Fluid, Electrolyte, and Acid-Base Balance Notes

Homeostasis

• Maintaining relatively constant conditions in fluid compartments.
• The body must regulate fluids to maintain internal balance.
• All organs and structures are involved in homeostasis.

Fluid Compartments

• Intracellular Fluid (ICF):
  • Fluid within cells.
  • Most of the body's fluids are found within cells.
  • Two-thirds of body water
• Extracellular Fluid (ECF):
  • Fluid outside cells.
  • Intravascular Fluid: In blood vessels as plasma or serum.
  • Interstitial Fluid: Surrounding cells, including lymph.

Transport of Water and Electrolytes

• Membranes:
  • Selectively permeable, separating fluid compartments.
  • Control movement of water and solutes.
  • Maintain unique composition while allowing nutrient and waste transport.
  • Some solutes cross membranes more easily than others.

Transport Processes

• Diffusion:
  • Random movement of particles from high to low concentration areas.
  • Necessary for substance movement.
• Facilitated Diffusion:
  • Carrier protein transports molecules across membranes to lower concentration areas.
• Active Transport:
  • Carrier proteins transport substances from low to high concentration areas.
  • Requires energy expenditure.
  • Examples: sodium, potassium, glucose, and hydrogen.
• Filtration:
  • Water and solutes move through a membrane from high to low pressure areas.
  • Hydraulic Pressure: Combination of gravity and heart pumping action.
  • Needed for fluid movement out of capillaries and kidney filtration.
• Osmosis:
  • Movement across a membrane from less to more concentrated solution.
  • Involves water movement; solutes may be carried along.
  • Water moves to more concentrated compartments to create balance.

Osmolarity

• Concentration of solution by dissolved particles per kg of water.
• Controls water movement and distribution.
• Intracellular and extracellular fluid osmolality tend to equalize due to water shifting.

Age-Related Changes Affecting Fluid Balance

• Aging kidney adjusts slower to changes in acid-base, fluid, and electrolyte balances.
• Older adults may have reduced thirst and chronic dehydration.
• Total body water declines with age; greatest loss from intracellular fluid.
• Limited reserves to maintain fluid balance during abnormal losses.
• Antihypertensives, diuretics, and antacids can contribute to imbalances.
• Fluid requirements based on ideal body weight:
  • 30 mL/kg for ages 55 to 65
  • 25 mL/kg for 65 years and older

Composition of Body Fluids: Water

• Largest portion of body weight.
• Percentage affected by age, sex, body fat.
• Females have lower percentage due to more fat.
• Obese people have lower percentage due to increased fat cells.

Composition of Body Fluids: Solutes

• Electrolyte:
  • Substance developing electrical charge when dissolved in water.
  • Examples: Sodium (Na), Potassium (K), Chloride (Cl), Calcium (Ca), Magnesium (Mg2+).
• Sodium (Na2+):
  • Normal range: 136 \text{ to } 145 \frac{\text{mEq}}{\text{L}}
  • Most abundant electrolyte; primary in extracellular fluid.
  • Regulates body fluid volumes, muscular activity, nerve impulse conduction, and acid-base balance.

Hyponatremia

• Lower than normal sodium in blood serum.
• Can be actual deficiency or increase in body water.
• Symptoms: headache, muscle weakness, fatigue, apathy, confusion, abdominal cramps, and orthostatic hypotension.
• Medical treatment: fluid restriction, diuretics (furosemide/Lasix), and sodium replacement therapy.
• Nursing care: administer medications and IV fluids, measure fluid intake/output, and assess mental status.

Hypernatremia

• Higher than normal concentration of sodium in the blood.
• Very serious imbalance; can lead to death.
• Occurs with excessive water loss or sodium retention.
• Signs and symptoms: thirst, flushed skin, dry mucous membranes, low urine output, restlessness, increased heart rate, convulsions, and postural hypotension.
• Medical treatment: oral or IV water replacement, low-sodium diet.
• Nursing care: encourage water intake, monitor IV fluids, teach tracking of intake/output & signs/symptoms of retention/depletion.

