Fluids Lecture Notes Part I
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Transcript of Fluids Lecture Notes Part I
Fluids Lecture
PAGE 20
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
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
Obese
Females
Apathetic, confused, very ill (debilitated)
Unconscious, comatose
Patients with
Fever
Tracheostomy
Cerebral injury
Swallowing difficulties
Burn patients
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)
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
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
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.)
DocumentIntake 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
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
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
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
Third-spacing
Neck Veins
Neck veins are normally distended when a client is in the supine position
These veins flatten when the client moves to a sitting 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
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
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
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
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 severeInadequate 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
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
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 osmolalityHypertonic Dehydration: Assessment
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
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
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