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Fluids Lecture Notes Part I


Water

Most important nutrient of life; humans can only survive for a few days without it
Main need for the bodys life-supporting functions
90-93% of body fluids

Water

Solvent in which body salts, nutrients, and wastes are dissolved and transported

Protection of the blood volume (intravascular compartment) is the single most important aspect of fluid balance
homeostasis, even at the expense of creating other electrolyte imbalances
Fluid Balance

Fluid is a state of balance when the following occurs :

Water and electrolytes are in the proper proportions


Fluids are distributed normally between compartments
Lost body water and electrolytes are replaced
Excess water and electrolytes are eliminated

Even small fluctuations in the amount of water in the body can have harmful or fatal consequences
Functions of Water in the Body

Water is vital to health and normal cellular function, serving as:


1. Transportation
2. Excretion
3. Regulation
4. Lubrication
5. Medium
6. Insulator

Review of Basics

Water: 60% body weight in adults (approximately 40 liters)


Intracellular fluid (ICF): 60% of body fluids (approximately 25 liters)
Extracellular (ECF): 40% of body fluids (approx. 15 liters)
Plasma (IVF): 25% ECF (3 5 liters)
Interstitial: 75% ECF (11 liters)
Transcellular (CSF, GI tract, etc.): 1-2 liters
Electrolytes control fluid shifts between compartments

Body Fluid Distribution


Transcellular (Third-Space) Fluid: Fluid in Transit & Special Spaces
Water Movement in Major Fluid Compartments

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Electrolyte Composition of Body Fluids

3 Factors Affecting Amount of Body Water

AgeElderly have less water

GenderFemales have less water due to increased body fat

Body fatLess water, because fat cells contain very little water

Changes in Body Water Content with Age, Sex, Body Weight


The older a person gets, the less % of body fluid there is
Females have less water due to increased body fat
Obese people have lower than normal body water %
Patients at Risk for Fluid Imbalances

Infants

Elderly

Patients with
Fever
Tracheostomy
Cerebral injury
Swallowing difficulties
Burn patients

Obese
Females
Apathetic, confused, very ill (debilitated)
Unconscious, comatose

Renal, cardiac patients

Require diligent monitoring by nursing staff!


Infants and Young Children

Greater need for water


F & E alterations occur more frequently, rapidly
ECF: over half of the total body water at birth

Large body surface


Increased metabolic rate (need more water)
Immature kidneys (not as efficient in conserving water)
The Elderly

High risk for imbalances due to age related changes

Less total body water

More chronic disease processes


Decreased thirst
Difficulty concentrating or diluting urine
Difficulty regulating Na+ and K+

Each Day

The body gains and loses water


Gains and losses must be balanced to maintain body fluid balance

Water Balance

Total body water


Enters body
Osmosis from digestive tract
Also produced by cellular metabolism

Exits body

Urinary, digestive, respiratory, & integumentary systems

Maintaining Fluid Balance

Intake should equal output and average around 2,600 ml for an adult

Average adult intake:


Fluids: 1,500 ml
Water from ingested foods: 800 ml
Water formed from cellular metabolism (metabolic water): 300 ml

Maintaining Fluid Balance

Average adult output:


Urine: 1,500 ml
Output at least 30 ml/hour
Feces: 100 ml
Insensible loss: 1,000 ml (600 ml losses from skin and 400 ml expired air from lungs)

Sources of Fluid Intake

Measurable:

Oral fluids

Rehydration fluids

Enteral feedings

Parenteral fluids

Enemas

Irrigation fluids

Not measurable:
Solid foods
Metabolic water (water produced through oxidation)

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Oral Rehydration Therapy

Oral fluid and electrolyte replacement


Used to treat mild to moderate dehydration in a stable patient
Contains: water, electrolytes, glucose in therapeutic amounts

Examples: Pedialyte, Resol


Oral Rehydration Therapy

Fluids like soda, tea, fruit juices, and water are not appropriate for oral rehydration (dont contain proper
electrolytes; too much sugar)

