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Monday, April 20, 2015

Fluid & Electrolyte Problems in Surgical Patients

Surgery, fluid, electrolyte, assessment, nurse, nursing school, OR, OR nurse, Surgical nurse, NCLEX, Med-surge, labs

Fluid and Electrolyte Problems in Surgical Patients


No matter what field of nursing you go into, you'll most likely take care of patients who have had surgery. Even if you're not an OR nurse, it's important to know these common fluid and electrolyte issues that can occur in surgical patients. Here's a quick guide on F&E for the preoperative, intraoperative, and postoperative patient.

Preop


Many of us will take care of patients before and after surgery. So what do I as the nurse need to look out for in the preop phase??

It's important to note any patient history that may have a significant influence on the patients F&E. Examples would be:
  • Heart patients- Congestive heart failure patients may have fluid volume excess.
  • Renal patients- May also have fluid volume excess/overload due to low clearance. 
  • Liver patients- They may have ascites caused from high portal blood pressure, causing them to retain fluid and be in fluid volume overload.
The patient may not be in fluid volume excess but could be in fluid volume deficit due to being NPO, or due to bowel preps before some GI surgeries. Or perhaps the patient has been vomiting or having diarrhea in excess and that is the cause for the FVD. 

Watch your patient's potassium levels. Hypokalemia would be a cause to cancel a surgery since it predisposes the patient to a cardiac arrhythmia. But cancellation can vary dependent upon how emergent the surgery is, or how extreme the hypokalemia is. Just be aware. You might need to give fluids before the patient goes down to surgery.

Intraoperative


Unless you're an OR nurse this won't really pertain to you. Very rarely am I ever in the OR, so this isn't my spot of expertise. Be sure to leave a comment if you're an OR nurse and I've left out something important! :)

The patient in OR would be at risk for fluid volume deficit due to loss of blood, 3rd spacing, or evaporation from the wound site. You'll monitor the patient's blood pressure and heart rate. If the blood pressure decreases that can be a sign of FVD. Malnourished patients are at the greatest risk for complications. Unfortunately, if they're having surgery chances are that the patient is sick and is partially malnourished. Healthy people don't typically have surgeries. So we should try our best to provide nutrients to the patient prior to surgery.

Albumin can compensate a bit for blood loss, but if it's a trauma patient then they may have 3rd spacing due to loss of albumin. It's common to replace blood loss using a crystalloid fluid (lactated ringers for example) by administering 3 mL for every 1 mL of blood lost. 

Postop


After surgery the body goes through a stress response for a couple days. Cortisol is increased, ADH is increased. Increased Cortisol can lead to hyperglycemia. An increase in ADH can mean reduced urine output. 

The patient should be placed on an isotonic solution for the first day. Since ADH is increased, the patient can retain fluid and lead to hyponatremia because sodium is being diluted. 0.9% NaCl is a solution recommended for this phase. LR can be used too. If the patient is receiving NS be aware that it contains 154 meq of chloride. This could end up with the patient having too much chloride. LR has 109 meq of chloride. Chloride is supposed to be around 95-105 meq, so you can see where I'm coming from with that thought process. There may be 3rd spacing due to loss of albumin, so you may find yourself administering albumin. The patient may have a fever leading to FVD.  Depending upon how much fluid is being infused, you may need to obtain a warmer.

The patient may have fluid volume deficits due to GI losses. Vomiting or excessive NG suctioning could send the patient into Metabolic Alkalosis. Diarrhea or shock could send the patient into Metabolic Acidosis

The patient can develop Respiratory Acidosis due to shallow breathing as a result of the anesthesia or narcotics. The patient can also develop Respiratory Alkalosis due to hyperventilating from pain.

Monitor for FVD by looking at urine output, an elevated BUN, hypotension, tachycardia, skin turger, body weight, etc...

If the patient had a neck surgery, they may be at risk for developing Hypocalcemia. Remember where the parathyroid/thyroid glands are located. 


*******

Bottom line: your patient's labs, I/Os, and vital signs will drive the care that is given. 


Sorry I haven't posted anything all week. It's been insane. But I made a new header, and I think I likes it. ;)

Is there anything that you look for in particular in your surgical patient?? Leave a comment below! 

Xoxo,

Nightingale

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