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Fluid and Electrolytes (24)

1. Identify normal and abnormal ranges of electrolytes
Na+ (130-150 mEq/L)

HYPOnatremia : <130 HYPERnatremia :

>150

D/T: D/T:

Prolonged low-sodium diet High salt intakeenteral or IV

Decreased sodium intake Renal disease
Fever Fever
Excess sweating Insufficient breast milk intake in neonate
Increased water intake without electrolytes (dehydration hypernatremia)
Tachypnea (infants) High insensible water loss:
Cystic fibrosis Increased temperature
Burns and wounds Increased humidity
Vomiting, diarrhea Hyperventilation
Nasogastric suction Diabetes insipidus
Fistulas Hyperglycemia
Adrenal insufficiency
Renal disease
Diabetic ketoacidosis (DKA)
Malnutrition

S/S: S/S:

Associated with water loss: Intense thirst

Same as with water lossdehydration, Dry, sticky mucous membranes
weakness, dizziness, nausea, abdominal cramps, Flushed skin
apprehension Temperature possibly increased Fever
Mildapathy, weakness, nausea, weak pulse Hoarseness
Moderatedecreased blood pressure, lethargy Oliguria
o Muscle Cramps Pulmonary Edema
o Confusion Nausea and vomiting
Possible progression to disorientation, convulsions,
Laboratory findings: muscle twitching, nuchal rigidity, lethargy at rest,
hyperirritability when aroused
Sodium concentration<130 ( may be normal if Laboratory findings:
volume loss) Serum sodium concentration 150 mEq/L
High plasma volume
Urine Specific Gravity depends Alkalosis

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NURSING CARE: NURSING CARE:

Determine and treat cause of sodium deficit Determine and treat cause of sodium excess

Administer IV fluids with appropriate saline Administer IV fluids as prescribed NO SODIUM IVs
concentration
Measure fluid intake and output Weigh Daily
Monitor fluid intake and output
Monitor neurologic status
Check BP frequently
Ensure adequate intake of breast milk and provide
Restrict Fluids lactation assistance with new mother-baby pair
before hospital discharge.
GIVE HYPERTONIC FLUIDS
GIVE HYPOTONIC FLUIDS

K+ (3.5-5.5 mEq/L)
HYPOkalemia: <3.5
HYPERkalemia: >5.5 ( See changes when >7)
D/T: D/T:

Starvation Renal disease

Clinical conditions associated with poor food Renal failure

intake
Adrenal insufficiency (Addison disease)
Malabsorption
Associated with metabolic acidosis
IV fluid without added potassium
Too-rapid administration of IV potassium
Gastrointestinal lossesdiarrhea, vomiting, chloride
fistulas, nasogastric suction
Transfusion with old donor blood
Diuresis Administration of diuretics
Severe dehydration
Administration of corticosteroids
Crushing injuries
Diuretic phase of nephrotic syndrome
Burns
Healing stage of burns
Hemolysis
Potassium-losing nephritis
Dehydration
Hyperglycemic diuresis (e.g., diabetes mellitus)
Potassium-sparing diuretics
Familial periodic paralysis
Increased intake of potassium (e.g., salt
IV administration of insulin in DKA substitutes)

Alkalosis

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S/S: S/S:

Muscle weakness, cramping, stiffness, paralysis, Muscle weakness, flaccid paralysis

hyporeflexia
Twitching
Hypotension
Hyperreflexia
ardiac arrhythmias, gallop rhythm
Bradycardia
Tachycardia or bradycardia Ileus
Ventricular fibrillation and cardiac arrest
Apathy, drowsiness
Oliguria
Irritability
Apnearespiratory arrest
Fatigue , Anorexia
Laboratory findings:
Laboratory findings:
High serum potassium concentration
Decreased serum potassium concentration 5.5 mEq/L
3.5 mEq/L
Variable urine volume
Abnormal ECGnotched or flattened T waves,
decreased ST segment, premature ventricular Flat P wave on ECG, peaked T waves( Tall
contractions, RAPID THREADY PULSE. & Tented), widened QRS complex,
increased PR interval

NURSING CARE: NURSING CARE:

Determine and treat cause of potassium deficit.
Monitor vital signs, including ECG.
Administer supplemental potassium (IV,
Bananas, Oranges, Spinach)
Determine and treat cause of potassium
excess
Monitor vital signs, including ECG
Administer exchange resin, if prescribed.

