fluids lecture notes part i

Fluids Lecture

PAGE 20

Fluids Lecture Notes Part I

Water

Most important nutrient of life; humans can only survive for a few days without it

Main need for the bodys life-supporting functions

90-93% of body fluids

Water

Solvent in which body salts, nutrients, and wastes are dissolved and transported

Protection of the blood volume (intravascular compartment) is the single most important aspect of fluid balance homeostasis, even at the expense of creating other electrolyte imbalances

Fluid Balance

Fluid is a state of balance when the following occurs :

Water and electrolytes are in the proper proportions

Fluids are distributed normally between compartments

Lost body water and electrolytes are replaced

Excess water and electrolytes are eliminated

Even small fluctuations in the amount of water in the body can have harmful or fatal consequences

Functions of Water in the Body

Water is vital to health and normal cellular function, serving as:

1. Transportation

2. Excretion

3. Regulation

4. Lubrication

5. Medium

6. Insulator

Review of Basics

Water: 60% body weight in adults (approximately 40 liters)

Intracellular fluid (ICF): 60% of body fluids (approximately 25 liters)

Extracellular (ECF): 40% of body fluids (approx. 15 liters)

Plasma (IVF): 25% ECF (3 5 liters)

Interstitial: 75% ECF (11 liters)

Transcellular (CSF, GI tract, etc.): 1-2 liters

Electrolytes control fluid shifts between compartments

Body Fluid Distribution

Transcellular (Third-Space) Fluid: Fluid in Transit & Special Spaces

Water Movement in Major Fluid Compartments

Electrolyte Composition of Body Fluids

3 Factors Affecting Amount of Body Water

AgeElderly have less water

GenderFemales have less water due to increased body fat

Body fatLess water, because fat cells contain very little water

Changes in Body Water Content with Age, Sex, Body Weight

The older a person gets, the less % of body fluid there is

Females have less water due to increased body fat

Obese people have lower than normal body water %Patients at Risk for Fluid Imbalances

Infants

Elderly

Obese

Females

Apathetic, confused, very ill (debilitated)

Unconscious, comatose

Patients with

Fever

Tracheostomy

Cerebral injury

Swallowing difficulties

Burn patients

Renal, cardiac patients

Require diligent monitoring by nursing staff!

Infants and Young Children

Greater need for water

F & E alterations occur more frequently, rapidly

ECF: over half of the total body water at birth

Large body surface

Increased metabolic rate (need more water)

Immature kidneys (not as efficient in conserving water)

The Elderly

High risk for imbalances due to age related changes

Less total body water

More chronic disease processes

Decreased thirst

Difficulty concentrating or diluting urine

Difficulty regulating Na+ and K+

Each Day

The body gains and loses water

Gains and losses must be balanced to maintain body fluid balance

Water Balance

Total body water

Enters body

Osmosis from digestive tract

Also produced by cellular metabolism

Exits body

Urinary, digestive, respiratory, & integumentary systems

Maintaining Fluid Balance

Intake should equal output and average around 2,600 ml for an adult

Average adult intake:

Fluids: 1,500 ml

Water from ingested foods: 800 ml

Water formed from cellular metabolism (metabolic water): 300 ml

Maintaining Fluid Balance

Average adult output:

Urine: 1,500 ml

Output at least 30 ml/hour

Feces: 100 ml

Insensible loss: 1,000 ml (600 ml losses from skin and 400 ml expired air from lungs)

Sources of Fluid Intake

Measurable:

Oral fluids

Rehydration fluids

Enteral feedings

Parenteral fluids

Enemas

Irrigation fluids

Not measurable:

Solid foods

Metabolic water (water produced through oxidation)

Oral Rehydration Therapy

Oral fluid and electrolyte replacement

Used to treat mild to moderate dehydration in a stable patient

Contains: water, electrolytes, glucose in therapeutic amounts

Examples: Pedialyte, Resol

Oral Rehydration Therapy

Fluids like soda, tea, fruit juices, and water are not appropriate for oral rehydration (dont contain proper electrolytes; too much sugar)

