19.3: Considerations for Fluid and Electrolyte Imbalances
By the end of this section, you will be able to:
- Examine how modifications to fluid intake maintain balance
- Recognize how administering medications maintains balance
- Recall and utilize patient education for self-management of fluid and electrolyte balance
When patients experience body systems that are unable to maintain fluid and electrolyte balance, the patient may need to modify what they consume. Modifications can be made in fluid intake or in the number of electrolytes consumed. Patients may need the assistance of the nurse to help them identify what foods and beverages should be avoided and what alternatives are available. When providing education about diets, the nurse can consult a dietitian for guidance as needed. As a general rule, the nurse is assisting the patient to choose and/or limit foods and or beverages in support of a diet that has already been prescribed by a dietitian or provider.
Modifying Fluids and Electrolytes
Patients experiencing diseases that alter fluid and/or electrolyte levels may need to adjust their oral fluid intake and dietary choices. The nurse’s role is to provide education and encouragement to patients who need to make these lifestyle changes. Education will focus on what which foods are considered liquid and which liquids are best, depending on the goals for fluid modification.
Similarly, the nurse will assist the patient to make the best food choices to increase or decrease specific electrolytes. Educating patients on how to read nutrition information is key to assist patients in making correct food choices. The nurse should remind patients that the only way to know how much of a substance is in food is to look at the nutrition label or read about the food from a reliable source. This advice includes food seasonings, some of which can contain hidden electrolytes.
Increasing Fluids
The patient may be encouraged to increase oral fluid intake during times of active fluid loss, such as occurs with diarrhea, or to regain fluid lost from illness. In the healthcare setting and in some home care settings, IVFs are an option. However, as will be discussed in Administering Intravenous Fluid, IVFs can have complications and should be avoided unless necessary. Long periods without liquids and food entering the GI system can result in atrophy of the intestinal muscles and decreased GI function. For these reasons, oral fluid and electrolyte replacement is preferred if the clinical situation supports oral replacement.
The nurse should understand the goals of fluid replacement. If water needs to be replaced, the nurse will encourage the patient to drink water. Beverages with sugar, such as juices, sports drinks and sodas, can add to interstitial dehydration by filling the vascular system with glucose, which will then draw water from the interstitial space into the vascular system. Low-calorie beverages may be a better choice, but they commonly contain artificial sweeteners that, in some cases, also increase blood glucose levels. In most cases where rehydration is the goal, water is the best choice. The nurse should ensure patients have fresh water available at all times and monitor fluid intake.
Fluid Restrictions
During existing FVE, or to prevent FVE in patients at high risk for it, such as in patients experiencing decreased kidney or cardiac function, providers may limit the amount of fluid a patient receives. If the goal is simply to limit fluid intake, the nurse must educate the patient as to what is included as fluid. As discussed earlier, there are special considerations for things like cream-based soups and puddings, as well as frozen liquids. The nurse must educate the patient about the prescribed daily fluid intake and may need to help the patient divide a 24-hour limit by how much should be consumed with each meal and snack.
The nurse must also understand that patients with diseases that affect the cardiac, kidney, and liver systems, especially, may have other restrictions that will influence fluid choices. For example, patients with kidney disease may need to avoid foods high in sodium and potassium. Vegetable juices and some fruit juices are high in sodium and potassium, so even if the amount is within the prescribed limit, the patient should be encouraged to make a different choice.
Nurse
: Jasmine, BSN
Clinical setting
: Case manager for home health care
Years in practice
: 11
Facility location
: A small rural community outside Nashville, Tennessee
I had been a nurse for over a decade when I transitioned into home health care. One of my first patients was a man named Richard. Richard had been discharged from a local hospital following an acute coronary event diagnosed as unstable angina secondary to early-stage, left-sided heart failure. Richard also had a diagnosis of type 2 diabetes mellitus. He was smart and motivated; he wanted to avoid a heart attack. He was focused on eating healthy and exercising. Richard was assigned a home health nurse for two visits per week for 2 weeks to assess how he was doing on his new diuretic therapy. In addition to the usual fluid volume assessment indicators, I wanted to see how Richard was managing his new fluid intake restriction of 1,500 mL per day.
