FLUID VOLUME DEFICIT (FVD) (HYPOVOLEMIA)

- Loss of extracellular fluid exceeds intake ratio of OLIGURIA - excretion of less than 400ml urine/day in
water adult, may or may not present in FVD.
- Electrolytes lost in same proportion as they
exist in normal body fluids thus the ratio of Medical management:
serum electrolytes to water remains the same. provide fluids to meet body needs
- FVD should not be confused with Dehydration - Oral fluids
which refers loss of water alone with increased - IV solutions
serum sodium levels. - For example pt with fever - (LR or 0.9 NaCl) -
- FVD may occur in combination with other first-line choice to treat hypotensive pt with
imbalances FVD bcoz they expand plasma volume.
- dehydration - If normotensive, a hypotonic solution
Causes: (0.45%NaCl) is used to provide both electrolyte
- fluid loss from vomiting and water for renal excretion of metabolic
- diarrhea waste
- GI suctioning
- Sweating Nursing Management:
- decreased intake - I&O, daily weight, vital signs
- inability to gain access to fluid - Monitor for symptoms: skin and tongue turgor,
mucosa, urine output, mental status
Risk factors: - Measures to minimize fluid loss
- diabetes insipidus (a decreased ability to - Oral care
concentrate urine due to either antidiuretic - Administration of oral fluids
hormone (ADH) or nephron resistance to ADH), - Administration of parenteral fluids
- adrenal insufficiency
- osmotic diuresis FLUID VOLUME EXCESS (HYPERVOLEMIA)
- hemorrhage - Refers to an expansion of the ECF caused by
- coma abnormal retention of water and sodium in
- third-space shifts approximately the same proportions in which
they normally exist in the ECF.
*Third-spacing occurs when too much fluid moves from - Due to fluid overload or diminished
the intravascular space (blood vessels) into the homeostatic mechanisms
Interstitial or "third” space - the non functional area
between cells. This can cause potentially serious Risk factors:
problems such as edema, reduced cardiac output, and - heart failure
hypotension.* - renal failure
- cirrhosis of liver.
Manifestations: rapid weight loss, decreased skin
turgor, oliguria, concentrated urine, postural Contributing factors:
hypotension, rapid weak pulse, increased temperature, excessive dietary sodium or sodium-containing IV
cool clammy skin due to vasoconstriction, lassitude, solutions in a pt with impaired regulatory mechanisms
thirst, nausea, muscle weakness, cramps.
Manifestations: edema, distended neck veins,
Laboratory data: abnormal lung sounds (crackles due to interstitial
A. Elevated BUN in relation to serum creatinine pulmonary fluid), tachycardia, increased blood pressure,
concentration (Normal BUN to serum creatinine pulse pressure and CVP, increased weight, increased
conc ratio is 10:1) urine output, shortness of breath and wheezing.
B. Increased hematocrit level due to decreased
plasma volume which concentrates the volume Medical management:
of RBC's. - directed at cause (if related to excessive
C. Serum electrolyte changes may occur administration of sodium-containing fluids,
(decrease/increase Na K)
 - discontinuing the infusion may be all that is duration, and has less serious neurological
needed), sequelac/result.
- restriction of fluids and sodium,
- administration of diuretics Causes: adrenal insufficiency, water intoxication, The
syndrome of inappropriate secretion of antidiuretic
Nursing Management hormone (SIADH) or losses by vomiting, diarrhea,
 I&O and daily weights, assess lung sounds, sweating, diuretics,
monitor degree of edema (feet and ankles in
ambulatory patients and the sacral region in Manifestations: depend on the cause, magnitude and
patients confined to bed) other symptoms speed with which deficits occurs, poor skin turgor, dry
 Monitor responses to medications- diuretics mucosa, headache.
 Promote adherence to fluid restrictions, patient
teaching related to sodium and fluid restrictions (B) Features of hyponatremia associated with sodium
 Monitor, avoid sources of excessive sodium, loss and water gain include anorexia, muscle cramps,
including medications and a feeling of exhaustion.
 Promote rest The severity of symptoms increases with the degree of
 Semi-Fowler's position for orthopnea hyponatremia and the speed with which it develops.
 Skin care, positioning/turning When the serum sodium level decreases to less than
115 mEq/L (115 mmol/L), signs of increasing intracranial
PICTURE (table) pressure, such as lethargy, confusion, muscle twitching,
focal weakness, hemiparesis, papilledema, seizures, and
ELECTROLYTE IMBALANCES death, may occur.
 Sodium: hyponatremia, hypernatremia
 Potassium: hypokalemia, hyperkalemia Medical management: water restriction, sodium
 Calcium: hypocalcemia, hypercalcemia replacement
 Magnesium: hypomagnesemia,
hypermagnesemia Nursing management: assessment and prevention,
 Phosphorus: hypophosphatemia, dietary sodium and fluid intake, identify and monitor at-
hyperphosphatemia risk patients, effects of medications (diuretics, lithium)
 Chloride: hypochloremia, hyperchloremia
Hypernatremia
SODIUM IMBALANCES Serum sodium greater than 145 mEq/L
Sodium is the most abundant electrolyte in the ECF; its
concentration ranges from 135 to 145 mEq/L (135 to Causes: excess water loss, fluid deprivation in patients
145 mmol/L), and it is the primary determinant of ECF who cannot respond to thirst, excess sodium
volume and osmolality. administration, diabetes insipidus, heat stroke,
Also functions in establishing the electrochemical state hypertonic IV solutions.
necessary for muscle contraction and the transmission
of nerve impulses (Sahay & Sahay, 2014). Manifestations: A primary characteristic of
Sodium has a major role in controlling water hypernatremia is
distribution throughout the body, because it does not THIRST; elevated temperature; dry, swollen tongue;
easily cross the cell wall membrane and because of its sticky mucosa; neurologic symptoms; restlessness;
abundance and high concentration in the body. weakness
Note: thirst may be impaired in elderly or the ill.
Hyponatremia
-Serum sodium less than 135 mEq/L Medical management: hypotonic electrolyte solution
-Hyponatremia can present as an acute or chronic form. (0.3%NaCi) or an isotonic nonsaline solution (DSW)