Sodium and glucose should be in a 1:1 ratio in terms of osmolarity

Rehydration solution (homemade recipe): 8 tsp of table sugar, 1/2 tsp of salt, 1/2 tsp of sodium bicarbonate
(baking soda), and 1/3 tsp of potassium chloride to 1 L of water
Enteral Feedings: Use GI System

Enteral: alimentary, GI tract (much preferred)

Commercial formulas: water, protein, vitamins, electrolytes, glucose


NG tube, PEG tube
Example: Jevity, Pulmocare
Need supplemental water

Enteral Feedings

Any or all gastric residuals must be returned to stomach

Signs of feeding intolerance:


Vomiting, diarrhea
Discomfort
Distention
Residuals > one half (1/2) of the feeding volume

IV Therapy: Parenteral

Parenteral: any fluid or medication administered by means other than alimentary tract (i.e., intravenous,
intramuscular)

Intravenous therapy: administration of fluids, electrolytes, nutrients, or medications by venous route


Severe, life-threatening dehydration
Clients receiving IV therapy require constant monitoring for complications

Types of IV Solutions

Hypotonic (< 270 mmol/L)


Provides more water than electrolytes, diluting ECF
Movement of water from ECF to cells

0.45% saline; D5W (after dextrose metabolized)


Provides free water for cellular hydration and renal excretion
Not for clients with ICP or third-space fluid shifts
Types of IV Solutions

Isotonic (270-300 mmol/L)


Expands only ECF
No net loss or gain from ICF
Fluid replacement for patients with ECF volume deficit

NS (0.9% saline), LR
Expands vascular volume
Assess for hypervolemia (bounding pulse, SOB)
Types of IV Solutions

Hypertonic (>300 mmol/L)


Raises osmolarity of ECF and expands it
Draws water out of cells into ECF

D5NS, D5NS, D5LR, 3% NaCl, TPN, electrolyte additives


Irritating to veins
Not for clients with kidney, heart disease, dehydrated
Fluid overload, hypervolemia
Plasma Expanders

Stay in vascular space, increase intravascular osmotic pressure


Advantages: remain in intravascular space for hours
Disadvantages: risk of sensitivity reactions
Colloids, dextran, & hetastarch; blood products

Plasma Expanders

Colloids: protein solutions such as albumin


Dextran: complex synthetic sugar
Metabolized slowly; remains in vascular space longer than dextrose

Blood products (whole blood or PRBC)

Restores hemoglobin in blood loss

Sources of Fluid Output

Measurable (sensible loss):


Urine
Emesis
Feces
Drainage from body cavities (NG suction, chest tube drainage)

Sources of Fluid Output

Not measurable (insensible loss):


Perspiration
Skin vaporization

Lung vaporization
15-20 ml/ kg/ day

Nasogastric Suction

Increased loss of electrolytes


Hypochloremic metabolic alkalosis
Irrigate tube with isotonic saline (0.9% saline)

Regulators of Fluid Balance

Thirst mechanism

Primary regulator of fluid intake

Kidneys

Primary regulator of fluid output, F & E

GI tract

Intake & output

Insensible loss

Skin, lungs

Hormone regulators

ADH, aldosterone, ANP


Thirst

Earliest symptom of water deficit


Increased osmolarity, fluid volume deficit
Occurs when water loss is 2% of body weight
Elderly: decreased thirst sensation

Kidneys

Major regulatory organ for output, fluid & electrolyte balance

Urine: waste materials from blood


Receive 180 liters of blood/ day to filter
Produce 1200 -1500 ml of urine

GI Tract

Absorb water from fluid, food


Lose water: feces

Skin

Regulated by sympathetic nervous system


Activates sweat glands
Insensible: 500 - 600 ml/ day

Lungs

Insensible

Increases with rate and depth of respirations, oxygen delivery


400 ml/ day

Hormonal Regulators: Compensatory Mechanisms

Antidiuretic hormone (ADH) from posterior pituitary

Aldosterone from adrenal cortex (renin-angiotensin-aldosterone system)


Atrial natriuretic peptide (ANP)

Antidiuretic Hormone (ADH)