Sodium and glucose should be in a 1:1 ratio in terms of osmolarity

Rehydration solution (homemade recipe): 8 tsp of table sugar, 1/2 tsp of salt, 1/2 tsp of sodium bicarbonate (baking soda), and 1/3 tsp of potassium chloride to 1 L of water

Enteral Feedings: Use GI System

Enteral: alimentary, GI tract (much preferred)

Commercial formulas: water, protein, vitamins, electrolytes, glucose

NG tube, PEG tube

Example: Jevity, Pulmocare

Need supplemental water

Enteral Feedings

Any or all gastric residuals must be returned to stomach

Signs of feeding intolerance:

Vomiting, diarrhea

Discomfort

Distention

Residuals > one half (1/2) of the feeding volume

IV Therapy: Parenteral

Parenteral: any fluid or medication administered by means other than alimentary tract (i.e., intravenous, intramuscular)

Intravenous therapy: administration of fluids, electrolytes, nutrients, or medications by venous route

Severe, life-threatening dehydration

Clients receiving IV therapy require constant monitoring for complications

Types of IV Solutions

Hypotonic (< 270 mmol/L)

Provides more water than electrolytes, diluting ECF

Movement of water from ECF to cells

0.45% saline; D5W (after dextrose metabolized)

Provides free water for cellular hydration and renal excretion

Not for clients with ( ICP or third-space fluid shifts


Isotonic (270-300 mmol/L)

Expands only ECF

No net loss or gain from ICF

Fluid replacement for patients with ECF volume deficit

NS (0.9% saline), LR

Expands vascular volume

Assess for hypervolemia (bounding pulse, SOB)


Hypertonic (>300 mmol/L)

Raises osmolarity of ECF and expands it

Draws water out of cells into ECF

D5NS, D5NS, D5LR, 3% NaCl, TPN, electrolyte additives

Irritating to veins

Not for clients with kidney, heart disease, dehydrated

Fluid overload, hypervolemia

Plasma Expanders

Stay in vascular space, increase intravascular osmotic pressure

Advantages: remain in intravascular space for hours

Disadvantages: risk of sensitivity reactions

Colloids, dextran, & hetastarch; blood products

Plasma Expanders

Colloids: protein solutions such as albumin

Dextran: complex synthetic sugar

Metabolized slowly; remains in vascular space longer than dextrose

Blood products (whole blood or PRBC)

Restores hemoglobin in blood loss

Sources of Fluid Output

Measurable (sensible loss):

Urine

Emesis

Feces

Drainage from body cavities (NG suction, chest tube drainage)

Sources of Fluid Output

Not measurable (insensible loss):

Perspiration

Skin vaporization

Lung vaporization

15-20 ml/ kg/ day

Nasogastric Suction

Increased loss of electrolytes

Hypochloremic metabolic alkalosis

Irrigate tube with isotonic saline (0.9% saline)

Regulators of Fluid Balance

Thirst mechanism

Primary regulator of fluid intake

Kidneys

Primary regulator of fluid output, F & E

GI tract

Intake & output

Insensible loss

Skin, lungs

Hormone regulators

ADH, aldosterone, ANP

Thirst

Earliest symptom of water deficit

Increased osmolarity, fluid volume deficit

Occurs when water loss is 2% of body weight

Elderly: decreased thirst sensation

Kidneys

Major regulatory organ for output, fluid & electrolyte balance

Urine: waste materials from blood

Receive 180 liters of blood/ day to filter

Produce 1200 -1500 ml of urine

GI Tract

Absorb water from fluid, food

Lose water: feces

Skin

Regulated by sympathetic nervous system

Activates sweat glands

Insensible: 500 - 600 ml/ day

Lungs

Insensible

Increases with rate and depth of respirations, oxygen delivery

400 ml/ day

Hormonal Regulators: Compensatory Mechanisms

Antidiuretic hormone (ADH) from posterior pituitary

Aldosterone from adrenal cortex (renin-angiotensin-aldosterone system)

Atrial natriuretic peptide (ANP)

Antidiuretic Hormone (ADH)

