Fluid and Electrolytes,
Balance and Disturbances
Larry Santiago, MSN, RN
Fluid and Electrolytes
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60% of body consists of fluid
Intracellular space [2/3]
Extracellular space [1/3]
Electrolytes are active ions:
positively and negatively charged
Fluid and Electrolytes 2
Regulation of Body Fluid
Compartments
• Osmosis is the diffusion of water
caused by fluid gradient
Regulation of Body Fluid
Compartments 2
• Tonicity is the ability of solutes to
cause osmotic driving forces
Regulation of Body Fluid
Compartments 3
• Diffusion is the movement of a substance
from area of higher concentration to one of
lower
concentration
• “Downhill
Movement”
Regulation of Body Fluid
Compartments 4
• Filtration is the movement of water
and solutes from an area of high
hydrostatic pressure to an area of
low hydrostatic pressure
Regulation of Body Fluid
Compartments 5
• Osmolality reflects the
concentration of fluid that affects
the movement of water between
fluid compartments by osmosis
Regulation of Body Fluid
Compartments 6
• Osmotic pressure is the amount of
hydrostatic pressure needed to
stop the flow of
water by osmosis
Sodium-Potassium Pump
• Sodium concentration is higher in
ECF than ICF
• Sodium enters cell by diffusion
• Potassium exits cell into ECF
Gains and Losses
• Water and electrolytes move in a
variety of ways
–Kidneys
–Skin
–Lungs
–GI tract
Fluid Volume Disturbances
• Fluid Volume Deficit
(Hypovolemia)
Fluid Volume Deficit
• Mild – 2% of body weight loss
• Moderate – 5% of body weight loss
• Severe – 8% or more of body
weight loss
Fluid Volume Deficit
• Pathophysiology – results from loss of
body fluids and occurs more rapidly when
coupled with decreased fluid intake
Fluid Volume Deficit 2
• Clinical manifestations
- Acute weight loss
- Decreased skin turgor
Fluid Volume Deficit 3
- Oliguria
- Concentrated urine
- Postural hypotension
- Weak, rapid, heart rate
- Flattened neck veins
- Increased temperature
- Decreased central venous pressure
Fluid Volume Deficit 4
• Gerontologic considerations
Nursing Diagnosis
• Fluid volume Deficit r/t
Insufficient intake, vomiting, diarrhea, hemorrage
m/b dry mucous membranes, low BP, HR 112-122,
BUN 28, Na 152, urine dark amber; Intake
200mL/Output 450mL over 24 hours
Goal: Client will have adequate fluid volume within
24 hours AEB:
Moist tongue, mucous membranes, BNL WNL, HR
WNL, BUN between 8-20, Na 135-145, Urine
clear yellow, balanced I/O
Fluid Volume Deficit 5
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Nursing management
Restore fluids by oral or IV
Treat underlying cause
Monitor I & O at least every 8 hours
Daily weight
Vital signs
Skin turgor
Urine concentration
Fluid Volume Disturbances 2
• Fluid Volume Excess
(Hypervolemia)
Fluid Volume Excess
• Pathophysiology – may be related to fluid
overload or diminished function of the
homeostatic mechinisms responsible for
regulating fluid balance
• Contributing factors – CHF, renal failure,
cirrhosis
Fluid Volume Excess 2
• Clinical manifestations – edema,
distended neck veins, crackles,
tachycardia, increased blood pressure,
increased weight
Nursing Diagnosis and Goal
• Fluid volume excess r/t CHF, excess sodium
intake, renal failure AEB:
Weight gain of 6 lb. in 24 hours; lungs with
crackles in bases bilaterally; 2+ edema in ankles
bilaterally
Goal: Client will have normal fluid volume within 48
hours AEB:
Decreased weight of 1 lb. per day, lung sounds
clear in all fields, ankles without edema
Fluid Volume Excess 3
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Nursing management
Preventing FVE
Detecting and Controlling FVE
Teaching patients about edema
Electrolyte Imbalances
Sodium!
