TEORETICAL BACKGROUND OF FLUID AND ELECTROLYTE DISTURBANCE

AT IDAMAN BANJARBARU HOSPITAL

AHMAD AZKIA
1614401110044

INTERNATIONAL CLASS OF NURSING DIPLOMA PROGRAM

NURSING FACULTY OF HEALTH AND SCIENCE
UNIVERSITY OFMUHAMMADIYAH BANJARMASIN
ACADEMIC YEAR 2017/2018
A. Anatomy physiology

(http://www.scribd.com/doc/7244500/needs-fluid-and-electrolyte)
1. Kidney
Representsorgan has a significant role in the regulation of fluid and electrolyte
needs. This is seen in the renal function as a regulator of water, regulating the
concentration of salt and blood, regulating acid-base balance of the blood fluid and waste
material or a regulator excretion of excess salt.
The regulatory process needs water balance is preceded by the capability of the
renal glomerulus as a contender liquid. On average, every 1 liter of blood contains 500 cc
of plasma flowing through the glomerulus, 10% is filtered out. The filtered liquid (filtrar
glomerulus), then flows through the renal body whose cells absorb all the materials
needed. The amount of urine produced by the kidneys can be affected by ADH and
aldosterone with an average of 1 ml / kg / mm / hr.
2. The skin
is an important part in the regulation of fluids involved in the heat setting process.
This process is regulated by a central regulator of heat disarafi by vasomotor with the
ability to control arteriolakutan by way of vasodilation and vasoconstriction. The amount
of blood flowing through blood vessels in the skin affects the amount of sweat released.
Heat release process can then be performed by evaporation.
Sweat is an active secretion of sweat glands under the control of the sympathetic
nerve. Through these sweat glands release temperature can be lowered by the amount of
water less than half a liter a day. Stimulation of sweat glands can be obtained from muscle
activity, ambient temperature, and heat through body condition.
 Other heat release process is done through broadcasting means, namely by
releasing heat into the surrounding air. How the form of conduction and convection. How
is the transfer of heat conduction to the objects being touched, while the convection that
the air stream that has heat to a cooler surface.
3. Lung
lungs Organ role in the discharge by generating insensible water loss ± 400 ml /
day. The process of discharge associated with responses due to changes in the frequency
and depth of respiration (breathing ability), for example, people who exercise heavily.
4. Gastrointestinal
tract is a digestive organ that plays a role in removing fluid through the process of
absorption and water expenses. Under normal conditions, the fluid lost in the system is
around 100-200 ml / day.
In addition, arrangements can keseimbangann fluid through thirst mechanism is
controlled via the endocrine system (hormonal) that antidiuretic hormone (ADH),
aldosterone system, prostaglandins and glucocorticoids.
a) ADH
This hormonehas a role in increasing water reabsorption so that it can control
the water balance in the body. This hormone is formed by the hypothalamus in the
posterior pituitary secreting ADH by raising and lowering the extracellular fluid
osmolarity.
b) aldosterone
This hormonesecreted by the adrenal glands and the renal tubular function on
sodium absorption. Aldosterone expenditure process is governed by the change in the
concentration of potassium, sodium, and renin angiotensin system.
c) glucocorticoid
This hormonefunction of regulating an increased reabsorption of sodium and
water which causes an increase in blood volume, causing sodium retention.
(Hidayat, AAA and Uliyah. 2011)
B. DEFINITIONS
1) OF LIQUID
liquid is water volume can be a lack or excess of water. The body fluid consists of
a liquid external and internal fluids. Intracellular fluid volume can not be measured
directly with the principle of diffusion since there is no material that is only found in the
intracellular fluid. Intracellular fluid volume can be determined by reducing the number
of external fluid, consisting of total body water.

External fluid consisting of total body fluids:

1.LiquidInterstitiel:part of the existing extra-cellular fluid outside the blood vessel.
 2.transcellularfluid,the fluid contained in special cavities such as the pleural, pericardial,
joint fluid, cerebrospinal fluid.

