2B

Fluid and Electrolytes

Learning Activity: ATI CHAPTER 57 Fluid Imbalances

1. Differentiate the Following Fluid Imbalances

a. Dehydration:

● A lack of fluid in the body due to insufficient intake or

excessive loss.

● Can be actual dehydration (loss of fluid) or relative

dehydration (fluid shifts from blood to interstitial space).

● Causes: Excessive sweating, fever, hyperventilation,

diabetes insipidus, inadequate intake.

● Complications: Can cause seizures, hypovolemic shock.

b. Circulatory Overload:

● An excessive amount of fluid in the circulatory system.

● Causes: Rapid IV fluid infusion, heart failure, kidney

failure.

● Manifestations: Increased blood pressure, bounding pulse,

pulmonary edema.

c. Hypervolemia (Fluid Volume Excess - FVE):

● Excess of both water and electrolytes in the correct

proportions.

● Causes: Heart failure, kidney failure, excessive sodium

intake.

● Complications: Can lead to pulmonary edema and heartfailure.

d. Hypovolemia (Fluid Volume Deficit - FVD):

● Loss of both fluid and electrolytes, leading to decreased

circulating blood volume.

● Causes: Hemorrhage, excessive vomiting/diarrhea,

diuretics.

● Complications: Hypovolemic shock.

e. Fluid Volume Excess (FVE):

● Overhydration caused by excess fluid retention.

● Can be due to SIADH, IV fluid overload, or kidney failure.

f. Fluid Volume Deficit (FVD):

● Loss of fluid due to bleeding, vomiting, diarrhea, excessive

diuretic use, or burns.

2. Expected Findings for Fluid Imbalances

● Dehydration

○ Vital Signs: Hyperthermia, tachycardia, thready pulse,

hypotension, tachypnea, hypoxia

○ Neuromuscular: Dizziness, confusion, weakness,

seizures (if severe)

○ Gastrointestinal (GI): Thirst, dry mouth, nausea,

vomiting, weight loss

○ Other: Oliguria, decreased skin turgor, sunken eyes,

dry mucous membranes

● Fluid Volume Deficit (FVD)

○ Vital Signs: Tachycardia, hypotension, tachypnea

○ Neuromuscular: Weakness, dizziness, syncope

○ Gastrointestinal (GI): Dry mucous membranes,

nausea

○ Other: Decreased capillary refill, cool clammy skin

● Fluid Volume Excess (FVE)

○ Vital Signs: Bounding pulse, hypertension, tachypnea,

increased central venous pressure

○ Neuromuscular: Confusion, muscle weakness,

seizures (if severe)

○ Gastrointestinal (GI): Increased motility, ascites

○ Other: Pitting edema, distended neck veins, weight

gain

3. Nursing Care for Fluid Imbalancesa. Nursing Care for Dehydration

● Monitor vital signs, urine output, skin turgor, and mucous

membranes.

● Encourage oral rehydration or IV fluid therapy.

● Check neurological status for confusion or seizures.

● Monitor for orthostatic hypotension and ensure client

safety.

b. Nursing Care for Fluid Volume Deficit (FVD)

● Monitor I&O, daily weight, electrolytes, and vital signs.

● Provide IV fluids (isotonic solutions like normal saline).

● Assess for hypotension and tachycardia.

● Encourage slow position changes to prevent dizziness.

c. Nursing Care for Fluid Volume Excess (FVE)

● Monitor respiratory status for dyspnea and crackles.

● Position in semi-Fowler’s position to ease breathing.

● Administer diuretics as prescribed.

● Restrict fluid and sodium intake.

● Monitor edema and daily weights.

Learning Activity: ATI CHAPTER 58 Electrolyte Imbalances, ATI ENGAGE FUNDAMENTALS- FLUID,

ELECTROLYTE, AND ACID-BASE REGULATION, UWorld Lectures: Fundamentals: Acid-Base Imbalances:

Metabolic, Acid-Base Imbalances: Respiratory

1. Identify foods recommended for clients experiencing

electrolyte imbalances, including hypokalemia.