Normal range – 135 to 145 mEq/L
- Primary regulator of ECF volume (a loss or
gain of sodium is usually accompanied by
a loss or gain of water)
Hyponatremia
• Sodium level less than 135 mEq/L
• May be caused by vomiting, diarrhea,
sweating, diuretics, etc.
Hyponatremia 2
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Clinical manifestations
Poor skin turgor
Dry mucosa
Decreased saliva production
Orthostatic hypotension
Nausea/abdominal cramping
Altered mental status
Hyponatremia 3
• Medical management
- Sodium Replacement
- Water Restriction
Hyponatremia 4
• Nursing Management
- Detecting and controlling hyponatremia
- Returning sodium level to normal
Critical Thinking Exercise: Nursing
Management of the Client with
Hyponatremia
• Situation: An 87 year old man was
admitted to the acute care facility for
gastroenteritis, 2 day duration. He is
vomiting, has severe, watery diarrhea and
is c/o abd cramping. His serum
electrolytes are consistent with
hyponatremia r/t excessive sodium loss.
Critical Thinking Exercise: Nursing
Management of the Client with
Hyponatremia 2
• 1. What is the relationship between
vomiting, diarrhea, and hyponatremia?
• 2. What s/s should the client be monitored
for that indicate the presence of sodium
deficit?
• 3. In addition to examining the client’s
serum electrolyte findings, how will the
nurse know when the client’s sodium level
has returned to normal?
Hypernatremia
• Sodium level is greater than 145 mEq/L
- Can be caused by a gain of sodium in
excess of water or by a loss of water in
excess of sodium
Hypernatremia 2
• Pathophysiology
- Fluid deprivation in patients who cannot
perceive, respond to, or communicate their
thirst
- Most often affects very old, very young,
and cognitively impaired patients
Hypernatremia 3
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Clinical manifestations
Thirst
Dry, swollen tongue
Sticky mucous membranes
Flushed skin
Postural hypotension
Hypernatremia 4
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Medical Management
Nursing Management
- Preventing Hypernatremia
- Correcting Hypernatremia
Critical Thinking Exercise: Nursing
Management of the Client with
Hypernatremia
• Situation: A 47 year old woman was taken to the
ER after she developed a rapid heart rate and
agitation. Physical assessment revealed dry
oral mucous membranes, poor skin turgor, and
fever of 101.3 orally. The client’s daughter
stated her mother had been very hungry recently
and drinking more fluids than usual. Suspecting
DM, the practitioner obtained serum electrolytes
and glucose levels, which revealed serum
sodium of 163 mEq/L and serum glucose of 360
mg/dL.
Critical Thinking Exercise: Nursing
Management of the Client with
Hypernatremia 2
• 1. Interpret the client’s lab data.
• 2. Why are clients with DM prone to the
development of hypernatremia?
• 3. What precautions should the nurse take when
caring for the client with hypernatremia?
• 4. List 4 food items this client should avoid and
why.
• 5. Identify 3 meds that could have an increased
effect on the client’s sodium level.
All About Potassium
• Major Intracellular electrolyte
• 98% of the body’s potassium is inside the
cells
• Influences both skeletal and cardiac
muscle activity
• Normal serum potassium
concentration –
3.5 to 5.5 mEq/L.
Hypokalemia
• Serum Potassium below 3.5 mEq/L
Causes:
Diarrhea, diuretics, poor K intake, stress,
steroid administration
Hypokalemia 2
• Clinical manifestations:
Muscle weakness, cardiac arrythmias,
increased sensitivity to digitalis
toxicity, fatigue, EKG changes
(like ST elevation)
SUCTION
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Skeletal muscle weakness
U wave (EKG changes)
Constipation, ileua
Toxicity of digitalis glycosides
Irregular, weak pulse
Orthostatic hypotension
Numbness (paresthesia)
Hypokalemia 3
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Nursing interventions:
Encourage high K foods
Monitor EKG results
Dilute KCl! – can cause
cardiac arrest if given IVP
Hypokalemia 4
• Administering IV Potassium
- Should be administered only after
adequate urine flow has been established
- Decrease in urine volume to less than 20
mL/h for 2 hours is an indication to stop
the potassium infusion
- IV K+ should not be given faster than 20
mEq/h
Critical Thinking Exercise: Nursing
Management of the Client with
Hypokalemia
• Situation: A 69 year old man has a history
of CHF controlled by Digoxin and Lasix.
