FLUIDS

HOW IMPORTANT IS WATER?

• Between 50% and 60% of the human body
by weight is water
• Water provides a medium for transporting
nutrients to cells and wastes from cells and
for transporting substances such as
hormones, enzymes, blood platelets, and red
and white blood cells
• Water facilitates cellular metabolism and
proper cellular chemical functioning
• Water acts as a solvent for electrolytes and
nonelectrolytes
• Helps maintain normal body temperature
• Facilitates digestion and promotes
elimination
• Acts as a tissue lubricant

Variations in Fluid Content

Regulating Body Fluid Volumes
Body Fat
OBLIGATORY LOSS- essential fluid loss required to
Because fat cells contain little water and lean tissue
maintain body functioning.
is rich in water, the more obese the person, the
 About 1300mL/day
smaller the percentage of total body water
Fluid intake
compared with body weight. This is also true
between sexes because females tend to have  Adult requires 2500mL of fluid/day
proportionally more body fat than males. There is Fluid output
also an increase in fat cells in older people  Urine
 Insensible fluid loss
AGE  Sweat
 Loss through the GIT

Avenues

by which
water

enters
and
leaves
the body

Fluid Movements
Factors affecting Fluids and Electrolytes
 Fluids and solutes constantly move within Balance
the body, which allows the body to maintain
 Age
homeostasis
 Climate
 Fluids along with nutrients and waste
products constantly shift within the body’s  Diet
compartments from the cell to the interstitial  Stress
spaces, to the blood vessels and back again  Illness
Types of Transport  Medical treatments
A. Active transport  Medications
B. Passive transport  Surgery
 Diffusion
 Osmosis ANTIDIURETIC HORMONE REGULATION
 Filtration MECHANISMS
 solution until the two solutions had equal
concentrations
 Ex. Half normal or 0.45%SS

Hypertonic:
 Has a higher solute concentration than
another solution
 Fluid from the second solution would shift
into the hypertonic solution until the two
solutions had equal concentrations
 Ex. D5NSS

Assessment
 CLINICAL MEASUREMENT
• Daily weights
• Each kg = 1 L of fluid
• To gain accuracy:
• Balance the scale
before each use and
weigh the client;
• At same time
each day before
breakfast after
the first void
• Wear the same
or similar
clothing
• On the same
Fluid types scale
 Fluids in the body generally aren’t found in • Vital signs
pure forms • Tachycardia – first sign of
 Isotonic, hypotonic, and hypertonic types hypovolemia
 Defined in terms of the amount of solute or • Fluid I & O
dissolve substances in the solution • Oral fluids
 Balancing these fluids involves the shifting • Ice chips
of fluid not the solute involved • Foods that tend to become
Isotonic: fluid at room temperature
 No net fluid • Tube feedings
shifts occur • Parenteral fluids
between • IV meds
isotonic • Catheter or tube irrigant
solutions • Urinary output – if with diaper,
because the 1 g = 1 mL
solution are • Vomitus or liquid feces
equally • Diaphoresis
• Tube drainage
• Wound dressing or wound
fistula
concentrated
Ex. NSS or 0.9SS LABORATORY TESTS FOR EVALUATING FLUID
STATUS
Hypotonic:  Osmolality – measures the solute
 Has a lower concentration per kilogram in blood and
solute urine.
concentration  Osmolarity – concentration of solution per
than another liter.
solution  BUN – (10-20 mg/dL)made up of urea, an
 Fluid from the end product of protein metabolism by the
hypotonic liver.
solution  Creatinine (0.7 to 1.5 mg/dL)- end product
would shift of muscle metabolism
into the  Serum electrolytes
second
 CBC

Diagnosis
 Fluid volume deficit
 High risk for Fluid volume deficit
 Fluid volume excess
 Altered oral mucous membrane
 • Turn the patient at least every 2
Fluid balance hours to prevent skin breakdown
 The desirable amount of fluid intake and loss • Encourage oral fluids
in adults ranges from 1500 to 3500 mL each
24 hours. Ave= 2500 mL  Warning Signs
 Normally INTAKE = OUTPUT • Cool pale skin over the arms and legs
• Decreased central venous pressure
Fluid Imbalance • Delayed capillary refill
• Changes in ECF volume = alterations in • Deterioration in mental status flat
sodium balance jugular veins
• Change in sodium/water ratio = either • Orthostatic hypotension
hypoosmolarity or hyperosmolarity • Tachycardia
• Fluid excess or deficit = loss of fluid balance • Urine output initially more than
• As with all clinical problems, the same 30ml/min, then dropping below
pathophysiologic change is not of equal 10ml/hour
significance to all people • Weak or absent peripheral pulses
• Weight loss

