NURSING

MANAGEMENT
 Assess
Assessing clients for fluid,
ment
electrolyte, and acid-base balance
and imbalances is an important
nursing responsibility.
Assessment
01 Nursing History

02 Physical Assessment of
the Client

03 Clinical Measurements

04 Review of Laboratory Test

Results
 ASSESSMENT

NURSING
HISTORY

Nursing History is important for

identifying clients who are at
risk for fluid, electrolyte, and
acid-base imbalances.
Current and past medical
history reveals conditions such
as chronic lung disease that can
disrupt normal balances.
Medications prescribed to treat
acute or chronic conditions.
(e.g. diuretic therapy for
hypertension).
 Nursing
History

Old people, young children and

people who cannot afford or do
not have the means to cook for
a balanced diet are at greater
risk of fluid and electrolyte
imbalances.
When obtaining a nursing history

The nurse needs to gather data about

the client’s food and fluid intake.

The nurse needs to gather data about

the client’s fluid output.

The presence of signs or symptoms

suggestive of altered fluid and
electrolyte balance.
 Common Risk Factors for Fluid,
Electrolyte, and Acid-Base Imbalances
Chronic Disease and Conditions Medications
 Chronic Lung disease (COPD,  Diuretics
Asthma, Cystic Fibrosis)  Corticosteroids
 Heart Failure  Nonsteroidal anti-inflammatory
 Diabetes Mellitus drugs
 Cancer
 Malnutrition

Acute Conditions Treatments

 Acute gastroenteritis  Chemotherapy
 Bowel obstruction  IV therapy
 Head injury or decreased level of  Enteral feedings
consciousness  Mechanical Ventilation
 Surgery
 Fever

Other Factors
 Age: Very old or very young
 Inability to access food and fluids
independently.
Nursing Management
Physical
Assessment
Physical assessment to
evaluate a client’s fluid,
electrolytes, and acid-base
status focuses on the skin,
the oral cavity and mucous
membranes, the eyes, the
cardiovascular and
respiratory systems, and
neurologic and muscular
status.
Physical Assessment

Data from this physical assessment are used to

expand and verify information obtained in the
nursing history.
 Focused Physical Assessment for Fluid, Electrolyte, or Acid-
Base Imbalances
System Assessment Focus Technique Possible Abnormal
Findings
Skin  Color, Temperature,  Inspection, Palpation  Flushed, warm, very
Moisture dry, moist or
 Turgor  Gently pinch up a fold diaphoretic
of skin over sternum for  Poor turgor: Skin
adults, on the abdomen remains tented for
or medial thigh for several seconds.
children
 Inspect the eyes for
visible swelling around
eyes, in fingers, and in
 Edema lower extremities.
 Skin around eyes is
puffy, lids appear
swollen
Mucous membranes  Color, Moisture  Inspection  Mucous membranes
dry, dull in appearance;
tongue dry and
cracked.
Eyes  Firmness  Gently palpate the  Eyeball feels soft to
eyeball with lid closed palpation
 Focused Physical Assessment for Fluid, Electrolyte, or Acid-
Base Imbalances
System Assessment Focus Technique Possible Abnormal
Findings
Cardiovascular System  Heart Rate  Auscultation, cardiac  Tachycardia,
monitor bradychardia
 Peripheral pulses  Palpation
 Weak and thready;
 Capillary Refill  Palpation bounding
 Venous filling  Inspection of jugular  Slowed capillary refill
veins and hand veins  Jugular venous
distention; flat jugular
veins, poor venous refill
Respiratory System  Respiratory rate and  Inspection  Increased or decreased
pattern rate and depth of
 Auscultation respirations
 Lung sounds  Crackles or moist rales
Neurologic  Level of consciousness  Observation,  Decreased LOC
(LOC) stimulation  Disoriented, confused
 Orientation, cognition  Questioning  Concentrating
 Motor function  Strength testing
 Clinical Measurements
Three simple clinical
measurements that the nurse
can initiate without a primary
care provider’s order are:

Daily Fluid intake

Vital signs
weights and output
 Place Your Picture Here

Daily Weights
Daily weights provide a relatively accurate assessment
of the client’s fluid status. Significant changes in weight
over a short time. For example: more than 2.3 kg (5 lb) in a week or
more than 1 kg (2.2 lb) in 24 hours, are indicative of
acute fluid changes.
Clinical Measurements
Daily
Weights
Each kilogram of weight gained or
lost corresponds to 1L of fluid gained
or lost.

Such fluid volume rather than in any

specific compartment, such as the
intravascular compartment.

