Body fluid is composed primarily of water and electrolytes. The body is equipped with homeostatic mechanisms to keep the composition and volume of body fluids within narrow limits. Organs involved in this mechanism include the kidneys, lungs, heart, blood vessels, adrenal glands, parathyroid glands, and pituitary gland. Body fluid is divided into two types: intracellular (within the cells) and extracellular (interstitial or tissue fluid, intravascular or plasma, and transcellular, such as cerebrospinal or synovial fluids).
RELATED CONCERNS
All plans of care specific to underlying health condition causing imbalance, e.g., DM, HF, upper GI bleeding, renal failure/dialysis.
Metabolic acidosis (primary base bicarbonate deficit)
Metabolic alkalosis (primary base bicarbonate excess)
Respiratory acidosis (primary carbonic acid excess)
Respiratory alkalosis (primary carbonic acid deficit)
NURSING PRIORITIES
1. Restore homeostasis.
2. Prevent/minimize complications.
3. Provide information about condition/prognosis and treatment needs as appropriate.
DISCHARGE GOALS
1. Homeostasis restored.
2. Free of complications.
3. Condition/prognosis and treatment needs understood.
4. Plan in place to meet needs after discharge.
Note: Because fluid and electrolyte imbalances usually occur in conjunction with other medical conditions, the following information is offered as a reference. The interventions are presented in a general format for inclusion in the primary plan of care.
FLUID BALANCE
Total body water, essential for metabolism, declines with age and also varies with body fat content and gender. It constitutes about 80% of an infant’s body weight, 60% of an adult’s, and as little as 40% of an older person’s weight.
Hypervolemia (Extracellular Fluid Volume Excess)
PREDISPOSING/CONTRIBUTING FACTORS
Excess sodium intake including sodium-containing foods, medications, or fluids (PO/IV)
Excessive, rapid administration of hypertonic (or possibly isotonic) parenteral fluids
Increased release of antidiuretic hormone (ADH); excessive adrenocorticotropic hormone (ACTH) production, hyperaldosteronism
Decreased plasma proteins as may occur with chronic liver disease with ascites, major abdominal surgery, malnutrition/protein depletion
Chronic kidney disease/acute renal failure (ARF)
Heart failure (HF)
Patient Assessment Database
ACTIVITY/REST
May report: Fatigue, generalized weakness
CIRCULATION
May exhibit: Hypertension, elevated central venous pressure (CVP)
Pulse full/bounding; tachycardia usually present; bradycardia (late sign of cardiac decompensation)
Extra heart sounds (S3)
Edema variable from dependent to generalized
Neck and peripheral vein distension
ELIMINATION
May report: Decreased urinary output, polyuria if renal function is normal
Diarrhea
FOOD/FLUID
May report: Anorexia, nausea/vomiting
Thirst (may be absent, especially in elderly)
May exhibit: Abdominal girth increased with visible fluid wave on palpation (ascites)
Sudden weight gain, often in excess of 5% of total body weight
Edema initially dependent, pitting may progress to facial/periorbital, general/anasarca
NEUROSENSORY
May exhibit: Changes in level of consciousness, from lethargy, disorientation, confusion to coma; aphasia
Muscle twitching, tremors, seizure activity
Hyperreflexia, rigid paralysis (severe hypernatremia)
PAIN/DISCOMFORT
May report: Headache
Abdominal cramps
RESPIRATION
May report: Shortness of breath
May exhibit: Tachypnea with/without dyspnea, orthopnea; productive cough
Crackles
SAFETY
May exhibit: Fever
Skin changes in color, temperature, turgor, e.g., taut and cool where edematous
TEACHING/LEARNING
Refer to predisposing/contributing factors
Discharge plan DRG projected mean length of inpatient stay: depends on underlying condition considerations: May require assistance with changes in therapeutic regimen, dietary management
Refer to plan of care concerning underlying medical/surgical condition for possible postdischarge considerations.
DIAGNOSTIC STUDIES
Hematocrit: Elevated in dehydration, decreased in fluid overload.
Serum sodium: May be high, low, or normal (between 135 and 145 mEq/L).
Serum potassium and BUN: Normal, or decreased in fluid overload unless renal damage present.
Total protein: Plasma proteins/albumin may be decreased.
