Fluid, Electrolyte, and Acid-Base Balance

Fluid, Electrolyte, and Acid-Base Balance
B260: Fundamentals of Nursing

Characteristics of Body Fluids
Fluid = Water that contains dissolved or suspended substances such as glucose, mineral salts, and proteins. Fluid amount = Volume. Fluid concentration = Osmolality. Fluid composition (electrolyte concentration) Degree of acidity = pH The characteristics of body fluids influence body system function through their effects on cell function. All of these characteristics have regulatory mechanisms, which keep them in balance for normal function.

Scientific Knowledge Base : Location and Movement of Water and Electrolytes
Intracellular Fluid (ICF) = Fluids within cells ~2/3 of total body water Extracellular Fluid (ECF) = Fluid outside of cells ~1/3 of total body water Three divisions: – Interstitial – Intravascular – Transcellular •Body fluids containing water, Na+, and other electrolytes are distributed between distinct compartments: extracellular fluid (ECF) outside the cells, and intracellular fluid (ICF) inside the cells. •ECF fluids: Interstitial fluids are the fluids between cells and outside the blood vessels. These include lymph (fluid in the lymphatic channels). Intravascular fluid is blood plasma found in the vascular system. Transcellular fluids are secreted by epithelial cells and include cerebrospinal, pleural, peritoneal, and synovial fluids.

Hemoglobin The hemoglobin test measures the amount of hemoglobin in blood and is a good measure of the blood’s ability to carry oxygen throughout the body. Norm Males: g/dL Females: g/dL

Hematocrit This test measures the amount of space (volume) red bloods cells take up in the blood. The value is given as a % of RBCs in a volume of blood. For example, a hematocrit of 38 means that 38% of the blood’s volume is made of RBCs. Norm: Male: 39%-50% Females: 35%-47%

Hematocrit

HYPOVOLEMIA – ECF FLUID VOLUME DEFICIT

Fever (↑ perspiration)
Hypovolemia Causes Abnormal fluid loss Diarrhea Hemorrhage Polyuria Fever (↑ perspiration) Inadequate intake Osmotic diuresis

Cardiovascular Changes Alteration in Mental Status
Hypovolemia Cardiovascular Changes Respiratory Changes Renal Changes Neurologic Changes Mild to moderate ↑ HR 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 ↑ respiratory rate 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 CV changes a good indicators of hydration status Because the decreased blood volume is perceived by the body as decreased oxygen levels (hypoxia). The increased respiratory rate is an attempt to maintain oxygen delivery. Neurologic Assessment LOC Orientation X 3 Pupil response to light and equality of pupil size Voluntary movement of the extremities, degree of muscle strength, and reflexes Nursing care: maintaining patient safety

Assessment Findings 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 Patient C/O thirst Eyes: soft, sunken Lab data: ↑ H & H; BUN; Josie King Good skin care for the person with ECF volume excess or deficit is important. Edematous tissues must be protected from extremes of heat and cold, prolonged pressure, and trauma. Frequent skin care can changes in position will protect the patient from skin breakdown. Elevation of edematous extremities helps promote venous return and fluid reabsorption. Dehydrated skin needs frequent care without the use of soap. The application of moisturizing creams or oils will increase moisture retention and stimulate circulation. Because more water is lost and other substances remain, increasing the osmolarity or concentration of the blood

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 Determine if pt has any special fluid needs Make carefully time schedule to provide fluids Teach UAP how to offer fluids

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

HYPERVOLEMIA – ECF FLUID VOLUME EXCESS

ECF Volume Excess: Hypervolemia
Causes Excessive intake of fluids Abnormal retention of fluids Heart failure Renal failure Long-term corticosteroid therapy

ECF Volume Excess: Hypervolemia
Cardio Changes Respiratory Changes Skin Changes Neurologic Changes Other Changes ↑ Pulse: full and bounding Full peripheral pulses Distended neck veins ↑ BP ↑ respiratory rate Shallow respirations ↑ dyspnea with exertion or in the supine position Pulmonary congestion and pulmonary edema SOB Irritative cough Moist crackles Edematous may feel cool Skin may feel taut and hard Edema-eyelids, facial, dependent (sacrum), pitting, peripheral extremities Altered LOC Visual disturbances Skeletal muscle weakness Parenthesis Cerebral edema Headache Confusion Lethargy Diminished reflexes Seizures, coma Urine: polyuria, nocturia Lab data ↓Hematocrit, BUN GI Changes Increased motility Enlarged liver CV changes a good indicators of hydration status Because the decreased blood volume is perceived by the body as decreased oxygen levels (hypoxia). The increased respiratory rate is an attempt to maintain oxygen delivery. Neurologic Assessment LOC Orientation X 3 Pupil response to light and equality of pupil size Voluntary movement of the extremities, degree of muscle strength, and reflexes Nursing care: maintaining patient safety

