Interventions for Clients with Fluid and Electrolyte imbalances
Deficient Fluid Volume
Deficient fluid volume (DFV) exists when the client experiences vascular, interstitial, or intracellular dehydration. The degree of dehydration is classified as mild, marked, severe, or fatal on the basis of the percentage of body weight lost. There are three types of dehydration based on the proportion of fluid and particles in the intracellular and extracellular spaces (see the accompanying display). Kleiner (1999) reports that a portion of the general population may be chronically mildly dehydrated based on the Nationwide Food Consumption Surveys. According to Sansevero (1997), approximately 1 million elderly people a year are admitted to hospitals with iso- tonic dehydration, and 19% of emergency room admissions were prompted by dehydration, frequent falling, or failure to care for self. Mild dehydration, as little as 2% loss of body weight, results in impaired physiological and performance responses, and may be misinterpreted as a sign of aging and not hydration status (Kleiner, 1999).
findings in the client with DFV include thirst and weight loss, with the amount
varying with the degree of dehydration. With marked dehydration, the mucous
membranes and skin are dry. There is poor skin turgor; low-grade temperature
elevation; tachycardia; respirations 28 or greater; a decrease (10–15 mm Hg) in
systolic blood pressure; slowing in venous filling; a decrease in urine (less
than 25 ml per hour); concentrated urine; elevated Hct, Hgb, BUN, and an acid
blood pH (less than 7.4). Severe dehydration is characterized by the symptoms
of marked dehydration. Also, the skin becomes flushed. The systolic blood
pressure continues to drop (
NURSING DIAGNOSES FOR FLUID ALTERATIONS
Excess Fluid Volume related to:
• Excessive fluid intake secondary to excess sodium intake
• Compromised regulatory mechanism (renal and cardiac dysfunction)
• Inaccurate intravenous infusion rate
Deficient Fluid Volume related to:
• Excessive fluid loss secondary to vomiting, blood loss, surgical drains and tubes, diarrhea, and diuretics
Risk for Deficient Fluid Volume related to:
• Extremes of age (very young or old) and weight
• NPO and fluid restrictions
• Increased fluid output from normal routes: vomiting, diarrhea, urine
• Increased fluid losses from drainage or suction routes: wounds, drains, indwelling tubes (e.g., urine catheter, nasogastric suction)
• Loss of plasma associated with severe trauma and burns
• Disorders that impair fluid intake or absorption (immobility, unconsciousness)
• Chronic disorders: congestive heart failure, pulmonary edema, chronic obstructive lung disease, renal failure, diabetes, cancer, transplant candidates
• Deficient knowledge related to factors influencing fluid requirements (hypermetabolic states, hyperthermia, and dry, hot environment)
• Medications (e.g., diuretics)
Risk for Deficient Fluid Volume
Risk for fluid volume deficit exists when the client is at high risk of developing vascular, interstitial, or intracellular dehydration resulting from active or regulatory losses of body water in excess of needs. The multiple factors that can place the client at risk for FVD are listed in the preceding accompanying display.
Other Nursing Diagnoses
The relationship between the primary nursing diagnoses just discussed and the secondary diagnoses in clients with fluid imbalances are reciprocal: The primary diagnoses influence and are influenced by the secondary diagnoses. Holistic nursing requires that all diagnoses relative to clients be considered when developing their plan of care.
Impaired Gas Exchange
Impaired gas exchange related to a ventilation perfusion imbalance occurs when clients experience a decreased passage of oxygen or carbon dioxide between the alveoli of the lungs and the vascular system. This alteration is assessed by measuring the oxygen and carbon dioxide content through arterial blood gas analysis or pulse oximetry or both
Decreased Cardiac Output
Decreased cardiac output occurs when the blood pumped by a client’s heart is reduced so much that it is inadequate to meet the needs of the body’s tissue. This alteration may be caused by heart failure and various types of shock. Assessment findings may include low blood pressure; cool, clammy skin; weak, thready pulses; decreased urinary output; and a diminished level of consciousness.
Risk for Infection
Many disorders may place the client at risk for invasion by pathogenic organisms. Clients receiving IV therapy are at risk for an infection because their primary defense, the skin, is broken at the puncture site. Assessment findings indicative of IV site infection are client complaints of soreness around site, erythema, swelling at site, and foul-smelling discharge.