Stored in posterior pituitary gland

Released in response to increased blood osmolarity (dehydration, hemoconcentration, hypovolemia)


Makes tubules and collecting ducts more permeable to water

ADH Increased HYPOTONIC IVF Volume

ADH = WATER

Pure water returns into systemic circulation

Increased HYPOTONIC intravascular fluid volume

Dilutes blood

Decreased serum osmolarity

Scant urinary output (concentrated urine)


Aldosterone

Aldosterone released by adrenal cortex in response to


Plasma sodium
Plasma potassium
Causes the kidney to retain sodium & water and excrete potassium

Renin-Angiotensin-Aldosterone System

Blood pressure falls


Renin-angiotensin-aldosterone mechanism activated

Renin released from juxtaglomerular complex in kidneys


Renin Angiotensin Aldosterone

Renin: activates angiotensin


Causes muscular walls of the small arteries (arterioles) to constrict, increasing blood pressure
Triggers release of aldosterone from adrenal gland

Aldosterone Increased ISOTONIC IVF Volume

Aldosterone = SODIUM + WATER

Aldosterone acts on distal tubules

Reabsorption of sodium & water

Water follows sodium

ISOTONIC intravascular fluid volume


Serum osmolarity unchanged
Blood pressure rises

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Increased excretion of potassium
Atrial Natriuretic Peptide (ANP)

Aldosterone antagonist

Counterbalance to renin-angiotensin-aldosterone system

Released when atria are stretched by increased blood volume

ANP Decreased ISOTONIC IVF Volume

Promotes excretion of both sodium and water

Reduced: blood volume, blood pressure


Serum osmolarity unchanged
Increased: urinary output, salty urine (large amount of urine with high osmolarity)

Urine

Urine output at least 30 ml/hr


Kidneys: concentrate, dilute urine
Maintain F & E balance
Aldosterone, ADH, ANP
Specific gravity: 1.010-1.025
> 1.025: concentrated, high osmolarity
Dehydrated
Conserving fluids
< 1.010: dilute, low osmolarity
Large fluid intake
Large urine output

Obligatory Urine Output

Minimum amount of urine needed daily to dissolve and excrete toxic waste products (400 - 600 ml/ 24)
S.G. 1.032: maximally concentrated, 1200 mmol/L
If 24 output < 400-600 ml:
Wastes are retained
Lethal electrolyte build-up (especially K+)
Toxic nitrogen build-up
Metabolic acidosis

Urine Terms

Anuria: urine output less than 100 ml/ 24


Oliguria: urine output 100 - 400

ml/ 24

Polyuria: urine production greater than 2,000 ml/ 24

Calculate Fluid Replacement

Method to calculate specific 24 hour fluid needs (do this for your care plans)

30 ml/ kg
Example: 150-pound woman
150 2.2 = 68.18
68.18 X 30 = 2,045.4
24-hour fluid needs (150-lb woman): 2,045.4 mL
Exception: Cardiac or Renal patients

Calculation of Fluid Loss or Gain

1 L of water = 2.2 lb (1 kg)


500 ml of fluid gain = 1 lb weight gain
500 ml of fluid loss = 1 lb weight loss
Sudden weight gain or loss = gain / loss of body fluid
Weight gain / loss > 0.5 lb daily (250 ml)
2.2 lb (1 kg) gain / loss = 1 L
4.4 lb (2 kg) gain / loss = 2 L

Hydration

Normal state of fluid balance

Normally hydrated adult:


Alert
Moist eyes, mucous membranes
Urine output = fluid intake
Urine specific gravity 1.010-1.025
Skin turgor elastic & mobile

Assessment of Fluid Balance

Health History.

Diagnostic and Laboratory Data.