Assess for adequate renal output before Administer IV fluids

administration.
Administer IV insulin (10-20% glucose
For IV replacement, administer potassium w/regular insulin) to facilitate movement of
slowly. potassium into cells

Always monitor ECG for IV bolus potassium KAYEXALATE

replacement.
Evaluate acid-base status
For oral intake, offer high-potassium fluids and
foods. Renal Dialysis may be required

Evaluate acid-base status

EXTRA NOTES: EXTRA NOTES: Peripheral line for glucose 20%

Ca+ (8.5-10.5 mEq/L)

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HYPOcalcemia: <8.5 (non-emergent)

HYPERcalcemia: >10.5
D/T: D/T:

Inadequate dietary calcium Acidosis

Vitamin D deficiency Prolonged immobilization

Rapid transit through gastrointestinal tract Conditions associated with increased bone
catabolism
Advanced renal insufficiency
Hypoproteinemia
Administration of diuretics
Kidney disease
Hypoparathyroidism
Hypervitaminosis D Hyperparathyroidism
Alkalosis
Hyperthyroidism
Calcium trapped in diseased tissues
Excessive IV or oral administration
Increased serum protein (albumin)

Cows milktetany of the newborn

(inappropriate calcium/phosphorus ratio in
whole milk for newborn)

Exchange transfusion with citrated blood

Inadequate parenteral administration in

diseased status

S/S: S/S:

Neuromuscular irritability Constipation

Tingling of nose, ears, fingertips, toes Weakness, fatigue

Tetany Nausea, vomiting

Laryngospasm Anorexia

Generalized convulsions Dry mouth (thirst)

Diarrhea , Numbness Behavioral Changes

May be changes in clotting Muscle hypotonicity

Positive Chvostek and Trousseau signs Bradycardia or cardiac arrest

Hypotension Increased calcium concentration in urine,

Cardiac arrest
Laboratory findings:
Decreased serum calcium concentration (8.8-
10.8 mEq/L) or increased serum protein levels
causing formation of kidney stones
Laboratory findings:
Increased serum calcium levels or
decreased serum protein levels
Prolonged QRS complex or PR interval,

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Prolonged QT interval shortened QT interval

NURSING CARE: NURSING CARE:

Determine and treat cause of calcium deficit. Determine and treat cause of calcium
excess.
Administer oral calcium supplements as
prescribed; administer IV slowly and diluted. Monitor serum calcium levels.

Monitor IV site; calcium may cause vascular
irritation.
Monitor serum calcium, vitamin D, and
parathyroid levels.
Administer Calcitonin to reduce Calcium
Monitor ECG.
Renal Dialysis may be required

Monitor serum protein levels.

Avoid cows milk in infants younger than 12

months.

Increase Dietary Calcium

2. Factors that influence electrolyte concentration

Alterations in fluid volume affect the electrolyte component, and changes in

electrolyte concentration influence fluid movement.

Thirst

The impetus to ingest water is stimulated by increased solute

concentration (osmolality) of extracellular fluid and/or diminished intravascular
volume.

Antidiuretic hormone (ADH)

ADH is released from the posterior pituitary gland in response to

increased osmolality and decreased volume of intravascular fluid; it promotes water

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retention in the renal system by increasing the permeability of renal tubules to

water.

Aldosterone

Aldosterone is secreted by the adrenal cortex; it enhances sodium

reabsorption in renal tubules, thus promoting osmotic reabsorption of water.

Renin-angiotensin system

Diminished blood flow to the kidneys stimulates renin secretion, which

reacts with plasma globulin to generate angiotensin, a powerful vasoconstrictor.
Angiotensin also stimulates the release of aldosterone.

3. Apply appropriate interventions for the management of hypo- and hyper-

values of electrolytes

QUESTION #1 CHARTS

4. Recognize clinical manifestations of hypo- and hyper- values of major

electrolytes

QUESTION #1 CHARTS

5. Calculate daily maintenance fluid requirements, hourly fluid rate, and bolus
fluid rate

Fluid requirements depend on hydration status, size, environmental factors,

and underlying disease.

Bolus Fluid Formula

20 ml/kg

Body Surface Area (BSA) formula

Hourly Fluid Rate

BODY WEIGHT AMOUNT FLUID PER

HOUR

1-10 kg 4 ml/kg

11-20 kg 2 ml/kg

>20 kg (remainder) 1 ml/kg

Daily Maintenance Fluid Requirements (Not for IV )

BODY WEIGHT AMOUNT FLUID

PER DAY

1-10 kg 100 ml/kg

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11-20 kg 50 ml/kg

>20 kg (remainder) 20 ml/kg

6. Identify nursing considerations related fluid and electrolyte imbalances

Question #1 CHARTS

EXTRA BOOK/SLIDE NOTES

For SIADH give Hypertonic fluids

Hypertonic: More Salt
o D5 0.45% NS
o D5LR
o D5NS
Hypotonic: Less salt
o 0.5% NS
o 0.45%NS
Isotonic:
o LR
o D5W
o 0.9%NS
Maintenance water requirement is the volume of water needed
to replace obligatory fluid loss such as that from insensible water loss
(through the skin and respiratory tract), evaporative water loss, and losses
through urine and stool formation.