Solutes (cont.)

• Potassium (K+):
  • Normal range: 3.5 \text{ to } 5.0 \frac{\text{mEq}}{\text{L}}
  • Mainly in intracellular fluid.
  • Maintains fluid osmolarity and volume within the cell.
  • Essential for membrane excitability, nerve impulse transmission.
  • Needed for protein synthesis, glycogen synthesis/breakdown, and plasma acid-base balance.

Hypokalemia

• Low serum potassium.
• May result in gastrointestinal, renal, cardiovascular, and neurologic disturbances.
• Can cause abnormal, potentially fatal, heart rhythm.
• Signs and symptoms: anorexia, abdominal distention, vomiting, diarrhea, muscle cramps, weakness, dysrhythmias, postural hypotension, dyspnea, shallow respirations, confusion, depression, polyuria, and nocturia.
• Medical treatment: potassium replacement (IV or oral).
• Nursing care: monitor at-risk patients for decreased bowel sounds, weak/irregular pulse, decreased reflexes/muscle tone; use cardiac monitors; administer potassium; ensure urine output no less than 30 mL/hr.

Hyperkalemia

• High serum potassium.
• Patients at risk: decreased renal function, metabolic acidosis, potassium supplements.
• Serious imbalance due to potential for life-threatening dysrhythmias.
• Signs and symptoms: explosive diarrhea/vomiting, muscle cramps/weakness, paresthesia, irritability, anxiety, abdominal cramps, and decreased urine output.
• Medical treatment: correct underlying cause, restrict potassium intake, polystyrene sulfonate (Kayexalate), intravenous calcium gluconate, insulin with 50% Dextrose.
• Nursing care: monitor patients with low urine output or those taking potassium-sparing diuretics; carefully monitor IV fluid flow rate (not exceeding 10 mEq/hr through peripheral veins); screen lab results.

Solutes (cont.)

• Calcium (Ca2+):
  • Normal range: 9.0 \text{ to } 10.5 \frac{\text{mg}}{\text{dL}}
  • Combined with phosphorus to form mineral salts of bones and teeth.
  • 99% in bones and teeth; 1% in extracellular fluid.
  • Ingested through diet and absorbed through the intestine.
  • Promotes nerve impulse transmission; regulates muscle contraction and relaxation.
  • Reciprocal relationship with phosphorus.

Calcium Imbalance

• Regulated by the parathyroid glands.
• Hypocalcemia:
  • Causes: diarrhea, inadequate dietary intake of calcium or vitamin D, multiple blood transfusions, some diseases (hypoparathyroidism).
  • Signs/Symptoms: neuromuscular irritability, tingling sensation in face/hands, muscle twitches/cramps, positive Trousseau sign, positive Chvostek's sign, seizures, muscle weakness, lightheadedness, and bradycardia.
• Hypercalcemia:
  • Causes: high calcium or vitamin D intake, hyperparathyroidism, immobility.
  • Signs/Symptoms: anorexia, nausea/vomiting, constipation/abdominal pain, increased thirst/frequent urination, fatigue/weakness/muscle pain, confusion/disorientation/difficulty thinking, headaches, depression, and palpitations.

Trousseau Sign

• A test for hypocalcemia. Carpal spasm induced by inflating a blood pressure cuff above systolic blood pressure for a few minutes.

Chvostek's Sign

• A test for hypocalcemia. Tap facial nerve in front of ear. Facial muscle spasm indicates a positive sign.

Solutes (cont.)

• Magnesium (Mg2+):
  • Normal range: 1.3 \text{ to } 2.1 \frac{\text{mEq}}{\text{L}}
  • Cation in bone (50-60%), intracellular fluid (39-49%), and extracellular fluid (1%).
  • Plays a role in carbohydrate and protein metabolism, intracellular energy storage/use, and neural transmission.
  • Important in heart, nerve, and muscle function.

