Fluid + Electrolytes-Acid Base
Dehydration= FVD; Hypovolemia o Common causes of dehydration:
Vomiting
Fluid intake/retention does not meet body’s fluid Diarrhea
needs; results in fluid volume deficit
o Clinical manifestations:
o Lack of fluid intake or excess fluid loss Peripheral pulses cold and clammy
o Alteration in the fluid balance extremities
regulators: Weak and tready
Thirst Dry mucous membrane
Hormones Abnormal lab values
Lymphatic system
Kidneys
Interventions Push fluids without IV
Daily morning weights
Monitoring input and output every 24 hours
Monitor for falls
Braden scale (skin problems)
Fluid Overload: FVE- Hypervolemia (Third- Excess of body fluid=” everything is watered down”
Spacing) “Over hydration”
Can develop from administration of too much or Hypervolemia- excess fluids in vascular
a failure to excrete fluids and usually results in system
an elevated sodium level Third-spacing- excess fluids in interstitial
spaces, water intoxication
o Failure to excrete fluids Water intoxication-excess fluids in the
Renal failure cells
Edema as with heart failure o Peripheral vascular resistance increases too,
which can lead to pulmonary edema and heart
failure.
o Nursing interventions: assess lungs sounds at
least every two hours
Labs Respiratory + cardiovascular
BUN will be low (diluted) Crackles, pallor
Hematocrit will be low (diluted) Elevated blood pressure
Sodium will be low (diluted) Moist mucous membrane
Shallow, rapid respirations
Peripheral edema (pitting)
Weight gain
JVD
Interventions for Excess Fluids Volume /FVE Reduce sodium + fluid intake
Mobilize fluids
Turning, positioning
Prevent complications
Elevate head of bed (HOB) 30 degrees
Monitor lab values
Provide skin care
Modification for older adult patients
Teach
Low-sodium diet
Use of alternative seasonings
Avoid mixing, ACE inhibitors - K+ salt
substitutes
Fluid restrictions
Daily weights
, Electrolyte Imbalances
Sodium- 135-145 mmol/L Responsible for where salt goes water follows
Hyponatremia: o Sodium <135 (less than)
o Causes:
Most common electrolyte disorder; it is directly abnormal loss or excretion of sodium
related to changes in the fluid volume status as Water imbalance
sodium moves into cells + potassium moves into Hormonal imbalance (such as excess
ECF, which results in INTRACEULLAR EDEMA. ADH)
Hypothyroidism
Renal failure
Diuretics; excessive use is a common
cause of hyponatremia as well as GI
wound drainage.
Diarrhea
Vomiting
Wound drainage
Burns
Excess perspiration
o Risk:
Seizures + death if electrolytes not
corrected
o S/S:
Headache + apprehension
Confusion; Hypotension (especially
orthostatic) Hallucinations, seizures,
coma, + even death may occur.
o The decrease in vascular volume presents as
hypotension, tachycardia, + weak thready
pulse.