Physical Examination
Most important:
Daily Weight
Intake and Output
Vital signs
Others:
Thirst, skin, oral cavity & mucous membranes, eyes, cardiovascular & respiratory systems, neurological status

Health History

Nutritional history

Output (urine, bowel, excessive perspiration, drainage)


Medications
Body weight changes
Thirst or excessive drinking

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Exposure to hot environments


Medical disorders

Diagnostic and Laboratory Data

Hemoglobin and Hematocrit (H & H)

Blood Urea Nitrogen (BUN)


Serum Sodium
Serum Glucose
Osmolarity
Serum Osmolarity: 270 - 300 mmol
Urine Osmolarity: 500 - 800 mmol
Urine specific gravity: 1.010 - 1.025

Daily Weights

Best assessment of hydration status if accurate


Each kilogram of weight lost or gained suggests 1 liter of fluid lost or gained
Same time each day, preferably before breakfast and after first void
Same calibrated scale
Same conditions (clothing, bedding, emptied Foley bag, etc.)
Document

Intake and Output

Intake
Oral fluids
Parenteral fluids
Tube feedings
Catheter irrigants
Output
Urine output
Liquid feces
Vomitus
NG drainage
Wound drainage
Draining fistulas

Vital Signs

Signs and symptoms of ECF volume excess and deficit are reflected in changes in:
BP
Heart rate

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Respiratory rate
Temperature

Orthostatic (Postural) Hypotension

Postural changes in blood pressure or heart rate

Measurement of BP and HR first in supine, then in sitting, then standing position


Dehydration:
SBP by 15
DBP by 10
HR by 20

Pulse Quality

A normal pulse can be felt with moderate pressure of the fingers and can be obliterated with greater pressure

Easily obliterated
Fluid volume deficit
Rapid, weak, thready
Fluid volume deficit
Bounding
Fluid volume excess

Lung Status

Pulmonary edema

CracklesAir passing through fluid in alveoli


Shortness of breath, crackles, rales, or rhonchimay signal fluid volume excess due to fluid buildup in the lungs
Pink, frothy secretions

Skin Turgor

A decrease in skin turgor is indicated when the skin (on the back of the hand, sternum, or forehead) is pulled up
for a few seconds and does not return to its original state

Fluid volume deficit


Integument

Skin should be pink, warm, and dry

Flushed, dry skin


Hypernatremia, fluid volume deficit
Cold, clammy skin
Capillary refill > 3 seconds
Fluid volume deficit

Mucous Membranes

MM, conjunctiva should be moist


Eyes
Absence of tearing
Eyeball soft and sunken
Fluid volume deficit

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Tongue
Rough, dry, red
Dry, fissured tongue
Absence of salivation
Fluid volume deficit
Lips: cracked
Hand Veins

Hand vein filling is a useful indicator of hydration status

Normally, hand veins fill and become engorged when the hands are lower than the level of the heart
Collapsed hand veins in a dependent position indicate deficient fluid status

Edema

Excessive ECF accumulates in tissue (interstitial) spaces


Nonfunctioning fluid
Caused by
Increased hydrostatic pressure
Decreased plasma protein (decreased colloid osmotic pressure)
Increased capillary permeability
Lymphatic obstruction

Edema

Dependent edema
Peripheral edema
Periorbital edema: significant fluid retention
Cool to touch, taut, shiny
Good skin care
Elevate extremities

Edema

Pitting vs nonpitting
Generalized vs localized
Anasarca: severe generalized edema, over entire body

Pitting Edema: Assessment Findings

1+ edema minimal at pedal sites, 2 mm indentation


2+ marked edema of lower ext., < 5 mm
3+ edema evident in face, hands, abdomen, sacrum, 5-10 mm
4+ generalized edema, > 10 mm

System for Grading Edema


Anasarca
Third-Spacing

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Abnormal fluid shifts into transcellular space (pericardial, pleural, peritoneal spaces; joint cavities, bowel;
abdomen)

Fluid trapped and stays there

Physiologically useless
Causes:
Tissue damage
Hydrostatic pressure
Colloid osmotic pressure (low albumin)
Blocked lymph drainage
Ascites

Abnormal fluid shifts (third-spacing) of intraperitoneal fluid


Fluid trapped, cannot get back into vascular system
Measure abdominal girth every shift with a centimeter tape and record (mark on sides)

Fluid Retention

What is the most reliable way to determine if pt is retaining fluid?

Daily weights

If a pt gains 1 kg or 2.2 lbs, how much fluid has he retained?