Magnesium Imbalance

• Hypomagnesemia:
  • Causes: decreased gastrointestinal absorption, excessive gastrointestinal loss (vomiting/diarrhea), or increased urinary loss.
• Hypermagnesemia:
  • Causes: excessive use of magnesium-containing medications or intravenous solutions in patients with renal failure or preeclampsia of pregnancy.

Solutes (cont.)

• Nonelectrolytes:
  • Other substances dissolved in body fluids; do not carry an electrical charge.
  • Examples: urea, protein, glucose, creatinine, and bilirubin.

Fluid Gains and Losses

• In healthy adults, 24-hour fluid intake and output are approximately equal.
• Fluids gained by drinking and eating and lost through kidneys, skin, lungs, and gastrointestinal tract.
• Usual adult urine volume is between 1 and 2 L/day, or 1 mL/kg of body weight per hour.
• Water loss varies with solute excretion and antidiuretic hormone level.
• Losses through the skin via sweating.
• Water loss through the lungs by evaporation at 300 to 400 mL/day.
• Usual fluid loss in the gastrointestinal tract is about 100 to 200 mL/day.
• Kidney urine output is about 1500 ml/day.

Diagnostic Tests and Procedures

• Urine studies:
  • Urine pH, specific gravity, osmolality, creatinine clearance tests, urine sodium, and urine potassium.
• Blood studies:
  • Serum hematocrit, serum creatinine, blood urea nitrogen (BUN), serum albumin, serum electrolytes, and blood gas.
  • Hemoconcentration (dehydration).
  • Hemodilution (fluid overload).
• Radiology: Chest X-ray

Compensation

• The process by which the body attempts to correct changes and imbalances in pH levels.
• Full compensation occurs when the pH level of the blood returns to normal (7.35 to 7.45).
• If the pH level is not able to normalize, it is referred to as partial compensation.

Maintenance of Acid-Base Balance

• Chemical (bicarbonate and intracellular fluid) buffers.
• Protein buffers (albumin and globulins).
• Respiratory buffers: hyperventilation/hypoventilation.
• Kidney buffers.

Respiratory Acidosis: Hypoventilation

• Results from respiratory depression (opioids, poisons, anesthetics).
• Clients who have brain tumors, cerebral aneurysm, stroke or overhydration, trauma, or neurologic diseases (myasthenia gravis, Guillain-Barré when respiratory effort is affected).
• Inadequate chest expansion (muscle weakness, pneumothorax/hemothorax, flail chest, obesity, sleep apnea, tumors, or deformities).
• Airway obstruction (neck edema, localized lymph node enlargement, foreign bodies or mucus).
• Alveolar-capillary blockage (pulmonary embolus/thrombus, acute respiratory distress syndrome, chest trauma, drowning, or pulmonary edema).
• Inadequate mechanical ventilation.
• Manifestations:
  • Vital signs: Initial tachycardia/hypertension; bradycardia/hypotension develop as acidosis worsens.
  • Dysrhythmias: Ventricular fibrillation can be the first indication in a client receiving anesthesia.
  • Neurologic: Initial anxiety/irritability/confusion; lethargy/coma develop as acidosis worsens.
  • Respiratory: Ineffective, shallow, rapid breathing.
  • Skin: Pale or cyanotic.
  • Chronic respiratory acidosis seen in clients who have pulmonary disease, sleep apnea, and obesity.

Respiratory Alkalosis: Hyperventilation

• Results from hyperventilation due to fear, anxiety, intracerebral trauma, salicylate toxicity, or excessive mechanical ventilation.
• Hypoxemia from asphyxiation, high altitudes, shock, or early-stage asthma or pneumonia.
• Results in decreased CO2 and decreased or normal H+ concentration.
• Manifestations:
  • Vital signs: Tachypnea.
  • Neurologic: Inability to concentrate, numbness, tingling, tinnitus, and possible loss of consciousness.
  • Cardiovascular: Tachycardia, ventricular, and atrial dysrhythmias.
  • Respiratory: Rapid, deep respirations.

