1
Fluid and Electrolyte Balance
Objectives
At the completion of this module, the student will be able to: 1. Describe Describe normal normal laborato laboratory ry values values for commonly commonly ordered ordered electrolyt electrolytes. es. 2. Discuss Discuss the the major major functions functions of serum serum sodium sodium and potassi potassium. um. 3. List the the potential potential complication complicationss associated associated with with the loss of electrol electrolytes ytes from from the gastrointestinal (GI) tract. 4. State the the nursing nursing implicatio implications ns for monitor monitoring ing a client client with fluid fluid and electr electrolyte olyte imbalances.
Case Study
C. Morris is a 53-year-old woman who has been suffering from Crohn’s disease for the past 25 years. She lives with her husband of 30 years. She experiences periods of acute of acute symptoms of Crohn’s Crohn’s disease several times a year and currently is taking prednisone taking prednisone 10 mg bid. The Crohn’s disease is currently under control. For the past week Mrs. Morris has been experiencing GI pain GI pain and a burning sensation in her stomach. This morning she woke up vomiting profusely, and her emesis contained a large amount of bright red blood. b lood. Her husband called her physician and was instructed to bring her to the hospital immediately. Mrs. Morris was admitted with a diagnosis of peptic ulcer and ulcer and upper GI bleeding related to the prolonged use of corticosteroids. of corticosteroids. Admission vital signs are BP 130/80, P 88, R 24. Physician’s order includes NPO, nasogastric n asogastric (NG) tube to low suction, flush NG tube with 30 to 50 ml saline solution for irrigation q2h prn to keep tube patent; IV 1000 cc lactated Ringer’ Ringer ’s, infuse at 125 ml/hour, cefoperazone (Cefobid) (Cefobid) 2 g q12h IVPB, hydrocortisone (Solu-Cortef) (Solu-Cortef) 25 mg Intravenous Push (IVP) qd. Electrolytes Electrolytes:: sodium,, potassium sodium potassium,, chloride chloride,, calcium calcium,, magnesium magnesium,, hemoglobin, and hematocrit daily for 3 days. Indwelling urinary catheter , intake and output (I&O) (I&O),, hourly output, type and crossmatch 2 units of packed cells and hold until further orders. During the evening shift the nurse’s assessment indicates these findings: a weak, mildly confused female. The vital signs are relatively unchanged, excep t the pulse is irregular. The NG tube is draining a moderate amount of coffee of coffee ground material, and the nurse notes that the urine in the drainage bag is dark yellow. The husband expresses concern a bout his wife’s confusion. Results of lab work are:
Sodium 130 mEq/L (normal range 135 to 145mEq/L) Potassium 2.8 mEq/L (normal range 3.5 to 5mEq/L) Chloride 92 mEq/L (normal range 96 to 106mEq/L) Calcium 9 mg/dl (normal range 8.2 to 10.2 mg/dl) Magnesium 1.3 mEq/L (normal range 1.3 to 2.1 mEq/L) Hemoglobin 9 g/dl (normal range 12 to 16 g/dl) Hematocrit 27% (normal range 38% to 47%)
2 Problems/Nursing Diagnoses Based on the data in the case study for Mrs. Morris, what problem/nursing diagnosis do you wish to address first? Choose the three nursing diagnoses with the highest priority.
Deficient Fluid Volume Deficient Fluid Volume. Yes, this is a priority diagnosis. Mrs. Morris had experienced profuse vomiting prior to admission. She also has an NG tube to low suction, which is pulling out both fluid and electrolytes from the stomach. Results of lab tests show hypokalemia, hyponatremia, and borderline hypomagnesemia. Her urine is dark yellow. Risk for Infection Risk for Infection. Yes, this is a priority problem. Corticosteroid therapy depresses the inflammatory response, putting clients at risk for infection. Acute Confusion Acute Confusion. Yes, this is a priority problem. Fluid losses from vomiting and NG tube suctioning have led to hyponatremia and hypokalemia. Sodium and potassium imbalances have a direct effect on central nervous system functioning. Loss of blood volume from bleeding and vomiting decreases circulation to the brain and leads to decreased cerebral perfusion. Clinical Decisions Based on the data, what do you wish to accomplish? Choose three priority outcomes.