Fluid and electrolyte needs is a dynamic process because the body's metabolism
requires certain changes that remain in responds to physiological and environmental
stressors. Interconnected fluid and electrolyte imbalance stand-alone rarely occurs in the
form of excess or deficiency.

2) ELECTROLYTE
The electrolyte is a substance yanag cause cation ion (+) and anion (-). There are
three of the most essential liquid electrolyte, namely:

1. Sodium (sodium)
a. cations merupaka most that there exist in the extracellular fluid (CES)
b. Na+mempenagruhi water balance, araf implus conduction and muscle contraction.
c. Sodium salt intake is regulated by aldosterone, and urine output. Normally between 135-
148 mEq / l.

2. Potassium (potassium)
a. is a major cation in the CIS
b. Serves as neuromuscular excitability and muscle contraction.
c. Glikkogen required for the formation, protein synthesis, regulation of acid-base
keseibangan, because Kions+can be converted into Hions.+The normal value of about
3.5-5.5 mEq / l.

3. Calcium
a. is useful for skin integrity and structure of cells, kondusi heart, blood clotting and the
formation of bones and teeth.
b. The calcium in the extracellular fluid is regulated by the parathyroid gland and thyroid.
c. Mengarbsobsi parathyroid hormone calcium through the gastrointestinal, kidneysecretion
through
d. hormoneCathirocaltitonim inhibit the absorption of+bone.

C. FACTORS AFFECTING THE FLUID AND ELECTROLYTE

1. Minimum
age variation related to body surface area, metabolism and weight required.
2. Ambient temperature
 Excessive heat causes sweating. A person may experience a loss of NaCl as much as
15-30 g / hr.
3.diet
At the time of nutritionlack of nutrients, the body will break down energy reserves, this
process will cause fluid from intertistial keintra pegerakan mobile.
4. Sickness
Circumstances surgery, tissue trauma, renal and cardiac disorders, hormonal disorders
will disrupt the balance of fluids.
5. The situation of stress
Stress can cause an increase in cell metaabolisme, blood concentration and muscle
glycolysis, this mechanism may cause retention of sodium and water. This process can
increase the production of ADH and decrease urine production.

D. Pathophysiology / PATHWAY

Cairan dan elektroit

Cairan dan elektroit

usia iklim diet stress Kondisi sakit

usia iklim diet stress Kondisi sakit

Difusi, filtrasi, transport aktif,

Difusi, filtrasi,
osmosistransport aktif,
osmosis

hipovolemia hipervolemia Gangguan keseimbangan Gangguan

hipovolemia hipervolemia Gangguan keseimbangan
elektrolit: Gangguan
elektrolit: keseimbangan asam
-hiponatremia&hypernatremia keseimbangan asam
-hiponatremia&hypernatremia
-hipokalemia&hyperkalemia basa:
-hipokalemia&hyperkalemia basa:
-hipokalsemia&hyperkalsemia -asidosis respiratorik
MK: MK: kelebihan -hipokalsemia&hyperkalsemia
-hipokloremia&hyperkloremia -asidosis respiratorik
MK: MK: kelebihan -hipokloremia&hyperkloremia -asidosis metabolic
kekurangan volume cairan
-hipofosfatemia&hiperfosfatemia -asidosis metabolic
kekurangan
volume cairan volume cairan -hipofosfatemia&hiperfosfatemia -alkalosis respiratorik
volume cairan -alkalosis respiratorik
-alkalosis metabolik
-alkalosis metabolik

MK: risiko MK: gangguan

MK: risiko
ketidakseimbangan MK: gangguan
pertukaran gas
ketidakseimbangan
elektrolit Ketidakefektifangas
pertukaran pola
http://www.scribd.com/doc/36196080/Ask elektrolit Ketidakefektifan pola
napas
napas
ep-Keb-Cairan-Dan-Elektrolit
E. Investigations
laboratory examination conducted to obtain more objective data about fluid balance,
electrolyte and acid-base. These checks include serum electrolyte levels, complete blood
count, blood creatine levels, urine specific gravity, and arterial blood gas levels.