Metabolic Acidosis

• Body retains too many hydrogen ions or loses too many bicarbonate ions; with too much acid and too little base, blood pH falls.
• Causes: starvation, dehydration, diarrhea, shock, renal failure, and diabetic ketoacidosis.
• Signs and symptoms: changing levels of consciousness, headache, vomiting and diarrhea, anorexia, muscle weakness, cardiac dysrhythmias.
• Medical treatment: treat the underlying disorder.
• Nursing care: assessment of vital signs, mental status, and neurologic status. Emergency measures and administer drugs/intravenous fluids as prescribed. Reassure and orient confused patients.

Metabolic Alkalosis

• Increase in bicarbonate levels or a loss of hydrogen ions.
• Loss of hydrogen ions may be from: prolonged nasogastric suctioning, excessive vomiting, diuretics, and electrolyte disturbances.
• Signs and symptoms: headache; irritability; lethargy; changes in level of consciousness; confusion; changes in heart rate; slow, shallow respirations with periods of apnea; nausea and vomiting; hyperactive reflexes; and numbness of the extremities.
• Medical treatment: depends on the underlying cause and severity of the condition.
• Nursing care:
  • Assessment: Take vital signs and daily weight; monitor heart rate, respirations, and fluid gains and losses; keep accurate intake and output records, including the amount of fluid removed by suction; assess motor function and sensation in the extremities; monitor laboratory values, especially pH and serum bicarbonate levels.
  • Intervention: To prevent metabolic alkalosis, use isotonic saline solutions rather than water for irrigating nasogastric tubes because the use of water for irrigation can result in a loss of electrolytes. Provide reassurance and comfort measures to promote safety and well-being.

Nursing Care For all acid-base imbalances

• it is imperative to treat the underlying cause
  Education can vary in relation to the client’s condition.
• Adhere to the prescribed diet and dialysis regimen if with kidney dysfunction.
• Weigh daily and notify the provider if there is a 1- to 2-lb (0.5 to 0.9 kg) gain in 24 hr or a 3-lb (1.4 kg) gain in 1 week.
• Consider smoking cessation if a smoker.
• Take medication as prescribed. Adhere to the medication regimen if with COPD.
• Set up referral services (home oxygen).

Complications

• Convulsions, coma, and respiratory arrest
• Nursing Actions
  • Implement seizure precautions and perform management interventions if necessary.
  • Provide life-support interventions if necessary.

ACID-BASE DISTURBANCES

Arterial Blood Gases

• See separate ABG guide to determine type acid-balance of imbalance

Arterial Blood Gas

• Measure of the O2 & CO2 in the blood
• Measure of the acid-base balance in the blood
• Kidney function
• Respiratory function

ABG - ROME

• Respiratory Opposite
• Metabolic Equal

ABG Tic Tac Toe

• PH: ACID 7.35-7.45 BASE
• CO: BASE 36-45 ACID
• HCOS: ACID 21-23 BASE
• LOW NORMAL HIGH
  *PC02 † OR RESPIRATORY
• HCO OR METABOLIC
• BOTH ↑ AND COMBINED

Arterial Blood Gases

• pH acidosis < 7.4 > Alkalosis
• pH 7.35 – 7.45
• PaCO2 35 – 45 Respiratory
• HCO3 22 – 28 Metabolic
• R Respiratory
  • pH PaCO2 Alkalosis
  • O Opposite
  • pH PaCO2 Acidosis
  • M Metabolic
  • pH HCO3 Alkalosis
  • E Equal (Same)
  • pH HCO3 Acidosis
    Uncompensated: PaCO2 or HCO3 normal
    Partially Compensated: Nothing is normal
    Compensated: pH is normal (7.4 baseline/neutral)

Kidneys (renal)

• Filtration
• Tubular reabsorption
• Tubular secretion
• Renin → Aldosterone
• Aldosterone → Retain sodium & water
• Antidiuretic hormone (ADH)
• Stimulated by ↑ osmolality
• Causes capillaries to reabsorb water
• More concentrated urine and ↓ water excretion

