Fluid Imbalances
Fluid Volume Deficient (FVD) à aka Hypovolemia aka Isotonic Dehydration
- Lack of both water and electrolytes, causing a decrease in circulating blood
volume.
- Contributing factors
o Excess GI and/or renal loss
o Diaphoresis
o Fever
o Long-term NPO
o Hemorrhage
o Insufficient intake
o Burns
o Diuretic therapy
o Aging: older adults have less body water and decreased thirst
sensation.
- Manifestations
o Weight loss
o Dry mucous membranes
o Increased HR and RR
o Thready pulse
o Cap refill < 3 seconds
o Weakness, fatigue
o Orthostatic hypotension
o Poor skin turgor
o LATE SIGNS: oliguria, decreased CVP, flattened neck veins
- Labs/Diagnostics
o Blood sodium à over 145 mEq/L (with dehydration)
o BUN à over 25 mg/dL
o Creatinine
o Hct à May be high due to hemoconcentration
o Urine specific gravity à over 1.030
o Blood osmolality à over 295 mOms/kg with
dehydration/hypernatremia
- Nursing Interventions
o Monitor vital signs, pulse quality, and amplitude.
o Monitor skin turgor. In older adults, check skin over sternum or
forehead.
o Maintain strict I&O. Output should be at least 0.5mL/kg/hr
o Weight client daily
Monitor laboratory data
Correct underlying cause
Fluid replacement
§ Increased oral fluid intake; initiate oral rehydration
solution
§ IV fluids for severe dehydration/maintain as prescribed
§ Monitor response to therapy
§ Initiate fall precautions
Medications
o Electrolyte replacement
o Intravenous fluids
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Fluid Volume Excess (FVE)
- Contributing Factors
o Kidney failure (late phase)
o Heart failure
o Cirrhosis
o Interstitial to plasma fluid shifts (e.g., hypertonic fluids, burns)
o Excessive water intake
o Long-term corticosteroid therapy.
- Manifestations
o Cough, dyspnea, crackles
o Increased BP
o Tachypnea, tachycardia
o Bounding pulse
o Weight gain (1 L water = 1 kg of water)
o Jugular vein distention
o Increased central venous pressure
o Pitting edema
- Diagnostic Procedures
o Serum: electrolytes, BUN, creatinine, Hct
o Urine specific gravity and osmolarity
o Chest X-ray if respiratory complications present
- Nursing Interventions
o Monitor respiratory rate, symmetry, effort
o Monitor breath sounds for signs of pulmonary edema.
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Monitor for edema; measure pitting edema on scale of 1+
(minimal) to 4+ (severe); monitor dependent edema by measuring
circumference of extremities.
Monitor for ascites and measure abdominal girth
Weight the client daily
Maintain strict I&O
Isotonic Fluids
- Indication à Treatment of vascular system
fluid deficit
- Characteristics
o Concentration equal to plasma
o Prevent fluid shift between
compartments
- Solutions
o Normal saline (0.9% NS)
o Lactated Ringer’s (LR)
o 5% dextrose in water (D5W)
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Monitor vital signs
Administer diuretics (osmotic, loop) as prescribed
Limit fluid intake
Maintain skin integrity
Use semi-fowlers position; reposition Q 2 hr
Restrict sodium intake.
Hypotonic Fluids
- Indication à Treatment of intracellular
dehydration
- Characteristics
o Lower osmolality than the ECF
o Shift fluid from ECF to ICF
- Solutions
o 0.45% normal saline (0.45% NS)
o 2.5% dextrose in 0.45% saline
(D2.5 45% NS)
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Hypertonic Fluids
- Indication à Used only when serum
osmolality is critically low
- Characteristics
o Osmolality higher than the ECG
o Shift fluid from ICF to ECG
- Solutions
o 10% dextrose in water (D10W)
o 50% dextrose in water (D50W)
o 5% dextrose in 0.9% saline (D5NS)
o 5% dextrose in 0.45% saline (D5W
in 0.45% NaCl)
o 5% dextrose in lactated Ringer’s
(D5LR)
Electrolyte Imbalances
Potassium (K+) à Hypokalemia
Potassium under 3.5 mEq/L
- Risk Factors
o Adverse effects of medications
§ Corticosteroids
§ Diuretics
§ Digitalis
§ Laxatives (abuse of)
o Body fluid loss
§ Vomiting
§ Diarrhea
§ Wound drainage
§ NG suction
o Excessive diaphoresis
o Kidney disease
o Dietary deficiency
o Alkalosis
- Manifestations
o Muscle weakness, cramping
o Fatigue
o N/V
o Irritability, confusion
o Decreased bowel motility
o Paresthesia
o Dysrhythmias
o Flat and/or inverted T waves (ECG)
- Interventions
o Monitor respiratory status.
o Initiate fall precautions
o Initiate and monitor potassium
replacement (oral, IV)
o Monitor ECG
o Monitor I&O
o Provide client education
o Dietary sources
o Medications
- NOTE: NEVER give K+ IV bolus, MUST dilute.