A 17-year-old high school football player has passed away after drinking too much water during practice. Zyrees Oliver, a star student and athlete at Douglas County High School in Georgia, drank two gallons of water and two gallons of Gatorade to stave off cramps last Tuesday, his relatives said. He felt better that evening but on Wednesday morning - just hours before he was set to start his first day of his senior year - he collapsed in his Douglasville home and was rushed to hospital. Doctors said Zyrees was brain dead after suffering devastating brain swelling from water intoxication

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

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)

Sodium Hypernatremia and Hyponatremia

Functions of Sodium Regulates osmolality
ICF: 14 mmol/L & ECF: 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.

Hypernatremia

Hypernatremia –Water Loss
Causes Inadequate water intake Unconscious or cognitively impaired individuals NPO status Excessive water loss ↑ insensible water loss High fever Diuretic therapy Watery diarrhea Disease states Uncontrolled diabetes mellitus Signs & Symptoms Restlessness, agitation, twitching, confusion Seizures*, Coma Intense thirst Dry, swollen tongue Sticky mucous membranes Weight loss Weakness, lethargy Postural hypotension

Hyponatremia

Hypernatremia – Na Gain
Causes Na intake IV fluids: hypertonic NaCl, excessive isotonic NaCl Hypertonic tube feeding with out water supplement Use of Na containing drugs corticosteroids Diseases Renal failure Signs & Symptoms Restlessness, agitation, twitching Seizures, Coma Intense thirst Flushed skin Weight gain Peripheral and pulmonary edema ↑ BP

Hyponatremia – Dilution (Water Gain)
Causes Use of hypotonic irrigation solution Tap water enemas Excessive water gain Excessive hypotonic IV fluid Signs & Symptoms Headache, apathy, confusion Nausea, vomiting, anorexia Lethargy Weakness Muscle spasms, seizures, coma Diarrhea, Abdominal cramps Weight gain ↑ BP

Hyponatremia – Na Loss Causes Signs & Symptoms GI Vomiting Diarrhea
NG suctioning NPO Status Kidney Diuretic Skin Burns Wounds Excessive diaphoresis Signs & Symptoms Irritability, apprehension, confusion Dizziness Personality changes Tremors, seizures, coma Dry mucous membranes Postural hypotension Tachycardia, thread pulse Cold & clammy skin

Potassium Hyperkalemia and Hypokalemia

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 Controls cardiac rate & rhythm, conduction of nerve impulses, skeletal muscle contraction 98% ICF 2% ECF Small changes in K level have a profound effect on the body and are poorly tolerated. Hydrogen ions moves in cell in acidosis (DKA) and K moves out Kidneys eliminate approx 90% of K Remaining is excreted through stool and perspiration

Hyperkalemia

Hyperkalemia Signs & Symptoms Causes Clinical Manifestations
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 Excess potassium Intake Excessive or rapid parenteral administration Shift of potassium Out of Cells Acidosis Crushing injury Tissue catabolism (fever, sepsis, burns) Failure to Eliminate Potassium Renal disease Potassium-sparing diuretics ACE inhibitors Signs & Symptoms Clinical Manifestations Irritability Abdominal cramping, diarrhea Weakness of lower extremities Irregular pulse Cardiac arrest if hyperkalemia sudden or severe Electrocardiogram Changes Ventricular fibrillation Ventricular standstill

Hypokalemia

Hypokalemia Causes Signs & Symptoms Potassium Loss
GI losses: diarrhea, vomiting, fistulas, NG suction, NPO status Renal losses: diuretics, Skin losses: diaphoresis Dialysis Shift of Potassium into Cells Lack of Potassium Intake Starvation Diet low in K Failure to include K in parenteral fluids if NPO TPN Signs & Symptoms Clinical Manifestations Fatigue Muscle weakness, leg cramps Nausea, vomiting, paralytic ileus Soft, flabby muscles Paresthesias, decreased reflexes Weak, irregular pulse Irregular heartbeat Electrocardiogram Changes Ventricular dysrhythmias (e.g., PVCs) Bradycardia