On my first visit, Richard seemed to be doing fine. He verbalized an understanding of how to weigh himself every morning at the same time, on the same scale, with the same amount of clothing; how to consider how his rings, socks, and shoes were fitting; and whether he was able to participate in his typical daily activities without dyspnea or chest pain. He understood his fluid restriction and wrote down any fluids he consumed during the day. However, when I went back 3 days later, Richard reported he was having a bad day. His weight hadn’t changed in the morning, but by late afternoon when I visited, he was feeling some dyspnea and felt tired. Although his vital signs were within his normal range, he did look somewhat short of breath. I asked Richard if he had done anything different today than during the days since he was discharged from the hospital. Richard told me that he had had a fun morning because his daughter had taken him to the local farmers’ market where he picked up a new houseplant and some fresh fruit, including a watermelon. After he got home from shopping, he just watched TV and ate half of his watermelon. We talked some more and together we determined that he most likely took in more fluid than he should have for the entire day because he didn’t account for the watermelon being included as fluid intake. Additionally, we discussed how much sugar is in fruit and how that extra sugar likely increased his blood glucose level, making him retain water more than usual. We discussed the importance of considering serving size and what foods contain a high amount of fluid. I also called his provider and obtained an order to see Richard the next day for an extra visit. The next day he was doing better. He never needed an extra dose of diuretic and had no permanent complications from his watermelon overload. I discharged Richard at the end of the next week on time because he was doing excellent managing his new cardiac regimen.
Administering Medications
Medications may be ordered to correct fluid and electrolyte levels. It is important that the nurse monitor the patient’s physical and laboratory data before and after administering medications that alter fluid and electrolyte levels to ensure the medications are safe to administer and have satisfied any deficit or maintenance requirement. Common medications administered to treat fluid and electrolyte imbalance include mineral-electrolyte preparations, diuretics, and IVFs.
Mineral-Electrolyte Preparations
At times, through dietary deficiencies, excessive loss from GI or kidney dysfunction or illness, or due to various metabolic abnormalities, patients may experience a decreased level of serum electrolytes. Electrolytes are minerals that have an ionic charge; they include sodium, potassium, calcium, magnesium, phosphorous, and chloride.
The method of electrolyte administration will depend on the patient’s ability to take oral medications and the severity of the deficit. When deficits are mild and manifestations are not life threatening, oral supplementation is adequate (Table 19.6).
| Electrolyte | Level | Example Medication(s) | Mechanism of Action | Nursing Implications |
|---|---|---|---|---|
| Na + (sodium) | <136 mEq/L = hyponatremia |
Sodium chloride (NaCl): “salt tablets”
IVF: 0.9 percent NaCl to 3 percent NaCl Conivaptin (Vaprisol) |
Directly supplements sodium and chloride through GI absorption.
Directly supplements sodium and chloride through intravascular administration. Inhibits the release of ADH to correct or prevent dilutional hyponatremia |
Monitor serum sodium levels.
Use cautiously in patients with kidney disease. Thoroughly assess for fluid shifts, tissue dehydration, hypervolemia. Monitor for manifestations of hypernatremia. |
| >144 mEq/L = hypernatremia |
IVF: 0.45 percent NaCl or 5 percent dextrose in water (D
5
W)
Vasopressin (e.g., Vasostrict) |
Replenishes water without adding extra sodium.
Synthetic ADH; used specifically for the treatment of diabetes insipidus |
Monitor serum sodium levels.
Use cautiously in patients with kidney disease. Thoroughly assess for fluid shifts; peripheral, pulmonary, and cerebral edema. Monitor for manifestations of hypernatremia. |
|
| K + (potassium) | <3.7 mEq/L = hypokalemia | Potassium chloride (e.g., Klor, K-Lyte) | Directly increases serum potassium levels via oral or parenteral routes |
Monitor serum potassium and creatinine levels.
IV potassium should not exceed 10 mEq/h. IV potassium may cause burning when administered in peripheral veins. |
| > 5.1 mEq/L = hyperkalemia | Sodium polystyrene sulfonate (e.g., Kayexalate) | Decreases serum potassium by facilitating the exchange of Na + and K + in intestinal cells and increasing fecal excretion |
Monitor serum potassium levels.