FLUID DEFICIT/HYPOVOLEMIA
 May occur as a result of:
• Reduced fluid intake FLUID REPLACEMENT THERAPY
• Loss of body fluids  Aimed at restoring and maintaining
• Sequestration (compartmentalizing) homeostasis
of body fluids  Methods:
• Oral and gastric feeding
Pathophysiology and Clinical Manifestations • Parenteral therapy
 Choice of therapy affected by several factors
• Type and severity of imbalance
• Patient’s overall health status, age,
renal and cardiovascular status
• Usual maintenance requirements
Advantages
Dextrose Na Cl K Lactate
IVF
(g/L) (meq/L) (meq/L) (meq/L) (meq/L)
D5
0.9
50 154 154
%
NaCl
D5
0.15
50 25 25
%
NaCl
D5
0.3
50 51 51
%
NaCl
D5
0.45
50 77 77
%
NaCl
HYPOVOLEMIA
 Nursing Intervention D5
50 25 22 20 23
• Monitor fluid intake and output IMB
• Checked daily weight (a 1lb(0.45kg) LRS 0 130 109 4 28
weight loss equals a 500 ml fluid loss)
• Monitor hemodynamic values such as NSS 0 154 154
CVP
• Monitor results of laboratory studies D5L
50 130 109 4 28
• Assess level of consciousness RS
• Administer and monitor I.V. fluids • Provides the patient with life-
• Apply and adjust oxygen therapy as sustaining fluids, electrolytes, and drugs
ordered • Immediate and predictable
• If patient is bleeding, apply direct therapeutic effects
continuous pressure to the area and • Preferred for administering fluids,
elevate it if possible electrolytes, and drugs in emergency
• Assess skin turgor situations
• Assess oral mucous membranes
 • Allows fluid intake when a patient has
GI malabsorption
• Permits accurate dosage titration for
analgesics and other drugs

Administration routes
• Oral route : oral ingestion of fluids
and electrolytes as liquids or solids
administered directly into the GI tract
• Nasogastric route: instillation of fluids
and electrolytes through feeding tubes, such
as NG, gastrostomy and jejunostomy tubes
• I.V. route: administration of fluids and
electrolytes directly into the bloodstream
using continuous infusion, bolus, or I.V. push
injection through peripheral or central
venous site
Composition of Different Intravenous Solution

IV FLUIDS
 Diagnostic Findings:
• Decreased hematocrit resulting from
hemodilution
• Normal serum Na level
• Low serum K and BUN levels
• either due to hemodilution or
higher levels may indicate
renal failure
• Low oxygen level
• Abnormal chest x-ray
• Indicates fluid accumulation
• May reveal pulmonary edema
or pleural effusions

 Treatment
• Na and fluid intake restriction
• Diuretics to promote excess fluid
excretion
• Morphine and nitroglycerin (Nitro-
Dur) for pulmonary edema
• Dilate blood vessels
• Reduce pulmonary congestion
and amount of blood returning
to the heart
• Digoxin for heart failure
• Strengthens cardiac
contractions