1 liter

Can a pt have fluid retention and yet be hypovolemic? Explain

Yes, fluid not in intravascular space

These veins flatten when the client moves to a sitting position

Third-spacing
Neck Veins

Neck veins are normally distended when a client is in the supine position

Should be < 4 cm
Jugular vein distention in a sitting position
Fluid volume excess

Assessment of Jugular Venous Pressure

HOB 45
Vertical distance from sternal angle to highest level of pulsation of internal jugular vein
Normal: 0 4 cm
CVP = 4 + this height

External vs Internal Jugular Vein


External Jugular Vein Distention
Central Venous Pressure

Pressure in the right atrium: central venous pressure (CVP)

Estimates blood volume


Normal: 4-8
Decreased CVPhypovolemia

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Increased CVPhypervolemia

Central Nervous System

Assessment of clients level of consciousness and mental status

Subtle changes in mental status or level of consciousness


Neuromuscular irritability (DTRs)
Confusion, weakness, coma
Severe dehydration

Nursing Diagnoses Relevant to Fluid Imbalances

Fluid Volume, excess

Fluid Volume, deficient [Isotonic]


Fluid Volume, deficient [hyper/hypotonic]
Fluid Volume, risk for deficient
Fluid Volume, risk for imbalanced
Gas Exchange, impaired
Cardiac Output, decreased
Deficient Knowledge
Breathing Pattern, ineffective
Anxiety
Thought Processes, disturbed
Injury, risk for
Oral Mucous Membrane, impaired

Client Goals

The client will reestablish normal ECF volume, water, and/or electrolyte balance

The client will demonstrate knowledge regarding how to promote future ECF volume, water, and electrolyte
balance
The client will remain free of complications from fluid or electrolyte imbalance
Fluid Balance & Implementation

Nursing interventions:

Monitor daily weights

Vital signs

Strict I & O

Provide oral hygiene

Initiate oral fluid therapy

Maintain tube feedings

Maintain IV access

Monitor intravenous therapy

Client teaching
Collaborative interventions:
Treat cause of illness
Assess and reassess patient response to treatment
Client Teaching

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Especially important: older adults


Reinforce good diet and fluid intake
Preventative home maintenance: Teach clients how to detect signs of fluid and electrolyte imbalance, such as
rapid weight gain or loss, swelling, changes in normal urine output, muscle weakness, or abnormal skin sensation, and
give them guidelines for when to notify a physician
Client Teaching: Medications

Diuretics and other medications can increase the risk of fluid and electrolyte imbalance

Teaching is important to ensure client compliance and to help prevent any problems that can occur with treatment
Fluid Imbalances

Dehydration (fluid volume deficit)


Overhydration (fluid volume excess)

Fluid Imbalances: Correlate to Serum Sodium Imbalances


Dehydration

Fluid volume deficit


Fluid intake is not sufficient to meet bodys fluid needs
Output is increased over intake
Elderly, infants, children more at risk

Dehydration

In dehydration, fluid loss occurs first in the extracellular fluid


Losses occur from both intravascular and interstitial spaces
Actual vs. Relative

Dehydration: Signs & Symptoms

Decreased skin turgor

Dry mucous membranes


Urine output: < 30 ml/hr in adult
Postural hypotension
Weak, rapid, thready pulse

Increased rate and depth respirations


Low-grade fever
Thirst
Slow filling peripheral veins
Dehydration: Signs & Symptoms

CVP less than 4 cm H20 in vena cava


BUN elevated out of proportion to serum creatinine
Specific gravity (SG) high (urine)
Flat neck veins in supine position

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Marked oliguria, late


Mental status changes
Cold extremities, late

Degrees of Dehydration

Mild dehydration
2%, 1-2 liters
Symptoms: thirst
Moderate
5%, 3-5 liters
Symptoms: marked thirst; dry MM; dry skin; poor skin turgor; temp; tachycardia; tachypnea; SBP 10-15;

oliguria
Degrees of Dehydration

Severe
8%, 5-10 liters
Symptoms: flushed skin; SBP 60 or ; behavioral changes
Fatal
22-30 liters