● Hypokalemia (Low Potassium)

○ Clients should consume potassium-rich foods.

Vegetables: Baked potatoes (941 mg K+ per medium

potato), spinach, white beans. Fruits: Bananas,

avocados, prune juice. Dairy: Plain, nonfat yogurt.

Protein: Salmon

● Hyperkalemia (High Potassium)

○ Clients should avoid high-potassium foods like

bananas, potatoes, and oranges and limit potassium-

containing salt substitutes.

● Hyponatremia (Low Sodium)

○ Cheese, Canned soups, Processed meats, Salted nuts,

Table salt, Sports drinks (for sodium replenishment)

● Hypernatremia (High Sodium)

○ Clients should reduce processed and canned foods and

increase water intake.

● Hypocalcemia (Low Calcium)○ Dairy products (milk, cheese, yogurt), Leafy greens

(kale, spinach), Almonds, Sardines

● Hypomagnesemia (Low Magnesium)

○ Cooked spinach, Pumpkin seeds, Black beans,

Cashews, Avocados, Dark chocolate

2. Distinguish assessment findings associated with:

Metabolic acidosis, Metabolic alkalosis, Respiratory

acidosis, Respiratory alkalosis

How to Identify Metabolic vs. Respiratory Disorders

Step 1: Look at the pH

● Acidosis: pH less than 7.35 (too much acid or loss of base)

● Alkalosis: pH greater than 7.45 (too much base or loss of

acid)

Step 2: Check PaCO₂ (Respiratory Component) (Partial

Pressure of Carbon Dioxide (PaCO2), Normal Range: 35 - 45)

● PaCO2 greater than 45 mmHg: Respiratory Acidosis

(CO2 retention, hypoventilation)

● PaCO2 less than 35 mmHg: Respiratory Alkalosis (CO2

loss, hyperventilation)

Step 3: Check HCO3 (Metabolic Component) (Bicarbonate

(HCO3), Normal Range: 22 - 26)

● HCO3 less than 22 mEq/L: Metabolic Acidosis (Loss of

base or excess acid)

● HCO3 greater than 26 mEq/L: Metabolic Alkalosis (Too

much base, loss of acid)

Step 4: Match the pH with the Abnormal Value

● If PaCO2 is abnormal, the cause is respiratory.

● If HCO3 is abnormal, the cause is metabolic.

Metabolic (Kidney-Related) Disorders

Bicarbonate (HCO3), Normal Range: 22 - 26 mEq/L, Controlled

by: Kidneys (Metabolic System): Function: Acts as a base that

helps buffer excess acid in the blood. The kidneys regulate

HCO3 levels to maintain acid-base balance.

Types of Metabolic Disorders:

a. Metabolic Acidosis● HCO3 less than 22 mEq/L (Loss of base or excess acid)

● Causes: Diabetic ketoacidosis (DKA), Kidney failure,

Lactic acidosis, Severe diarrhea, Shock

● Findings: Kussmaul respirations (deep, rapid breathing),

Confusion, headache, Hypotension, tachycardia,

Hyperkalemia (peaked T waves on ECG)

b. Metabolic Alkalosis

● HCO3 greater than 26 mEq/L (Too much base, loss of

acid)

● Causes: Vomiting, NG suctioning, Diuretics, Antacid

overuse

● Findings: Muscle twitching, tetany, tremors,

Lightheadedness, confusion, Hypokalemia (flattened T

waves, U waves on ECG)

2. Respiratory (Lung-Related) Disorders

Partial Pressure of Carbon Dioxide (PaCO2), Normal Range: 35

- 45 mmHg, Controlled by: Lungs (Respiratory System):

Function: Reflects the amount of CO2 (carbon dioxide)

dissolved in arterial blood. CO2 is an acid, so changes in PaCO₂

affect blood pH.