Two weeks ago he developed diarrhea,
which has persisted in spite of his taking
OTC antidiarrheal meds. His partner
transported him to the ER when she found
him lethargic and confused. Initial
assessment of the client reveals heart rate
at 86 bpm, respiratory rate 10, and blood
pressure 102/56 mmHg.
Critical Thinking Exercise: Nursing
Management of the Client with
Hypokalemia 2
• 1. An electrolyte panel shows the client’s serum
potassium is 2.9 mEq/L. Does the nurse have
cause to be concerned about the client’s serum
potassium? Why or why not?
• 2. What data supports the presence of
hypokalemia in this client?
• 3. What, if anything, should the nurse do?
• 4. What foods should the client be advised to eat
that are high in potassium?
Hyperkalemia
• Serum Potassium greater than 5.5 mEq/L
- More dangerous than hypokalemia
because cardiac arrest is frequently
associated with high serum K+ levels
Hyperkalemia 2
• Causes:
- Decreased renal potassium excretion as
seen with renal failure and oliguria
- High potassium intake
- Renal insufficiency
- Shift of potassium out
of the cell as seen in
acidosis
Hyperkalemia 3
• Clinical manifestations:
- Skeletal muscle weakness/paralysis
- EKG changes – such as peaked T waves,
widened QRS complexes
- Heart block
Hyperkalemia 4
• Medical/Nursing Management:
- Monitor EKG changes – telemetry
- Administer Calcium solutions to neutralize
the potassium
- Monitor muscle tone
- Give Kayexelate
- Give Insulin and D50W
Calcium
• More than 99% of the body’s calcium is
located in the skeletal system
• Normal serum calcium level is 8.5 to
10mg/dL
• Needed for transmission of
nerve impulses
• Intracellular calcium is needed
for contraction of muscles
Calcium 2
• Extracellular needed for blood clotting
• Needed for tooth and bone formation
• Needed for maintaining a normal heart
rhythm
Hypocalcemia
• Serum Calcium level less than 8.5 mEq/L
Hypocalcemia 2
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Causes
Vitamin D/Calcium deficiency
Primary/surgical hyperparathyroidism
Pancreatitis
Renal failure
Hypocalcemia 3
• Clinical Manifestations
- Tetany and cramps in muscles of
extremities
Definition – A nervous affection
characterized by intermitten tonic spasms
that are usually paroxysmal and involve
the extremities
Hypocalcemia 4
• Trousseau’s sign – carpal spasms
Hypocalcemia 5
• Chvostek’s sign – cheek twitching
Hypocalcemia 6
• Seizures, mental changes
Hypocalcemia 7
- EKG shows prolonged QT intervals
Hypocalcemia 8
• Medical/Nursing management
- IV/PO Calcium Carbonate or Calcium
Gluconate
- Encourage increased dietary intake of
Calcium
- Monitor neurlogical status
- Establish seizure precautions
Hypercalcemia
• Serum Calcium level greater than 10.5
mEq/L
Hypercalcemia 2
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Causes:
Hyperparathyroidism
Prolonged immobilization
Thiazide diuretics
Large doses of Vitamin A and D
Hypercalcemia 3
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Clinical manifestations:
Muscle weakness, nausea and vomiting
Lethargy and confusion
Constipation
Cardiac Arrest (in
hypercalcemic crisis,
level 17mg/dL or
higher)
Hypercalcemia 4
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Medical/Nursing Management
Eliminate Calcium from diet
Monitor neurological status
Increase fluids (IV or PO)
Calcitonin
Calcitonin
• - used to lower serum calcium level
- useful for pts with heart disease or renal
failure
- reduces bone resorption
- increases deposit of calcium and
phosphorus in the bones
- increases urinary excretion of calcium
and phosphorus
• Parathyroid pulls, calcitonin keeps
Parathyroid hormone pulls calcium out of
the bone.