Symptoms: anuria; coma; death


Three Types of Dehydration

Isotonic dehydration
With equal sodium and fluid loss
ECF isotonic
Contraction of the extracellular fluid space only

Three Types of Dehydration

Hypotonic dehydration
Greater sodium loss than water
ECF hypotonic
Contraction of the extracellular fluid and expansion of the intracellular fluid

Three Types of Dehydration

Hypertonic dehydration
Water lost exceeds sodium loss
ECF hypertonic
Expansion of the extracellular fluid and contraction of the intracellular fluid

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Isotonic Dehydration

Most common form of dehydration

Deficit of ECF only


Also called hypovolemia
(decreased circulating blood volume)

Water and electrolytes lost in even amounts: serum electrolytes normal


Isotonic Dehydration Contd

ISO = SAME: there is no gradient, no fluid shifts, no movement of fluid between compartments

Involves loss of isotonic fluids from the ECF only (blood and interstitium)

Renin-angiotensin-aldosterone cycle activated


S/S of shock occur if severe
Inadequate tissue perfusion (hypoxia)
Isotonic Dehydration

Common Causes:
Hemorrhage
Decreased fluid intake
Loss of isotonic fluids (GI, renal, & skin)
Excessive vomiting
Gastrointestinal suction
Diarrhea
Diuretic therapy
Excessive urine loss
Severe wound drainage
Excessive diaphoresis

Isotonic Dehydration: Assessment

Weight loss
Hypotension and Orthostatic Hypotension
Rapid, weak pulse
Oliguria: dark, concentrated, scanty urine
Poor skin turgor
Dry skin, MM
Urine SG
Changes in LOC (irritable to lethargic)
H & H (except in hemorrhage), serum protein, and BUN
Severe: can lead to SHOCK

Isotonic Dehydration: Interventions

Monitor daily weight, I&O, skin turgor, LOC and VS

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Check skin turgor on forehead or sternum on elderly


Monitor lab values - urine SG, BUN, CBC and Lytes
Replace fluid loss using ISOTONIC fluids
Treat the underlying cause (Imodium, Zofran)
Meticulous oral care

Hypovolemic Shock

Shock: failure of the heart and blood vessels (circulatory system) to maintain perfusion (enough oxygen-rich
blood) to the vital organs of the body (hypoxia)

Hypovolemic shock: decreased intravascular fluid volume

Usually caused by serious bleeding (hemorrhage)


Hypovolemic Shock

Healthy adult can compensate well up to 15% blood loss (500-750 ml)

Loss of compensation occurs at 30-40% blood loss (1500-2000 ml): at risk for irreversible organ damage,
exsanguination, death

Dehydration due to diarrhea, vomiting, or heavy perspiration can also lead to the development of hypovolemic

shock
Assessment of Shock

Hypotension
Rapid, weak pulse
Cold, moist, clammy skin
Rapid respirations
Decreased urinary output
Thirst
Changes in LOC
Early: apprehension and restlessness
Late: lethargy to coma

Interventions for Shock

Goal: increase ECF volume and pressure, in order to increase tissue perfusion

Monitor VS frequently
Maintain airway, O2
HOB flat, legs elevated 45 degrees
Keep warm

16 or 18-gauge IV, Type & Cross, CBC


Start NS, be ready to give blood or plasma expanders
Continuous pulse oximetry, cardiac monitoring
Hypertonic Dehydration

Second most common type of dehydration

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Water-loss hypernatremia
Deficit of ICF and expansion of ECF
Occurs when water loss from ECF is greater than electrolyte (sodium) loss
Hyperosmolarity is present (Na+ > 145)
Fluid pulled from the cells into the blood stream, leading to cellular shrinkage

Hypertonic Dehydration

Free water deficit or sodium excess

Hypotonic water loss:


Excessive perspiration
Hyperventilation
Ketoacidosis
Fever
Watery diarrhea
Renal failure
Diabetes insipidus

Hypertonic Dehydration

Hypertonic sodium gain:


Tube feedings
Hypertonic fluid replacement

Hypertonic Dehydration

Debilitation (nursing home client):


Dysphagia
Impaired thirst
Unconsciousness
Impaired motor function

Diabetes Insipidus (DI)

A disorder of water metabolism


Deficiency of ADH
Caused by damage/destruction of the pituitary gland/hypothalamus (severe head injury)

Diabetes Insipidus (DI)

Kidney unable to concentrate urine


Massive diuresis (4-30 L/ day)
Constant extreme thirst
Hypernatremia (Na+ > 145)
Low urinary osmolality

Hypertonic Dehydration: Assessment

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Thirst
Fair skin Turgor
Warm, doughy skin
Parched mucous membranes
Increased serum sodium (>150 mEq/L)
Increased serum Osmolarity
Increased urine specific gravity (>1.030)
Decreased urine output
Signs of shock are usually not present
Changes in LOC (lethargy, hyperirritability)

Hypertonic Dehydration: Compensatory Mechanisms

Activation of thirst reflex


ADH secretion

Hypertonic Dehydration: Interventions

Correct the free water deficit / sodium excess


Prevent: dilute tube feedings with adequate amounts of water
Monitor I&O, daily weight, skin turgor, LOC, serum sodium and serum Osmolarity
Administer Hypotonic fluids orally or SLOWLY by IV

Hypertonic Dehydration: Interventions

Be aware that rapid administration of hypotonic IV fluids can cause swelling of the brain cells, and increased
intracranial pressure

Treat underlying cause (Tylenol, Imodium, Lomotil)


Meticulous oral care

Hypertonic dehydration: Prevention

Prevent insensible fluid loss

Hyperventilation, pure water loss with high fevers, and watery diarrhea

Control disease processes

Diabetic ketoacidosis and diabetes insipidus

Prevent medical treatment causes

Prolonged NPO, excessive hypertonic fluids, sodium bicarbonate, or tube feedings with inadequate water

Monitor older, debilitated clients

Hypotonic Dehydration

Relatively uncommon

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Loss of more solute (usually sodium) than water


Sodium-loss hyponatremia
Deficit of ECF and expansion of ICF
Na+ and K+ levels decreased

Hypotonic Dehydration

Osmolarity is decreased (below 270)


Fluids shift from the blood stream into the cells, leading to decreased vascular volume/ shock
Increased cellular swellingcauses increased intracranial pressure and neurological changes - H/A and confusion

Hypotonic Dehydration: Common Causes

Chronic illness
Chronic renal failure
Malnutrition
Hypotonic fluid replacement
Seen in heat exhaustion / heat stroke

Hypotonic Dehydration: Prevention

Avoid NPO with ice chips over long periods


Avoid overadministration of hypotonic fluids
Select the correct IV fluid and rate to meet patients rehydration needs
Replace fluid loss during exercise with isotonic fluids

Hypotonic Dehydration: Prevention

Watch for low serum osmolarity and serum sodium


Persons on hypotonic IV fluids
Persons with chronic renal failure
Persons with chronic malnutrition

Hypotonic Dehydration: Assessment

Hypotension

Tachycardia
Very poor skin turgor
Cold, clammy skin
Changes in LOC (lethargic to comatose, convulsions)
Na+ < 120 mEq/L
K+

Hypotonic Dehydration: Interventions

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Treat the underlying cause


Rehydrate orally with hypertonic fluids
IV administration of NS to restore sodium balance
Potassium replacement
In rare instances hypertonic sodium (3% NS) may be used
Monitor for cardiac dysrhythmias
Meticulous oral care

Administration of IV Fluids: Guidelines

Give isotonic fluids (NS, LR) for isotonic dehydration


Give hypotonic fluids - (0.45% saline, D5W) SLOWLY to treat hypertonic dehydration
Give NS or hypertonic fluids (D5/0.9% saline, D5/LR) to treat hypotonic dehydration
Monitor: symptoms F & E imbalance
Keep track of I & O

Outcomes

The client will:


Ingest at least 1500 ml of appropriate fluids
Maintain a fluid output approximately equal to fluid intake