Impaired Oral Mucous Membrane
Altered oral mucous membrane occurs when a client experiences disruption in the tissue layers of the oral cavity. It is frequently related to dehydration. Assessment findings may include: oral pain or discomfort; stomatitis; and decreased salivation.
Loss of Gastric Juices
Clients who lose excessive amounts of gastric juices, either through vomiting or suctioning, are prone to develop not only DFV but also metabolic alkalosis, hypokalemia, and hyponatremia; gastric juices contain hydrochloric acid, pepsinogen, potassium, and sodium.
A knowledge deficit may exist to varying degrees in clients with fluid imbalances. Information obtained from a client’s health history may indicate the client’s level of understanding and perception of these alterations and direct teaching. Clients need to participate actively in their plan of care.
PLANNING AND OUTCOME
Holistic nursing care for clients experiencing fluid imbalances requires that the nurse, in collaboration with each client, identify specific goals for the nursing diagnosis. These goals should be individualized to reflect the client’s capabilities and limitations and should be appropriate to the diagnosis as determined by the assessment data. During the planning phase, the nurse also selects and prioritizes nursing interventions to support the client’s achievement of expected outcomes based on the goals. For example, if vomiting and diarrhea, with a weight loss of 5% and dry mucous membranes, led to a diagnosis of Deficient Fluid Volume, then goals might include relief from vomiting and diarrhea and achievement of the proper fluid balance of intake and output. Expected outcomes for clients with fluid imbalances are not only specific to their primary diagnosis but also require inclusion of outcomes relative to interventions. An expected outcome for clients receiving IV therapy might read: IV site remains free from erythema, edema, and purulent drainage, because these clients are at risk for infection. Achievement of the goals and the client’s expected outcomes indicates resolution of the problem.
Nurses have the responsibility to collaborate with and advocate for clients to assure that they receive care that is appropriate, ethical, and based on practice standards. Nurses rely heavily on the data obtained from the history in formulating expected outcomes and selecting appropriate nursing interventions to support the clients’ natural patterns as revealed in their history. The rationale for interventions related to alterations in either body fluid or electrolytes is based on the goal of maintaining homeostasis and regulating and maintaining essential fluids and nutrients. The nurse capitalizes on the clients’ adaptive capabilities by selecting interventions based on the clients’ perception of their support, strengths, and options. Bulechek and McCloskey (1999) address the importance of the nursing interventions relative to fluid therapy by identifying the nurse’s responsibilities to:
• Understand the client’s metabolic needs and to make judgments concerning the outcomes of therapy
• Perform frequent assessment and monitoring to recognize the adverse effects of fluid and electrolyte therapy and prevent complications
• Prevent the rapid depletion of the body’s protein and energy reserves
The nursing activities relative to assessment and implementation often require the same measurements: for example, weight and vital signs. Common interventions that promote attainment of expected outcomes to restore and maintain homeostasis are discussed next.
Monitor Daily Weight
Daily weight is one of the main indicators of water and electrolyte balance. The nurse is responsible for the accurate measurement and recording of daily weights; the health care practitioner uses these data with other clinical findings in determining the client’s fluid therapy.
Measure Vital Signs
The frequency of measuring the vital signs is dependent upon the client’s acuity level and clinical situation. For example, the vital signs of the typical postoperative client might be taken every 15 minutes until stable, whereas a client experiencing shock or hemorrhage should have vital signs monitored continuously. Vital sign measurements and other clinical data are used to determine the type and amount of fluid therapy.
Measure Intake and Output
Intake and output measurements are initiated to monitor the client’s fluid status over a 24-hour period (see Procedure 37-1 for information on how to measure the I&O). Agency policy relative to I&O may vary with regard to:
• The time frames for charting (e.g., every 8 hours versus every 12 hours)
• The time at which the 24-hour totals are calculated
• The definition of “strict” I&O
“Strict” I&O measurement usually involves accounting for incontinent urine, emesis, and diaphoresis and might require weighing soiled bed linens. Don gloves before handling soiled linen. The nurse reviews the client’s 24-hour I&O calculations to evaluate fluid status. Intake should exceed the output by 500 ml to account for insensible body loses. I&O and daily weights are critical components of intervention because these measurements are also used to evaluate the effectiveness of diuretic or rehydration therapy.