 Treatment
• Supportive measures
• Oxygen administration
• Bed rest
• Hemodialysis or continuous renal
replacement therapy for renal
dysfunction
 • diuretics
 Nursing Interventions
• Monitor fluid intake and output
• Monitor daily weight
• Monitor cardiopulmonary status
• Auscultate breathe sounds
• Assess for complaints of dyspnea
• Monitor chest x-ray results
• Monitor arterial blood gas values
• Assess for peripheral edema
• Inspect the patient for sacral edema
• Monitor infusion of I.V. solutions
• Monitor the effects of prescribed
medications
ELECTROLYTES
Sodium (Na+)
• Controls and regulates volume of body fluids
• Its concentration is the major determinant
of ECF volume
• Is the chief electrolyte of ECF
• Influence ICF Volume
• Participates in the generation and
transmission of nerve impulses
• Is an essential electrolyte in the sodium-
potassium pump
• RDA: not known precisely. 500 mg
• Eliminated primarily by the kidneys, smaller
in feces and perspiration
• Salt intake affects sodium concentrations
• Sodium is conserved through reabsorption
in the kidneys, a process stimulated by
aldosterone
• Normal value: 135-145 mEq/L
Potassium (K+)
• Major cation of the ICF. Chief regulator of
cellular enzyme activity and cellular water
content
• The more K, the less Na. The less K, the
more Na
• Plays a vital role in such processes such as
transmission of electrical impulses,
particularly in nerve, heart, skeletal,
intestinal and lung tissue; CHON and CHO
metabolism; and cellular building; and
maintenance of cellular metabolism and
excitation
• Assists in regulation of acid-base balance by
cellular exchange with H
• RDA: not known precisely. 50-100 mEq
• Sources: bananas, peaches, kiwi, figs,
dates, apricots, oranges, prunes, melons,
raisins, broccoli, and potatoes, meat, dairy
products
• Excreted primarily by the kidneys. No
effective conserving mechanism
• Conserved by sodium pump and kidneys
when levels are low
• Aldosterone triggers K excretion in urine
• Normal value: 3.5 – 5 mEq/L
Calcium (Ca2+)
• Most abundant electrolyte in the body. 99%
in bones and teeth
• Close link between calcium and phosphorus.
High PO4, Low Ca
• Necessary for nerve impulse transmission
and blood clotting and is also a catalyst for
muscle contraction and other cellular
activities
• Needed for Vitamin B12 absorption and use
• Necessary for strong bones and teeth and
thickness and strength of cell membranes
• RDA: 1g for adults. Higher for children and
pregnant and lactating women according to
body weight, older people, esp. post-
menopausal
• Found in milk, cheese, and dried beans;
some in meat and vegetables
• Use is stimulated by Vitamin D. Excreted in
urine, feces, bile, digestive secretions, and
perspiration
• Normal value 8.5 – 10.5 mg/dl
Magnesium (Mg2+)
• Mostly found within body cells: heart, bone,
nerve, and muscle tissues
• Second most important cation in the ICF, 2nd
to K+
• Functions: Metabolism of CHO and CHON,
protein and DNA synthesis, DNA and RNA
transcription, and translation of RNA,
maintains normal intracellular levels of
 potassium, helps maintain electric activity in
nervous tissue membranes and muscle Diagnostic Title Possible Etiologic
membranes Factors
• RDA: about 18-30 mEq; children require Deficient fluid volume Active fluid volume loss
larger amounts (hemorrhage,
• Sources: vegetables, nuts, fish, whole diarrhea, gastric
grains, peas, and beans intubation, wounds, diaphoresis),
• Absorbed in the intestines and excreted by inadequate fluid intake, failure of
the kidneys regulatory mechanisms,
• Plasma concentrations of magnesium range sequestration of body
from 1.5 – 2.5 mEq/L, with about one third of fluids
that amount bound to plasma proteins
Excess Fluid Volume Excess fluid intake,
NURSING MANAGEMENT OF PATIENT WITH excess sodium intake,
FLUID AND ELECTROLYTE IMBALANCES compromised regulatory
processes

EXPECTED PATIENT OUTCOMES

1. Will maintain functional fluid volume as

evidenced by adequate urinary output, stable
weight, normal vital signs, normal urine specific
gravity, moist mucus membranes, balanced intake
and output, elastic skin turgor, prompt capillary
refill, and absence of edema
2. Will verbalize understanding of treatment plan
and causative factors that led to the imbalance

1,2 Intake and Output Monitoring

• Type and amount of fluid the patient has
received and the route by which they were
administered
• Record of solid food intake. Gelatin or
Popsicles are recorded as fluids
• Ice chips are recorded by dividing the
amount of chips by ½ (60 mL of chips = 30
mL water)
• Accurate output record and described by
color, content, and odor (Normally, gastric
contents are watery and pale yellow-green;
they usually have a sour odor)
• With acid-base balance upset, gastric
secretions may have a fruity odor because of
ketone bodies
• NGT irrigation added to intake
• Stools: difficult to estimate amount;
consistency, color, and number of stools
provide a reasonable estimate
• Peritoneal or pleural fluid drainage is
recorded as output as with its amount, color,
and clarity
• Character and volume of urine. Place signs
and materials so that an accurate record of
UO is maintained

1,2 Intake and Output Monitoring

LABORATORY VALUES
FLUID DEFICIT
Hemoconcentration Hemodilution
↑ Hct, BUN, E+ levels
levels
↑ Urine Specific Gravity
Specific Gravity
• Evaluate and refer urine specific gravity as
appropriate (normal value is 1.003 – 1.030).
The implications are:
High Dehydration
Low SIADH, overhydration
• Drainage, fluid aspirated from any body
cavity must be measured. With dressings,
FLUID EXCESS fluid loss is the difference between the wet
dressings and the dry weight of the dressing
↓ Hct, BUN, E+ • Accurate recording of the temperature to
help the physician determine how much fluid
↓ Urine should be replaced
1,2 Daily Weight