Educate the patient that this medication will cause diarrhea. Monitor for coinciding FVD. |
|
| Ca ++ (calcium) | <8.5 mg/dL = hypocalcemia |
Calcium carbonate (oyster shell calcium)
Calcitriol (Rocaltrol) |
Calcium supplement
Vitamin D 3 to increase GI calcium absorption |
Monitor serum calcium and phosphate levels. |
| >10.5 mg/dL = hypercalcemia | Alendronate (e.g., Fosamax) | A bisphosphonate that decreases bone breakdown. Stops calcium from being taken from bones in hyperparathyroidism and slows the progression of osteoporosis | There are numerous oral and IV bisphosphonates available in the United States. Some are taken daily, whereas others are taken weekly, monthly, or yearly. Educate the patient about the correct frequency. | |
| Mg + (magnesium) | <1.7 mg/dL = hypomagnesemia |
Magnesium citrate
Magnesium sulfate |
Oral magnesium supplement for prevention or treatment of mild hypomagnesemia
IV magnesium supplement for severe hypomagnesemia |
Monitor serum magnesium levels. |
| >2.2 mg/dL = hypermagnesemia | IV calcium gluconate | IV calcium supplement that decreases the manifestations of hypermagnesemia by competing for cell receptors |
Monitor serum magnesium and calcium levels.
The rate of administration of calcium gluconate is based on the severity of hypermagnesemia. |
|
| P + /PO 4 (phosphorus/phosphate) | <2.5 mg/dL = hypophosphatemia | IV sodium phosphate or potassium phosphate | IV supplements for hypophosphatemia; the selection will depend on sodium and potassium levels |
Monitor serum phosphate and calcium levels.
Most oral supplements cause GI upset. |
| >4.8 mg/dL = hyperphosphatemia | Calcium carbonate (e.g., Caltrate) | Calcium binds with phosphate and decrease GI phosphate absorption while increasing urinary excretion. | Monitor serum phosphate and calcium levels. | |
| Cl − (chloride) | <97 mEq/L = hypochloremia | IVF: 0.9 percent NaCl | As low levels are usually related to fluid loss; rehydration is with IVF that contains Cl − . | Monitor fluid volume status for manifestations of FVE. |
| >105 mEq/L = hyperchloremia |
IVF: D
5
W
Sodium bicarbonate |
IVF without Cl
−
to dilute hyperchloremia
Hyperchloremia-induced acidosis can be neutralized with the administration of a base. |
Monitor serum sodium and chloride levels.
Monitor for the development of metabolic alkalosis manifestations. |
When a patient is not able to take oral medications, or when the need to replace depleted electrolytes is more urgent, IV solutions may be prescribed. As with any IV medication, it is important for the nurse to know the safe rate of administration. Too rapid administration of electrolytes can cause a sudden excess of extracellular electrolytes, which can be dangerous. For this reason, IV electrolytes are always administered using an IV pump.
The nurse is requested to administer three doses of IV potassium chloride to a patient with an 18 gauge peripheral intravascular access. The nurse prepares the IV solution of 10 mEq KCl mixed in 100 mL of 0.9 percent NaCl and begins the infusion. Almost immediately the patient tells the nurse he is experiencing a burning sensation. The nurse knows potassium can be irritating to peripheral veins. The nurse considers the options: slowing the IV rate until it doesn’t hurt the patient, or diluting the potassium until it doesn’t hurt the patient. The nurse shared her concerns with the provider, who agreed to order an additional IV infusion of 0.9 percent NaCl to which the infusing potassium will be piggybacked, to dilute the infusion.
At change-of-shift report, the nurse explained, “Mr. Shearer’s potassium was only 3.1 so I didn’t want to slow down the replacement infusion any more. He doesn’t have any cardiac or kidney history and isn’t on a fluid restriction. Obtaining an order for the additional 50 mL per hour normal saline allowed me to get all three doses in on time.”
Diuretics
Diuretics are a type of medication that decrease fluid volume. The mechanism of action differs for different categories of diuretics, as do the medications’ effect on electrolytes. Loop diuretics inhibit NaCl reabsorption in the ascending loop of Henle of the kidney tubule. Common examples of loop diuretics include furosemide (Lasix), bumetanide (Bumex), and torsemide. The nurse must monitor serum Na + and Cl − levels, and also serum K + levels, because potassium is lost in the loop of Henle, as well.
Potassium-sparing diuretics are weak diuretics for managing FVE. They prevent sodium reabsorption in the collecting tubule, thereby increasing water elimination. However, potassium-sparing diuretics allow potassium reabsorption, thereby limiting potassium loss. Potassium-sparing diuretics are often used in combination with potassium-wasting diuretics for the purpose of maintaining serum potassium levels. Common potassium-sparing diuretics include spironolactone (e.g., Aldactone) and triamterene (Dyrenium).