Increased Fluid requirements: Decreased Fluid

Requirements:

Fever (add 12% per rise of 1 C) HF

DI, DKA SIADH

Vomiting , Diarrhea Mechanical Ventilation

Postop Bowel Surgery Increased ICP

( Gastroschisis)

Shock, Burns After Surgery

High- Output Kidney Failure Oliguric Renal Failure

Tachypnea

Phototherapy (Infant )

Radiant Warmer ( preterm infant)

The infant loses a considerable amount of fluid in the first few

days after birth and still maintains a larger amount of ECF than the adult until
about 2 to 3 years of age. This contributes to greater and more rapid water
loss during this age period.

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The ECF diminishes rapidly from approximately 40% of body

weight at birth to less than 30% at 1 year of age.
Infant is less able to handle large quantities of solute-free water
than is the older child and is more likely to become dehydrated when given
concentrated formulas or overhydrated when given excessive free water or
dilute formula.
o Infants ingest and excrete a greater amount of fluid per
kilogram of body weight than do older children.
When water is lost and sodium concentration becomes
elevated, compensatory mechanisms in the kidney stop ADH secretion so
water is retained. The thirst mechanism (not fully functional in infants) is also
stimulated so water is replaced, thus increasing the total body water content
and returning sodium to a normal level
Low BP in infants and young children is usually a late sign of
shock.
Predictors of fluid loss :
o changing level of consciousness (irritability to lethargy)
o altered response to stimuli
o decreased skin elasticity and turgor
o prolonged capillary refill (>2 sec)
o increased heart rate EARLIEST SIGN
o sunken eyes and fontanels

ALERTS!!!!

o In a child with a history of fluid loss and potential

or actual dehydration, gear nursing assessment toward the
possibility of impending shock

INTRACELLULAR: EXTRACELLULAR:

o K+ maintains Osmotic pressure o Na+ maintains most abundant Osmotic pressure

o K+ Imbalances may be threatening o Remember: When either the ECF or ICF changes
in concentration, fluid shifts from area of LESSER
concentration to HIGHER concentration.
o Lower to Higher

Dehydration ( FV Deficit): Water

Intoxication (Excess):

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D/T: D/T:
o Failure to absorb or reabsorb water o Water intake in excess of output:
o Complete or sudden cessation of intake or Excessive oral intake( Over hydration)
prolonged diminished intake: Hypotonic fluid overload (0.45% NS)
Neglect of intake by self or caregiverconfused, Plain water enemas
psychotic, unconscious, or helpless o Failure to excrete water in presence of normal
Loss from gastrointestinal tractvomiting, intake
diarrhea, nasogastric suction, fistula Kidney disease (Renal Failure)
o Disturbed body fluid chemistry: inappropriate ADH CHF (MOST COMMON)
secretion Malnutrition
o Excessive renal excretion: glycosuria (diabetes)
o Loss through skin or lungs:
o Acute IV overload
Excessive perspiration or evaporationfebrile o Too rapid reduction of glucose in DKA
states, hyperventilation, increased ambient o Congenital Heart Defect
temperature, increased activity (basal metabolic o Hormone Imbalance
rate) o CNS Infex
Impaired skin integritytransudate from injuries o Administration of inappropriate prepared
Hemorrhage formula Infants
o Iatrogenic:
Overzealous use of diuretics
Improper perioperative fluid replacement
Use of radiant warmer or phototherapy
o DKA
o Extensive Burns
o Massive Edema

S/S: S/S:
o Irritability
o Thirst o Altered LOCSomnolence
o Dry Skin and mucous membranes o HA
o Changing Sensorium (irritability to lethargy) o Vomiting, Diarrhea
o Decreased response to stimuli o Generalized Seizures, Coma
o Decreased elasticity and turgor o EDEMA
o Prolonged capillary refill ( >4 severe) Generalized (orbital , peripheral)
o Increased HR Tachycardia Pulmonary (moist rales or crackles)
o Sunken eyes ( Sunken fontanelsinfants)
Intracutaneous (noted especially in loose
o Oliguria : Diminished UO
areolar tissue)
o Weight Loss
o Fatigue o Elevated BP, CVP
o Postural Hypotension o Dyspnea
o Mottled extremities o Hepatomegaly
o Tachypnea o Weight Gain

LABS: LABS:
o Low urine specific gravity
o Increased hematocrit , Hgb, BUN, Serum Osmolality o Decreased serum electrolytes
o High Urine specific gravity o Decreased hematocrit, Hgb
o Increased /normal Creatinine o Variable urine volume
o Variable serum electrolytes & urine volume

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TX/ NURSING CARE: TX/ NURSING CARE:

o Replace Fluids (ISOTONIC) LR, 0.9% NS o Diuretics
o 20ml/kg IV bolus over 5-20 min o Fluid Restriction
o Replace fluids 4-6 hrs (Mild 50ml/kg) o Weigh Daily
o Monitor BP o Monitor K+
o Blood only if hemorrhaging o Implement seizure precautions
o Weigh daily

EXTRA NOTES: EXTRA NOTES:

o In Hypertonic dehydration the skin has a smooth, o Infants unable to turn off fluid intake properly
velvety feel before disturbed elasticity. so this leads to overload. Decreased GFR
doesnt allow for repeated excursion of water.

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