Calcitonin keeps it there.
Magnesium
- Normal serum magnesium level is 1.5 to 2.5
mg/dL
- Helps maintain normal muscle and nerve activity
- Exerts effects on the cardiovascular system,
acting peripherally to produce vasodilation
- Thought to have a direct effect
on peripheral arteries and
arterioles
Hypomagnesemia
• Serum Magnesium level less than 1.5
mEq/L
Hypomagnesemia
• Causes
- Chronic Alcoholism
- Diarrhea, or any disruption in small bowel
function
Hypomagnesemia 2
- TPN
- Diabetic ketoacidosis
Hypomagnesemia 4
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Clinical manifestations
Neuromuscular irritability
Positive Chvostek’s and Trousseau’s sign
EKG changes with prolonged QRS,
depressed ST segment, and cardiac
dysrhythmias
- May occur with hypocalcemia and
hypokalemia
STARVED
• Starved – possible cause of hypomagnesemia
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Seizures
Tetany
Anorexia and arrhythmias
Rapid heart rate
Vomiting
Emotional lability
Deep tendon reflexes increased
Hypomagnesemia 5
• Medical/Nursing management
- IV/PO Magnesium replacement, including
Magnesium Sulfate
- Give Calcium Gluconate if accompanied
by hypocalcemia
- Monitor for dysphagia, give soft foods
- Measure vital signs closely
Hypomagnesemia 6
• Foods high in Magnesium:
- Green leafy vegetables
Hypomagnesemia 7
- Nuts
- Legumes
Hypomagnesemia 8
• Seafood
• Chocolate
Hypermagesemia
• Serum Magnesium level greater than 2.5
mEq/L
Hypermagnesemia 2
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Causes
Renal failure
Untreated diabetic ketoacidosis
Excessive use of antacids and laxatives
Hypermagnesemia 3
• Clinical manifestations
- Flushed face and skin warmth
- Mild hypotension
Hypomagnesemia 4
- Heart block and cardiac arrest
- Muscle weakness and even paralysis
RENAL
• Reflexes decreased (plus weakness and
paralysis)
• ECG changes (bradycardia and
hypotension)
• Nausea and vomiting
• Appearance flushed
• Lethargy (plus drowsiness and
coma)
Hypermagnesemia 5
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Medical/Nursing management
Monitor Mg levels
Monitor respiratory rate
Monitor cardiac rhythm
Increase fluids
IV calcium for
emergencies
Phosphorus
- Normal serum phosphorus level is 2.5 to
4.5 mg/dL
- Essential to the function of muscle and red
blood cells, maintanence of acid-base
balance, and nervous system
- Phosphate levels vary inversely to calcium
levels
- High Calcium = Low Phosphate
Hypophosphatemia
• Serum Phosphorus level less than 2.5
mEq/L
Hypophosphatemia 2
• Causes
- Most likely to occue with overzealous
intake or administration of simple
carbohydates
- Severe protein-calorie
malnutrition (anorexia or
alcoholism)
Hypophosphatemia 3
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Clinical manifestations
Muscle weakness
Seizures and coma
Irritability
Fatigue
Confusion
Numbness
Hypophosphatemia 4
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Medical/Nursing management
Prevention is the goal
IV Phosphorus for severe
Prevention of infection
Monitor phosphorus levels
Increase oral intake of phosphorus rich
foods
Hypophosphatemia 5
Foods rich in Phosphorus:
- Milk and milk products
- Organ meats
- Nuts
- Fish
Hypophosphatemia 6
- Poultry
- Whole grains
Hyperphosphatemia
• Serum Phosphorus level greater than 4.5
mEq/L
• Causes
- Renal failure
- Chemotherapy
- Hypoparathyroidism
- High phosphate intake
Hyperphosphatemia 2
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Clinical manifestations
Tetany
Muscle weakness
Similar to Hypocalcemia because of
reciprocal relationship
Hyperphosphatemia 3
• Medical/Nursing management
- Treat underlying cause
- Avoid phosphorus rich foods
Nursing Management in
Cancer Care
Larry Santiago, MSN, RN
7 Warning Signs of Cancer
• Change in bowel or bladder habits
A sore that does not heal
Unusual bleeding or discharge
Thickening or lump in breast or elsewhere
Indigestion or difficulty in swallowing
Obvious change in a mole or wart
Nagging cough or hoarseness
Benign Tumors
• Benign – Not recurrent or progressive.