- NOTE: “No P = No L.” If that client is not
urinating, do NOT administer potassium.
Potassium (K+) à Hyperkalemia
Potassium over mEq/L
- Risk Factors
o Renal failure
o Adrenal insufficiency
o Acidosis
o Excessive potassium intake
o Medications
§ Potassium sparing
diuretics
§ ACE inhibitors.
- Manifestations
o Peaked T-waves (ECG)
o Ventricular dysrhythmias
o Muscle twitching and paresthesia
(early)
o Ascending muscle weakness (late)
o Increased bowel motility
- Interventions
o Monitor ECG
o Monitor bowel sounds
o Initiate dialysis
o Dietary restriction and teaching
o Administer medications
§ Kayexalate (monitor
bowel sounds)
§ 50% glucose with insulin
§ Calcium gluconate
§ Bicarbonate
§ Loop diuretics
Sodium (Na+) à Hyponatremia
Sodium under 136 mEq/L
- Risk Factors
o GI loss
o SIADH
o Adrenal insufficiency
o NPO
o Restricted sodium diet
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Water intoxication
Excessive diaphoresis
Medications
§ Diuretics
§ Anticonvulsants
§ SSRIs
§ Lithium
§ Demeclocycline
Manifestations
o Weakness
o Lethargy
o Confusion
o Seizures
o Headache
o Anorexia, N/V
o Muscle cramps, twitching
o Hypotension
o Tachycardia
o Weight gain, edema
Interventions
o Sodium replacement (oral, GI tube,
IV)
o Restrict oral fluid intake.
o Daily weight
o I&O
o Medication
§ Conivaptan hydrochloride
NOTE: Risk with hypertonic solutions à
cerebral edema
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Sodium (Na+) à Hypernatremia
Sodium over 145 mEq/L
- Risk Factors
o Dehydration
o GI loss
o Hyperaldosteronism
o Hypertonic tube feedings
o Diabetes insipidus
o Kidney failure
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o Burns
o Heatstroke
o Corticosteroids
Manifestations
o Fever
o Swollen, dry tongue
o Sticky mucous membranes
o Lethargy, restlessness, irritability
o Seizures
o Tachycardia
o Hypertension
o Hyperreflexia, twitching
o Pulmonary edema
o Blood osmolality over 295
mOms/kg
Interventions
o Daily weight
o I/O
o Seizure precautions
o IV infusion of hypotonic or isotonic
fluid
o Diuretics
o Dietary sodium restriction and
education
o Increased oral fluid intake
Calcium (Ca++) à Hypocalcemia
Calcium total under 9.0 mg/dL
- Calcium has inverse relationship with
phosphorus.
- Risk Factors
o Hypoparathyroidism
o Hypomagnesemia
o Kidney failure
o Vitamin D deficiency
o Inadequate intake
o GI loss (wound drainage, diarrhea)
o Disease Process
§ Celiac disease
§ Lactose intolerance
§ Crohn’s disease
§ Alcohol use disorder
- Manifestations
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o Tetany, cramps
o Paresthesia
o Dysrhythmias
o Trousseau’s sign
o Chvostek’s sign
o Seizures
o Hyperreflexia
o Impaired clotting time
Interventions
o Seizure precautions
o IV calcium replacement
o Daily calcium supplements
o Vitamin D therapy
o Monitor for Orthostatic
hypotension
o Dietary increase and education
NOTE: IV calcium must be administered
slowly and the site monitor for
extravasation. It is diluted in D5W NEVER in
NS.
Calcium (Ca++) à Hypercalcemia
Calcium total over 10.5 mg/dL
- Calcium has inverse relationship with
phosphorus.