F. Management
● MANAGEMENTmajor medical or treatment directed at controlling the underlying
disease. The drugs, for example; Prednisone can reduce the severity of diarrhea and
sickness.
● For mild diarrhea with oral fluid and immediately improved oral glucose and
electrolyte solution can be administered to patients rehydrasi.
● For moderate diarrhea, due to non-infectious source, non-specific drugs such as
defenosiklat (Lomotil) and loperamit (Imodium) are also attributed to lower motility.
● Mixture preparation is given when the anti-microbial infectious been teridentifiksi or
if the diarrhea is very severe.
● Intravenous fluid therapy may be required for fast hydrasi, especially for small
children and the elderly.

G. PLAN Nursing
1. Assessment
a) Nursing history
- receipts and liquids and food (oral and parenteral)
- Common symptoms of electrolyte problems
- Signs of lack of fluids such as thirst, dry skin, dry mucous membranes, urine
concentration and urine output.
-sign excess fluid: as leg swelling, difficulty breathing and increased BB.
- Certain medications are being undertaken to disrupt the fluid status
- Status of the development such as age or social situation
b) clinic Measurement
- Weight: loss / weight gain indicating with
aproblemfluid balance. Weight change:
Down 2% - 5% Lack of fluid volume * mild
Down 5% - 10% Lack of fluid volume * was
down 10% - 15% of fluid volume deficiency * weight
Down 15% - 20% Deaths
Up 2% Excess fluid volumelighter
Up to 5% Excessfluid volume are
 Up 8% Excess fluid volume weight
weight measurements performed every day at the same time.

c. Physical examination
Because disorders of fluid, electrolyte and acid-base can affect all systems, we
have to identify systematically all their abnormalitaspada body. Such as pulse rate
and blood pressure, respiratory system gastrotestinal system, renal system, the
neuromuscular system, leather
d. laboratory examination
laboratory examination conducted to obtain more objective data about fluid
balance, electrolyte and acid-base. These checks include serum electrolyte levels,
complete blood count, blood creatine levels, urine specific gravity, and arterial blood
gas levels.
2. Nursing diagnosis
a. fluid volume deficiency bd regulation mechanism disorder.
b. Excess fluid volume bd excess fluid intake, compensation adjustment
mechanism.
c. The risk of electrolyte imbalance
d. Ineffective breathing
e. pattern,Ineffective airway clearance

Nursing Diagnosis / Issues Nursing Plan

Collaborative Goals and Criteria Results Intervention

Fluid Volume Deficit NOC NIC:

- Associated with: ▪ Fluid balance ∙ Maintain records accurate intake and output
- Loss of fluid volume actively
▪ Hydration ∙ Monitor the status of hydration (moisture of mucous
- The failure of regulatory
mechanisms
▪ Nutritional Status: Food and Fluid membranes, adequate pulse, orthostatic blood

Intake pressure), if required

DS:
- Haus After nursing actions during ... .. ∙ Monitor lab results that correspond to fluid retention

DO: fluid volume deficit is resolved (BUN, Hmt, urine osmolality, albumin, total

- Decreased skin turgor / tongue by outcomes: protein)

- Mucous membranes / dry skin
- Increased pulse rate, decreased
blood pressure, decreased volume /
pulse pressure
- Charging vein decreased
- Changes in mental status
- Increases urine concentration
- Increased body temperature
- Losing weight suddenly
- Decreased urine output
▪ Maintain urine output in ∙ Monitor vital signs every 15 minutes - 1 hour
accordance with the age and BB, ∙ Collaboration IV fluid administration
BJ normal urine,
∙ monitor nutritional status
▪ Blood pressure, pulse, body
∙ Give oral fluids
temperature within normal limits
∙ Provide appropriate replacement nasogatrik output
▪ There are no signs of dehydration,
(50 - 100cc / hour)
elasticity good skin turgor,
mucous membranes moist, no
∙ Encourage the family to help patients eat
excessive thirst ∙ Collaboration doctor if signs of excess fluid appears