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 Risk for injury related to muscle weakness and hyporeflexia Risk for decreased cardiac output related to dysrhythmias Decreased cardiac output Fatigue Constipation Bathing/hygiene self-care deficit

Calcium Hypercalcemia & Hypocalcemia

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

Hypercalcemia

Hypercalcemia Signs & Symptoms Causes Increased Total Calcium
Prolonged immobilization Thiazide diuretics Dehydration Renal failure Signs & Symptoms Clinical Manifestations Lethargy, weakness Depressed reflexes (DTR) Decreased memory Confusion, personality changes, psychosis Anorexia, nausea, vomiting, constipation Bone pain, fractures Electrocardiogram Changes Ventricular dysrhythmias Hypertension

Hypocalcemia

Hypocalcemia Causes Signs & Symptoms Decreased Total Calcium
Chronic renal failure Loop diuretics (e.g., furosemide [Lasix]) Chronic alcoholism Diarrhea Decreased Ionized Calcium Excess administration of citrated blood Signs & Symptoms Clinical Manifestations Easy fatigability 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 Electrocardiogram Changes Ventricular tachycardia

Magnesium Hypermagnesemia & Hypomagnesaemia

Functions of Magnesium
Cofactor in clotting cascade Acts directly on myoneural junction, affecting muscular irritability and contractions Maintains strong and healthy bones

Hypermagnesemia

Hypermagnesemia Signs & Symptoms 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 Signs & 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

Hypomagnesemia

Hypomagnesemia Causes Signs & Symptoms Malabsorption disorders
Inflammatory bowel disease (IBD) Bowel resection Bariatric population who undergoes gastric bypass surgery Alcoholism Prolonged diarrhea Draining GI fistulas Diuretics Signs & Symptoms Confusion Hyperactive deep tendon reflexes Tremors Seizures Hypertension Neuromuscular changes Numbness and tingling Painful muscle contractions

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. You will apply knowledge about fluid, electrolyte, and acid-base imbalance in many clinical settings. You will incorporate nursing and collaborative interventions to maintain or restore fluid and electrolyte balance. Skills and techniques for safe IV therapy are a vital area of the nursing knowledge base and the focus of much nursing research to support evidence-based practice.

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 Using a systematic approach in assessment enables you to help patients safely maintain or restore fluid, electrolyte, and acid-base balances. A patient’s fluid, electrolyte, or acid-base imbalance is sometimes so severe that it prevents initial discussion of his or her expressed needs, values, and preferences. However, when a patient is alert enough to discuss care, you need to elicit this information. Focus on the patient’s experience with fluid, electrolyte, or acid-base alterations and his or her perceptions of the illness. Ask about the patient’s greatest concerns regarding fluid status to build the basis for active partnership in planning, implementing, and evaluating patient-centered care. Clinical assessment begins with a patient history designed to reveal risk factors that cause or contribute to fluid, electrolyte, and acid-base imbalances. Ask specific, focused questions to identify factors that contribute to a patient’s potential imbalances. First, assess a patient’s age. Infants are at greater risk for ECV deficit and hypernatremia because body water loss is proportionately greater per kilogram of weight. Fluctuations in fluid balance are greater in adolescent girls because of hormonal changes associated with the menstrual cycle. Older adults experience a number of age-related changes that potentially affect fluid, electrolyte, and acid-base balances. They often have more difficulty recovering from imbalances resulting from the combined effects of normal aging, various disease conditions, and multiple medications. Excessive sweating without adequate replacement of salt and water can lead to ECV deficit, hypernatremia, or clinical dehydration. Ask patients about their normal level of physical work, and whether they engage in vigorous exercise in hot environments. Do these patients have fluid replacements containing salt available during exercise and activity? Assess dietary intake of fluids; salt; and foods rich in potassium, calcium, and magnesium. Ask patients if they follow weight loss diets. Starvation diets and those with high fat and no carbohydrate content often lead to metabolic acidosis. In addition, assess the patient’s ability to chew and swallow, which, if altered, interferes with adequate intake of electrolyte-rich foods and fluids. Take an alcohol intake history. Chronic alcohol abuse commonly causes hypomagnesemia, in part because it increases renal magnesium excretion. Obtain a complete list of your patient’s current medications, including over-the-counter (OTC) and herbal preparations, to assess the risks for fluid, electrolyte, and acid-base imbalances. Use a drug reference book or a reputable online database to check the potential effects of other medications. Ask specifically about the use of baking soda as an antacid, which can cause ECV excess because of its high sodium content that holds water in the extracellular compartments. For an individual who uses laxatives, ask about the consistency and frequency of stools. Multiple loose stools remove fluid and electrolytes from the body, thus causing numerous imbalances. [See Figure 41-9 on text p. 895 Critical thinking model for fluid, electrolyte, and acid-base balances assessment; Table 41-9 on text p. 896 Risk Factors for Fluid, Electrolyte, and Acid-Base Imbalances; Box 41-1 on text p. 896 Nursing Assessment Questions; Box 41-2 on text p. 897 Focus on Older Adults: Factors Affecting Fluid, Electrolyte, and Acid-Base Balance; and Box 41-3 on text p. 897 Commonly Used Medications That Cause Fluid, Electrolyte, and Acid-Base Imbalances.]