Securing an accurate I&O requires the full support of the client and his or her family. The client and family members should be taught how to measure and record the intake (see the accompanying display for special home health care considerations).
Provide Oral Hygiene
The nurse is responsible for providing oral hygiene to promote client comfort and integrity of the buccal cavity. Refer to Chapter 31 for the procedure on oral hygiene. The frequency of oral hygiene depends on the condition of the client’s buccal cavity and the type of fluid imbalance. A client who is dehydrated or NPO for more than 24 hours may have decreased or absent salivation, coated tongue, and furrows on the tongue. These clients are at risk for developing oral diseases such as stomatitis, oral lesions or ulcers, and gingivitis.
Initiate Oral Fluid Therapy
Oral fluids may be totally restricted—a situation commonly referred to as nothing by mouth (NPO, which is from the Latin non per os)—or they may be restricted or forced, depending on the client’s clinical situation. For example, oral replacement therapy is often used for clients with mild dehydration. According to Hugger, Harkless, and Rentschiler (1998), oral rehydration therapy has a very high success rate in the treatment of childhood diarrhea with mild to moderate dehydration, and it has fewer complications when compared to intravenous replacement therapy. Severe dehydration in children is a medical emergency and must be treated with intravenous replacement therapy.
Nothing by Mouth
Clients are placed NPO status as prescribed by the health care practitioner. On the basis of agency policy and clarification with the health care practitioner, the client may be allowed small amounts of ice chips or medications with a sip of water when NPO. Common clinical situations that may require NPO status include the need to:
• Avoid aspiration in unconscious, perioperative, and preprocedural clients who will receive anesthesia or conscious sedation
• Rest and heal the gastrointestinal (GI) tract in clients with severe vomiting or diarrhea or when the client has a GI disorder (inflammation or obstruction)
• Prevent the further loss of gastric juices in clients with nasogastric suctioning NPO clients should receive oral hygiene every 1 to 2 hours or as needed for comfort and to prevent alterations of the mucous membranes.
APPLICATION: HOME CARE
Considerations for Measuring I&O
• Elicit client and family member input when selecting household items to be used for intake measurement.
• Provide containers for measuring output; adapt the urinary container to home facilities, and include teaching relative to proper washing and storage.
• Teach handwashing technique.
• Provide written instructions on what is to be measured.
• Provide sufficient I&O forms to last between the nurse’s visits.
• Identify the parameters for evaluating a discrepancy between the intake and output and for notifying the nurse or health care practitioner.
Remove Gloves before Charting
Remove gloves and wash hands before recording the amount of drainage on the I&O form, to prevent the transfer of microorganisms when the form is removed from the client’s room.
Intake may be restricted to 200 ml over a 24-hour period; intake is commonly restricted in the treatment of EFV related to heart and renal failure. Client and family teaching and collaboration are the main nursing interventions in implementing this measure. How the nurse limits the fluids should be determined in collaboration with the client. For example:
• Fifty percent of the allowed fluids might be taken at breakfast and lunch.
• The remaining 50% might be taken with the evening meal, before bedtime, unless the client has to be awakened during the night for a medication.
Forcing or encouraging the intake of oral fluids, mainly water, may be done when treating elderly clients who are at risk for dehydration and clients with renal and urinary problems, for example, kidney stones. Compliance is obtained by client education and preference relative to timing and the type of liquids. A client might, for example, be requested to consume 2,000 ml over a 24-hour time period. If the client is intimidated on hearing this amount, which may sound very large, explain that the number of glasses to which this volume equates is only eight. Follow a similar time frame as set forth for restricted fluids, with the largest quantity of fluids administered with meals. Ice, gelatin, and ice cream count as liquid intake.
Maintain Tube Feeding
When the client cannot ingest oral fluids and has a normal GI tract, fluids and nutrients can be administered through a feeding tube as prescribed by a health care practitioner. Refer to Chapter 38 for a complete discussion of feeding tubes.