- HMT increases ▪ Orientation to time and a good meburuk

- Weaknesses:
Nursing Diagnosis / Issues
Collaborative
Excess Fluid Volume
- Associated with:
- Weak regulatory mechanisms
- Excessive fluid intake
DO / DS:
- Body weight increased in the short
term
- Excessive intake than output
- Jugular venous distention
- Changes in breathing patterns,
dyspnoe / shortness of breath,
orthopnoe, abnormal breath sounds
(Rales or crakles), pleural effusion
- Oliguria, azotemia
- Mental status changes, nervousness, ▪ Freed from the jugular venous
anxiety
Nursing Diagnosis / Issues
Collaborative
place
▪ Number and respiratory rhythm
within normal limits
▪ Electrolytes, hemoglobin, Hmt
within normal limits
▪ Urinary pH within normal limits
▪ Intake of adequate oral and
intravenous
Goals and Criteria Results
NOC:
▪ Electrolit and acid base balance
▪ Fluid balance
▪ Hydration
After nursing actions during .... -
Excess fluid volume is resolved
with the following criteria:
▪ Freed from edema, effusions,
anaskara
▪ Clean breath sounds, no dyspnea /
ortopneu
distention,
▪ Maintain central venous pressure, -
pulmonary capillary wedge
pressure, cardiac output and vital
signsDBN
▪ Freed from fatigue, anxiety or
confusion
Goals and Criteria Results
∙ Adjust the possibility of transfusion
∙ Preparation for transfusion
∙ Replace the catheter if necessary
∙ Monitor intake and urine output every 8 hours
Nursing Plan
Intervention
NIC:
- Maintain records accurate intake and output
- Replace urinary catheter if necessary
- Monitor lab results that correspond to fluid retention
(BUN, Hmt, urine osmolality)
- Monitor vital signs
Monitor indication retention / excess fluid (cracles,
CVP, edema, neck vein distention, ascites)
- Assess the location and extent of edema
- Monitor enter the food / liquid
- Monitor nutritional status
- Give diuretic according interuksi
- Collaboration of drugs:
....................................
- Monitor weight
- Monitor electrolytes
Monitor for signs and symptoms of edema
Nursing Plan
Intervention
 Ineffective Airway
Clearancerelated to:
- Infection, neuromuscular
dysfunction, hyperplasia of the
bronchial wall, allergic airway,
asthma, trauma
- Airway obstruction: airway spasm,
retained secretions, the amount of
mucus, the artificial airway,
bronchial secretions, exudate in the❖ Demonstrate effective cough and
alveoli, the presence of foreign
bodies in the airway.
DS:
- Dispneu
DO:
- Decreased breath sounds
- Orthopneu
- cyanosis
- Abnormalities of breath sounds
(rales, wheezing)
- Difficulty speaking
- Cough, not efekotif or no
- Sputum production
- Fidget
- Changes in the frequency and
rhythm of the breath
Nursing Diagnosis
Riskelectrolyte imbalance
Definition: Risk changes in serum∙
electrolyte levels that can harm
health
risk factors:
∙ fluid volume deficiency
∙ diarrhea
∙ endocrine dysfunction
∙ Excess fluid volume
∙ Disorders regulatory mechanisms
(eg., Diabetes, isipidus,
NOC:
❖ Respiratory Status: Ventilation
▪ Make sure that the needs of oral / tracheal suctioning.
❖ Respiratory status: Airway
▪ Give O2 ...... l / min, method .........
patency
▪ Instruct the patient to rest and deep breathing
❖ Aspiration Control
∙ Position the patient to maximize ventilation
After nursing actions during
∙ Perform chest physiotherapy if necessary
............ ..pasien demonstrates the
∙ Remove secretions by coughing or suctioning
effectiveness of airway
∙ Auscultation of breath sounds, noting the additional
evidenced by outcomes:
sound
∙ Give bronchodilators:
breath sounds were clean, no
- ...........................
cyanosis and dyspnea (capable of
- ............................
removing sputum, breathing
- ...........................
easily, no pursed lips)
∙ monitor hemodynamic status
❖ Shows that patent airway (the
∙ Give Kassa moist air humidifierMoisture NaCl
client does not feel suffocated,
∙ Give antibiotics:
breathing rhythm, respiratory
.........................
frequency in the normal range,
.........................
no abnormal breath sounds)
∙ Set intake to optimize fluid balance.
❖ Being able to identify and prevent
∙ Monitor respiration and O2 status
factors that cause.
∙ Maintain adequate hydration to thin secretions
❖ O2 saturation within normal limits
∙ Explain to patients and families on the use of
❖ Thoracic images within normal
equipment: O2, Suction, Inhalation.
limits
ObjectivesandCriteria Nursing Interventions
Results
NOC NIC
∙ Fluid balance Fluid management
Hydration ∙ Weigh diapers / pads if
∙ Nutritional Status: Food needed
and Fluid ∙ Maintain records accurate
∙ Intake intake and output
∙ Monitor the status of
Criteria Results: hydration (moisture of
∙ Maintain urine output in mucous membranes, adequate
accordance with the age pulse, orthostatic blood
and BB, BJ urine normal, pressure), if required
normal HT ∙ Monitor vital signs
∙ Blood pressure, pulse, ∙ Monitor enter the food / liquid
 imprecision syndrome of body temperature within
inappropriate antidiuretic hormone normal limits
secretion) ∙ There are no signs of
∙ renal dysfunction dehydration,
∙ The side effects of medications ∙ Elasticity good skin
(eg, medications, drain) turgor, mucous
∙ vomiting membranes moist, no
excessive thirst
and calculate daily calorie
intake
∙ Collaborate IV fluid
administration
∙ monitor nutritional status
∙ Give IV fluids at room
temperature
∙ Encourage oral input
∙ Provide appropriate
replacement nesogatrik output
∙ Encourage the family to help
patients eat
∙ Offer a snack (fruit juice,
fresh fruit)
∙ Collaboration doctor if signs
of excess fluid appears to
worsen
∙ Adjust the possibility of
transfusion
∙ Preparation for transfusion
Hypovolemia Management
∙ Including fluid status monitor
fluid intake and output
∙ Maintain IV line
∙ Monitor hemoglobin and
hematocrit levels
∙ monitor vital signs
∙ Monitor patient response to
fluid replenishment
∙ Monitor weight
∙ Encourage the patient to
increase oral intake
∙ IV fluid administration
monitor for signs and
symptoms of fluid volume
overload
∙ Monitor for signs of renal
 failure