Opposite of malignant
Pathophysiology of the Malignant
Process
• Characteristics of Malignant Cells
- All cancer cells share some common
cellular characteristics
- Cell membrane of malignant cells contain
proteins called tumor-specific antigens,
such as carcinoembryonic antigen and
PSA
Pathophysiology 2
• Invasion – growth of the primary tumor into
the surrounding host tissues
• Metastasis – dissemination or spread of
malignant cells from the primary tumor to
distant sites
Detection and Prevention of
Cancer
• Primary Prevention
- Use teaching and counseling
skills to encourage patients to
partipate in cancer prevention and
promote a healthy lifestyle
Detection and Prevention of
Cancer 2
• Secondary Prevention
• Examples – breast and testicular selfexamination, Pap smear
Detection and Prevention of
Cancer 3
• Tumor Staging and Grading
–Staging determines size of tumor
and existence of metastasis
–Grading classifies tumor cells by
type of tissue
Cancer ManagementCure, Control, or Palliation
• Surgery
• Radiation
• Chemotherapy
Chemotherapy problems
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Myelosuppression
Pulmonary or cardiac toxicity
Nausea and vomiting
Extravasation
Hypersensitivity reactions
Neuropathy
Pain at the injection site
Flulike syndrome
Hyperglycemia
Cancer ManagementCure, Control, or Palliation
• Bone marrow transplantation
Nursing Process: The Patient
with Cancer
• Risk for Infection
• Impaired Skin Integrity
• Impaired Oral Mucous Membrane:
Stomatitis
• Imbalanced Nutrition: Less Than Body
Requirements
• Fatigue
• Chronic Pain
Leukemia
• A neoplastic proliferation of one particular
cell type (granulocytes, monocytes,
lymphocytes, or megakaryocytes)
• Common feature is an unregulated
proliferation of WBCs in the bone marrow
Acute leukemia
• Progresses rapidly; characterized by
ineffective, immature cells in the bone marrow
pushing out the normal cells.
• Acute myeloid leukemia (AML)--adults
• Acute lymphocytic leukemia (ALL)--children
• Signs and symptoms: Pallor, headache,
fatigue, malaise, loss of appetite, weight loss,
tachycardia, shortness of breath, petechiae,
ecchymosis, splenomegaly, and bone
tenderness.
Acute myelogenous leukemia
(AML)
• Normally, myelogenous line of cells mature into
neutro-phils, monocytes, eosinophils, RBCs, and
platelets. AML develops when cells commit to
one type, typically neutrophils.
• Diagnosis: Bone marrow biopsy
• Prognosis: Favorably affected by age under 60
years, spontaneous rather than secondary
leukemia, WBC less than 10,000/mm3 and
remission after one round of chemotherapy.
AML treatment options
• Induction chemotherapy
– Goal is remission
– Cytosine arabinoside and an anthracycle
• Postinduction therapy (consolidation)
– Goal is to prevent relapse after remission, but
effective in only 25% to 35% of patients.
– High-dose cytarabine has improved duration of
first remission in young patients with AML.
