Fluid and Electrolyte Balance: Nursing Considerations
Terms in this set (37)
Regulation of Fluid balance
-Done in he kidneys
- ADH(Anti Diuretic Hormone)
- Natriuretic peptides
- Thirst mechanism
- Major organs work TOGETHER!
- Amt. gained should = amt lost
Extracellular Fluid (ECF)
Outside the cells
- interstitial: fluid surrounding cells
- vascular: fluid in blood vessels
Intracellular fluid (ICF)
Within the cells
Potential spaces (Third spacing)
Ex: pleural spaces, peritoneal spaces, and mediastinal spaces
- consequences of third spacing = takes fluid away from useable areas (ECF & ICF)
Nurses role in F&E balance
- know major s/sx, etiology & contributing factors
- carry out MD orders = meds, IV therapy, ensure compliance w/ diet orders(NAS, FL rest)
- independent nursing measures = I&O, daily wgt, assist w/ fluid intake
Subjective data of imbalance
- loss of appetite
- productive cough
- tires easily
- muscle weakness
- tingling/weak extremities
- constipation/ abd cramping
Critical questions to ask!!!!!
Does pt have... disease process/injury state that affects f/e
-meds/IV fluids/ other Tx that disrupts f/e?
- abnormal loss of body fluids? What source?
- dietary restrictions?
- adequate intake of fluids? (PO or IV?)
Objective data of imbalance
- fluid gains: PO, TF, IV
- fluid losses: urine, stool, emesis, wound drains, respiratory secretions(sx or coughing sputum), perspiration (w/ fever, etc)
How would you record bladder irrigation?
Subtract from total output
Fluid tapped from PLEURAL space
Fluid tapped from PERITONEAL space
How would you record fluid taken for various tests
Add it to total output
O should = 2/3 (at least) of I
----Minimal UO per 8h shift = 30 mL/hr or 240mL total
How does BP relate to fluid volume?
Volume up = BP up
Volume down = BP down
SBP <90 or >140
DBP <50 or >90
How does HR relate to FV?
Volume up = HR bounding pulse, low (b/c of added workload)
Volume down = HR up, weak pulses
<60 or >100
What is positive orthostasis?
Significant DECREASE in BP &/or significant INCREASE in HR w/ position changes
-SBP decrease of 15-20 mm Hg
- R increase 10-20 bpm
How does FV affect respiratory tract & RR?
FV high = RR changes (first up, then down), changes in resp character(labored, noisy, crackles, sounds wet, accessory muscles, wheezing, SOB)
FV low = RR increases
<12 or >24
Hw does FV affect temperature & vice versa?
High temp = low FV (from diaphoresis)
Low FV = high temp (loose "coolant" = increases core temperature)
<97.0 or >100.5
BEST indicator of acute FV changes
FV up = wgt up
FV down = wgt down
change of 1 kg (2.2lbs) in 24 h
------1 kg = 1L of fluid
-Skin dry, cracked or tight/shiny/edematous
-Head/neck : facial swelling? JVD? (PT has to be sitting upright for JVD to be positive
- Oral: dry mucous membranes
- Thorax: HR/rhythm, congested LS
- Abd: distended, hypo/hyperactive BS
- LE: edema
- Serum electrolytes : amt in the intravascular space
- Serum CBC: RBC, WBC, Hgb(measures part of RBC that carries O2), Hct(% or RBC's in whole blood=>main focus!), platelets
Using Hgb & Hct as a guide for hydration status
What hemodynamic values are associated w/ increased FV?
High FV =>hemodilution=>low Hct=>low serum osmolality(<270)=>low SG(<1.003)
What hemodynamic values are associated with decreased FV?
Low FV=>hemoconcentration=>high Hct=>high serum osmolality(>300)=>high SG(>1.030)
What is serum osmolarity? What is the normal range?
Normal range= 270-300 mOsm/L
Evaluates particle concentration (# of solutes) in the blood
- used to eval body's H2O balance and ability to produce & concentrate urine
- investigate hyponatremia, detects toxins, monitor drug Tx
How is serum osmolarity affected by FV changes?
>300mOsm/L=> low FV, high solutes/electrolytes
<270 mOsm/L=> high FV, low solutes
What is Specific Gravity? (SG)
The weight of a substance compared to the weight of an equal amount of another substance (one that is taken as a standard)
- determines the degree of solutes concentration in tone urine (the higher the SG, the more concentrated the urine, lower SG=more dilute)
Similar test is urine osmolality
How is SG affected by FV changes?
High FV=low SG (<1.003)/ urine more dilute
Low FV=High SG (>1.030)/ urine more concentrated
Renal Fn tests
- BUN(Nitrogenous wastes)
- Creatinine (Cr), waste eliminated by kidneys
-------IF FV increases, renal fn decreases = increased BUN/Cr-------------
What about hemoconcentration? => high BUN/Cr
What are some possible nursing Dx for F&E imbalance?
- Excess FV
- Risk for decreased CO => shock?!
- Risk for injury/falls => orthostasis
- Imbalanced nutrition: less than BR
- Risk for impaired Skin Integrity
- Risk for impaired Oral Mucous membranes
General Management for F&E imbalaces
- replace/maintain fluids via "force fluids" orally
- TF/water blouses
- IVFM (hypo/hyper/ & isotonic solutions depending on implications)
- Concentration of solutes<normal body fluids
- Crease a concentration gradient
- Body uses OSMOSIS to restore equilibrium.
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