o Treatment: Water restriction, administer saline
solution IV slowly if FVD, furosemide if fluid
overload, TX underlying cause
o Nursing DX: FVD, FVE, Risk for disturbed
thought process, decreased cardiac output
o Fall precautions
Hypernatremia: Sodium/ Na+: >145 (greater o Causes: insufficient water intake, insufficient
than) sodium excretion due to hormone imbalance,
renal failure, corticosteroids, increased sodium
Associated with high mortality rate. It occurs in intake or increased water loss because of
about 1% of hospitalized patients + usually fever, hyperventilation, increased metabolism,
associated with water loss (watery diarrhea) or + dehydration owing to sweating, vomiting, or
sodium gain. diarrhea
o Risk: Hypervolemia associated with
hypernatremia in some patients may cause HF
+ or pulmonary edema
S/S: o Confusion
o Weight gain due to fluid retention
o Restlessness
o Irritability
o Agitation owing to increase neural activity
with normal or low fluid volume
Dehydration= FVD; Hypovolemia o Common causes of dehydration:
Vomiting
Fluid intake/retention does not meet body’s fluid Diarrhea
needs; results in fluid volume deficit
o Clinical manifestations:
o Lack of fluid intake or excess fluid loss Peripheral pulses cold and clammy
o Alteration in the fluid balance extremities
regulators: Weak and tready
Thirst Dry mucous membrane
Hormones Abnormal lab values
Lymphatic system
Kidneys
Interventions Push fluids without IV
Daily morning weights
Monitoring input and output every 24 hours
Monitor for falls
Braden scale (skin problems)
Fluid Overload: FVE- Hypervolemia (Third- Excess of body fluid=” everything is watered down”
Spacing) “Over hydration”
Can develop from administration of too much or Hypervolemia- excess fluids in vascular
a failure to excrete fluids and usually results in system
an elevated sodium level Third-spacing- excess fluids in interstitial
spaces, water intoxication
o Failure to excrete fluids Water intoxication-excess fluids in the
Renal failure cells
Edema as with heart failure o Peripheral vascular resistance increases too,
which can lead to pulmonary edema and heart
failure.
o Nursing interventions: assess lungs sounds at
least every two hours
Labs Respiratory + cardiovascular
BUN will be low (diluted) Crackles, pallor
Hematocrit will be low (diluted) Elevated blood pressure
Sodium will be low (diluted) Moist mucous membrane
Shallow, rapid respirations
Peripheral edema (pitting)
Weight gain
JVD
Interventions for Excess Fluids Volume /FVE Reduce sodium + fluid intake
Mobilize fluids
Turning, positioning
Prevent complications
Elevate head of bed (HOB) 30 degrees
Monitor lab values
Provide skin care
Modification for older adult patients
Teach
Low-sodium diet
Use of alternative seasonings
Avoid mixing, ACE inhibitors - K+ salt
substitutes
Fluid restrictions
Daily weights
, Electrolyte Imbalances
Sodium- 135-145 mmol/L Responsible for where salt goes water follows
Hyponatremia: o Sodium <135 (less than)
o Causes:
Most common electrolyte disorder; it is directly abnormal loss or excretion of sodium
related to changes in the fluid volume status as Water imbalance
sodium moves into cells + potassium moves into Hormonal imbalance (such as excess
ECF, which results in INTRACEULLAR EDEMA. ADH)
Hypothyroidism
Renal failure
Diuretics; excessive use is a common
cause of hyponatremia as well as GI
wound drainage.
Diarrhea
Vomiting
Wound drainage
Burns
Excess perspiration
o Risk:
Seizures + death if electrolytes not
corrected
o S/S:
Headache + apprehension
Confusion; Hypotension (especially
orthostatic) Hallucinations, seizures,
coma, + even death may occur.
o The decrease in vascular volume presents as
hypotension, tachycardia, + weak thready
pulse.
o Treatment: Water restriction, administer saline
solution IV slowly if FVD, furosemide if fluid
overload, TX underlying cause
o Nursing DX: FVD, FVE, Risk for disturbed
thought process, decreased cardiac output
o Fall precautions
Hypernatremia: Sodium/ Na+: >145 (greater o Causes: insufficient water intake, insufficient
than) sodium excretion due to hormone imbalance,
renal failure, corticosteroids, increased sodium
Associated with high mortality rate. It occurs in intake or increased water loss because of
about 1% of hospitalized patients + usually fever, hyperventilation, increased metabolism,
associated with water loss (watery diarrhea) or + dehydration owing to sweating, vomiting, or
sodium gain. diarrhea
o Risk: Hypervolemia associated with
hypernatremia in some patients may cause HF
+ or pulmonary edema
S/S: o Confusion
o Weight gain due to fluid retention
o Restlessness
o Irritability
o Agitation owing to increase neural activity
with normal or low fluid volume