- Risk Factors
o Hyperparathyroidism
o Hyperthyroidism
o Malignant disease
o Prolonged immobilization
o Dehydration
o Vitamin D excess
o Thiazide diuretics
o Lithium
o Glucocorticoids
o Digoxin toxicity
o Overuse of calcium supplements
- Manifestations
o Muscle weakness
o Hypercalciuria/kidney stones
o Dysrhythmias
o Lethargy/coma
o Hyporeflexia
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o Pathologic fractures
o Flank pain
o Deep bone pain
o Polyuria, polydipsia, dehydration
o Hypertension
o Nausea, vomiting
Interventions
o Increased mobility
o Isotonic IVF
o Dialysis
o Cardiac monitoring
o Medications
§ Furosemide
§ Calcitonin
§ Glucocorticoids
§ Bisphosphonates
§ Calcium chelators
Magnesium (Mg++) à Hypomagnesemia
Magnesium under 1.3 mEq/L
- Risk Factors
o GI loss
o Alcoholism
o Hypocalcemia
o Hypokalemia
o DKA
o Hyperparathyroidism
o Malabsorption
o TPN
o Laxative abuse
o Acute MI
o Medications
§ Cisplatin
§ Cyclosporine
§ Aminoglycoside
antibiotics
§ Diuretics
§ Amphotericin B
- Manifestations
o Paresthesia
o Dysrhythmias
o Trousseau’s sign
o Chvostek’s sign
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o Agitation, confusion
o Hyperreflexia
o Hypertension
o Insomnia, irritability
o Anorexia, nausea, vomiting
o Dysphagia
Interventions
o Seizure precautions
o Monitor swallowing.
o Dietary measures and education.
o Administer medications
§ IV magnesium sulfate
§ PO magnesium salts
o Monitor urine output.
o Monitor respirations.
NOTE: monitor for signs of magnesium
toxicity with IV replacement and treat with
calcium gluconate.
Magnesium (Mg++) à Hypermagnesemia
Magnesium over 2.1 mEq/L
- Risk Factors
o Renal failure
o Excessive Mg++ therapy
o Adrenal insufficiency
o Laxative overuse
o Lithium toxicity
o Extensive soft tissue injury or
necrosis
- Manifestations
o Hypotension
o Drowsiness
o Bradycardia
o Bradypnea
o Coma
o Cardiac arrest
o Hyporeflexia
o Nasuea, vomiting
o Facial flushing
- Interventions
Mechanical ventilation
IV fluids: lactated Ringers or NS
Administer medications
§ IV calcium gluconate
§ Loop diuretics
o Monitor respirations and blood
pressure.
o Monitor deep tendon reflexes.
NOTE: magnesium should not be
administered to clients in renal failure.
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Phosphorus à Hypophosphatemia
Phosphorus under 3.0 mg/dL
- Phosphorus has an inverse relationship with
calcium
- Risk Factors
o Vitamin D deficiency
o Refeeding after starvation
o Alcohol use disorder
o DKA
o Alkalosis
o Hypomagnesemia
o Hypokalemia
o Excessive loss of body fluids;
sweat, diarrhea, vomiting,
hyperventilation
o Burns
o TPN
o Overuse of antacids
- Manifestations
o Paresthesia
o Muscle weakness
o Bone pain and deformities
o Chest pain
o Confusion
o Seizures
o Nystagmus
- Interventions
o Oral phosphate replacement
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Careful IV administration of
phosphorus (for severe cases)
Gradual introduction of solution
for clients on TPN
Protect from infection
Dietary management and
education
Seizure precautions
Phosphorus à Hyperphosphatemia
Phosphorus over 4.5 mg/dL
- Phosphorus has an inverse relationship with
calcium
- Risk Factors
o Renal failure
o Chemotherapy
o Acute pancreatitis
o High vitamin D
o High phosphorus intake
o Hypoparathyroidism
o Excessive enema use
o Acidosis
- Manifestations
o Tetany, cramps
o Paresthesia
o Dysrhythmias
o Trousseau’s sign
o Chvostek’s sign
o Hyperreflexia
o Anorexia, nausea, vomiting
o Soft tissue calcifications
- Interventions
o Medications
§ Vitamin D
§ Aluminum hydroxide
§ Diuretics
o IV NS
o Dialysis
o Dietary management and
Education
Acid-Base Balance
pH à 7.35 to 7.45
PCO2 à 35 to 45 mm Hg
HCO3 à 21 to 28 mEq/L
Respiratory Acidosis pH ↓ under PCO2 ↑
- Risk Factors
o Respiratory depression
o Pneumothorax
o Airway obstruction
o Inadequate ventilation