Nursing Process: Assessment
Medical history Recent surgery (physiological stress) Gastrointestinal output Acute illness or trauma Respiratory disorders Burns Trauma Chronic illness Cancer Heart failure Oliguric renal disease •Patients who are very young or very old, whose intake and output (I&O) of fluid and/or electrolytes are not equal, or who have various chronic diseases or trauma are at high risk for fluid, electrolyte, and acid-base imbalances. Surgery causes a physiological stress response, which increases with extensive surgery and blood loss. On the second to fifth postoperative days, increased secretion of aldosterone, glucocorticoids, and ADH causes increased ECV, decreased osmolality, and increased potassium excretion. In otherwise healthy patients, these imbalances resolve without difficulty, but patients who have preexisting illnesses or additional risk factors often need treatment during this time period. Increased output of fluid through the GI tract is a common and important cause of fluid, electrolyte, and acid-base imbalances that requires careful assessment. Many acute respiratory disorders predispose patients to respiratory acidosis. For example, bacterial pneumonia causes alveoli to fill with exudate that impairs gas exchange, causing the patient to retain carbon dioxide, which leads to increased PaCO2 and respiratory acidosis. Burns place patients at high risk for ECV deficit from numerous mechanisms, including plasma-to-interstitial fluid shift and increased evaporative and exudate output. The greater the body surface burned, the greater is the fluid loss. Hemorrhage from any type of trauma causes ECV deficit from blood loss. Some types of trauma create additional risks. Chronic illness. Many chronic diseases create ongoing risks of fluid, electrolyte, and acid-base imbalances. In addition, the treatment regimens for chronic disease often cause imbalances. The types of fluid and electrolyte imbalances that occur with cancer depend on the type and progression of the cancer and treatment regimen. Patients who have chronic heart failure have diminished cardiac output, which reduces kidney perfusion and activates the RAAS. The action of aldosterone on the kidneys causes ECV excess and risk of hypokalemia. Most diuretics used to treat heart failure increase the risk of hypokalemia while reducing the ECV excess. Dietary sodium restriction is important with heart failure because Na+ holds water in the ECF, making the ECV excess worse. In severe heart failure, restriction of both fluid and sodium is prescribed to decrease the workload of the heart by reducing excess circulating fluid volume. Oliguria occurs when the kidneys have a reduced capacity to make urine. Some conditions, such as acute nephritis, cause a sudden onset of oliguria, whereas other problems, such as chronic kidney disease, lead to chronic oliguria. Oliguric renal disease prevents normal excretion of fluid, electrolytes, and metabolic acids, resulting in ECV excess, hyperkalemia, hypermagnesemia, hyperphosphatemia, and metabolic acidosis. The severity of these imbalances is proportionate to the degree of renal failure.