Outcome: Rationale:
Fluid volume and electrolyte levels will be within normal limits. Decrease in body fluid and electrolyte imbalance can lead to serious cardiac and other systemic complications.
Outcome: Rationale:
Client will be free from infection during hospitalization. Infection places stress on an already compromised immune system.
Outcome: Rationale:
Client will be oriented to time, place, and person. Fluid volume deficit and electrolyte imbalance can affect mental functioning.
Based on data for Mrs. Morris, the nursing diagnosis of Deficient Fluid Volume, and the expected outcomes you have identified, which actions will you take?
Intervention: Administer and monitor IV fluids of lactated Ringer’s as ordered. Rationale: IV therapy is a direct and effective way to replace fluids and electrolytes. Electrolyte replacement is essential to prevent cardiac complications. Intervention: Monitor lab results closely. Rationale: It is important for the nurse to closely monitor serum electrolyte results. When there is trauma to the cells, potassium moves out of the cells into the extracellular fluid. Potassium levels can change rapidly as fluid and electrolyte replacement
3 takes place. Intervention: Take apical pulse for 1 full minute with vital signs and report any irregularities. Rationale: Potassium imbalance puts the client at risk for cardiac complications. Early detection of signs and symptoms of imbalance (irregularity in cardiac rhythm) and intervention can prevent further complications. Based on data for Mrs. Morris, the nursing diagnosis of Risk for Infection, and the expected outcomes you have identified, which actions will you take?
Intervention: Use proper handwashing techniques before and after client contact. Rationale: Studies show that handwashing is an important factor in reducing the transmission of infections. Intervention: Administer antibiotic IV piggyback per physician’s orders. Rationale: Timely administration of antibiotic therapy will maintain therapeutic levels in the body. Intervention: Frequently monitor client for signs and symptoms of infection such as elevated temperature, complaints of sore throat, redness, swelling at IV insertion site, and elevated white blood count (WBC), etc. Rationale: Early detection and treatment of infection promotes healing. Based on data for Mrs. Morris, the nursing diagnosis of Acute Confusion, and the expected outcomes you have identified, which actions will you take?
Intervention: Assess and document levels of consciousness every 1 to 2 hours. Rationale: Level of consciousness is a significant way to evaluate central nervous system function. With accurate documentation, the nurse can see a pattern of increased or decreased mental function. Intervention: Provide regular periods of orientation and plan nursing management that is routine and predictable. Rationale: It is beneficial to the confused client to provide a regimen that is consistent and routine. Intervention: Educate the family as to the nature of the client’s mental status and how to support the client. Rationale: Understanding of the client’s condition will assist the family with coping mechanisms and facilitate support for the client. Content Mastery 1. The nurse checks the results of lab tests for Mrs. Morris and notes that the potassium level is 2.8 mEq/L. After reporting this finding to the physician, the nurse assesses the client for: a. a weak, irregular pulse. b. increased peristalsis.
4 c. a bounding pulse. d. hypertension. Answers and Rationales 1a. Correct: A low potassium level can cause electrographic changes. 1b. Incorrect: Increased peristalsis is not caused by low potassium. 1c. Incorrect: A bounding pulse is seen in conditions that cause hypervolemia. 1d. Incorrect: This is not a finding associated with hypokalemia.
2. The physician’s order reads flush NG tube with 30 to 50 ml saline solution for irrigation q2h prn. The nurse knows that saline solution is used instead of water because: a. flushing with water can deplete electrolytes in the stomach. b. water is irritating to the gastric mucosa. c. the sterility of the stomach is maintained with saline solution. d. saline is better in maintaining tube patency. Answers and Rationales 2a. Correct: Saline is preferred to minimize the risk of electrolyte depletion. 2b. Incorrect: Water does not irritate the gastric mucosal lining. 2c. Incorrect: This is not an appropriate response for using saline solution instead of water. 2d. Incorrect: Saline, water, and even air can assist in maintaining tube patency.