Heart (Cardiac/circulatory)

• Atria monitors for ↑ blood volume via stretching of atria
• Releases atrial natriuretic factor (ANF)
• Stimulates kidneys
• Excrete sodium & water
• Decrease production/release of renin and aldosterone
• Vasodilation
• ↓ blood volume/blood pressure

Thirst

• Regulates intake
• ↑ sodium/↓ water = ↑ osmolality
• ↑ osmolality stimulates the hypothalamus to trigger thirst

Fluid Balance Regulation

ASSESSMENT OF FLUID AND ELECTROLYTE BALANCE

• Vital signs
  • Pulse, respiration, temperature, and blood pressure can indicate changes in fluid and electrolyte balance.
  • Temperature variations can be associated with fluid volume excess or deficit.
  • Pulse rate and quality may change in response to blood volume alterations
  • Electrolyte changes can affect heart rate and rhythm.
  • Blood pressure is directly related to blood volume.
  • Respirations are minimally affected by electrolyte changes.
• Vital signs Pulse
  • rate ~ Fluid volume deficit, sodium deficit, or magnesium deficit
  • rate ~ Magnesium excess or potassium deficit
  • Weak quality, irregular rhythm, and rapid rate ~ severe potassium excess or sodium deficit
  • Bounding quality ~ fluid volume excess
• Vital signs Respiration
  • Dyspnea & tachypnea ~ fluid volume excess can cause pulmonary edema
  • Changes is respiratory function with acid-base imbalances
  • Slow, shallow respirations with intermittent periods of apnea ~ metabolic alkalosis
  • Deep, rapid respirations ~ metabolic acidosis
  • Severe potassium excess or sodium deficit

ASSESSMENT OF FLUID AND ELECTROLYTE BALANCE (CONT)

• Vital signs
  • Temperature
    • Fever ~ metabolic rate ~ fluid loss
    • if also respiratory rate ~ water loss via lung
  • Blood pressure
    • 20 mm Hg in SBP measurements from lying to sitting or standing (orthostatic hypotension ~ fluid volume deficit)
    • Elevated blood pressure may indicate fluid volume excess

ASSESSMENT OF FLUID AND ELECTROLYTE BALANCE (CONT)

• Intake and output
  • Accurate records are essential to determine whether the patient’s intake is equal to output
  • All fluids entering or leaving the body should be noted
  • A changing urine output may reflect attempts by the kidneys to maintain or restore balance, or it may reflect a problem that causes fluid disturbances
  • Urine characteristics also give clues to fluid balance
  • Clear, pale urine in a healthy person suggests the excretion of excess water, whereas darker, concentrated urine indicates the kidneys are retaining water
  • Constipation is possible early sign of dehydration, especially in older adults
• Skin
  • Characteristics
    • Moisture, turgor, and temperature reflect fluid balance.
    • Dry, flushed skin—dehydration.
    • Pale, cool, clammy skin—severe fluid volume deficit that occurs with shock. Moist, edematous tissue seen with excess fluid volume
  • Facial characteristics
    • Severely dehydrated patient has a pinched, drawn facial expression.
    • Soft eyeballs and sunken eyes indicate severely deficient fluid volume.
    • Puffy eyelids and fuller cheeks suggest excess fluid volume

ASSESSMENT OF FLUID AND ELECTROLYTE BALANCE (CONT)

• Skin turgor
  • Measured by pinching the skin over the sternum, the inner aspects of the thighs, or the forehead
  • In patients who are dehydrated, skin flattens more slowly after the pinch is released
• Edema
  • Reflects water and sodium retention, which can result from excessive reabsorption or inadequate secretion of sodium, as may occur with kidney failure
  • Pitting depression remains in the tissue after pressure is applied with a fingertip

ASSESSMENT OF FLUID AND ELECTROLYTE BALANCE (CONT)

• Mucous membranes
  • Tongue turgor
    • In a well person, tongue has one longitudinal furrow.
    • Fluid volume deficit causes additional longitudinal furrows, and the tongue is smaller.
    • Sodium excess causes the tongue to appear red and swollen.
  • Moisture of the oral cavity
    • A dry mouth may be the result of deficient fluid volume or mouth breathing.
  • Veins
    • Appearance of the jugular veins in the neck and the veins in the hands can suggest either a fluid volume deficit or excess.