Stored in posterior pituitary gland

Released in response to increased blood osmolarity (dehydration, hemoconcentration, hypovolemia)

Makes tubules and collecting ducts more permeable to water

ADH( Increased HYPOTONIC IVF Volume

ADH = WATER

Pure water returns into systemic circulation

Increased HYPOTONIC intravascular fluid volume

Dilutes blood

Decreased serum osmolarity

Scant urinary output (concentrated urine)

Aldosterone

Aldosterone released by adrenal cortex in response to

( Plasma sodium

( Plasma potassium

Causes the kidney to retain sodium & water and excrete potassium

Renin-Angiotensin-Aldosterone System

Blood pressure falls

Renin-angiotensin-aldosterone mechanism activated

Renin released from juxtaglomerular complex in kidneys

Renin( Angiotensin( Aldosterone

Renin: activates angiotensin

Causes muscular walls of the small arteries (arterioles) to constrict, increasing blood pressure

Triggers release of aldosterone from adrenal gland

Aldosterone( Increased ISOTONIC IVF Volume

Aldosterone = SODIUM + WATER

Aldosterone acts on distal tubules ( ( Reabsorption of sodium & water

Water follows sodium

( ISOTONIC intravascular fluid volume

Serum osmolarity unchanged

Blood pressure rises

Increased excretion of potassium

Atrial Natriuretic Peptide (ANP)

Aldosterone antagonist

Counterbalance to renin-angiotensin-aldosterone system

Released when atria are stretched by increased blood volume

ANP ( Decreased ISOTONIC IVF Volume

Promotes excretion of both sodium and water

Reduced: blood volume, blood pressure

Serum osmolarity unchanged

Increased: urinary output, salty urine (large amount of urine with high osmolarity)

Urine

Urine output at least 30 ml/hr

Kidneys: concentrate, dilute urine

Maintain F & E balance

Aldosterone, ADH, ANP

Specific gravity: 1.010-1.025

> 1.025: concentrated, high osmolarity

Dehydrated

Conserving fluids

< 1.010: dilute, low osmolarity

Large fluid intake

Large urine output

Obligatory Urine Output

Minimum amount of urine needed daily to dissolve and excrete toxic waste products (400 - 600 ml/ 24)

S.G. ( 1.032: maximally concentrated, 1200 mmol/L

If 24 output < 400-600 ml:

Wastes are retained

Lethal electrolyte build-up (especially ( K+)

Toxic nitrogen build-up

Metabolic acidosis

Urine Terms

Anuria: urine output less than 100 ml/ 24

Oliguria: urine output 100 - 400 ml/ 24

Polyuria: urine production greater than 2,000 ml/ 24

Calculate Fluid Replacement

Method to calculate specific 24 hour fluid needs (do this for your care plans)

30 ml/ kg

Example: 150-pound woman

150 ( 2.2 = 68.18

68.18 X 30 = 2,045.4

24-hour fluid needs (150-lb woman): 2,045.4 mL

Exception: Cardiac or Renal patients

Calculation of Fluid Loss or Gain

1 L of water = 2.2 lb (1 kg)

500 ml of fluid gain = 1 lb weight gain

500 ml of fluid loss = 1 lb weight loss

Sudden weight gain or loss = gain / loss of body fluid

Weight gain / loss > 0.5 lb daily (250 ml)

2.2 lb (1 kg) gain / loss = 1 L

4.4 lb (2 kg) gain / loss = 2 L

Hydration

Normal state of fluid balance

Normally hydrated adult:

Alert

Moist eyes, mucous membranes

Urine output = fluid intake

Urine specific gravity 1.010-1.025

Skin turgor elastic & mobile

Assessment of Fluid Balance

Health History.

Diagnostic and Laboratory Data.