Monitor Intravenous Therapy
When fluid losses are severe or the client cannot tolerate oral or tube feedings, fluid volume is replaced parenterally through the intravenous route. Intravenous (IV) therapy is the administration of fluids, electrolytes, nutrients, or medications by the venous route. The health care practitioner prescribes IV therapy to treat or prevent fluid and electrolyte or nutritional imbalances. The nurse has specific responsibilities relative to IV therapy (see the accompanying Nursing Process Highlight). The Intravenous Nurses Society (INS) is the professional organization that establishes standards of practice to promote excellence in intravenous nursing to ensure the highest quality, cost-effective care for all individuals requiring infusion therapies (INS, 2000). INS standards of practice direct the development of agency policy/protocols in accordance with state and federal regulations and should complement the manufacturer’s direction for usage. The nurse should review the agency’s protocols before gathering the equipment. IV therapy requires parenteral fluids (solutions) and special equipment: administration set, IV pole, filter, regulators to control IV flow rate, and an established venous route.
The nurse confirms the type and amount of IV solution by reading the health care practitioner’s prescription in the medical record. IV solutions are sterile and packaged in plastic bags or glass containers. Solutions that are incompatible with plastic are dispensed in glass containers. Plastic IV solution bags collapse under atmospheric pressure to allow the solution to enter the infusion set. Plastic solution bags are packaged with an outer plastic bag, which should remain intact until the nurse prepares the solution for administration. When the plastic solution bag is removed from its outer wrapper, the solution bag should be dry. If the solution bag is wet, the nurse should not use the solution. The moisture on the bag indicates that the integrity of the bag has been compromised and that the solution cannot be considered sterile. The bag should be returned to the dispensing department that issued the solution. Glass containers are discussed in the section on equipment. IV solutions are usually packaged in quantities ranging from 50 to 1,000 ml. The nurse should select a container that has the prescribed amount of solution or select several containers that together contain the prescribed volume. At no time should the nurse select a container Implementation of IV Therapy
• Know why the therapy is prescribed.
• Document client understanding.
• Select the appropriate equipment in accordance to agency policy.
• Obtain the correct solution as prescribed.
• Assess the client for allergies: tape, iodine, ointment, or antibiotic preparations to be used for
skin preparation of the venipuncture site.
• Administer the fluid at the prescribed rate.
• Observe for signs of infiltration (the seepage of substances into the interstitial tissue that occurs as the results of accidental dislodgement of the needle from the vein) and other complications that are fluid-specific.
• Document implementation of prescribed IV therapy in the client’s medical record. whose volume is greater than that prescribed. For example, if the client is to receive 600 ml of normal (0.9%) saline, the nurse must not select a 1000 ml container, but rather two containers, 100 ml and 500 ml (containers are not prepared in volumes of 600 ml). Crystalloids (electrolyte solutions with the potential to form crystals) are used to replace concurrent losses of water, carbohydrates, and electrolytes. Sodium chloride and Ringer’s lactate are commonly used crystalloid solutions. There are three types of parenteral fluids that are classified in accord with the tonicity of the fluid relative to normal blood plasma. As previously discussed, an osmolar solution can be hypotonic, isotonic, or hypertonic. The type of solution is prescribed on the basis of the client’s diagnosis and the goal of therapy. The normal osmolarity of blood is between 280 and 295 mOsm/L, so the desired effect of the tonicity of the fluid is determined as follows:
1. Hypotonic fluid (hypo-osmolar, less than 290 mOsm/L) lowers the osmotic pressure and causes fluid to move into the cells; if fluid is infused beyond the client’s tolerance, water intoxication may result.
2. Isotonic fluid (iso-osmolar, 290 mOsm/L) increases extracellular fluid volume; if fluid is infused beyond the client’s tolerance, cardiac overload may result.
3. Hypertonic fluid (hyperosmolar, greater than 290 mOsm/L) increases the osmotic pressure of the blood plasma, drawing fluid from the cells; if fluid is infused beyond the client’s tolerance, cellular dehydration may result (Bulechek & McCloskey, 1999). Table 37-5 discusses the common types of intravenous solutions in terms of their tonicity, contents, and clinical usage. Crystalloid solutions can be isotonic (equal to the sodium chloride concentration of blood, 0.9%); hypotonic (less than the sodium chloride concentration of blood); and hypertonic (greater than the sodium chloride concentration of blood) (Kee & Paulanka, 2000). Colloids (nondiffusable substances) function like plasma proteins in blood by exerting a colloidal pressure to replace intravascular volume only. Examples of colloidal solutions are albumin, dextran, Plasmanate, and hetastarch (artificial blood substitute). During the administration of these solutions, the nurse should monitor the client for hypotension and allergic reactions (Bulechek & McCloskey, 1999; Kee & Paulanka, 2000). Blood transfusions are discussed later in this chapter.