Types of Respiratory Disorders:

c. Respiratory Acidosis

● PaCO₂ greater than 45 mmHg (CO₂ retention due to

hypoventilation)

● Causes: Hypoventilation (COPD, opioids, pneumonia,

airway obstruction)

● Findings: Confusion, lethargy, headache, drowsiness,

Respiratory depression, hypoxia, Hyperkalemia (peaked T

waves on ECG)

d. Respiratory Alkalosis

● PaCO₂ less than 35 mmHg (Excess CO₂ loss due to

hyperventilation)

● Causes: Hyperventilation (anxiety, pain, fever, high

altitude, pulmonary embolism)

● Findings: Lightheadedness, dizziness, tachycardia,

Tingling, muscle cramps, Hypocalcemia (tetany,

Chvostek’s sign, Trousseau’s sign)

3. Identify abnormal findings and conditions associated

with

a. Positive Chvostek’s sign: Twitching of facialmuscles when tapping the facial nerve near the ear.

Indicates: Hypocalcemia (< 9 mg/dL),

hypoparathyroidism

b. Positive Trousseau’s sign: Carpal spasm when

inflating a BP cuff above systolic pressure for 3–5

minutes. Indicates: Hypocalcemia, hypomagnesemia

Learning Activity: UWorld Lectures-Fundamentals: Peripheral Venous Access Device (PVAD), Pearson Concepts:

Module 6 Fluid and Electrolytes

1. Dehydration and Overhydration Causes & Nursing

Interventions

Dehydration (Fluid Volume Deficit - FVD)

● Causes: Vomiting, diarrhea, sweating, hemorrhage, burns,

fever, diuretics, diabetes

● Nursing Interventions:

○ Monitor intake and output, daily weights, vital signs

(decreased blood pressure, increased heart rate),

lab values (blood urea nitrogen, creatinine,

hematocrit, osmolality, urine specific gravity)

○ Mild to Moderate Dehydration: Encourage oral

rehydration (oral rehydration solution)

○ Severe Dehydration: Administer intravenous fluids

(0.9 percent sodium chloride or lactated Ringer’s

solution)

○ Assess skin turgor, mucous membranes, encourage

fluid intake

Overhydration (Fluid Volume Excess - FVE)

● Causes: Excess intravenous fluids, kidney or heart failure,

syndrome of inappropriate antidiuretic hormone, high

sodium intake

● Nursing Interventions:

○ Monitor intake and output, daily weights, vital signs

(increased blood pressure, bounding pulse),

presence of edema, lung sounds (crackles), jugular

vein distention

○ Administer diuretics, fluid and sodium restrictions

○ Elevate edematous extremities, monitor for

neurological changes

2. Expected Findings in Dehydration

Severity Findings

Mild (less than 5 Alert, thirsty, moist mucous membranes, normal blood pressurepercent weight loss) and heart rate

Moderate (6 to 9

percent weight loss)

Dry mucous membranes, delayed capillary refill, increased heart

rate, slightly sunken fontanels (infants)

Severe (greater than 10

percent weight loss)

Lethargy, low blood pressure, weak pulse, parched mucous

membranes, deeply sunken eyes or fontanels, poor skin turgor,

absent urine output

3. Lifespan Considerations & Priority Clients

● Infants: Higher risk due to increased surface area and water

loss through skin and respiration.

○ Signs: Sunken fontanel, dry mucous membranes,

absence of tears.

○ Treatment: Oral rehydration solution (5 to 10

milliliters every few minutes), intravenous fluids if

severe.

● Children: Increased metabolic rate and fever response.

Causes: Diarrhea (rotavirus).

○ Signs: Poor skin turgor, sunken eyes, irritability.

○ Treatment: Oral rehydration solution (50 to 100

milliliters per kilogram over four hours),

intravenous fluids if severe.

● Pregnant Women: Causes: Vomiting, miscarriage.

○ Signs: Dizziness, hypotension, dry mucous

membranes.

○ Treatment: Intravenous fluids, antiemetics,

hydration.

● Older Adults: Risks: Decreased thirst, kidney function,

voluntary fluid restriction due to incontinence concerns.