Physical Examination

Most important:

Daily Weight

Intake and Output

Vital signs Others:

Thirst, skin, oral cavity & mucous membranes, eyes, cardiovascular & respiratory systems, neurological status

Health History

Nutritional history

Output (urine, bowel, excessive perspiration, drainage)

Medications

Body weight changes

Thirst or excessive drinking

Exposure to hot environments

Medical disorders

Diagnostic and Laboratory Data

Hemoglobin and Hematocrit (H & H)

Blood Urea Nitrogen (BUN)

Serum Sodium

Serum Glucose

Osmolarity

Serum Osmolarity: 270 - 300 mmol

Urine Osmolarity: 500 - 800 mmol

Urine specific gravity: 1.010 - 1.025

Daily Weights

Best assessment of hydration status if accurate Each kilogram of weight lost or gained suggests 1 liter of fluid lost or gained

Same time each day, preferably before breakfast and after first void

Same calibrated scale

Same conditions (clothing, bedding, emptied Foley bag, etc.)

DocumentIntake and Output

Intake

Oral fluids

Parenteral fluids

Tube feedings

Catheter irrigants

Output

Urine output

Liquid feces

Vomitus

NG drainage

Wound drainage

Draining fistulas

Vital Signs

Signs and symptoms of ECF volume excess and deficit are reflected in changes in:

BP

Heart rate

Respiratory rate

Temperature

Orthostatic (Postural) Hypotension

Postural changes in blood pressure or heart rate

Measurement of BP and HR first in supine, then in sitting, then standing position

Dehydration:

SBP ( by 15

DBP ( by 10

HR ( by 20

Pulse Quality

A normal pulse can be felt with moderate pressure of the fingers and can be obliterated with greater pressure

Easily obliterated

Fluid volume deficit

Rapid, weak, thready


Bounding

Fluid volume excess

Lung Status

Pulmonary edema

CracklesAir passing through fluid in alveoli

Shortness of breath, crackles, rales, or rhonchimay signal fluid volume excess due to fluid buildup in the lungs

Pink, frothy secretions

Skin Turgor

A decrease in skin turgor is indicated when the skin (on the back of the hand, sternum, or forehead) is pulled up for a few seconds and does not return to its original state


Integument

Skin should be pink, warm, and dry

Flushed, dry skin

Hypernatremia, fluid volume deficit

Cold, clammy skin

Capillary refill > 3 seconds


Mucous Membranes

MM, conjunctiva should be moist

Eyes

Absence of tearing

Eyeball soft and sunken


Tongue

Rough, dry, red

Dry, fissured tongue

Absence of salivation


Lips: cracked

Hand Veins

Hand vein filling is a useful indicator of hydration status

Normally, hand veins fill and become engorged when the hands are lower than the level of the heart

Collapsed hand veins in a dependent position indicate deficient fluid status

Edema

Excessive ECF accumulates in tissue (interstitial) spaces

Nonfunctioning fluid

Caused by

Increased hydrostatic pressure

Decreased plasma protein (decreased colloid osmotic pressure)

Increased capillary permeability

Lymphatic obstruction

Edema

Dependent edema

Peripheral edema Periorbital edema: significant fluid retention

Cool to touch, taut, shiny

Good skin care

Elevate extremities

Edema

Pitting vs nonpitting

Generalized vs localized

Anasarca: severe generalized edema, over entire body

Pitting Edema: Assessment Findings

1+ edema minimal at pedal sites, 2 mm indentation

2+ marked edema of lower ext., < 5 mm

3+ edema evident in face, hands, abdomen, sacrum, 5-10 mm

4+ generalized edema, > 10 mm

System for Grading Edema

Anasarca

Third-Spacing

Abnormal fluid shifts into transcellular space (pericardial, pleural, peritoneal spaces; joint cavities, bowel; abdomen)

Fluid trapped and stays there

Physiologically useless

Causes:

Tissue damage

( Hydrostatic pressure

( Colloid osmotic pressure (low albumin)

Blocked lymph drainage

Ascites

Abnormal fluid shifts (third-spacing) of intraperitoneal fluid

Fluid trapped, cannot get back into vascular system

Measure abdominal girth every shift with a centimeter tape and record (mark on sides)

Fluid Retention

What is the most reliable way to determine if pt is retaining fluid?

Daily weights

If a pt gains 1 kg or 2.2 lbs, how much fluid has he retained?