IV equipment is sterile, disposable, and prepackaged with user instructions. The user instructions are usually placed on the outside of the package, with a schematic that labels the parts, allowing the user to read the package prior to opening. The following discussion regarding intravenous equipment, inclusive of the frequency when to change disposal intravenous therapy equipment, is based on the revised 2000 Infusion Nursing Standards of Practice developed by INS. All intravenous equipment must be inspected by the nurse to determine the integrity of the IV product before, during, and after use. Product integrity refers to the sterility of the equipment. Products are assessed for integrity by visual examination of the product and checking the expiration date on the equipment. All products identified with a defect must be returned to the appropriate department within the agency with a written report identifying the defect. Since intravenous therapy provides a direct access into the vascular system, the nurse must understand the basic epidemiology principles and common organisms that may cause an infection and implement infection control measures to minimize the potential for infectious complications. The nurse uses aseptic technique and standard precautions when assembling and changing intravenous equipment. To decrease the risk of pathogen transmission, handwashing is required before and immediately after all IV procedures and upon removal of gloves. The frequency of changing sterile intravenous equipment not only reflects the national standards of practice but the agency’s established infection control policies. Infection control data may allow the agency to increase the time interval beyond the recommended standard provided the data verifies low infection rates. INS (2000) recommends that an organization that exhibits an increased rate of catheter-related bloodstream infection with the practice of 72-hour administration set changes should return to a 48-hour administration set change interval.
The administration set (infusion set) refers to the plastic disposal tubing that provides for the infusion of a solution. There are several types of infusion sets to accommodate the solution and the mode of administration: primary continuous; secondary; primary intermittent; and special tubing for certain solutions such as blood/blood components. There are several add-on devices, such as extension sets, filters, stopcocks, PRN adaptor, and needleless devices that are used in conjunction
with the administration set and changed whenever the set is changed. Administration sets are changed at established time intervals and immediately upon suspected contamination or when the integrity of the set has been compromised. The administration set contains an insertion spike with a protective cap, a drip chamber, tubing with a slide clamp and regulating (roller) clamp, a rubber injection port, and a protective cap over the needle adapter (Figure 37-10). The protective caps keep
both ends of the infusion set sterile and are removed only just before usage. The insertion spike is inserted into the port of the IV solution container. Infusion sets can be vented or nonvented. The nonvented type is used with plastic bags of IV solutions and vented bottles. The vented set is used for glass containers that are not vented. Glass containers require an air vent so that air can displace fluid from the container into the IV tubing.
Some glass bottles are vented with an inside tube that exits the bottle into a rubber stopper in the neck of the bottle; if the bottle is not vented, then the nurse needs to select a vented infusion set. The drip chamber is calibrated to allow a predictable amount of fluid to be delivered. There are two types of drip chambers: a macrodrip, which delivers 10 to 20 drops per milliliter of solution, and a microdrip, which delivers 60 drops per milliliter. The drip rate varies with the manufacturer as indicated on the package. The administration set has a manual flow-control device such as a slide clamp (Figure 37-10), a roller clamp, or a screw to regulate a prescribed infusion rate. Follow the manufacturer’s guidelines when using the manual flow-control device to regulate the prescribed infusion rate. The end of the IV tubing contains a needle adapter that attaches to the sterile device inserted in the client’s vein. Extension tubing may be used to lengthen the primary tubing. A primary continuous administration set is used to administer routine solutions prescribed to infuse continuously over a 24 hour period. The primary administration set, inclusive of the add-on devices, is changed every 48 to 72 hours in conjunction with the peripheral cannula change. A bag of intravenous solution should not hang longer than 24 hours. Secondary administration sets are often referred to as “piggyback” administration sets. The secondary tubing is connected into the primary tubing at an injection site (see Figure 37-11) and allows for the administration of a second solution such as medication. Secondary administration sets are also changed every 48 to 72 hours. Primary intermittent administration sets are used to deliver medications at prescribed intervals through an injection/access port and are changed every 48 to 72 hours; all add-on devices such as extension sets, filters, PRN adaptors, and stopcocks are changed with the intermittent administration set. A sterile needle/ needleless device should be aseptically attached to the intermittent administration set prior to administering the medication and removed immediately after each use.