Rapid losses or grains of 5% to 8% of

total body weight indicate moderate
to severe fluid volume deficits or
excesses.
 Your Picture Here

To obtain accurate weight

measurements, the scale
should be balanced before
each use, and the client
should be weighed:

(a)At the same time each

day (e.g. before
breakfast and after the
first void)
(b)Wearing the same or
similar clothing
(c)On the same scale (e.g.
standing, bed or chair)

Should be documented.
Regular assessment of the weight is important for clients in the
community and extended care facilities who are at risk for fluid
imbalance.
WHY?
For this clients, measuring intake and output may be impractical
because of lifestyle of problems with incontinence.
Tachycardia is an
early sign of
VITAL
hypovolemia. Pulse
volume will decrease
in FVD and increase in
SIGNS
Changes in vital signs
FVE.
Changes in the
respiratory rate and
may indicate, fluid
depth may cause electrolyte, and acid-
respiratory acid-base base imbalances.
imbalances or
indicate a
compensatory Example: Elevated
mechanism in
Blood Pressure (BP),
body temperature
metabolic acidosis ora
sensitive
alkalosis. measure for may be a result of
detecting blood
volume changes, may
dehydration or a
fall significantly with cause of increased
FVD and hypovolemia
or increase with FVE.
body fluid lossess.
(a) Measure the clients
BP and pulse in a
supine position
VITAL
(b)Allow the client to
remain in that
SIGNS
position for 3-5
minutes, leaving
To assess for
the pressure cuff on orthostatic
the arm.
(c) Ask the client to
hypotension
stand up
immediately
reassess the BP and
pulse.

A drop of 10 to 15
mmHg in the systolic
BP with a
corresponding drop in
diastolic pressure and
an increased pulse
FLUID INTAKE AND
OUTPUT
Measurement and recording of all fluid intake
and output during a 24-hour period provides
important data about a client’s fluid and
electrolyte balance.
The unit used to measure I&O is the milliliter
(mL). In house hold measures, 30 mL is
roughly equivalent to 1 fluid ounce, 500 mL to 1
pint, and 1,000 mL to 1 quart.

To measure fluid intake, nurses

convert household measures such
as a cup or soup bowl to metric units
Fluid Intake
Oral fluids. to measure the amount of water
consumed from a water pitcher, measure how
much water remains in the pitcher and subtract
this amount from the volume of the full pitcher.
 
Ice chips . record the fluid volume as
approximately one half the volume of the ice
chips. For example, if the ice chips fill a cup
holding 200 ml and the client consumed all of
the ice chips, the volume of the consumed
would be recorded as 100 ml.
 
Foods that are or become liquid at room
temperature . do not measure foods that are
pureed, because pureed are simply solid foods
prepared in a different form.
 
Fluid Intake
Tube feedings. remember to
include the volume of water used
for flushes before and after
medication administration,
intermittent feedings, residual
checks, or any other water given
via a feeding tube.
 
Parenteral fluids. the exact
amount of IV fluid administered
must be recorded, since some fluid
containers may be overfilled. Blood
transfusions are included in the
total.
Fluid Intake
IV medications. intermittent or
continuous infusion administered
must also be included. Most IV
medications are mixed in 50 – 100
ml of solution.
 
Catheter or tube irrigants. Fluids
used to irrigate urinary catheters,
nasogastric tubes, and intestinal
tubes must be recorded if not
immediately withdrawn as part of
the irrigation.
 
Fluid Output
URINARY OUTPUT:
following each voiding,
pour the urine into a
measuring container, note
the amount, and record
the amount and time on
the I &O form. For clients
with retention catheters,
empty the drainage bag
into a measuring container
at the end of the shift (or
at prescribed times if
output is to be measured
more often).
 Your Picture Here

WOUND AND
Fluid Output FISTULA
VOMITUS AND DRAINAGE:
drainage may be
LIQUID FECES: the
recorded by
amount and type of documenting the
the fluid and the time type and number of
need to be specified. dressings or linen
TUBE DRAINAGE: saturated with
this includes gastric or drainage, or by
measuring the exact
intestinal drainage.
amount of drainage
collected in a
vacuum drainage or
gravity drainage
system
LABORATORY TESTS
CONDUCTED TO
DETERMINE A CLIENT’S
FLUID, ELECTROLYTE, AND
ACID-BASE STATUS.
Serum electrolytes: screening test for
electrolyte and acid-base imbalances
(e.g. clients who are being treated with a
diuretic for hypertension or heart failure).
Most commonly ordered serum tests are
for sodium, potassium, chloride,
magnesium, and bicarbonate ions.

Complete blood count (CBC): includes

information about hematocrit (Hct), which
measures the percentage of the volume
of whole blood that is composed of
RBC’s.
LABORATORY TESTS
CONDUCTED TO
DETERMINE A CLIENT’S
FLUID, ELECTROLYTE, AND
ACID-BASE STATUS.
Osmolality: is the measure of the
solute concentration of blood and is
used primarily to evaluate fluid
balance.

Urine osmolality is a measure of the

solute concentration of urine. The
particles included are nitrogenous
wastes , such as creatinine, urea,
and uric acid.
ARTERIAL BLOOD GASES
(ABGs)

Arterial blood gases are performed to

evaluate a client’s acid-base balance
and oxygenation. Arterial blood is used
because it provides a more accurate
reflection of gas exchange in the
pulmonary system than venous blood.
Can be drawn by laboratory
technicians, respiratory therapy
personnel, or nurses with specialized
skills.
ABGs
Six Measurements
pH is a measure of the relative acidity or alkalinity of the
blood, and is an inverse measure of the number of
hydrogen ions in a solution.

PaO2 is the partial pressure of oxygen dissolved in

arterial plasma, and is an indirect measure of blood
oxygen content.

PaCO2 is the partial pressure of carbon dioxide in arterial

plasma, and is the respiratory component of acid-base
determination.

HCO-3 is a measure of the bicarbonate dissolved in

arterial plasma, and represents the metabolic component
of acid-base balance.