1 liter

Can a pt have fluid retention and yet be hypovolemic? Explain

Yes, fluid not in intravascular space

Third-spacing

Neck Veins

Neck veins are normally distended when a client is in the supine position

These veins flatten when the client moves to a sitting position

Should be < 4 cm

Jugular vein distention in a sitting position

Fluid volume excess

Assessment of Jugular Venous Pressure

HOB 45

Vertical distance from sternal angle to highest level of pulsation of internal jugular vein

Normal: 0 4 cm

CVP = 4 + this height

External vs Internal Jugular Vein

External Jugular Vein Distention

Central Venous Pressure

Pressure in the right atrium: central venous pressure (CVP)

Estimates blood volume

Normal: 4-8

Decreased CVPhypovolemia

Increased CVPhypervolemia

Central Nervous System

Assessment of clients level of consciousness and mental status

Subtle changes in mental status or level of consciousness

Neuromuscular irritability (DTRs)

Confusion, weakness, coma

Severe dehydration

Nursing Diagnoses Relevant to Fluid Imbalances

Fluid Volume, excess

Fluid Volume, deficient [Isotonic]

Fluid Volume, deficient [hyper/hypotonic]

Fluid Volume, risk for deficient

Fluid Volume, risk for imbalanced

Gas Exchange, impaired

Cardiac Output, decreased

Deficient Knowledge

Breathing Pattern, ineffective

Anxiety

Thought Processes, disturbed

Injury, risk for

Oral Mucous Membrane, impaired

Client Goals

The client will reestablish normal ECF volume, water, and/or electrolyte balance

The client will demonstrate knowledge regarding how to promote future ECF volume, water, and electrolyte balance

The client will remain free of complications from fluid or electrolyte imbalance

Fluid Balance & Implementation

Nursing interventions:

Monitor daily weights

Vital signs

Strict I & O

Provide oral hygiene

Initiate oral fluid therapy

Maintain tube feedings

Maintain IV access

Monitor intravenous therapy

Client teaching

Collaborative interventions:

Treat cause of illness

Assess and reassess patient response to treatment

Client Teaching

Especially important: older adults

Reinforce good diet and fluid intake

Preventative home maintenance: Teach clients how to detect signs of fluid and electrolyte imbalance, such as rapid weight gain or loss, swelling, changes in normal urine output, muscle weakness, or abnormal skin sensation, and give them guidelines for when to notify a physician

Client Teaching: Medications

Diuretics and other medications can increase the risk of fluid and electrolyte imbalance

Teaching is important to ensure client compliance and to help prevent any problems that can occur with treatment

Fluid Imbalances

Dehydration (fluid volume deficit)

Overhydration (fluid volume excess)

Fluid Imbalances: Correlate to Serum Sodium Imbalances

Dehydration


Fluid intake is not sufficient to meet bodys fluid needs

Output is increased over intake

Elderly, infants, children more at risk

Dehydration

In dehydration, fluid loss occurs first in the extracellular fluid

Losses occur from both intravascular and interstitial spaces

Actual vs. Relative

Dehydration: Signs & Symptoms

Decreased skin turgor

Dry mucous membranes

Urine output: < 30 ml/hr in adult

Postural hypotension

Weak, rapid, thready pulse

Increased rate and depth respirations

Low-grade fever

Thirst

Slow filling peripheral veins

Dehydration: Signs & Symptoms

CVP less than 4 cm H20 in vena cava

BUN elevated out of proportion to serum creatinine

Specific gravity (SG) high (urine)

Flat neck veins in supine position

Marked oliguria, late

Mental status changes

Cold extremities, late

Degrees of Dehydration

Mild dehydration

2%, ( 1-2 liters

Symptoms: thirst

Moderate

5%, ( 3-5 liters

Symptoms: marked thirst; dry MM; dry skin; poor skin turgor; ( temp; tachycardia; tachypnea; SBP (10-15; oliguria