Ineffective Patterns Breath

Definition: Air exchange inspiration and / or expiration inadequate

Defining characteristics:
- The pressure drop of inspiration / expiration
- Decrease in air changes per minute
- Use respiratory muscles extra
- Nasal flaring
- Dyspnea
- Orthopnea
- Changes irregularities chest
- Shortness of breath
- Assumption of 3-point position
- pursed-lip breathing
- expiratory phase lasts a very long time
- Increased anterior-posterior diameter
- Respiratory average / minimum
- Infants: <25 or> 60
- Age 1-4: <20 or> 30
- Age 5-14: <14 or> 25
- Age> 14: <11 or> 24
- Depth of respiration
- Adult tidalnya volume of 500 ml at the break
- Baby tidalnya volume of 6-8 ml / kg
- Timing ratio
- Reductions vital capacity

associated factors:
- hyperventilation
- Skeletal deformities
- deformity of the chest wall
- Decreased energy / fatigue
- Vandalism / attenuation musculo-skeletal
- Obesity
- The position of the body
- exhaustion of respiratory muscles
- Hypoventilation Syndrome
- Pain
- Anxiety
- Dysfunction Neuromuscular
- Damage perceptual / cognitive
- Sores on the spinal nerve tissue
- immaturity of Neurological

Goals and Criteria Results:

NOC:
- Respiratory Status: Ventilation
- respiratory status: Airway patency
- Vital signs Status
Criteria Results:
- Demonstrate effective cough and breath sounds were clean, no cyanosis and
dyspnea (capable of removing sputum, able to breathe easily, no pursed lips)
- Shows the airway patent (client do not feel suffocated, breathing rhythm,
respiratory frequency in the normal range, no breath sounds abnormal)
- Signs vital signs within normal range (blood pressure, pulse, respiration)