Thiazide diuretics achieve fluid volume control by inhibiting NaCl reabsorption into the blood in the distal convoluted tubule. Thiazide diuretics are potassium-wasting diuretics; potassium is also lost in the distal part of the kidney tubule and the collecting ducts. Common thiazide diuretics include chlorothiazide (e.g., Diuril) and hydrochlorothiazide (e.g., Hydrodiuril). A common combination of a potassium-sparing and thiazide diuretic is triamterene/hydrochlorothiazide (e.g., Maxide).
Osmotic diuretics are made of solutes that are easily filtered through the glomeruli but are not reabsorbed from the tubules back into the blood. When administered, osmotic diuretics increase the blood osmolarity and draw fluid into the vascular space. The fluid is then filtered by the glomeruli and eliminated as urine, along with the solutes. Because of the increased water excretion with osmotic diuretics, all electrolytes plus bicarbonate are also lost at a higher rate. Mannitrol (e.g., Osmitrol) is an example of an osmotic diuretic. Isosorbide (Isordil) also works as an osmotic diuretic, although it is in a class of medications called nitrates.
Disclaimer: Always follow the agency’s policy for medication administration.
Definition: Minimize risk of harm to patients and providers through both system effectiveness and individual performance.
Knowledge: Delineate general categories of errors and hazards in care.
Skill: Demonstrate effective use of technology and standardized practices that support safety and quality. The nurse will:
- Review laboratory data when determining the safety of administering diuretics, particularly serum creatinine, potassium, and sodium levels, and serum HCT.
-
Review the patient’s fluid volume status indicators when determining the safety of administering diuretics:
- I & O
- perfusion indicators
- vital signs
Attitude: The nurse will respect their individual role in preventing errors by adhering to safe, evidenced-based practice standards.
Administering Intravenous Fluid
When patients experience deficient fluid volume, IVFs are often prescribed. Intravenous fluid restores fluid to the intravascular compartment, and some IVFs are also used to facilitate the movement of fluid between compartments due to osmosis . There are three types of IVFs: isotonic, hypotonic, and hypertonic.
The osmotic gradient between two solutions is referred to tonicity , which is the suffix of the descriptive words iso tonic , hypo tonic , and hyper tonic . In this case, the two solutions are the IVF and the patient’s blood. What type of tonicity and how much of a gradient exists will determine what happens in the venous system once the IVF is administered.
IVFs that have a similar concentration of dissolved particles as blood are isotonic solutions . An example of an isotonic IV solution is 0.9 percent normal saline (0.9 percent NaCl). Because the concentration of the IVF is similar to the blood, the fluid stays in the intravascular space and osmosis does not cause fluid movement between compartments. Isotonic solutions are used for patients with FVD to raise their blood pressure. However, infusion of too much isotonic fluid can cause FVE.
Solutions that have a lower concentration of dissolved solutes than blood are hypotonic solutions . An example of a hypotonic IV solution is 0.45 percent normal saline (0.45 percent NaCl). Infusion of a hypotonic IV solution results in a decreased concentration of dissolved solutes in the blood as compared with the intracellular space. This imbalance causes osmotic movement of water from the intravascular compartment into the intracellular space. For this reason, hypotonic fluids are used to treat cellular dehydration .
However, if too much fluid moves out of the intravascular compartment into cells, cerebral edema can occur. It is also possible to cause worsening hypovolemia and hypotension if too much fluid moves out of the intravascular space and into the cells. Therefore, patient status should be monitored carefully when hypotonic solutions are infused.
Solutions that have a higher concentration of dissolved particles than blood are hypertonic solutions . An example of hypertonic IV solution is 3 percent normal saline (3 percent NaCl). When infused, hypertonic fluids cause an increased concentration of dissolved solutes in the intravascular space compared with the cells. This causes the osmotic movement of water out of the cells and into the intravascular space to dilute the solutes in the blood.