Dehydration

• Risk factors
  • Causes of isotonic fluid volume deficit (hypovolemia)
    • Excessive gastrointestinal (GI) loss: vomiting, nasogastric suctioning, diarrhea
    • Excessive skin loss: diaphoresis without sodium and water replacement
    • Excessive renal system losses: diuretic therapy, kidney disease, adrenal insufficiency
    • Third spacing: burns
    • Hemorrhage or plasma loss
    • Altered intake: anorexia, nausea, impaired swallowing, confusion, nothing by mouth (NPO) (decreased intake of water and sodium)
• Causes of dehydration
  • Hyperventilation or excessive perspiration without water treatment
  • Prolonged fever
  • Diabetic ketoacidosis
  • Insufficient water intake (enteral feeding without water administration, decreased thirst sensation, aphasia)
  • Diabetes insipidus
  • Osmotic diuresis
  • Excessive intake of salt, salt tablets, or hypertonic IV fluids

Hypovolemia

• Expected Findings
  • Vital signs: Hypothermia, tachycardia (in an attempt to maintain a normal blood pressure), thready pulse, hypotension, orthostatic hypotension, decreased central venous pressure, tachypnea (increased respirations to compensate for lack of fluid volume within the body), hypoxia
  • Neuromusculoskeletal: Dizziness, syncope, confusion, weakness, fatigue
  • Gastrointestinal: Thirst, dry furrowed tongue, nausea, vomiting, anorexia, acute weight loss
  • Renal: Oliguria (decreased production and concentration of urine)
• Laboratory Tests
  • With fluid loss due to hemorrhage, hemoconcentration does not occur.
    • Hematocrit (Hct): Increased in hypovolemia
    • BUN: Increased (greater 25 mg/dL) due to hemoconcentration
    • Urine specific gravity: Greater than 1.030
    • Blood sodium: Greater than 145 mEq/L with dehydration
    • Blood osmolality: Greater than 295 mOsm/kg with dehydration/hypernatremia

Management of Hypovolemia

• Provide oral or IV rehydration therapy.
• Monitor I&O.
• Monitor vital signs. Check orthostatic measurements, as a client is at increased risk of falls when orthostatic hypotension present.
• Monitor for changes in mentation and confusion (an indication of worsening fluid imbalance).
• Monitor weight while fluid replacement is in progress.
• Monitor level of gait stability. Encourage the client to use call light and ask for assistance because of the increased risk for falls. QS Encourage the client to change positions, rolling from side to side or standing up slowly

Complications of Hypovolemia

• Hypovolemic shock
  • Occurs with significant loss of body fluid. The client’s mean arterial pressure decreases (which slows blood flow and perfusion to tissues of the body) and the cells are no longer able to carry oxygen to the blood adequately (due to the loss of red blood cells).
  • Volume replacement is essential.
  • Administer oxygen, and monitor oxygen saturation. Oxygen saturation less than 70% is a medical emergency.
  • Stay with an unstable client suffering from hypovolemic shock.
  • Monitor vital signs at least every 15 min.
  • Provide fluid replacement with the following.
    • Colloids: whole blood, packed RBCs, plasma, synthetic plasma expanders
    • Crystalloids: lactated Ringer’s, normal saline
  • Assist with administering vasoconstrictors (dopamine, norepinephrine, phenylephrine), agents to improve myocardial perfusion (sodium nitroprusside), and/or positive inotropic medications (dobutamine, milrinone).
  • Maintain hemodynamic monitoring.