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 Data gathered through a focused physical assessment validate and extend the information collected in the patient history. Daily weights are an important indicator of fluid status. Each kilogram (2.2 lbs) of weight gained or lost overnight is equal to 1 L of fluid retained or lost. These fluid gains or losses indicate changes in the amount of total body fluid, usually ECF, but do not indicate a shift between body compartments. Weigh daily patients with heart failure and those who are at high risk for or who actually have ECV excess. Daily weights are also useful for patients with clinical dehydration or other causes of or risks for ECV deficit. Weigh the patient at the same time each day with the same scale after a patient voids. Calibrate the scale each day or routinely. The patient needs to wear the same clothes or clothes that weigh the same; if using a bed scale, use the same number of sheets on the scale with each weighing. Compare the weight of each day with that of the previous day to determine fluid gains or losses. Look at the weights over several days to recognize trends. Interpretation of daily weights guides medical therapy and nursing care. Teach patients with heart failure to take and record their daily weights at home and to contact their health care provider if their weight increases suddenly by a set amount (obtain parameters from their health care providers). Recognizing trends in daily weights taken at home is important. Research shows that patients who are hospitalized for decompensated heart failure often experience steady increases in daily weights during the week before hospitalization. A weight gain of more than 2.2 lbs (1 kg) was associated with increased risk of hospitalization due to heart failure. Measuring and recording all liquid intake and output (I&O) during a 24-hour period is an important aspect of fluid balance assessment. Compare a patient’s 24-hour intake with his or her 24-hour output. The two measures should be approximately equal if the person has normal fluid balance. To interpret situations in which I&Os are substantially different, consider the individual patient. For example, if intake is substantially greater than output, two possibilities exist: The patient may be gaining excessive fluid or may be returning to normal fluid status by replacing fluid lost previously from the body. Similarly, if intake is substantially smaller than output, two possibilities are known: The patient may be losing needed fluid from the body and developing ECV deficit and/or hypernatremia or may be returning to normal fluid status by excreting excessive fluid gained previously. In most health care settings, I&O measurement is a nursing assessment. Some agencies require a health care provider’s order for I&O. If you want to measure I&O for a patient with compromised fluid status, check your agency policies to determine whether you can institute it or if you need a health care provider’s order. Fluid intake includes all liquids that a person eats (e.g., gelatin, ice cream, soup), drinks, (e.g., water, coffee, juice), or receives through nasogastric or jejunostomy feeding tubes. IV fluids (continuous infusions and intermittent IV piggybacks) and blood components are also sources of intake. Water swallowed while taking pills and liquid medications counts as intake. A patient receiving tube feedings often receives numerous liquid medications, and water is used to flush the tube before and/or after medications. Over a 24-hour period, these liquids amount to significant intake and always are recorded on the I&O record. Ask patients who are alert and oriented to assist with measuring their oral intake, and explain to families why they should not drink or eat from the patient’s meal trays or water pitcher. Fluid output includes urine, diarrhea, vomitus, gastric suction, and drainage from postsurgical wounds or other tubes. Record a patient’s urinary output after each voiding. Instruct patients who are alert, oriented, and ambulatory to save their urine in a calibrated insert, which attaches to the rim of the toilet bowl. Teach patients and families the purpose of I&O measurements. Teach them to notify the nurse or nursing assistive personnel (NAP) to empty any container with voided fluid, or show them how to measure and empty the container themselves and report the results appropriately. Accurate I&O facilitates ongoing evaluation of a patient’s hydration status. Review the patient’s laboratory test results and compare them with normal ranges to obtain further objective data about fluid, electrolyte, and acid-base balances. Serum electrolyte tests usually are performed routinely on any patient entering a hospital to screen for imbalances and serve as a baseline for future comparisons. [Table on text p. 899 covers Focused Nursing Assessments for Patients with Fluid, Electrolyte, and Acid-Base Imbalances.]

Nursing Interventions
Interventions for electrolyte imbalances Support prescribed medical therapies Aim to reverse the existing acid-base imbalance Provide for patient safety In addition to the administration of prescribed medical therapies, nursing interventions may be performed to preserve or restore electrolyte imbalance. Teach patients the reasons for their therapies and the importance of balancing electrolyte I&O to prevent imbalances in the future. Nursing interventions to promote acid-base balance support prescribed medical therapies and aim at reversing the existing acid-base imbalance while providing for patient safety. Patients with acid-base imbalances often require repeated ABG analysis. Determination of a patient’s acid-base status requires obtaining a sample of arterial blood for laboratory testing. An ABG reveals acid-base status and the adequacy of ventilation and oxygenation.