- Manifestations
o Dizziness
o Palpitations
o Muscle twitching
o Convulsions
- Interventions
o Maintain patent airway
o Reversal agents for narcotics
o Regulation ventilation therapy
o Bronchodilators
o Mucolytics
PaO2 à 80 to 100 mm Hg
Metabolic Acidosis pH ↓ HCO3 ↓
- Risk Factors
o DKA
o Overdose à salicylates or ethanol
o Diarrhea
o Fever
o Hypoxia
o Starvation
o Seizure
o Renal failure
o Dehydration
- Manifestations
o Vitals signs: bradycardia, weak pulses, hypotension, tachypnea
o Flaccid paralysis
o Confusion
o Hyporeflexia
o Lethargy
o Warm, flushed, dry skin
o Kussmaul respirations
- Interventions
o Treat underlying cause
o Administer fluids, electrolytes
Respiratory Alkalosis pH ↑ PCO2 ↓
- Risk Factors
o Hyperventilation
o Hypoxemia
o Altitude sickness
o Asphyxiation
o Asthma
o Pneumonia
- Manifestations
o Tachypnea
o Anxiety, tetany
o Paresthesia
o Palpitations
o Chest pain
- Interventions
o Regulate oxygen therapy
o Reduce anxiety
o Rebreathing techniques
Metabolic Alkalosis pH ↑ HCO3 ↑
- Risk Factors
o Ingestion of antacids
o GI suction
o Hypokalemia
o TPN
o Blood transfusion
o Prolonged vomiting
- Manifestations
o Dizziness
o Paresthesia
o Hypertonic muscles
o Decreased respirations
- Interventions
o Treat underlying cause, admin fluids/electrolytes
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Therapeutic & Modified Diets
Blood Lipid Levels
Total serum cholesterol: desirable less than 200 mg/dL; risk for cardiac or stroke event with levels greater than 150 mg/dL is the target range for therapy and has been
shown to be the cut point to decrease cerebrovascular or arterial incidences.
LDL (low-density lipids): desirable less than 130 mg/dL
HDL (high-density lipids): males greater than 45 mg/dL; females greater than 55 mg/d:
Triglycerides: desirable less than 150 mg/dL; males 40 to 160 mg/dL; females 35 to 135 mg/dL
Blood Glucose Levels
Glucose (fasting): 70 to 105 mg/dL
Glycosylated hemoglobin (HbA1c): 4% to 6% is within the expected reference range. Greater than 8% indicates poor diabetes mellitus control.
Guidelines for Healthy Eating
Protein à 10% to 25% of total kcal/day
Fat à 20% to 35% of total kcal/day
Carbohydrates à 40 to 65% of total kcal/day
Fluidsà 2 to 3 L/day for women; 3 to 4 L/day for men.
Fiber à 25 g/day for women; 38 g/day for men.
Sodium à Less than 2,300 mg under age 50, 1,500 mg/day or less for people older than 50 years; Africans; history of diabetes mellitus, hypertension, or chronic kidney
disease.
Recommendations differ for pregnant/lactating women, children, and teen.
Consider cultural and religious influences on food preferences while planning diet.
Older adult recommendations:
o Drink 8 glasses of water, eat plenty of fiber, daily calcium, vitamin D and B12 supplements. Diet low in sodium and cholesterol.
Iron Alterations
Increased iron intake is indicated for correction or prevention of iron deficiency anemia, which is most likely to occur in in infants, toddlers, adolescents, and pregnant
women.
Food sources high in iron include fish, meats (particularly organ meats), green leafy vegetables, enriched breads, cereals and macaroni products, whole-grain products,
dried fruits such as raisins and apricots, and egg yolks.
Vitamin C enhances absorption of iron from the gastrointestinal tract.
Oral iron supplementation can cause constipation and GI distress, so adequate iron intake through food is idea.
Calcium Alterations
Increased calcium intake is indicated for growing children and adolescents, pregnant and lactating women, and post-menopausal women (to help prevent osteoporosis
and osteopenia)
Food sources high in calcium include milk and milk products such as yogurt and cheese; dark green vegetables such as collard greens, kale, and broccoli; dried beans
and peas; shellfish and canned salmon’ and antacids such as Tums, Rolaids, and Titralac.
