Nur 102 Spring 2015
Belinda Lowry, MSN, RN, CCRN
Body Fluid
 Adult body is 60% water;
Older adult 45-55%
water
 40% is intracellular
fluid
 20% extracellular fluid


15% interstitial (tissue)
fluid
5% intravascular fluid
Body Fluids
 Osmolality (aka osmolarity)
 The osmotic pull exerted by all particles (solutes) per
unit of water
 Mainly controlled by sodium
 Tonicity
 The effect of fluid on cellular volume
Tonicity
 IV fluids have different tonicities, giving different
results on body fluid maintenance
 Isotonic

0.9% sodium chloride (normal saline), D5W, LR
 Hypotonic

0.45% sodium chloride (1/2 NS)
 Hypertonic

D5 ½ NS, D5LR, D10W
Movement of Water & Electrolytes
IV Fluids: Four classifications
 Crystalloids: replacement and maintenance of fluids

NS, ½ NS, D5’s, LR, etc.
 Colloids: volume expanders

Hetastarch (hespan), dextran
 Blood and blood products

Whole blood, PRBC, platelets, plasma, albumin
 Lipids: fat emulsion solution

TPN (total parenteral nutrition) “IV food”
Fluid Balance
 Intake: Anything going in
 Oral fluids, IV fluids, irrigations
 Output: Anything coming out
 Urine, liquid stool, emesis, NGT output, drains
 Intake – Output = Balance
 1200 ml intake – 3000 ml output = - 1800 balance
 Is patient “overloaded” or “dry”?
 Insensible loss: sweat, weeping, lungs, formed stool
Fluid Imbalance
 Volume imbalance
 Disturbances in the amount of fluid in the extracellular
compartment
 Osmolality imbalance
 Disturbances of the concentration of body fluids
 Mostly affects sodium
Fluid Overload & Deficit Causes
Fluid Overload
 Shortness of breath
 Adventitious breath sounds
 Swelling, edema
 Neck vein distention
 Weight gain
 1 liter water = 1 kg
 1 kg = 2.2 lbs
 Sometimes ALOC
Fluid Deficit s/sx
 Low BP
 Increased HR
 Decreased urine output
(UO)
 Decreased skin turgor
 Dry mucous membranes
 Sometimes ALOC
Causes of Fluid Imbalance
 *** TABLE 41-3 *** (p. 888)
 Volume deficit
 Decreased salt and water intake, increased GI output,
bleeding, diuretics
 Volume excess
 Increased salt and water intake, excess isotonic IV fluid,
decreased renal output/function
I/O Practice: shift 0700-1500
 Oral intake: 600 ml
 IV fluids: 1000 ml
 Urine: 850 ml
 Emesis: 200 ml
 What is the total I/O for the shift?
 What is patient’s balance for the shift?
I/O Practice: shift 1500-2300
 Oral intake: 300 ml
 IV fluids: 850 ml
 IV medication: 50 ml
 Blood: 350 ml
 Urine: 400 ml
 Ileostomy: 300 ml
 What is the total I/O for the shift?
 What is the patient’s balance for the shift?
I/O Practice: shift 2300-0700





Oral intake: 500 ml
IV fluids: 750 ml
Irrigation: 100 ml (down nasogastric tube)
Urine: 530 ml
Amount in NGT suction canister: 200 ml (canister was
marked at 50 ml @ beginning of shift)
 Wound drain: 30 ml
 What is the total I/O for the shift?
 What is the patient’s balance for the shift?
BONUS
 What was the total I/O for the 24-hours?
 What was the patient’s balance for the day?
Break!
Electrolytes
 Substances in the body that carry electrical charges
 Necessary to transmit nerve impulses to muscles, and
to contract skeletal and smooth muscles
 Positive-charged most plentiful (cations)
 Potassium, magnesium, sodium, calcium
Sodium
+
(Na )
 Normal value 135-145 mEq/L
 Major electrolyte that
regulates body fluids
 Promotes transmission and
conduction of nerve
impulses
 Constantly shifts into cells
while K+ shifts out of cells to
maintain water balance and
neuromuscular activity
Sodium
Hyponatremia
Hypernatremia
 Na < 135 mEq/L
 Na > 145 mEq/L
 Results from vomiting, diarrhea,
 Results from dehydration and
surgery, potent diuretics
 s/sx include:
 Weakness, headaches,
lethargy, confusion, seizures,
dry mucous membranes
 Treatment: slow correction with
NS
 3% NS may be used for
<115mEq/L (hypertonic)
use of some antibiotics and
cortisone medications
 s/sx include:
 Agitation, flushed & dry skin,
tachycardia, muscle twitching,
hyperreflexia
 Treatment: sodium
restriction, hypotonic
solutions, free water flushes
Potassium
+
(K )
 Normal value 3.5-5.3 mEq/L
 Necessary for transmission
and conduction of nerve
impulses and for
contraction of skeletal,
cardiac, and smooth
muscles
 Also necessary for enzyme
action for glycolysis and
protein formation
Potassium
Hypokalemia
 K+ < 3.5 mEq/L
 Results from cell leakage
secondary to trauma, injury,
surgery, shock
 Can also result from vomiting
and diarrhea
 Side effect of diuretic and
laxative therapies
 s/sx include:
 n/v, confusion, dysrhythmias,
soft/flabby muscles
 Treatment: PO or IV
replacement (SLOW infusion
over 2 hours minimum)
Hyperkalemia
 K+ > 5.3 mEq/L
 Results from renal insufficiency
or large doses of potassium over
time
 s/sx include:
 Nausea, abdominal cramps,
tachycardia, weakness,
tingling in extremities, tall
peaked T-waves on ECG
rhythm
 Treatment: kay-exalate, calcium
gluconate, IV insulin + D50 amp
Calcium (Ca)
 Normal value: 8.5-10.5 mg/dL
 Promotes normal nerve and
muscle activity
 Increases contraction of
myocardium
 Maintains normal cellular
permeability and promotes
blood clotting