○ Signs: Confusion, dark urine, postural hypotension,

dry skin and mucous membranes.

○ Treatment: Encourage fluid intake, monitor intake

and output, fall prevention

Perfusion

Learning Activity: Pearson: Module 16, ATI CHAPTER 49 Intravenous Therapy, ATI Skills Modules 3.0: IV

therapy and peripheral access, Blood Administration. UWorld Lectures-Fundamentals: Peripheral Venous Access

Device (PVAD), Blood Transfusion

1. Nursing Skills and Techniques for Initiating IV Therapy● Preparation: Verify the prescription, check for allergies,

perform hand hygiene, and gather equipment.

● Vein Selection: Choose a distal vein on the non-dominant

hand, avoiding areas near flexion points, sclerosed veins, or

areas with previous infiltration.

● Site Preparation: Cleanse the area with antiseptic using

friction in a circular motion from the center outward.

● Insertion:

○ Apply a tourniquet or BP cuff 10–15 cm above the

insertion site.

○ Insert the catheter bevel-up at a 10°-30° angle.

○ Observe for blood return (flashback), then advance the

catheter while withdrawing the needle slightly.

○ Release the tourniquet, stabilize the catheter, and

connect the IV tubing.

○ Secure the site with a transparent dressing and

document the procedure.

2. Maintenance of an IV Site

● Patency: Ensure continuous infusions are not stopped to

prevent clot formation. Flush intermittent IV catheters after

medication administration or every 8-12 hours if not in use.

● Site Monitoring:

○ Assess the IV site and infusion rate at least every hour.

○ Look for redness, swelling, leakage, or pain.

● Dressing & Tubing:

○ Change IV sites per facility policy (typically every 72

hours).

○ Change continuous infusion tubing every 96 hours and

intermittent infusion tubing every 24 hours.

○ Ensure dressings remain intact and dry.

3. Signs, Symptoms, Complications, and Nursing Care

a. Infiltration: IV fluid leaking into surrounding tissue due to

improper catheter placement or dislodgment.

● Signs/Symptoms: Pallor, swelling, coolness, damp

dressing, slowed infusion rate.

● Nursing Care: Stop infusion, remove catheter. Elevate the

limb. Apply warm or cold compress (depending on

solution). Restart IV in a new site.

b. Extravasation: Leakage of vesicant (tissue-damaging)

medication into surrounding tissue.

● Signs/Symptoms: Pain, burning, redness, swelling,necrosis.

● Nursing Care: Stop infusion and aspirate the drug.

Administer antidote if available. Apply a cold compress

and elevate the limb. Notify provider and monitor tissue

damage.

c. Phlebitis: Inflammation of the vein due to mechanical,

chemical, or bacterial irritation.

1. Signs/Symptoms: Redness, warmth, pain, swelling,

palpable vein cord.

2. Nursing Care: Stop infusion, remove catheter. Apply

warm compresses 3-4 times/day. Elevate limb and restart

IV in a different vein. Obtain a specimen for culture if

drainage is present.

4. Nursing Considerations for Older Clients

● Use a blood pressure cuff instead of a tourniquet to avoid

vein damage.

● Avoid slapping the extremity to locate veins.

● Use smaller gauge needles (22-24G).

● Apply gentle pressure and avoid excessive friction when

cleaning the site.

● If edema is present, displace fluid by applying digital

pressure before cannulation.

● Secure the IV carefully to prevent dislodgment due to

fragile skin.