When administering hypertonic fluids, it is essential to monitor the patient for signs of hypervolemia , such as breathing difficulties and elevated blood pressure. Additionally, if hypertonic solutions with sodium are given, the patient’s serum sodium level should be closely monitored. See Table 19.7 for a comparison of types of IV solutions, their uses, and nursing considerations.
| Type | IV Solution | Uses | Nursing Considerations |
|---|---|---|---|
| Isotonic | 0.9% Normal saline (0.9% NaCl) | Fluid resuscitation for hemorrhaging, severe vomiting, diarrhea, GI suctioning losses, wound drainage, mild hyponatremia, or blood transfusions | Monitor closely for hypervolemia, especially with heart failure or kidney failure. |
| Isotonic | Lactated Ringer’s (LR) solution | Fluid resuscitation, GI tract fluid losses, burns, traumas, or metabolic acidosis. Often used during surgery | Should not be used if serum pH >7.5, because it will worsen alkalosis. May elevate potassium levels if used with kidney failure |
| Isotonic (starts as isotonic and then changes to hypotonic when dextrose is metabolized) | 5% Dextrose in Water (D 5 W) | Provides free water to help kidney excretion of solutes, hypernatremia, and some dextrose supplementation | Should not be used for fluid resuscitation because, after dextrose is metabolized, it becomes hypotonic and leaves the intravascular space, causing brain swelling. Used to dilute plasma electrolyte concentrations |
| Hypotonic | 0.45% NaCl | Used to treat intracellular dehydration and hypernatremia and to provide fluid for kidney excretion of solutes | Monitor closely for hypovolemia, hypotension, or confusion due to fluid shifting into the intracellular space, which can be life-threatening. Avoid use in patients with liver disease, trauma, and burns to prevent hypovolemia from worsening. Monitor closely for cerebral edema. |
| Hypotonic | D 5 W | Provides free water to promote kidney excretion of solutes and treat hypernatremia, as well as some dextrose supplementation | Monitor closely for hypovolemia, hypotension, or confusion due to fluid shifting out of the intravascular space, which can be life-threatening. Avoid use in patients with liver disease, trauma, and burns to prevent hypovolemia from worsening. Monitor closely for cerebral edema. |
| Hypertonic | 3% NaCl | Used to treat severe hyponatremia and cerebral edema | Monitor closely for hypervolemia, hypernatremia, and associated respiratory distress. Do not use it with patients experiencing heart failure, kidney failure, or conditions caused by cellular dehydration; it will worsen these conditions. |
| Hypertonic | 5% Dextrose (D 5 0) and 0.45% NaCl | Used to treat severe hyponatremia and cerebral edema | Monitor closely for hypervolemia, hypernatremia, and associated respiratory distress. Do not use it with patients experiencing heart failure, kidney failure, or conditions caused by cellular dehydration; it will worsen these conditions. |
| Hypertonic | 5% Dextrose and LR solution (D 5 LR), D 1 0 | Used to treat severe hyponatremia and cerebral edema | Monitor closely for hypervolemia, hypernatremia, and associated respiratory distress. Do not use it with patients experiencing heart failure, kidney failure, or conditions caused by cellular dehydration; it will worsen these conditions. |
Assessing Intravascular Access
To administer IVFs, the nurse must ensure the patient has a correctly placed and functioning intravascular catheter of the correct size. The nurse should assess for intravascular access patency by withdrawing blood from the intravascular catheter. Using a slow and gentle technique, the nurse pulls back on the syringe attached to the intravascular catheter.
Additionally, assessment includes observing the insertion site by comparing it with the same area on the opposite side of the body, looking for erythema and edema, and palpating for warmth. Inflammation of a vein that is visible on the surface of the skin is called phlebitis. Phlebitis may be a complication of IVFs and should be observed at least once per shift and any time the intravascular catheter is used. The intravascular catheter should be flushed prior to and in between uses, and the nurse assesses for any discomfort during flushing. In most cases, IVFs will be administered using an IV infusion pump to avoid infusion rates that are too fast or too slow. See Table 19.8 for potential local complications of peripheral intravascular therapy.
Definition: Integrate the best clinical evidence with clinical expertise and patient and family preferences and values for delivery of optimal health care.
Knowledge: Describe how the strength and relevance of available evidence influence the choice of interventions in provision of patient-centered care.
Skills: Consult with clinical experts before deciding to deviate from evidence-based protocols. The nurse will:
- Recognize the Centers for Disease Control and Prevention (CDC) recommendation to change peripheral intravascular catheters (PICs) after they have been in the patient 72–96 hours (Webster et al., 2019)
- Follow institutional protocols, but assess PICs frequently, including locked PICs—at least every 4 hours and early in the shift to determine patency.