3. Mrs. Morris is started on hydrocortisone 25 mg Intravenous push IVP. The primary reason for administering this drug to Mrs. Morris is that: a. it is a corticosteroid and will make Mrs. Morris feel better. b. Mrs. Morris needs to continue on corticosteroids, but have a different administration route due to nausea. c. it will protect Mrs. Morris from infection. d. it will replace the loss of electrolytes through the GI tract. Answers and Rationales 3a. Incorrect: Although Mrs. Morris may feel better with the administration of this drug, this is not the primary reason that it was ordered for Mrs. Morris. 3b. Correct: Mrs. Morris was on prednisone, a corticosteroid, at home. Corticosteroids should not be discontinued abruptly and because she is unable to take the medication orally, the corticosteroid will be administered intravenously. 3c. Incorrect: Corticosteroids decrease the body’s inflammatory response and place clients at risk for infection. 3d. Incorrect: Corticosteroids do not replace loss of electrolytes.
4. Mrs. Morris is given intravenous fluids of lactated Ringer’s solution. Which of the following describes the properties of lactated Ringer’s? a. Lactated Ringer’s contains electrolytes and is a hypertonic solution. b. Lactated Ringer’s is a hypotonic solution used for fluid volume replacement. c. Lactated Ringer’s provides fluid and does not contain electrolytes. d. Lactated Ringer’s is an isotonic solution and provides electrolytes.
5
Answers and Rationales 4a. Incorrect: This statement does not describe the properties of lactated Ringer’s. 4b. Incorrect: This statement does not describe the properties of lactated Ringer’s. 4c. Incorrect: This statement does not describe the properties of lactated Ringer’s. 4d. Correct: Lactated Ringer’s is an isotonic solution that contains multiple electrolytes in roughly the same concentrations as found in plasma (contains no magnesium or phosphorus).
5. The nurse notes that Mrs. Morris’s NG tube is draining a moderate amount of coffee ground material. The appearance of coffee ground gastric drainage indicates: a. active gastric bleeding. b. bleeding from the lower GI tract. c. stasis of digested foods. d. blood that has begun to be digested by the gastric secretions. Answers and Rationales 5a. Incorrect: Active bleeding is red. 5b. Incorrect: Lower GI bleeding is manifested in the color of the stool. 5c. Incorrect: This statement does not explain the appearance of coffee ground drainage. 5d. Correct: Coffee ground–like gastric drainage reflects blood that has begun to be digested by the gastric secretions in the stomach.
6. The nurse understands that clients who are hypovolemic can manifest a: a. low hematocrit level. b. high hematocrit level. c. normal hematocrit level. d. hematocrit level that is unaffected by fluid volume. Answers and Rationales 6a. Incorrect: A low hematocrit level is seen with excessive loss of erythrocytes, as in anemia or excessive loss of blood. 6b. Correct: A high hematocrit level is seen with a reduction in the plasma fluid volume. 6c. Incorrect: The hematocrit level is affected by the excessive loss of body fluid. 6d. Incorrect: The hematocrit level is affected by the excessive loss of body fluid.
7. Chloride is found abundantly in the body. Which statement is correct regarding chloride? a. Chloride is found in the intracellular fluid and helps to maintain water balance. b. Chloride is found in the extracellular fluid and helps to maintain water balance and acid base balance. c. During periods of excessive loss of fluids, such as vomiting, chloride is not depleted. d. Chloride is the major intracellular anion that works with sodium to regulate water balance. Answers and Rationales 7a. Incorrect: This statement is not correct regarding chloride. 7b. Correct: This statement describes the major function of chloride.
6 7c. Incorrect: Chloride is found in the GI tract; vomiting causes loss of chloride. 7d. Incorrect: This statement is not correct regarding chloride. 8. Sodium is found abundantly in the body. Which statement is correct regarding sodium? a. Sodium is found in the intracellular fluid and helps to maintain water balance. b. Sodium is regulated by the amount of daily oral intake. c. Sodium regulation is controlled only by the kidneys. d. Sodium is found in the extracellular fluid and helps to maintain water balance. Answers and Rationales 8a. Incorrect: This statement is not correct regarding sodium. 8b. Incorrect: This statement is not correct regarding sodium. 8c. Incorrect: The posterior pituitary and the hypothalamus also regulated sodium. 8d. Correct: Sodium is found primarily in the extracellular fluid and helps to maintain water balance in the body.