– Options: Standard chemotherapy, autologous
stem cells, or human-leukocyte-antigen (HLA)
matched sibling or donor (allogenic).
Acute lymphocytic leukemia (ALL)
• Rapidly developing immature lymphocytes
crowd our normal cells
• Poor prognostic factors: High WBCs (>
25,000/mm3 at presentation), age over 50 years,
and slow first remission (longer than 4 weeks).
Treatment - Induction chemotherapy,
administered in two phases, followed by
maintenance therapy for up to 36 months.
• Goal is complete remission.
Chronic leukemia
• Progresses slowly and rarely affects
people under age 20.
• Chronic myeloid leukemia (CML) strikes
ages 40 to 50, more in males.
• Chronic lymphocytic leukemia (CLL)
strikes after age 40 and is most common
in older men.
Chronic myeloid leukemia (CML)
• Too many neutrophils and the presence of the
Philadelphia chromosome.
• Chronic phase follows an indolent course, mild
symptoms, <10% blasts in the marrow.
• Accelerated phase characterized by spleen
enlargement and progressive intermittent fevers,
night sweats, and unexplained weight loss. 10% to
30% blasts and promyelocytes. It last 6 to 12 months.
• Blast phase characterized by transformation to a
very aggressive acute leukemia. 30% blasts and
premyelocytes; patients die in this phase.
CML treatment options
• Kinase inhibitor imatinib (Gleevec) is
treatment of choice
• Interferon alpha reduces growth and division
55% to 60%.
• Hydroxyurea may prolong the chronic phase.
• Stem cell transplant--greatest risk of dying in
the first 100 days.
Chronic lymphocytic leukemia
(CLL)
Average survival is 2.5 years for advanced
disease and 14 years for those with earlystage disease.
• Indolent disease characterized by
lymphocytosis, lymphadenopathy and
hepatosplenomegaly. Risk of death from
infection as the disease advances.
CLL treatment options
• Standard chemotherapy, which can
produce a remission not a cure and has
harsh adverse reactions. Usually delayed
till signs and symptoms appear.
Chemotherapy, radiation, and Rituximab to
enhance the response.
Lymphoma
• Neoplastic disease in which lymphocytes
undergo malignant changes and produce
tumors
• Classified as Hodgkin’s disease (accounts
for 12% of lymphomas) and non-Hodgkin’s
lymphoma (NHL)
• Hodgkin’s disease accounted for 5 % of all
cancer diagnoses in 2005; 3% NHL
Stages of lymphoma
• Stage I – involves a single lymph node or
localized involvement
• Stage II – involves two or more lymph
node regions on the same side of the
diaphragm
• Stage III – involves several lymph node
regions on both sides of the diaphragm
• Stage IV – involves extralymphatic tissue,
such as the bone marrow
Hodgkin’s treatment options
• Radiation is treatment of choice for stage
IA or IIA nonbulky (<9 cm) Hodgkin’s. Over
95% achieve complete remission and 90%
survive beyond 20 years.
• Chemotherapy is appropriate for stage IIIB
or IV, bulky disease. Standard ABVD
(adriamycin, bleomycin, vinblastine,
dacarbazine) regimen is used.
Non-Hodgkin’s lymphoma (NHL)
• Incidence has increased about 7%
annually over 20 years, primarily older
adults. Cause is unknown but increased
risk: long-term immunosuppressant
therapy, bone marrow transplant,
inherited immune defects, rheumatoid
arthritis, and prior Hodg-kin’s disease and
treatment. Spread through the
bloodstream.
NHL Treatment Options
• Radiation, chemotherapy, or both
• Stem cell transplant for recurrent disease
Multiple Myeloma
• A malignant disease of the most mature
form of B lymphocyte
Multiple Myeloma 2
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Clinical Manifestations
Bone pain
Hypercalcemia
Renal failure
Anemia
Oral hemorrhage
Fatigue, weakness
Assessment and Diagnostic
Findings
Medical/Nursing Management