- Be aware of medications that are considered vesicants when administered through PICs.
Attitude : The nurse will acknowledge their limitations in knowledge and clinical expertise before determining when to deviate from evidence-based best practice.
| Complication | Potential Causes and Prevention | Treatment |
|---|---|---|
| Phlebitis: The inflammation of the vein’s inner lining, the tunica intima. Clinical indications are localized redness, pain, heat, purulent drainage, and swelling that can track up the vein, leading to a palpable venous cord. |
Mechanical causes:
Inflammation of the vein’s inner lining can be caused by the cannula rubbing and irritating the vein. To prevent mechanical inflammation, use the smallest gauge possible to deliver the medication or required fluids.
Chemical causes: Inflammation of the vein’s inner lining can be caused by medications or fluids with high alkaline, acidic, or hypertonic qualities. To avoid chemical phlebitis, follow the parenteral drug therapy guidelines in a drug reference resource for administering IV medications, including the appropriate amount of solution and rate of infusion. Infectious causes: May be related to emergent vascular access device insertions, poor aseptic technique, or contaminated dressings |
Chemical phlebitis:
Evaluate infusion therapy and the need for different vascular access, different medication, slower rate of infusion, or more dilute solution. If indicated, remove the vascular access device.
Transient mechanical phlebitis: May be treatable by stabilizing the catheter, applying heat, elevating the affected limb, and providing analgesics as needed. Consider requesting other pharmacologic interventions such as anti-inflammatory agents, if needed. Monitor site for 24 hours after insertion, and if signs and symptoms persist, remove the catheter. Infectious phlebitis: If purulent drainage is present or infection is suspected, remove the catheter and obtain a culture of the purulent drainage and catheter tip. Monitor for signs of systemic infection. |
| Infiltration: A condition that occurs when a nonvesicant solution is inadvertently administered into surrounding tissue. Signs and symptoms include pain, swelling, redness, the skin surrounding the insertion site is cool to touch, there is a change in the quality or flow of IVF, the skin is tight around the intravascular access site, IVF is leaking from intravascular access site, or there are frequent alarms on the IV pump. |
Infiltration is one of the most common complications in infusion therapy involving an intravascular catheter. For this reason, the patency of an intravascular access site must always be checked before administering IV push medications.
Infiltration can be caused by piercing the vein, excessive patient movement, a dislodged or incorrectly placed intravascular catheter, or too rapid infusion of fluids or medications into a fragile vein. Always secure a PIC with tape or a stabilization device to avoid accidental dislodgement. Avoid sites that are areas of flexion. |
Stop the infusion and remove the cannula. Follow agency policy related to infiltration. |
| Extravasation: A condition that occurs when vesicant (an irritating solution or medication) is administered and inadvertently leaks into surrounding tissue and causes damage. It is characterized by the same signs and symptoms as infiltration but also includes burning, stinging, redness, blistering, or necrosis of the tissue. | Extravasation has the same potential causes of infiltration but with worse consequences because of the effects of vesicants. Extravasation can result in severe tissue injury and necrosis. For this reason, known vesicant medications should be administered via central lines. |
Stop the infusion. Detach all administration sets and aspirate from the catheter hub before removing the catheter to remove vesicant medication from the catheter lumen and as much as possible from the subcutaneous tissue.
Follow agency policy regarding extravasation of specific medications. For example, toxic medications have a specific treatment plan. |
| Hemorrhage: Bleeding from the intravascular access site | Bleeding occurs when the intravascular catheter becomes dislodged. | If dislodgement occurs, apply pressure with gauze to the site until the bleeding stops, and then apply a sterile transparent dressing. |
| Local infection: Infection at the site is indicated by purulent drainage, typically 2–3 days after an intravascular access site is started. | Local infection is often caused by nonadherence to aseptic technique during intravascular access initiation or intravascular catheter maintenance, or the dressing becomes contaminated or nonintact over the access site. | Remove the cannula and clean the site using sterile technique. If infection is suspected, remove the catheter and obtain a culture of the purulent drainage and catheter tip. Monitor for signs of systemic infection. |
| Nerve injury | Paresthesia-type pain occurring during venipuncture or during an indwelling intravascular catheter can indicate nerve injury. | Immediately remove the cannula, notify the provider, and document findings in the chart. |
Scenario: Mrs. Arlene Schreiber was admitted for urosepsis and has been in the hospital for 8 days. She has a peripheral intravascular catheter that is 4 days old, and hospital policy indicates PICs can only be left in for 96 hours.