Determined from analysis of patient data

 • Evaluate trends in weight (An increase in
1kg in weight is equal to the retention of 1L
of fluid in an edematous patient)
Considerations:
• Daily weights early in the morning after
voiding but before he or she has eaten or
defecated
1 Replacement of Fluid and Electrolytes
General Principles:
• Either by oral intake (healthiest way), tube
feeding, intravenous infusion, and/or total
parenteral nutrition
• Normal saline solution and plain water
should also be given by slow drip to replace
daily fluid loss
• IV administration per doctor’s orders
• Fluid replacement considerations:
- Most effective when apportioned over 24 hr
period
- (Better regulation, ↓potential for calculi
formation and subsequent renal
damage, ↓potential for circulatory overload
which may cause in fluid and electrolyte
shifts)
- Administer concentrated solutions of Na,
Glucose or protein because they require
body fluids for dilution
- Consider the size of the patient (small adult
has less fluid in each compartment,
especially in the intravascular compartment)
• Promote oral intake as appropriate
- Caution with coffee, tea, and some colas
- small amount at frequent intervals is more
useful than a large amount presented less
often
- Always give consideration to cultural and
aesthetic aspects of eating
• Give mouth care to a dehydrated patient
before and after meals and before bedtime
• Avoid irritating foods
• Stimulation of saliva may be aided by hard
candy or chewing gum or
carboxymethylcellulose (artificial saliva)
• Keep lips moist and well lubricated
• Give salty broth or soda crackers for sodium
replacement and tea or orange juice for
potassium replacement as appropriate.
Bananas, citrus fruits and juices, some fresh
vegetables, coffee, and tea are relatively
high in potassium and low in sodium. Milk,
meat, eggs, and nuts are high in protein,
sodium and potassium.
• Offer milk for patients with draining fistulas
from any portion of the GI tract. Lactose
intolerance is not necessarily a
contraindication (Lactase enzyme
preparations are available)
• Increase usual daily requirement of foods
when losses must be restored, as tolerated
- Patients with cardiac and renal impairments
are instructed to avoid foods containing high
levels of sodium, potassium and bicarbonate
• Administer replacement solutions through
tube feeding as is
• Either water, physiologic solution of NaCl,
high protein liquids, or a regular diet can be
blended, diluted and given by gavage
• The water content in the tube feeding needs
to be increased if:
1. the patient complains of thirst
2. the protein or electrolyte content of the tube
feeding is high
3. the patient has fever or disease causing an
increased metabolic rate
4. UO is concentrated
5. signs of water deficit develop
• Administer parenteral fluids as necessary
Types of solutions
• D5W (hypotonic) is given short-term for
hyponatremia
• D5NSS may be given depending on the
serum levels of sodium and vascular volume
+ KCl to meet normal intake needs and
replace losses for hyponatremia
• Dextrose 5% in 0.2% normal saline is
generally used as a maintenance fluid
• Dextrose 5% in ½ normal saline is generally
used as a replacement solution for losses
caused by gastrointestinal drainage
• PNSS is given primarily when large amounts
of sodium have been lost and for patients
with hyponatremia
• LRS is also isotonic because it remains in the
extracellular space
• Fructose or 10-20% glucose in distilled water
are hypertonic solutions and may partially
meet body needs for CHOs
• Dextran (commonly-used plasma expander)
increases plasma volume by increasing
oncotic pressure. May cause prolonged
bleeding time and is CI in patients with renal
failure, bleeding disorders, or severe CHF
Administration
• The rate should be regulated according to
the patient’s needs and condition per
doctor’s orders
• Monitor UO carefully. Refer marked
decreases!
• Verify orders for potassium administration in
patients with renal failure and untreated
adrenal insufficiency
• Usual rate for fluid loss replacement:
3ml/min
• Recognize signs of pulmonary edema
(bounding pulse, engorged peripheral veins,
hoarseness, dyspnea, cough, and rales) that
can result from ↑IV rate
• If infiltration occurs, the infusion should be
stopped immediately and relocated.
Peripheral IV sites are generally rotated
every 72 hours
• For dextran and other plasma expanders,
observe for anaphylactic reaction
(apprehension, dyspnea, wheezing,
tightness of chest, angioedema, itching,
hives and hypotension). If this happens,
switch infusion to nonprotein solution and
run at KVO rate, notify physician and
monitor VS
• Pronounced and continued thirst despite
administration of fluids is not normal and
should be reported (may indicate DM or
hypercalcemia)
Patient/Family Education
 • Include the signs and symptoms of water
excess in discharge instructions
• With drug therapy, instruct patient and
family regarding correct method of
administration, correct dose, and
therapeutic and adverse effects
• Instruct to read labels for nutritional content
* For K restriction: avoid organ meats, fresh and
dried fruits, and salt substitutes
• Skin assessment and care, positioning
techniques for patients with mobility
restrictions

• Achievement of outcomes is successful in

disturbances in fluid and electrolyte balance:
1. Maintains functional fluid volume level with
adequate UO, VS within the patient’s normal
limits, sp gr of urine within 1.003-1.035,
moist mucous membranes, stable weight,
Intake=output, elastic skin turgor, and no
edema
2. States possible causes of imbalance and
plan to prevent recurrence of imbalances
3. Reports a decrease or absence of symptoms
causing discomfort