Acute hyponatremia is commonly the result of a fluid Nursing management: assessment and prevention,
overload in a surgical patient. assess for OTC sources of sodium ((e.g., Alka Seltzer),
offer and encourage fluids to meet patient needs,
Chronic hyponatremia is seen more frequently in provide sufficient water with tube feedings. monitors
patients outside the hospital setting, has a longer
the patient's response to the fluids by reviewing serial lean meats, milk, and whole grains (Mount, 2014c),
serum sodium levels nursing care related to IV potassium administration.
(Pic) table Careful monitoring of fluid 1&0 is necessary, because 40
mEq of potassium is lost for every liter of urine output.
POTASSIUM IMBALANCES
Potassium (K+) is the major intracellular electrolyte; in Hyper kalemia
fact, 98% of the body's potassium is inside the cells. The -Serum potassium greater than 5.0 mEq/L
remaining 2% is in the EC and is important in -Less common but more dangerous because cardiac
neuromuscular function. Potassium influences both arrest 1s more frequently associated with high serum
skeletal and cardiac muscle activity. potassium levels.

The normal serum potassium concentration ranges Causes: decreased renal excretion of potassium, rapid
from 3.5 to 5 mEq/L (3.5 to 5 mmol/L) administration of potassium, and movement of
potassium from the ICF compartment to the ECF
To maintain potassium balance, the renal system must compartment. Usually treatment related, impaired
function, because 80% of the potassium excreted daily renal function, hypoaldosteronism, tissue trauma,
leaves the body by way of the kidneys; the other 20% is acidosis.
lost through the bowel and in sweat. Medications have been identified as a probable
contributing factor in more than 60% of hyperkalemic
Hypokalemia episodes.
Below-normal serum potassium (<35 mEq/L),
may occur with normal potassium levels with alkalosis Manifestations: cardiac conduction changes and
due to shift of serum potassium into cells dysrhythmias, muscle weakness with potential
respiratory impairment, paresthesias, anxiety, GI
Causes: GI losses, medications, alterations of acid-base manifestations.
balance, The normal serum potassium concentration
ranges from 3 5 to 5 mEq/L (3 5 to 5 mmol/L), poor Medical management: monitor ECG, limitation of
dietary intake. dietary potassium, For STAT Drug Therapy IV sodium
bicarbonate (necessary in severe metabolic acidosis to
Manifestations: fatigue, anorexic, nausea, vomiting, alkalinize the plasma, shift potassium into the cells, and
dysrhythmias, muscle weakness and cramps, fumish sodium to antagonize the cardize effects of
paresthesias (sensation of tingling, buming, pricking or potassium, effects begin within 30 to 60 minutes ), IV
prickling, skin-crawling, itching. "pins and ncedies" or calcium gluconate, regular insulin and hypertonic
numbness on or just underneath your skin), decreased dextrose IV(causes a temporary shift of potassium into
muscle strength, DTRs (Deep tendon reflex syndrome) the cells), B-2 agonists (move potassium into the cells
and may be used in the absence of ischemic cardiac
Medical management: increased dietary potassium, disese), dialysis
potassium replacement, IV for severe deficit. Potassium
loss must be corrected daily, administration of 40 to 80 Nursing management:
mEq/day of potassium is adequate in the adult it there • assessment of serum potassium levels,
are no abnormal losses of potassium. Dietary intake of mix IVs containing K* well, monitor medication affects,
potassium in the average adult is 50 to 100 mEq/day. dietary potassium restriction/dietary teaching for
Foods high in potassium include most fruits and patients at risk
vegetables, legumes, whole grains, milk, and meat • Potassium-rich foods to be avoided
(Dudek, 2013). include many fruits and vegetables, legumes, whole-
grain breads, lean meat, milk, eggs, coffee, tea, and
Nursing management: assessment (Fatigue, anorexia, cocoa (Dudek, 2013). Conversely, foods with minimal
muscle weakness, decreased bowel motility, potassium content include butter, margarine, cranberry
paresthesias, and dyschythmias are signals that warrant juice or sauce, ginger ale, gumdrops or jellybeans, hard
assessing the serum potassium concentration) severe candy, root beer, sugar, and honey.
hypokalemia is life-threatening, monitor ECG and ABGs, • Hemolysis of blood specimen or
dietary potassiuminclude bananas, melon, citrus fruits, drawing of blood above IV site may result in false
fresh and frozen vegetables (avoid canned vegetables), laboratory result
 • Salt substitutes, medications may • Should not be used in patients with
contain potassium renal dysfunction
• Potassium-sparing diuretics may cause
elevation of potassium