Nurse: Hi, Mrs. Schreiber, it is time to change your intravascular catheter site.
Patient: My intravascular catheter is fine; I don’t want to change it. It doesn’t hurt and it works fine.
Nurse: I understand you don’t want to change it, but let me explain why it is important. Our hospital policy states we need to change peripheral intravascular catheters after 96 hours. That is the best recommendation from the Centers for Disease Control and Prevention. Research by their researchers found that intravascular catheters left longer can lead to blood infections and are more likely to cause fluids or medication to leak out of your veins.
Patient: But why fix something that isn’t broken?
Nurse: Your doctors are indicating you are going to need at least 2 more days of antibiotics. You are going to need an intravascular catheter at least that long. Changing it now will save us from having to change it later when it might cause a problem or delay an antibiotic dose. There are a lot of good reasons to let us change your intravascular catheter today, but I can’t force you to.
Patient: I just hate it so much. Can you promise me this is the last one I’m going to have to get?
Nurse: I wish I could, but no I can’t make that promise. We can work together to find the best spot for the intravascular catheter, and I will do my best to find a good vein.
Age-Related Changes
There are several lifespan considerations when assessing for fluid and electrolyte balance. Newborns and infants have a large proportion of water weight compared with adults, with approximately 75 percent of weight being water. During the first week after birth, ECF is lost in urine, along with sodium. Additionally, compensatory mechanisms such as the RAAS are less developed, and newborn kidneys are less able to concentrate urine, resulting in a decreased ability to retain sodium. Newborns and infants also have a greater body surface area, making them more susceptible to insensible fluid losses through the skin and lungs via evaporation. This causes increased risk of developing hyponatremia and FVD. In contrast, newborns are less able to excrete potassium, placing them at risk for hyperkalemia . Episodes of vomiting and diarrhea also place infants at an increased risk of quickly developing fluid and electrolyte disturbances. When monitoring urine output in infants, parents are often asked about the number of wet diapers their infant has in a day. Nurses may also weigh diapers for hospitalized infants for more accurate measurement of urine output.
Children and adolescents are at risk for dehydration when physically active in hot environments that can cause excessive sweating. Illnesses causing diarrhea, vomiting, or fever can also quickly cause fluid deficit if there is little fluid intake to replace the water and sodium lost. For this reason, it is important to educate parents regarding the importance of fluid intake when their child is sweating or ill.
Older adults are at risk for fluid and electrolyte imbalances for a variety of reasons, including surgery, chronic diseases such as heart disease and kidney disease, diuretic use, and decreased mobility that limits the ability to obtain hydration. Older adults also have a decreased thirst reflex, which contributes to decreased fluid consumption. Kidney function naturally decreases with age, resulting in decreased sodium and water retention, as well as decreased potassium excretion. These factors place older patients at risk for FVD and electrolyte abnormalities.
Scenario: A patient is discussing a concern with the nurse when the nurse hears something that requires further conversation and patient teaching.
Patient: It seems like the older I get, the less interested I am in food. I spent so many years trying to lose a few pounds, now I almost have to force myself to eat enough.
Nurse: What are the kinds of foods you usually eat?
Patient: Toast or cereal in the morning usually. I eat a lot of soup and crackers, maybe with cheese during the day. I just don’t have an appetite for big meals anymore.
Nurse: What about beverages? Do you drink something throughout the day?
Patient: I drink coffee in the morning, just 1 cup of regular then I switch to decaf. If I feel thirsty, I make myself some tea.
Nurse: Feeling thirsty isn’t a great way to judge if your body needs more fluid. The National Council on Aging recommends people your age drink one-third of their body weight in ounces. How much do you weigh?
Patient: These days probably only 110 pounds or so. I used to weigh so much more.
Nurse: At 110 pounds, you should drink around 35–40 ounces every day. That’s 4–5 cups. Decaffeinated coffee can help to keep you hydrated and so can tea if it doesn’t have a lot of sugar. Soup counts, too, but if you use canned soup, look at the nutrition label, because soup can contain a lot of sodium. Would you like me to help you look at some of your soup’s nutrition labels?