Degrees of Dehydration

Severe

8%, ( 5-10 liters

Symptoms: flushed skin; SBP 60 or (; behavioral changes

Fatal

( 22-30 liters

Symptoms: anuria; coma; death

Three Types of Dehydration

Isotonic dehydration

With equal sodium and fluid loss

ECF isotonic

Contraction of the extracellular fluid space only


Hypotonic dehydration

Greater sodium loss than water

ECF hypotonic

Contraction of the extracellular fluid and expansion of the intracellular fluid


Hypertonic dehydration

Water lost exceeds sodium loss

ECF hypertonic

Expansion of the extracellular fluid and contraction of the intracellular fluid

Isotonic Dehydration

Most common form of dehydration

Deficit of ECF only

Also called hypovolemia(decreased circulating blood volume)

Water and electrolytes lost in even amounts: serum electrolytes normal

Isotonic Dehydration Contd

ISO = SAME: there is no gradient, no fluid shifts, no movement of fluid between compartments

Involves loss of isotonic fluids from the ECF only (blood and interstitium)

Renin-angiotensin-aldosterone cycle activated

S/S of shock occur if severeInadequate tissue perfusion (hypoxia)

Isotonic Dehydration

Common Causes:

Hemorrhage

Decreased fluid intake

Loss of isotonic fluids (GI, renal, & skin)

Excessive vomiting

Gastrointestinal suction

Diarrhea

Diuretic therapy

Excessive urine loss

Severe wound drainage

Excessive diaphoresis

Isotonic Dehydration: Assessment

Weight loss

Hypotension and Orthostatic Hypotension

Rapid, weak pulse

Oliguria: dark, concentrated, scanty urine

Poor skin turgor

Dry skin, MM

( Urine SG

Changes in LOC (irritable to lethargic)

( H & H (except in hemorrhage), serum protein, and BUN

Severe: can lead to SHOCK

Isotonic Dehydration: Interventions

Monitor daily weight, I&O, skin turgor, LOC and VS

Check skin turgor on forehead or sternum on elderly

Monitor lab values - urine SG, BUN, CBC and Lytes

Replace fluid loss using ISOTONIC fluids

Treat the underlying cause (Imodium, Zofran)

Meticulous oral care

Hypovolemic Shock

Shock: failure of the heart and blood vessels (circulatory system) to maintain perfusion (enough oxygen-rich blood) to the vital organs of the body (hypoxia)

Hypovolemic shock: decreased intravascular fluid volume

Usually caused by serious bleeding (hemorrhage)

Hypovolemic Shock

Healthy adult can compensate well up to 15% blood loss (500-750 ml)

Loss of compensation occurs at 30-40% blood loss (1500-2000 ml): at risk for irreversible organ damage, exsanguination, death

Dehydration due to diarrhea, vomiting, or heavy perspiration can also lead to the development of hypovolemic shock

Assessment of Shock

Hypotension

Rapid, weak pulse

Cold, moist, clammy skin

Rapid respirations

Decreased urinary output

Thirst

Changes in LOC

Early: apprehension and restlessness

Late: lethargy to coma

Interventions for Shock

Goal: increase ECF volume and pressure, in order to increase tissue perfusion

Monitor VS frequently

Maintain airway, O2

HOB flat, legs elevated 45 degrees

Keep warm

16 or 18-gauge IV, Type & Cross, CBC

Start NS, be ready to give blood or plasma expanders

Continuous pulse oximetry, cardiac monitoring

Hypertonic Dehydration

Second most common type of dehydration

Water-loss hypernatremia

Deficit of ICF and expansion of ECF

Occurs when water loss from ECF is greater than electrolyte (sodium) loss

Hyperosmolarity is present (Na+ > 145)

Fluid pulled from the cells into the blood stream, leading to cellular shrinkage


Free water deficit or sodium excess

Hypotonic water loss:

Excessive perspiration

Hyperventilation

Ketoacidosis

Fever

Watery diarrhea

Renal failure

Diabetes insipidus


Hypertonic sodium gain:

Tube feedings

Hypertonic fluid replacement


Debilitation (nursing home client):

