic solutions have lower osmotic pressure/osmolality/solute concentration than plasma.
• Examples: 0.45% Na CL or 1/2 normal saline, 0.225% sodium chloride (quarter normal saline; 1/4 NS; 0.225% NaCl)
• Treat intracellular dehydration and hypernatremia
• Provide fluid for renal excretion of solutes.

Hypotonic Solutions

• 0.45% NaCI (aka saline) is the main ingredient in all hypotonic solutions.
• Compared to isotonic and hypertonic IVs, hypotonic fluids are lower in sodium chlorine.
• 0.45% NaCI solutions are used in situations where patients have hypernatremia or high sodium chloride levels.
• Hypotonic solutions may negatively affect electrolyte levels or cause edemas if the body gets too much fluid.
• This fluid should not be used with patients who have heart or kidney failure.
• 0.33% NaCl can help people with impaired kidney function retain water
• 0.33% NaCl is not beneficial for those with more severe kidney disorders.
• Pulmonary edemas can result from 0.33% NaCl in people with severe kidney disorders as well as people with heart problems.
• 0.225% NaCl is a common type of IV fluid for pediatric health needs, typically in tandem with dextrose.
• 2.5% dextrose in water is an effective IV therapy for dehydration relief.

Intravenous Fluids: Isotonic

• Isotonic solutions' osmotic pressure/osmolality/solute concentration is equal to that of plasma.
• Eg- 5% dextrose in H2O (D5W).
• 0.9% NaCL or normal saline (NS).
• Ringer's lactate solution (RL), also known as sodium lactate solution and Hartmann's solution, contains Na+, K+, Ca2+, Cl-, and lactate, which the liver metabolizes to HCO3-.
• Expands ECV).
• Lactate ringers(LR) osmolality is 275-290 mOsm/L= 308 mOsm/L
• Lactated Ringer's is often found in emergency rooms, ambulances, and places dealing with critical health issues.
• Lactated Ringer's helps people with extensive burns, severe injuries or major blood loss.
• A variation of this isotonic fluid is called Ringer's Solution, and it is free of lactate.
• 0.9% NaCl, works well at alleviating dehydration symptoms.
• 5% dextrose in water supports hospitalized patients who can't eat normal food by supplying them with calories.
• PlasmaLyte is paired with red blood cells for IV treatment, sharing almost identical electrolyte levels that blood plasma in the body.

Intravenous Fluids: Hypertonic

• Hypertonic solutions have a higher osmotic pressure/osmolality/solute concentration than that of plasma (280 mOsm/L).
• Examples: 3% or 5% sodium chloride (hypertonic saline; 3% or 5% NaCl)
• Dextrose 10% in water (D10W)= 555mOsm/L
• Dextrose 5% in lactated Ringer's (D5 LR) = 530 mOsm/l
• Dextrose 5% in 0.45% NaCl sodium chloride (D5 ½ NS; D5 0.45% NaCl)
• Dextrose 5% in 0.9% sodium chloride (D5 NS; D5 0.9% NaCl).
• It draws fluid out of the intracellular and interstitial spaces into the vascular space.

Complications of Intravenous Therapy with Nursing Interventions

• Circulatory overload of IV solution.
• Infiltration or extravasation is when IV fluid enters subcutaneous tissue around the venipuncture site.
• Extravasation is a technical term when a vesicant (tissue-damaging) drug (e.g., chemotherapy) enters tissues.
• Phlebitis: Inflammation of the inner layer of a vein.
• Local infection: Infection at the catheter-skin entry point during infusion or after removal of the IV catheter.
• Bleeding at the venipuncture site: Oozing or slow, continuous seepage of blood from the venipuncture site

Changing IV Tubing

• For continuous infusion, change tubing after 96 hours unless the tubing has been compromised or contaminated, which requires an immediate tubing change.
• Change tubing every 24 hours for intermittent infusion.

Blood Transfusion

• Types of Blood Transfusions:
  • Autologous Transfusion
  • Allogeneic Transfusion.
• Types of transfused products:
  • Whole blood
  • Packed red cells (PRC)
  • FFP (Cryoprecipitate, Gamma globulin (IV immunoglobulin) transfusion)
  • Platelets
• Packed red cells (stored, washed, or frozen/washed) can have the following donor/recipient pairings:
  • Donor O, Recipients O, A, B, AB
  • Donor A, Recipients A, AB
  • Donor B, Recipients B, AB
  • Donor AB, Recipients AB
• Fresh-frozen plasma can have the donor/recipient pairings
  • Donor O, Recipient O
  • Donor A, Recipient A, O
  • Donor B, Recipient B, O
  • Donor AB, Recipient AB, B, A, O
• The universal FFP donor is AB because it will contain neither anti-A nor anti-B antibodies.
• Whole blood donors and recipients must be exact ABO matches as whole blood contains both RBCs and serum.

Adverse Effects of Blood Transfusions

• Acute Intravascular hemolytic
• Febrile Nonhemolytic (most common)
• Mild allergic
• Anaphylaxis
• Infection
• Circulatory overload

Nursing Intervention for Transfusion Reaction

• Stop the transfusion immediately.
• Keep the IV line open by replacing the IV tubing down to the catheter hub with new tubing and running 0.9% sodium chloride (normal saline).
• Don't turn off the blood and simply turn on the 0.9% sodium chloride (normal saline) that is connected to the Y-tubing infusion set, to prevent blood remaining in the IV tubing to infuse into the patient.
• Notify the health care provider or emergency response team immediately.
• Remain with the patient, observing signs and symptoms and monitoring vital signs as often as every 5 minutes.
• Prepare to administer emergency drugs such as antihistamines, vasopressors, fluids, and corticosteroids per health care provider order or protocol.
• Prepare to perform cardiopulmonary resuscitation.
• Save the blood container, tubing, attached labels, and transfusion record for return to the blood bank.
• Obtain blood and urine specimens per health care provider order or protocol

Massive Transfusion

• Massive transfusion (MT) is a medical procedure used to replace a large volume of blood in a patient who has experienced severe blood loss (the transfusion of 10 or more units of red blood cells within 24 hours, or the replacement of more than 50% of the patient's blood volume within 4 hours).
• Massive transfusions are required in situations such as:
  • Trauma: Severe injuries that cause significant blood loss.
  • Surgery: Major surgeries with high risk of bleeding.
  • Obstetric Emergencies: Complications during childbirth that lead to heavy bleeding.
  • Gastrointestinal Bleeding: Severe bleeding in the digestive tract.
• Goals:
  • Restore Blood Volume: Maintain adequate blood pressure and perfusion to vital organs.
  • Correct Coagulopathy: Address any clotting issues that may arise due to blood loss and transfusion.
  • Maintain Oxygenation: Ensure that tissues receive enough oxygen by restoring hemoglobin levels.
• Complications:
  • Volume Overload: Excessive fluid in the body.
  • Hypothermia: Lowered body temperature due to cold blood products.
  • Electrolyte Imbalances: Changes in levels of calcium, potassium, and other electrolytes.
  • Coagulopathy: Impaired blood clotting due to dilution of clotting factors.