Fluid, Electrolyte,

and Acid-Base
Balance
As a se!1ior student you are assigned to work with a pre- ; ,,.,,.~ ,c:-- -,..,.,,,_,....
ceptor m the Emergency Department. It is a very busy day ;
and it seems ;:i.s if every patient, regardless of chief com- / f
plaint, has an issue with fluid; electrolyte, and/or acid-base : f .1
balance. ! · if
The first patient you see is a 3 7-year-old landscaper ! ;· ·
who is brought to the ED after collapsing on a job at the : '.
local country dub ..He is slightly conf~sed .bu~ is able to :
tell you he feels dizzy and weak. His skm is flushed, i
t.
dry, and with poor turgor. He has dry, sticky mucous :
membranes. The nurse identifies a nursing diagnosis of '
deficient fluid volume.

1. Describe how each of the following would change

and the rationale for the change in the presence of
deficient fluid volume:
• Heart rate
• Blood pressure
• Serum hematocrit
• Urinary output
• Urine specific gravity
• Weight
 298 Unit 4 I Supporting Physiological Functioning
Parameter
Expected Change Rationale
Heart rate

Blood pressure
W~q,r, ~« i-o °""°'~
Serum hematocrit

Urinary output
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-
Urine specific gravity
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,-Weight
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1
-

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2. What is usually the first indicator that an individual needs more fluids?

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3. The EDvolume
a fluid physician orders
deficit dueIVtofluids for this patient. What types of fluids are indicated for
dehydration?

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J ~__jl>, cJ1& 11> ·- -

The preceptor tells you to go ahead and initiate an lV site and st.an the fluids. The
has a order
fluid is to st.an
drop factor of 1.51000 ml. of fluid as ordered at 150 mVhr. The infusion tubing
gtt/mL.

4. This infusion will run by gravity rather than an infusion pump. How many drops per
minute should you time the infusion at to ensure the correct hourly rate?
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Sb \ ~'\\ \µ_ ,it> Jrw"' ·

5. What factors should you be concerned about that may compromise the gravity infu-
sion rate? How will you intervene for these factors?
 Fluid, Electrolyte, and Acid-Base Balance 299

factor

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fl\. ex i\\~.

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6. The patient has a "full sleeve" tattoo on both arms. Discuss the implications of this
finding and how you will initiate the intravenous site.

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- - - - -- -- -
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7. You ha~e difficulty finding a vein in the presence of the deficient fluid volume. What
strategies can you employ to help make a vein more visible/palpable?

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Ya.,_ ¼rLllc..u_
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J:.. -1,,i..,,,. w.; \:c,,_

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-- - -

8. Considering the diagnosis, patient presentation, and fluid orders, what size catheter
is indicated in this situation? Give a rationale for your choice.

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___,"--------_

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300 Unit 4 I Supporting Physiological Functioning
. states, "MYarm where the
9. After 30 minutes of the infusion, the patient d f needle
the is
feels funny:' What should you do first? What further data do you nee rom
patient?

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~ ~f_ 1\t4o _ o(· i~ klL)1k. C«Ls ~b'

- - --- - - - -
. Several hours later the patient is feeling better and is now oriented x 3. The ED physi-
cian wants the patient to be drinking oral fluids without difficulty prior to being
discharged from the ED. · ·

10. Discuss the strategies to increase fluid intake that are most appropriate to this setting.

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<:µ,t'\ _Wj\~- RMbci L __ -- - - - - - --

11. The patient is dis.charged after adequate hydration. Discharge teaching includes ways
to prevent this from happening again on the job. What key points should the nurse
include in the teaching applicable to the job site?

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The next patient is a 67-year-old pati~m who presents with~ c~ief co~pl~int: "1 can'.t
sleep at iiight-I can't lie down, 1 get so out of breath." She 1s s1tt111~ 111 _high Fowle_r s
osition on the exam table. She has a history of heart pr_oble1?s. She 1s _d1ag~osed ~1th
;cu_te exacerbation of conge_~tive heart failure, and you 1dent1fy a nursmg d1agnos1s of
Flmd Volume Excess (FVE) .