Dysphagia

Impaired thirst

Unconsciousness

Impaired motor function

Diabetes Insipidus (DI)

A disorder of water metabolism

Deficiency of ADH

Caused by damage/destruction of the pituitary gland/hypothalamus (severe head injury)

Diabetes Insipidus (DI)

Kidney unable to concentrate urine

Massive diuresis (4-30 L/ day)

Constant extreme thirst

Hypernatremia (Na+ > 145)

Low urinary osmolalityHypertonic Dehydration: Assessment

Thirst

Fair skin Turgor

Warm, doughy skin

Parched mucous membranes

Increased serum sodium (>150 mEq/L)

Increased serum Osmolarity

Increased urine specific gravity (>1.030)

Decreased urine output

Signs of shock are usually not present

Changes in LOC (lethargy, hyperirritability)

Hypertonic Dehydration: Compensatory Mechanisms

Activation of thirst reflex

( ADH secretion

Hypertonic Dehydration: Interventions

Correct the free water deficit / sodium excess

Prevent: dilute tube feedings with adequate amounts of water

Monitor I&O, daily weight, skin turgor, LOC, serum sodium and serum Osmolarity

Administer Hypotonic fluids orally or SLOWLY by IV

Hypertonic Dehydration: Interventions

Be aware that rapid administration of hypotonic IV fluids can cause swelling of the brain cells, and increased intracranial pressure

Treat underlying cause (Tylenol, Imodium, Lomotil)


Hypertonic dehydration: Prevention

Prevent insensible fluid loss

Hyperventilation, pure water loss with high fevers, and watery diarrhea

Control disease processes

Diabetic ketoacidosis and diabetes insipidus

Prevent medical treatment causes

Prolonged NPO, excessive hypertonic fluids, sodium bicarbonate, or tube feedings with inadequate water

Monitor older, debilitated clients

Hypotonic Dehydration

Relatively uncommon

Loss of more solute (usually sodium) than water

Sodium-loss hyponatremia

Deficit of ECF and expansion of ICF

Na+ and K+ levels decreased

Hypotonic Dehydration

Osmolarity is decreased (below 270)

Fluids shift from the blood stream into the cells, leading to decreased vascular volume/ shock

Increased cellular swellingcauses increased intracranial pressure and neurological changes - H/A and confusion

Hypotonic Dehydration: Common Causes

Chronic illness

Chronic renal failure

Malnutrition

Hypotonic fluid replacement

Seen in heat exhaustion / heat stroke

Hypotonic Dehydration: Prevention

Avoid NPO with ice chips over long periods

Avoid overadministration of hypotonic fluids

Select the correct IV fluid and rate to meet patients rehydration needs

Replace fluid loss during exercise with isotonic fluids

Hypotonic Dehydration: Prevention

Watch for low serum osmolarity and serum sodium

Persons on hypotonic IV fluids

Persons with chronic renal failure

Persons with chronic malnutrition

Hypotonic Dehydration: Assessment

Hypotension

Tachycardia

Very poor skin turgor

Cold, clammy skin

Changes in LOC (lethargic to comatose, convulsions)

Na+ < 120 mEq/L

(K+

Hypotonic Dehydration: Interventions

Treat the underlying cause

Rehydrate orally with hypertonic fluids

IV administration of NS to restore sodium balance

Potassium replacement

In rare instances hypertonic sodium (3% NS) may be used

Monitor for cardiac dysrhythmias


Administration of IV Fluids: Guidelines

Give isotonic fluids (NS, LR) for isotonic dehydration

Give hypotonic fluids - (0.45% saline, D5W) SLOWLY to treat hypertonic dehydration

Give NS or hypertonic fluids (D5/0.9% saline, D5/LR) to treat hypotonic dehydration

Monitor: symptoms F & E imbalance

Keep track of I & O

Outcomes

The client will:

Ingest at least 1500 ml of appropriate fluids

Maintain a fluid output approximately equal to fluid intake

fluids lecture notes part i

Documents

normal body water

body water content

body water ageelderly

body fluids water solvent

water gains

compartments lost body

conserving water

water genderfemales