No more than 600 mg calcium can be absorbed at one time, so supplements should be taken 3 times daily; no more than 2,500 mg of calcium should be consumed per
day.
Vitamin D is required for absorption of calcium from the gastrointestinal tract.
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Fat-Soluble Vitamins
Vitamin A à Liver, egg yolk, whole milk, butter, green and yellow vegetables.
Vitamin D à Fish oils, fortified milk and margarine, sunlight
Vitamin K à Egg yolks, liver, cheese, green leafy vegetables
Low-Cholesterol Diet
Indications
o Cardiovascular disease
o Diabetes mellitus
o Hyperlipidemia
Limit animal products that are high in low-density lipoproteins, saturated
fats, and trans fats.
o Egg yolks
o Organ meats, Fatty meats (such as bacon)
o Whole milk, butter
Encourage high-density lipoproteins, omega-3 fatty acids, and unsaturated
fats.
o Sardines and salmon
o Olive and flaxseed oils
o Shellfish
o Walnuts
o Fruits and vegetables
o Lean meats
o Skinless fowl
Water-Soluble Vitamins
Vitamin C à Citrus, fruits, tomatoes, broccoli, cabbage
Thiamine (B1) à Lean meats (e.g., beef, pork, liver), whole grain cereals, legumes
Riboflavin (B2) à Milk, organ meats, enriched grains, green leafy vegetables
Niacin (B3) à Meat, beans, peas, peanuts, enriched grains
Pyridoxine (B6) à Products containing yeast, wheat, corn, organ meats.
Cobalamin (B12) à Lean meats, liver, kidneys
Folic Acid (B9) à Leafy green vegetables, eggs, liver
Low-Protein Diet
Indications
o Hepatic encephalopathy
o Hepatic coma
o Renal impairment
Limit high protein foods
o Meats
o Eggs
o Milk and milk products
o Beans
Other dietary considerations
o Increase carbohydrates to meet nutritional needs
o Limit sodium in presence of edema and/or ascites.
Modified-Fat Diet
Indications
o Gallbladder disease
o Hepatic disorders
o Cystic fibrosis
o Malabsorption syndrome
Avoid the following foods
o Whole-milk products
o Gravies, creams
o Fatty meat and fish
o Nuts and chocolate
o Polyunsaturated oils
Foods Allowed
o Two to three eggs per week
o Lean meat, fowl, fish
o Fruits and vegetables
o Bread and cereal
Foods allowed
High-Protein Diet
Indications
o Tissue repair and building
o Burns
o Malabsorption syndromes
o Pregnancy
Encourage high biological value (HBV) protein
o Egg whites (gold standard)
o Soy products
o Milk products
o Fish and fowl
o Organ and meat sources
Encourage oral fluids to decrease damage to renal capillaries as a result of
increased protein.
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Potassium-Modified Diets
High potassium foods
o Bananas
o Oranges
o Milk
o Spinach
o Apricots and prunes
o Soy, lima, and kidney beans
o Baked potatoes (white and sweet)
Low potassium foods
o Breads
o Cereals
o Asparagus
o Cabbage
o Cherries
o Blackberries and blueberries
Sodium-Restricted Diets
Indications
o Hypertension
o Heart failure
o Myocardial infarction
o Adrenal cortical diseases
o Kidney disease
o Liver cirrhosis
o Preeclampsia
High-Sodium Foods
o Salty snack foods (such as potato chips)
o Canned soups and vegetables
o Baked foods that contain baking powder or baking soda.
o Processed meats (e.g., bologna, ham, and bacon)
o Dairy products, especially cheese.
o Pickles, olives
o Soy sauce, steak sauce
o Salad dressings
Encourage patients to become “label savvy” for sodium.
Diet for Alteration in Amino-Acid Metabolism
Use for phenylketonuria (PKU), galactosemia, and lactose intolerance.
Dietary restrictions are aimed at reducing or eliminating the offending enzyme.
Avoid milk and milk products for all three diets; include soy-based supplements.
For PKU, avoid high-protein foods such as meats, dairy products, and eggs. In addition, avoid aspartame (Nutrasweet) as it contains phenylalanine.
For galactosemia, the simple sugar in lactose must be avoided. Educate families to read labels carefully, as galactosemia can be life threatening.
Supplement calcium and vitamin D in those with lactose-restricted or -eliminated diets.
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