1
cc) 20 12 NAN DA International
 Fluid, Electrolyte, and Acid-Base Balance 301

11. What .,sthe term youshou\d use to document the patient's chief complaint regarding
her breathing?

l\.-.\1M.D ,~~--
n. Besides the respiratory difficulty exhibited by the patient, what manifestation of FVE
may be immediately visible on assessment? •

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The physician gives the following orders: (You may need to review your drug
resources to help you understand the medication orders.)
• DsLR at 100 mVhr~
• Use infusion pump
: Furose_rnide (Lasix) 80 mg IV now
Potassmm citrate (K-Lyte) 10 mEq orally now and q4h x 2 doses
• 02 2-5 LPM to keep 0 2 sat greater than 92%

14. Which order should the nurse question? Why?

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fr~

15. Over the course of 4 hours the patient has a weight loss of 11 pounds. This repre-
sents how much fluid loss? .. .

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bV~l\Q:)6__ _
- - - - - - -- - - -- ------
The patient was admitted to the facility and after 2 days is ready for discharge.
Discharge orders include a low-sodium (2000 mg/day) diet and a fluid restriction of
1500 mL/day.

16. Describe the key information that the patient needs to know to follow these instructions.

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 A1:o~her patient is brought to the Emergency Department by a neighbor who noticed
her ~Ittmg, confused, on her front steps. The patient is a 24-year-old female and unable
to give a valid history at this time. Admission data include the following:
• Neurological: Confused
• Pulrn~mary: Respirations 28 breaths/min and shallow, lungs clear
• Card1o~ascu_lar: Irregular rapid pulse, ECG shows flattened T waves
• Gastromtestmal: Hypoactive bowel sounds
• Musculoskeletal: Muscle weakness

17. The preceptor identifies a·nursing~diagnosis, of Risk for• decreased cardiac outputt
related to el~ctrolyte imbalance. What is the electrolyte imbalance that is being
presented by this patient? ·

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18. What is the specific NOC outcome for this electrolyte imbalance? Identify two expected
outcomes for this patient.

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]Cl.h~L t~~\mbon. l" ~~ -1L~Lw1 ½,. -~ '
~ - ~A-- @.\<.. . . .

19. In light of the patient's confusion, what medication order can you anticipate from the
ED physician to correct this electrolyte problem? What are your responsibilities in the
implementation of the orders?

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,~~).,_ ~( ~~~".:) o.(\~~~~~s__ C)\--_~~~~ o(__

'SWr:L ~ ~ -~ \ ~- <'.:>~-~ 1A:>1#t

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W'\~ - ~ I~__1__j_~_ Jlf,Y__d_
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1,9 2012 NANDA International
 Fluid, Electrolyte, and Acid-Base Balance 303

Due to a bed shortage the patient remains in the ED for treatment for the n1xt
12 hours. At that time he'r confusion has cleared and her apical pulse is now regu ar
though still somewhat tachycardic at 102 beats/min. Sh~ tells you that she had been
using her grandmother's "water pills" to help her lose weight.

20. What is the significance of this information?

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-. . :. .:•.:.._
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~~~1\.lfyV-\ , t\ ~ ~ ~~_ol-- k( c ® J, l,m .

21. It is decided to discharge her home with instructions regarding dietary intake to
~nsure good serum levels of the compromised electrolyte. What foods should be
included in these instructions?

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m~ ~ =-"--'-
. _ _ _ _

A patien~ presents to the ED a diagnosis of exacerbation of Crohn's disease with

mala~sorpt1~n syndrome. He is also severely dehydrated from the excessive diarrhea
associated with the disease. A concurrent concern is hypocalcemia.

22. What subjective data would you expect to gain from the patient that describe
symptoms of hypocalcemia?

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23. Describe how you would assess for hypocalcemia in this setting.

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24. Your preceptor tells you, "Keep an eye on his breathing, okay?" What is the signifi-
cance of this directive?

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-
304 Unit 4 I Supporting Physiological Functioning

. for sta 6-1·

Hospitalization is required for this patient · and treatment
I izatton d . I of
d bothI
the hypocalcemia and the exacerbation of his disease. At discharge or ers, me u e ora
calcium supplements and/or a diet high in calcium.

25. What is the best dietary source of calcium? What additional dietary supplement is
necessary for adequate calcium absorption?

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~lJJ.L._~j'(,W. · - - - - -- - - -- -
26. Discuss alternative dietary choices for the patient who states, "I don't like milk
products. I am lactose intolerant'.'

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The last patient you see today presents to the ED with a complaint of chest tightness,
tingling in the hands, and headache. He has noticeable trembling of the hands. He
tells you, "I swear I think I am having a heart attack!" His vital signs are BP 162/88 -
104 - 32 and a febrile. The ED physician orders laboratory work including cardiac panel,
chemistry panel, CBC, and arterial blood gases (ABGs). He tells you "I think he is
having an anxiety attack."

27. What would you anticipate the ABG results to be (disorder and values) if this diagno-
sis 1s correct?

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28. What _is th_e most appropriate nursing diagnosis, NOC outcome, and NIC intervention
for this acid-base disorder?

29. How would you assist the patient to compensate for this acid-base disorder?

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