Acid-Base Regulation

Learning Activity: UWorld Lectures-Fundamentals: Acid-Base Imbalances: Metabolic, Acid-Base Imbalances:

Respiratory. Pearson Concepts: Module 6 Fluid and Electrolytes

Acid-Base Imbalances – UWorld Summary

Metabolic Acidosis

● Causes: Excess acid from diabetic ketoacidosis, lactic

acidosis, renal failure, aspirin toxicity. Loss of bicarbonate

from diarrhea

● Compensation: Increased respiratory rate (Kussmaul’s

breathing) to expel CO₂

● Signs/Symptoms: Hyperkalemia, hypotension, confusion,

deep rapid breathing

● Treatment: Address underlying cause. Administer IV

sodium bicarbonate if severe

Metabolic Alkalosis

● Causes: Excess base from antacids, blood transfusions. Lossof acid from vomiting, NG suctioning, diuretics

● Compensation: Decreased respiratory rate to retain CO₂

● Signs/Symptoms: Hypokalemia, muscle cramps, slow

shallow breathing, vomiting

● Treatment: Correct underlying cause. Provide antiemetics

for vomiting. Discontinue diuretics if necessary

Respiratory Acidosis

● Causes: Hypoventilation leading to CO₂ retention.

Conditions such as COPD, opioids, pneumonia, airway

obstruction

● Compensation: Kidneys retain bicarbonate to neutralize

acidity

● Signs/Symptoms: Hypoxia, confusion, lethargy,

hyperkalemia

● Treatment: Improve ventilation (raise HOB, oxygen

therapy, bronchodilators, BiPAP)

Respiratory Alkalosis

● Causes: Hyperventilation causing excessive CO₂ loss.

Triggers include anxiety, pain, fever, pulmonary embolism

● Compensation: Kidneys excrete bicarbonate to lower pH

● Signs/Symptoms: Lightheadedness, numbness/tingling,

tachycardia

● Treatment: Encourage slow breathing (do not use a paper

bag). Address underlying cause (anti-anxiety meds, treat

fever)

Electrolyte Regulation & Functions (Pearson Module 6,

Table 6-4)

● Sodium: Regulated by aldosterone, controls renal excretion

and reabsorption. Maintains fluid balance, transmits nerve

signals, aids muscle contraction

● Potassium: Regulated through renal excretion, with

aldosterone increasing excretion. Essential for heart

rhythm, muscle function, acid-base balance

● Calcium: Controlled by parathyroid hormone (increases

calcium) and calcitonin (decreases calcium). Supports bone

formation, nerve and muscle function, blood clotting

● Magnesium: Regulated by the kidneys. Needed for muscle

relaxation, nerve conduction, cardiac function

● Chloride: Follows sodium, regulated by the kidneys.

Contributes to acid-base balance, fluid regulation

● Phosphate: Has an inverse relationship with calcium.

Essential for energy production (ATP), bone health● Bicarbonate: Regulated by the kidneys through excretion

and reabsorption.Acts as the primary buffer in acid-base

balance

Learning Activity

1. Practice dosage calculation- including rate of IV

infusions

IV flow rate (mL/hr) = Total Volume (mL) ÷ Time (hr)

IV drip rate (gtt/min) = (Total Volume in mL × Drop

Factor) ÷ Total Time in Minutes

Example: If 1,000 mL of NS is to infuse over 8 hours, the

rate is 1,000 mL ÷ 8 hr = 125 mL/hr.

2. Be able to calculate a client’s intake and output (See

Pearson Skill 5.1 Intake and Output Measuring)

Intake: Oral fluids, IV fluids, enteral feedings, medications

Output: Urine, vomit, stool, drainage (NG tube, wound

drainage)

Formula: Total Intake – Total Output = Fluid Balance

Example: If a patient had 1,200 mL oral fluids, 500 mL IV

fluids, and 1,800 mL urine output, their fluid balance is:

(1,200 + 500) – 1,800 = –100 mL (negative balance means

fluid loss).

a. Describe how to accurately measure and record

I&O

Measure liquids in mL (1 oz = 30 mL).

Use graduated containers for precise measurement.

Document immediately to avoid errors.

Include insensible losses (e.g., diaphoresis, breathing

losses in ventilated patients).

b. Explain the use of leading zeros and trailing zeros

Leading Zero (correct): Always use for numbers <1 (e.g., 0.5

mg instead of .5 mg).

Trailing Zero (incorrect): Never use (e.g., 5 mg instead of 5.0

mg) to prevent dosing errors.