Fluid and Electrolyte Imbalances Exam PDF

Fluid and Electrolyte Imbalances NURS 1060: Exam 4 1 OUTCOME u Describe principles of safe, patient-centered, evidence-based nursing care to adults at the basic level, guided by the Caritas philosophy. u Discuss critical thinking and clinical reasoning to p...

Fluid and Electrolyte Imbalances NURS 1060: Exam 4 1 OUTCOME u Describe principles of safe, patient-centered, evidence-based nursing care to adults at the basic level, guided by the Caritas philosophy. u Discuss critical thinking and clinical reasoning to provide quality patient care. 2 COMPETENCY u Describe factors that create a culture of safety related to medication administration. u Discuss critical thinking and clinical judgment used to provide accurate and safe medication administration. 3 CONCEPT u Fluid and Electrolyte: The physiological mechanisms that maintain fluid and electrolyte balance that promote bodily functions. 4 Unit Outcomes u Describe the nursing process and collaborative management when caring for patients with common fluid and electrolyte imbalances. u Imbalances of Fluid: u Extracellular Fluid Volume Deficit u Extracellular Fluid Volume Excess 5 Fluid and Electrolyte Imbalances Overview u Directly caused by illness or disease u For example, burns or heart failure u Result of therapeutic measures u For example, IV fluid replacement or diuretics u The imbalances are commonly classified as deficits or excesses. u For example, a patient with prolonged nasogastric suction will lose Na+ and K. These imbalances may result in a deficiency of both Na+ and K. Fluid and electrolyte imbalances occur to some degree in most patients with a major illness or injury because illness disrupts the normal homeostatic mechanism. These imbalances can be directly caused by illness or disease or by therapeutic measures such as IV fluid replacement or certain medications. The imbalances are commonly classified as deficits or excesses. In actual clinical situations, it is common for more than one imbalance to occur in the same patient. For example, a patient with prolonged nasogastric suction will lose Na+, K+, H+, and Cl–. These imbalances may result in a deficiency of both Na+ and K+, a fluid volume deficit, and a metabolic alkalosis resulting from loss of HCl. 6  Extracellular Fluid Volume Imbalances ECF volume deficit ECF volume excess (Hypovolemia) (Hypervolemia and Edema) The term fluid volume deficit is not the same as dehydration. Dehydration refers to loss of pure water alone without corresponding loss of sodium. Hypovolemia- decreased blood volume (intravascular fluid) Hypervolemia- increased intravascular fluid Edema- increased interstitial fluid Review: Intracellular fluid Solutes: oxygen, electrolytes, glucose Cations: potassium, magnesium Anions: phosphate, sulfate Extracellular fluid Principal electrolytes: sodium, chloride, bicarbonate Interstitial fluid (surrounds cells), 75% Intravascular fluid (plasma), 20% Transcellular and lymph fluids 7  u Possible Causes: Abnormal loss of normal body fluids GI- vomiting, diarrhea, GI ECF Volume suctioning, fistulas, drainage, chronic laxative or enema abuse Deficit Renal-diuretics, renal disorders, endocrine disorders Hemorrhage Hypovolemia Excessive sweating and/or increased temperature Burns Inadequate intake Fluid volume deficit can occur from loss of normal body fluids such as occurs with vomiting, diarrhea, fistula drainage, hemorrhage, and diuresis. It can also occur secondary to disease processes such as diabetes insipidus, burns, hemorrhage, and intestinal obstruction. Clinical manifestations include restlessness, drowsiness, lethargy, confusion, postural hypotension, tachycardia, tachypnea, weakness, dizziness, weight loss, seizures, and coma. Skin turgor, capillary refill, and urine output are all decreased. Balanced IV solutions, such as lactated Ringer’s solution, are usually given to replace both water and any needed electrolytes. Isotonic (0.9%) sodium chloride is used when rapid volume replacement is indicated. Blood is administered when volume loss is a result of blood loss. 8 ECF Volume Deficit (Hypovolemia) u Clinical Manifestations: u Initial symptoms: thirst, dry mucus membranes, reduced urine output, weakness, lethargy, (postural) orthostatic hypotension u Possible hypovolemic shock: hypotension, tachycardia, tachypnea, decreased or absent urine output and decreased cardiac output u Coma, death u Assessments: u Intake and output u VS- including orthostatic BP and pulse u Skin turgor, mucus membrane moisture, cap refill Symptoms are a result from both decreased fluid and the body’s response to decreased fluid Labs may show increase hematocrit because RBC are more concentrated with less fluid in the vasculature. 9 ECF Volume Deficit: Management (Hypovolemia) Treatment: Replace water and electrolytes u PO fluids rehydration u IV Fluids u Lactated Ringerʼs solution, are usually given to replace both water and any needed electrolytes. u Isotonic (0.9%) sodium chloride is used when rapid volume replacement is indicated. u Blood is administered when volume loss is a result of blood loss What could be evaluated to demonstrate treatment was successful? -(I&Os) specifically urine output -BP 10  u Possible Causes: Retention of sodium and water ECF Volume (HF, liver cirrhosis, renal failure, stress conditions- increased ADH Excess and aldosterone) Excessive intake of: Hypervolemia Sodium-containing foods Drugs that cause sodium retention, Sodium-containing IV fluids Fluid volume excess may result form excessive intake of fluids, abnormal retention of fluids (e.g., heart failure, renal failure), or a shift of fluid from interstitial fluid into plasma fluid, increasing intravascular volume. Clinical manifestations are related to excess volume and CNS changes. Manifestations include headache, confusion, lethargy, peripheral edema, jugular venous distention, bounding pulse, hypertension, dyspnea, crackles, pulmonary edema, muscle spasms, weight gain, seizures, and coma. The primary cause of fluid volume excess must be identified and treated. Diuretics and fluid restriction are the primary forms of therapy. Restriction of sodium intake may also be indicated. If the fluid excess leads to ascites or pleural effusion, an abdominal paracentesis or thoracentesis may be necessary. 