Converts prothrombin into
thrombin
 Vit D necessary for calcium
absorption in GI tract
Calcium
Hypocalcemia
Hypercalcemia
 Ca <8.5 mg/dL
 Ca > 10.5 mg/dL
 Results from inadequate
 Results from hyperparathy-
intake, hypoparathyroidism,
vitamin D deficiency,
multiple blood transfusions
 s/sx include:
roidism, low PO4, prolonged
immobilization, multiple fx
 s/sx include:
 Anxiety, irritability, tetany
 Treatment: IV or PO
replacement
 Flabby muscles, pain over
bony areas, kidney stones
 Treatment: correct the
underlying cause
Magnesium (Mg)
 Normal value: 2.0 – 3.0




mg/dL
Promotes transmission of
neuromuscular activity
Important mediator of
neural transmission in CNS
Also promotes myocardial
contraction
Transports Na+ and K+
across cell membranes
Magnesium
Hypomagnesemia
Hypermagnesemia
 Mg < 2.0 mg/dL
 Mg > 3.0 mg/dL
 Frequently coincides with K+
 Results from excess intake of
or Ca+ deficit
 Generally asymptomatic until
level is < 1.0 mg/dL
 Treatment: IV replacement
magnesium salts (laxatives,
MOM, Maalox, Mylanta)
 Asymptomatic
 Treatment: termination of
mag salt intake, admin of
calcium gluconate
Phosphorus (PO4)
 Normal value: 2.0 – 2.6 mEq/L
 Mostly found in association
with calcium
 Essential in bone and teeth
formation, and for
neuromuscular activity
 Important component of DNA
and RNA
 Assists in cell energy transfer,
acid-base balance, and osmotic
pressure
Phosphorus
Hypophosphatemia
 PO4 < 2.0 mEq/L
 Results from GI
abnormalities, hormonal
changes (shock, surgery),
malabsorption
 s/sx include:
 Muscle weakness, tremors,
paresthesia, bone pain
 Treatment: IV replacement
Hyperphsphatemia
 PO4 > 2.6 mEq/L
 Results from renal
insufficiency or failure,
increased intake of phosphate
medications
 s/sx include:
 Hyperreflexia, tetany (with
decreased Ca), weakness,
tachycardia
 Treatment: Treat underlying
cause
NCLEX Practice
 The family of a client with chronic hyponatremia asks if the
water restriction is a punishment for his uncooperative
behavior. What is the nurse’s best response?
A. “No, limiting fluid intake decreases the risk for kidney
failure.”
B. “No, limiting water intake prevents him from losing too
much fluid by vomiting.”
C. “No, limiting fluid intake keeps his blood from becoming
more dilute and causing other complications.”
D. “No, limiting fluid decreases his sense of thirst and prevents
him from drinking liquids that contain an excess of sodium.”
NCLEX Practice
 A client has been taught to restrict dietary sodium.
Which food selection by the client indicates to the
nurse that teaching has been effective?
A. Chinese take-out, including steamed rice
B. A grilled cheese sandwich with tomato soup
C. Slices of ham and cheese on whole grain
crackers
D. A chicken leg, one slice of bread with butter,
and steamed carrots
NCLEX Practice
 The nurse assesses distended neck veins in a client
sitting in a chair to eat. What intervention is the
nurse’s priority?
A. Document the observation in the chart.
B. Measure urine specific gravity and volume.
C. Assess the pulse and blood pressure.
D. Assess the client’s deep tendon reflexes.
Case Study/Concept Map
Mrs. Hilda Beck is a 72-year-old being seen by her health
care provider this morning. She fell this morning after
becoming light-headed. She has had several episodes of
vomiting and diarrhea over the last 2 days. She was
admitted for oral and IV fluid therapy.
Case Study/Concept Map
 Why is Mrs. Beck likely becoming light-headed?
When should you expect this to resolve?
 What type of fluid (isotonic, hypotonic, hypertonic)
would you expect the physician to order?
 Mrs. Beck’s IV fluid order is 1000 ml 0.9% sodium
chloride to run over 8 hours. Calculate the milliliters
per hour (ml/hr) you should program into her pump.
Case Study/Concept Map
 You auscultate crackles in Mrs. Beck’s lung bases while
her IV is infusing. What do you now suspect?
 The physician has diagnosed Mrs. Beck with
gastroenteritis & dehydration. Create a concept map.