Patient Education for Self-Management of Fluid and Electrolyte Balance
It is the nurse’s responsibility to assess a patient’s understanding of how to monitor and manage their fluid and electrolyte status, and to provide education at a level that corresponds with their learning needs and abilities. For patients at risk for a fluid volume alteration, the nurse can suggest the patient weigh themselves daily at home. Remind the patient to weigh themselves at a consistent time of day, ideally first thing in the morning, and to use the same scale and to wear the same amount of clothing to get an accurate weight. The nurse can also encourage the patient to specifically note if their rings or shoes become tight or socks leave an indentation on their skin when removed; these can also indicate an increasing fluid volume.
Helpful suggestions for the nurse to educate the patient on the best choices for food and beverage options depending on the patient’s needs and goals were discussed earlier in this section. However, a general understanding of nutritional sources of electrolytes is necessary for the nurse to educate the patient about foods that deliver certain electrolytes, whether the goal is to encourage those foods in cases of deficiencies or to avoid those foods when patient levels are already elevated.
Calcium
Most people think of dairy foods when they think of calcium. Dairy foods are good sources of calcium, but they are also often high in sodium and saturated fat. Additionally, many people do not digest the lactose in dairy and, therefore, need to avoid foods that contain dairy. The nurse can recommend nondairy sources of calcium, including green leafy vegetables, as well as broccoli and edamame. Most beans and lentils are good sources of calcium, as are almonds and seeds like pumpkin, sesame, and chia seeds.
Chloride
Because of the added salt (sodium chloride) in many foods, dietary chloride deficiency, like dietary sodium deficiency, is rare. Because most dietary chloride is in the form of salt, sodium restrictions should be implemented for the patient trying to decrease chloride levels.
Magnesium
Unfortunately, dietary magnesium deficits are common in the United States, with up to 50 percent of Americans consuming less than the daily recommended dose, and some age groups, including children, consuming substantially less (Felton, 2024). Good sources of magnesium include green leafy vegetables, nuts, seeds, and most whole grains, such as whole wheat and oats.
Phosphorous
Because phosphorous levels have a negative relationship with calcium levels, the patient experiencing kidney disease often must avoid excess phosphorous. For healthy individuals, adequate dietary phosphorous is easily consumed through a diet containing a variety of lean animal meat, dairy, and seeds. Patients who are trying to decrease phosphorous intake should be made aware that most soda, especially colas, can be high in phosphorous.
Potassium
To modify the amount of dietary potassium a patient consumes, the nurse should educate the patient that potassium is found in green leafy vegetables like spinach, kale, and dark green lettuce. Other vegetables include root vegetables like potatoes, sweet potatoes, and carrots. Many fruits are high in potassium, including bananas, oranges, avocados, apples, and apricots, as well as fruits that grow on vines, such as tomatoes and pumpkin. Also educate patients that most salt substitutes are high in potassium.
Sodium
It is extremely rare for persons living in the United States to have a dietary deficiency of sodium (Felton, 2024). More often, the nurse will be educating the patient about foods that are high in sodium so they can avoid unnecessary salt in the diet. Most people are not surprised to learn that a variety of savory snacks are high in sodium. Chips and crackers, pizza, and most fast foods are notoriously high in sodium. However, other foods have high sodium and are lesser known. Breads and rolls can contain high amounts of sodium, as can cheeses and cold-cut meats. Many soups have added sodium. Prepackaged or frozen foods often contain sodium for added flavor but also as a preservative. Any food not prepared at home can have added sodium. As mentioned previously, it is best for the patient to read nutrition labels and, when eating in restaurants, specifically ask about added salt.
It is important for the nurse to understand and clearly communicate if certain foods are to be encouraged or avoided. Patient preferences need to be included when assisting patients to choose foods. Sadly, fresh foods like fresh green leafy vegetables and raw nuts and seeds often are more expensive than less healthy, often processed foods (Lewis et al., 2023), and the nurse needs to be sensitive to individual’s budgetary limitations and access to fresh healthy food. The nurse can also consult a dietitian to assist the patient with nutritional education and meal planning.
Refer back to Unfolding Case Study #3: Part 10 to review the patient data.
| Nursing Notes |
2300:
Furosemide administered as ordered. Patient immediately urinated 500 mL of clear urine. Crackles in lungs improving and patient reports improvement in dyspnea. |
| Provider’s Orders |
2340:
Morning laboratory tests: CBC, complete metabolic panel Daily weights Initiate 1,500 mL fluid restriction |