9. A client has experienced vomiting and diarrhea for several days. The nurse understands that the nursing interventions should include safety precautions because hypovolemia can lead to: a. shortness of breath and pedal edema. b. decreased cerebral circulation and postural hypotension. c. abdominal distention and rapid pulse. d. twitching and weak muscles. Answers and Rationales 9a. Incorrect: Shortness of breath and pedal edema are not present in hypovolemia. 9b. Correct: Loss of fluid volume can cause a decrease in cerebral perfusion and the client may experience postural hypotension. 9c. Incorrect: Abdominal distention is not a sign or symptom associated with hypovolemia. Pulse irregularity may be seen if electrolytes, such as potassium, are affected. 9d. Incorrect: Twitching and weak muscles are associated with electrolyte imbalance.
10. On admission a client was confused and weak and complained of fatigue. Lab tests showed hypokalemia and hyponatremia. After 2 days of IV therapy and electrolyte replacement, the client tells the nurse that she feels much better. The most appropriate way to evaluate electrolyte balance in a client is to: a. assess the client’s level of orientation and her ability to respond appropriately to simple questions. b. compare the client’s vital sign readings, especially the pulse, to those taken on admission. c. monitor lab results from admission to the most recent values. d. review the nurse's document indicating improved skin turgor and mucous membranes. Answers and Rationales 10a. Incorrect: Although this nursing intervention can assist in evaluating client improvement, it is not the most appropriate way to evaluate electrolyte balance. 10b. Incorrect: Although this nursing intervention can assist in evaluating client improvement, it is not the most appropriate way to evaluate electrolyte balance.
7 10c. Correct: This nursing intervention will provide the nurse with the appropriate data to evaluate electrolyte balance. 10d. Incorrect: Although this nursing intervention can assist in evaluating client improvement, it is not the most appropriate way to evaluate electrolyte balance.
Essay Questions Discuss the major functions of serum sodium and potassium.
Sodium is the major electrolyte outside the cell and is involved in many of the body’s functions. For example, sodium is vital for the conduction and transmission of nerve impulses, in maintaining the osmotic pressure of the extracellular fluid, in the regulation and concentration of other electrolytes such as potassium and chloride, and in maintaining acid-base balance. Its major role is in maintaining water balance in the body. Sodium homeostasis is regulated by the functions of the kidney, posterior pituitary, and the hypothalamus. The serum sodium concentration is normally 140 mEq/L. Potassium is the major electrolyte inside the cell and is vital for the transmission and conduction of electrical impulses in skeletal and cardiac muscle. Potassium plays a role in controlling osmotic pressure and is involved in maintaining acid-base balance. Because potassium is not stored in the body, foods rich in potassium must be ingested daily. When the potassium level drops below normal (3.5 mEq/L), cardiac muscle contraction is affected and electrocardiogram changes are evident. Discuss the potential complications of fluid and electrolyte loss and the nursing interventions associated with the care of a client who is experiencing excessive vomiting.
Excessive vomiting and diarrhea can place the client at risk for fluid and electrolyte imbalances. The gastric acid in the stomach contains potassium, sodium, chloride, and hydrogen ions. Excessive loss of these electrolytes can lead to dehydration, metabolic alkalosis, hyponatremia, and hypokalemia. The nurse needs to monitor the client for signs of fluid volume deficit, which include assessing the client’s skin turgor and oral mucous membranes, monitoring the intake and output, and checking the color and amount of urine. It is important to provide comfort measures such as rinsing the mouth, removing soiled linens, and administering an antiemetic to the client after an episode of vomiting. When the client is allowed or can tolerate oral intake, the nurse needs to provide the client with clear fluids initially to assess how well the client can tolerate this intake. The oral intake may be progressed based on the client’s tolerance and on the physician’s order. If there is an excessive loss of potassium, the client is at risk for cardiac irregularities, therefore the vital signs, especially the pulse, should be monitored regularly. In addition, excessive loss of fluid can lead to dehydration and hyponatremia. Clients with excessive fluid loss through vomiting should be monitored for signs and symptoms of hyp onatremia, which may lead to hypotension, confusion, muscle weakness, and changes in the rate, rhythm, and quality of the pulse.
8
The nurse needs to carefully monitor any intravenous fluids ordered for the client to ensure that the appropriate fluid replacement is achieved and carefully monitor the client’s electrolyte values.