Overhydration

• Too much fluid in the body from excessive intake or ineffective removal from the body
  Fluid overload is an excess of fluid or water, such as with water intoxication. This includes hemodilution, which makes the amount of blood components (blood cells, electrolytes) seem lower.
  Hypervolemia, or fluid volume excess, involves an excess of water and electrolytes, so that the two are still in the right proportions. For example, excessive sodium intake causes the body to retain water, so that there is too much of both.
  Clients who have fluid overload are at risk for developing pulmonary edema or congestive heart failure. In older adult clients, the risk of fluid imbalance is greater due to changes in the body with age (such as reduced kidney function)

Risks and causes of Overhydration

• Compromised regulatory systems (heart failure, kidney disease, cirrhosis)
• Overdose of fluids (oral, enteral, IV)
• Fluid shifts that occur following burns
• Prolonged use of corticosteroids
• Severe stress
• Hyperaldosteronism Causes of overhydration
• Water replacement without electrolyte replacement, excessive water intake (forced or psychogenic polydipsia)
• Syndrome of inappropriate antidiuretic hormone (SIADH)
• Excessive administration of IV D5W; use of hypotonic solutions for irrigations

Expected Findings of Overhydration

• Fluid volume overload Vital signs: Tachycardia, bounding pulse, hypertension, tachypnea, increased central venous pressure
• Neuromuscular: Weakness, visual changes, paresthesia, altered level of consciousness, seizures (if severe, sudden hyponatremia/water excess)
• Gastrointestinal: Ascites, increased motility, liver enlargement
• Respiratory: Crackles, cough, dyspnea Other signs: Peripheral edema due to an excess of fluids within the body and lungs, resulting in weight gain, distended neck veins, and increased urine output, skin cool to touch with pallor

Tests related to Overhydration

• Laboratory tests
  • Decreased Hct and Hgb
  • Decreased blood osmolarity with water/fluid excess
  • Decreased urine sodium and specific gravity
  • Decreased BUN due to plasma dilution
• Diagnostic Procedures
  • Chest x-ray: Reveals possible pulmonary congestion

Nursing Management for Overhydration

• Monitor I&O.
• Monitor daily weight. A weight gain or loss of 1 kg (2.2 lb) in 24 hr is equivalent to 1 L of fluid.
• Monitor breath sounds.
• Monitor peripheral edema.
• Maintain sodium-restricted diet as prescribed (indicated for isotonic/fluid volume excess).
• Maintain fluid restrictions if prescribed.
• Encourage rest.
• Monitor clients receiving diuretics.
• Encourage the client to discuss use of over-the-counter medications with the provider, as some of these contain sodium.
• Position the client in the semi-Fowler’s or Fowler’s position and reposition to prevent tissue breakdown in edematous skin.
• Use a pressure-reducing mattress and monitor bony prominence on a regular basis.
• Monitor blood sodium and potassium levels.

Complications of Overhydration

• Pulmonary edema
  • Pulmonary edema can be caused by severe fluid overload. Manifestations include anxiety, tachycardia, increased neck vein distention, premature ventricular contractions, dyspnea at rest, change in level of consciousness, restlessness, lethargy, breath sounds with moist crackles, and cough productive of frothy, pink-tinged sputum.

Nursing Actions

*   Position the client in high-Fowler’s to maximize ventilation. QEBP
*   Administer oxygen, positive airway pressure, and/or possible intubation and mechanical ventilation.
*   Assist with the administration of morphine, nitrates, and diuretic as prescribed if blood pressure is adequate.

AGE-RELATED CHANGES AFFECTING FLUID BALANCE

• Aging kidney slower to adjust to changes in acid-base, fluid, and electrolyte balances
• Older adult often has a reduced sense of thirst and therefore may be in a state of chronic dehydration
• Total body water declines with age; greatest loss from the intracellular fluid compartment
• Older person has limited reserves to maintain fluid balance when abnormal losses occur
• Antihypertensives, diuretics, and antacids can also contribute to imbalances