Nursing interventions:
NIC:
Airway Management
- Open the airway, guanakan engineering chin lift or jaw thrust if needed
- Position the patient to maximize venti Outcome
- Identify the patient's need for installation of equipment artificial airway
- Put mayo if necessary
- Perform chest physiotherapy if necessary
- Remove secretions by coughing or suctioning
- Auscultation of breath sounds, noting the additional sound
- Make a suction on the mayo
- Give bronchodilators if necessary
- Give moisturizer moist air NaCl wet Kassa
- Set intake to optimize fluid balance.
- Monitor respiration and status O2
 Oxygen Therapy
- Clear mouth, nose and secret trachea
- Maintain airway patent
- Manage equipment oxygenation
- Monitor the flow of oxygen
- Maintain the position of the patient
- Onservasi any signs of hypoventilation
- Monitor the patient's anxiety towards oxygenation

Vital Sign Monitoring

- Monitor BP, pulse, temperature, and RR
- Note the presence of fluctuations in blood pressure
- Monitor VS while the patient is lying down, sitting or standing
- Auscultation TD on both arms and compare
- Monitor BP, pulse, RR, before, during, and after activity
- Monitor the quality of the pulse
- Monitor respiratory rate and rhythm
- Monitor lung sounds
- Monitor abnormal breathing patterns
- Monitor temperature, color and moisture
- Monitor peripheral cyanosis
- Monitor their Cushing's triad (widened pulse pressure, bradycardia,
increased systolic)
- Identification of the causes of changes in vital signs

BARRIERS TO MOBILITY OF PHYSICAL IN THE BED

Factor That berubungan
● Cognitive disorders
● Dekondisi
● Kenala environment
● Muscle strength is insufficient
● Lack of knowledge (non Nanda)
● Impaired musculoskeletal
● disorder is a neuromuscular
● Obesity
● Pain
● Medication sedative
 Limits Characteristics

Barriers ability to:

● Change the position of your back to sitting position
● Changing position from sitting to supine
● Changing the position of his back to his stomach
● Changing the position of his stomach to his back
● Changing the position from supine to sit selonjor
● Changing the position of sitting selonjor to supine
● Move quickly or set repositioning themselves in bed
● Turning from side to side
Nursing interventions

Objectives and outcomes (NOC)

Having given the patient's care will:

● Achieving mobility in bed, as evidenced by the setting position of the body; own
volition, performance body mechanics, coordinated movements, active joint movement
and mobility satisfactory
● Demonstrating mobility, as evidenced by the following indicators:
1 eksterm disorders
2 heavy
3 being
4 lightweight
5 not impaired
Indicator 1 2 3 4 5
Coordination
Performance posture
movement of muscles and
joints

Nursing Interventions (NIC)

Assessment
● Perform assessment of the patient's mobility is continuously
● Assess the level of consciousness
● Assess muscle strength and joint mobility
counseling for patients / families
● Train range of motion of active and passive to improve strength and muscle endurance
 ● Trained technical flips and improve body alignment

Activities collaborative
use physical therapist / occupational as a source in the preparation of a plan to maintain and
improve mobility in bed

other activities
● Place tombola tau lights callers help place that is easily achieved
● Give tools , jiak need
● Give positive reinforcement for activity
● Perform pain control measures before starting an exercise or physical therapy
● treatment plan includes a number sure persona needed to reverse the position of the
patient
 REFERENCES
Fhatimfhatim (2012), LAPORAN PENDAHULUAN PADA PASIEN DENGAN GANGGUAN
KESEIMBANGAN CAIRAN DAN ELEKTROLIT, terdapat di:
http://fhatimfhatim.wordpress.com/2012/07/24/cairan-dan-elektrolit/
Lencana, Putra Satya (2012), Laporan Pendahuluan Kebutuhan Cairan dan Elektrolit, terdapat
di : http://satyaexcel.blogspot.com/2012/07/laporan-pendahuluan-kebutuhan-eliminasi.html
Hidayat, AAA dan Uliyah. 2011. Keterampilan Dasar Praktik Klinik. Jakarta: Salemba Medika
Kusuma Hardi. 2015. Nanda. MediAction : Jogjakarta