Serum osmolality: Usually unchanged, although hypo-osmolality may occur.
Urine sodium: May be low because of sodium retention.
Urine specific gravity: Decreased.
Chest x-ray: May reveal signs of congestion.
RELATED CONCERNS
All plans of care specific to underlying health condition causing imbalance, e.g., DM, HF, upper GI bleeding, renal failure/dialysis.
Metabolic acidosis (primary base bicarbonate deficit)
Metabolic alkalosis (primary base bicarbonate excess)
Respiratory acidosis (primary carbonic acid excess)
Respiratory alkalosis (primary carbonic acid deficit)
NURSING PRIORITIES
1. Restore homeostasis.
2. Prevent/minimize complications.
3. Provide information about condition/prognosis and treatment needs as appropriate.
DISCHARGE GOALS
1. Homeostasis restored.
2. Free of complications.
3. Condition/prognosis and treatment needs understood.
4. Plan in place to meet needs after discharge.
Note: Because fluid and electrolyte imbalances usually occur in conjunction with other medical conditions, the following information is offered as a reference. The interventions are presented in a general format for inclusion in the primary plan of care.
FLUID BALANCE
Total body water, essential for metabolism, declines with age and also varies with body fat content and gender. It constitutes about 80% of an infant’s body weight, 60% of an adult’s, and as little as 40% of an older person’s weight.
Hypervolemia (Extracellular Fluid Volume Excess)
PREDISPOSING/CONTRIBUTING FACTORS
Excess sodium intake including sodium-containing foods, medications, or fluids (PO/IV)
Excessive, rapid administration of hypertonic (or possibly isotonic) parenteral fluids
Increased release of antidiuretic hormone (ADH); excessive adrenocorticotropic hormone (ACTH) production, hyperaldosteronism
Decreased plasma proteins as may occur with chronic liver disease with ascites, major abdominal surgery, malnutrition/protein depletion
Chronic kidney disease/acute renal failure (ARF)
Heart failure (HF)
Patient Assessment Database
ACTIVITY/REST
May report: Fatigue, generalized weakness
CIRCULATION
May exhibit: Hypertension, elevated central venous pressure (CVP)
Pulse full/bounding; tachycardia usually present; bradycardia (late sign of cardiac decompensation)
Extra heart sounds (S3)
Edema variable from dependent to generalized
Neck and peripheral vein distension
ELIMINATION
May report: Decreased urinary output, polyuria if renal function is normal
Diarrhea
FOOD/FLUID
May report: Anorexia, nausea/vomiting
Thirst (may be absent, especially in elderly)
May exhibit: Abdominal girth increased with visible fluid wave on palpation (ascites)
Sudden weight gain, often in excess of 5% of total body weight
Edema initially dependent, pitting may progress to facial/periorbital, general/anasarca
NEUROSENSORY
May exhibit: Changes in level of consciousness, from lethargy, disorientation, confusion to coma; aphasia
Muscle twitching, tremors, seizure activity
Hyperreflexia, rigid paralysis (severe hypernatremia)
PAIN/DISCOMFORT
May report: Headache
Abdominal cramps
RESPIRATION
May report: Shortness of breath
May exhibit: Tachypnea with/without dyspnea, orthopnea; productive cough
Crackles
SAFETY
May exhibit: Fever
Skin changes in color, temperature, turgor, e.g., taut and cool where edematous
TEACHING/LEARNING
Refer to predisposing/contributing factors
Discharge plan DRG projected mean length of inpatient stay: depends on underlying condition considerations: May require assistance with changes in therapeutic regimen, dietary management
Refer to plan of care concerning underlying medical/surgical condition for possible postdischarge considerations.
DIAGNOSTIC STUDIES
Hematocrit: Elevated in dehydration, decreased in fluid overload.
Serum sodium: May be high, low, or normal (between 135 and 145 mEq/L).
Serum potassium and BUN: Normal, or decreased in fluid overload unless renal damage present.
Total protein: Plasma proteins/albumin may be decreased.
Serum osmolality: Usually unchanged, although hypo-osmolality may occur.
Urine sodium: May be low because of sodium retention.
Urine specific gravity: Decreased.
Chest x-ray: May reveal signs of congestion.
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