Implementation Health promotion Acute care 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) Health promotion activities focus primarily on patient education. Teach patients and caregivers to recognize risk factors for developing imbalances and to implement appropriate preventive measures. Parents must understand that infants and children need to replace fluids when vomiting or diarrhea occurs. Adults, especially the elderly and the infirm, also need to replace fluids when increased perspiration occurs. Patients with chronic health alterations often are at risk for developing fluid, electrolyte, and acid-base imbalances. They need to understand their own risk factors and the measures to be taken to avoid imbalances. Teach patients with chronic diseases and their family caregivers the early signs and symptoms of the fluid, electrolyte, and acid-base imbalances for which they are at risk, and what to do if these occur. Acute care nurses administer medications and oral and IV fluids to replace fluid and electrolyte deficits or to maintain normal homeostasis; they also assist with restricting intake as part of therapy for excesses. •Prevention and treatment of ECV deficit, hypernatremia, and electrolyte deficits are accomplished with enteral or parenteral administration of appropriate fluid. Enteral replacements with oral fluids and electrolytes are indicated for patients who are able to drink. Oral replacements may be contraindicated when the patient is vomiting, has a GI tract obstruction, is at risk for obstruction, or has impaired swallowing. A feeding tube is appropriate when the patient’s GI tract is healthy, but the patient cannot ingest fluids (e.g., after oral surgery, with impaired swallowing). Options for administering fluids include gastrostomy or jejunostomy instillations or infusions through small-bore nasogastric feeding tubes. Patients who have hyponatremia usually require restricted water intake. Patients who have very severe ECV excess sometimes have both sodium and fluid restrictions. It is important to allow patients to choose preferred fluids unless contraindicated. Frequently, patients on fluid restriction can swallow a number of pills with as little as 1 oz (30 mL) of liquid. Parenteral replacement includes total parenteral nutrition (TPN), crystalloids, and colloids (blood and blood components). Total parenteral nutrition (TPN) consists of IV administration of a complex, highly concentrated solution containing nutrients and electrolytes that is formulated to meet a patient’s needs. Depending on their osmolality, PN solutions may be administered through a central IV catheter (high osmolality) or peripherally (lower osmolality).

Implementation Restorative care Home intravenous therapy
Nutrition support Medication safety Medications OTC drugs Herbal preparations After experiencing acute alterations in fluid, electrolyte, or acid-base balance, patients often require ongoing maintenance to prevent a recurrence of health alterations. Older adults require special considerations to prevent complications from developing. Patient and family teaching is important for preventing fluid, electrolyte, and acid-base imbalances and for effective restorative care. IV therapy often continues in the home setting for patients requiring long-term hydration, PN, or long-term medication administration. A home IV therapy nurse works closely with the patient to ensure that a sterile IV system is maintained, and that complications can be avoided or recognized promptly. [Box 41-8 on text p. 914 summarizes patient education guidelines for home IV therapy.] Most patients who have had electrolyte disorders or metabolic acid-base imbalances require ongoing nutritional support. Depending on the type of disorder, fluid or food intake may be encouraged or restricted. Patients or family members who are responsible for meal preparation need to learn to understand the nutritional content of foods and to read the labels of commercially prepared foods. Numerous medications, OTC drugs, and herbal preparations contain components or create potential side effects that can alter fluid and electrolyte balance. Patients with chronic disease who are receiving multiple medications and those with renal disorders are at significant risk for alterations. Once patients return to a restorative care setting, whether in the home, long-term care, or other setting, drug safety is very important. Patient and family education regarding potential side effects and drug interactions that can alter fluid, electrolyte, or acid-base balance is essential. Review all medications with patients, and encourage them to consult with their local pharmacist, especially if they wish to try a new OTC drug or herbal preparation.

Evaluation Are the goals met? How do we know?
Evaluation of a patient’s clinical status is especially important if acute fluid, electrolyte, and/or acid-base imbalances exist. A patient’s condition can change very quickly, and it is important to recognize impending problems by integrating information about his or her presenting risk factors and clinical status, effects of the present treatment regimen, and potential causative agent. Some possible questions to ask if expected outcomes have not been met are shown on the slide. [Discuss ways to phrase questions to get honest answers from patients.] [See also Figure Critical thinking model for fluid, electrolyte, and acid-base balances evaluation.]

Fluid, Electrolyte, and Acid-Base Balance

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Fluid, Electrolyte, and Acid-Base Balance

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