11 ECF Volume Excess Hypervolemia Clinical Manifestations: u Excess volume u Weight gain > 5% of body weight u Circulatory overload u Bounding pulse, jugular vein distention, increased CVP u Dyspnea, orthopnea, crackles, cough (pulmonary edema) u Polyuria u Ascites, edema 12  u Daily weights Hypovolemia/ u #1 Accurate Assessment Hypervolemia u Weigh the patient at the same time every day, wearing the same garments, and on the same carefully calibrated scale. An Nursing increase of 1 kg (2.2 lb) is equal to about Implementation 1000 mL (1 L) of fluid retention. 13 ECF Volume Excess Management (Hypervolemia) Treatment Goal: Remove fluid without changing electrolyte composition or osmolality of ECF u Identify primary cause and treat the cause u Diuretics u Fluid restriction u Restriction of sodium intake may also be indicated. 14 Nursing Management Nursing Diagnoses Hypovolemia Hypervolemia u Excess fluid volume u Deficient fluid volume u Impaired gas exchange u Decreased cardiac u Risk for impaired skin output integrity u Risk for deficient fluid u Activity intolerance volume u Disturbed body image u Potential complication: u Potential complications: Pulmonary edema, ascites Hypovolemic shock Compare and contrast nursing dx for hypovolemia and hypervolemia. A patient with hypovolemia has, or is at risk for, a deficient fluid volume and decreased cardiac output related to excessive ECF losses or decreased fluid intake. This patient is at risk for hypovolemic shock if fluid loss continues without replacement. The patient with hypervolemia has excess fluid volume related to increased water and/or sodium retention. This patient may also have impaired gas exchange related to water retention leading to pulmonary edema. Peripheral edema increases the patient’s risk for impaired skin integrity. Increased water retention, fatigue, and weakness can lead to activity intolerance. The appearance of edema affects body image. Finally, the patient with excess fluid volume is at risk for pulmonary edema and ascites. 15  Hypovolemia/ Hypervolemia Nursing Implementation Monitor I & O Monitor cardiovascular changes Intake includes all oral, IV, enteral. ECG changes: Changes in blood pressure, Output includes urine, excess perspiration, pulse force, and jugular venous distention. wound or tube drainage, vomit, and Orthostatic hypotension may be evident in diarrhea. patients with fluid volume deficit. The care of patients with either a fluid deficiency or excess requires astute attention to their fluid volume status. This includes: Careful monitoring of I & O. Intake includes all oral, IV, enteral.. Output includes urine, excess perspiration, wound or tube drainage, vomitus, and diarrhea. Urine- specific gravity may also be measured. Readings of greater than 1.025 indicate concentrated urine, whereas readings of less than 1.010 indicate dilute urine. Cardiovascular signs and symptoms of ECF volume excess and deficit are reflected in changes in blood pressure, pulse force, and jugular venous distention. Orthostatic hypotension may be evident in patients with fluid volume deficit. Both fluid excess and deficit affect respiratory status. ECF excess can result in pulmonary congestion and pulmonary edema as increased hydrostatic pressure in the pulmonary vessels forces fluid into the alveoli. The patient will experience shortness of breath and moist crackles on auscultation. The patient with ECF deficit will demonstrate an increased respiratory rate as a result of decreased tissue perfusion and resultant hypoxia. Changes in neurologic function may occur with fluid volume excess or deficit secondary to either cerebral edema or reduced cerebral tissue perfusion. Assess the patient’s LOC, pupillary response, and voluntary movement of extremities. Weigh the patient at the same time every day, wearing the same garments, and on the same carefully calibrated scale. An increase of 1 kg (2.2 lb) is equal to 1000 mL (1 L) of fluid retention (provided the person has maintained usual dietary intake or has not been on nothing-by-mouth [NPO] status). {See next slide for figure about skin assessment.} 16 Hypovolemia/ Hypervolemia Nursing Implementation Assess respiratory changes Assess neurologic changes Both fluid excess and deficit affect Changes in neurologic function may occur respiratory status. with fluid volume excess or deficit ECF excess can result in pulmonary secondary to either cerebral edema or congestion and pulmonary edema as reduced cerebral tissue perfusion. pressure in the pulmonary vessels forces Confusion, restless, lethargy fluid into the alveoli. Assess the patientʼs LOC, pupillary The patient may experience shortness of breath and moist crackles on auscultation. response, and voluntary movement of extremities. The patient with ECF deficit may demonstrate an increased respiratory rate as a result of decreased tissue perfusion and resultant hypoxia. 17