Treating Dehydration DT Physical Exertion

psu_213, BSN, RN · May 29, 2018

What other choices were there? Was NS an option? In my experience, almost every ED pt is rehydrated with NS.

NurseNurseNurseNurse · May 29, 2018

the options were 0.45%, 3%, 0.9% or an electrolyte rich beverage

MunoRN, RN · May 29, 2018

The actual correct answer would be that you don't move on to an intervention without first assessing, since that is what would determine how to best treat the patient. If all it's possible to know is that they are dehydrated from activity, then the correct answer would be to just drink water or a complete fluid replacement like Gatorade. There's no reason based on the question to believe IVF are indicated, and 0.45% NaCl wouldn't be the best choice if it was, although for some reason nursing instructors are obsessed with half-NS and it seems to be their answer to everything.

A laboratory confirmation of electrolyte balance would be the most helpful, but that's not necessarily needed since the "symptoms" of dehydration can fairly reliably reveal any significant electrolyte imbalances and direct treatment, which generally could consist of PO replacement.

NurseNurseNurseNurse · May 29, 2018

Thanks for your response!

Are you saying that is it easy to identify an electrolyte balance from symptoms alone? In my reading many seemed to present with similar symptoms, I wouldn't feel confident diagnosing (though I know it's not in out scope as nurses) based on that alone.

In general, would you say that it is flawed logic to assume that someone presenting as dehydrated is also hypertonic?

psu_213, BSN, RN · May 29, 2018

A laboratory confirmation of electrolyte balance would be the most helpful, but that's not necessarily needed since the "symptoms" of dehydration can fairly reliably reveal any significant electrolyte imbalances and direct treatment, which generally could consist of PO replacement.

My ED brain kicked in when I read the original question. In my mind, a man comes in via EMS after having a syncopal episode while mowing his lawn on a hot day. During the recent fluid shortage, he would have been given PO fluid replacement, if possible. Pretty much any other time, he would have been started on NS. Electrolytes would have been replaced if there are any derangements, but NS would be started before labs are back. In the EDs in which I have worked, if you are getting labs, physicians generally just have you start an IV and give IVF while the labs "cook."

If he presented to the ED via POV, not EMS, was triaged and found to be otherwise stable other than self reported dehydration, perhaps with mild tachycardia, he may very well be treated only with PO fluids. Again we may get labs, increasing the likelihood of IVF just because we now have venous access.

So, to the OP, it really does depend on the entire clinical situation, the assessment, and the setting.

KatieMI, BSN, MSN, RN · May 29, 2018

In pure theory, sweating is considered to be mostly "water" loss, not salt loss, plus insensitive losses (with breathing) will increase in high temperature as well, and they are 100% water. "Sweating in a desert" is a medical textbook' picture of hypotonic (water alone) losses as opposed to isotonic (diarrhea) losses, thus leading to hypertonicity. By the same books, half normal saline is the right response. But the book is a book, and life is a life.

At least I hope you'll never pour couple of liter of half normal in such patient without questioning what exactly the doc was drinking the night before :)

PeakRN · May 29, 2018

The causes of dehydration are multifaceted. Was this patient also drinking beers while mowing the lawn increasing his urine output? If he had an increase in respiratory rate then he is also breathing off more water. He of course could be sweating as well. The questions is very reminiscent of nursing school, it gives you too little info, and the "best answer" isn't actually the correct answer.

Generally speaking patients who can tolerate PO fluids and are clinically stable should be doing so. If we are going to start IV fluids in the ED we typically start with NS, although based on a recent studies we are giving most of our large boluses in LR to preserve renal function. If they are hypernatremic then we would want to calculate their free water deficit and replace this with a lower sodium solution, typically D5W or LR.

MunoRN, RN · May 29, 2018

My ED brain kicked in when I read the original question. In my mind, a man comes in via EMS after having a syncopal episode while mowing his lawn on a hot day. During the recent fluid shortage, he would have been given PO fluid replacement, if possible. Pretty much any other time, he would have been started on NS. Electrolytes would have been replaced if there are any derangements, but NS would be started before labs are back. In the EDs in which I have worked, if you are getting labs, physicians generally just have you start an IV and give IVF while the labs "cook."
If he presented to the ED via POV, not EMS, was triaged and found to be otherwise stable other than self reported dehydration, perhaps with mild tachycardia, he may very well be treated only with PO fluids. Again we may get labs, increasing the likelihood of IVF just because we now have venous access.
So, to the OP, it really does depend on the entire clinical situation, the assessment, and the setting.

And that's the think, "symptomatic", particularly in a nursing school question, could refer to anything from mild tachycardia to seizures or cardiac arrest. I think there's sometimes the view that more aggressive treatments like IV fluid replacement instead of PO is always better, but if the plan is treat n' street then IV fluids would be an inferior mode of treatment since it doesn't allow you to establish that the patient can maintain their volume status with PO intake after they leave.

NurseNurseNurseNurse · May 29, 2018

In pure theory, sweating is considered to be mostly "water" loss, not salt loss, plus insensitive losses (with breathing) will increase in high temperature as well, and they are 100% water. "Sweating in a desert" is a medical textbook' picture of hypotonic (water alone) losses as opposed to isotonic (diarrhea) losses, thus leading to hypertonicity. By the same books, half normal saline is the right response. But the book is a book, and life is a life.
At least I hope you'll never pour couple of liter of half normal in such patient without questioning what exactly the doc was drinking the night before :)

Thanks you so much! That really answered my question perfectly! :)

MunoRN, RN · May 29, 2018

In pure theory, sweating is considered to be mostly "water" loss, not salt loss, plus insensitive losses (with breathing) will increase in high temperature as well, and they are 100% water. "Sweating in a desert" is a medical textbook' picture of hypotonic (water alone) losses as opposed to isotonic (diarrhea) losses, thus leading to hypertonicity. By the same books, half normal saline is the right response. But the book is a book, and life is a life.
At least I hope you'll never pour couple of liter of half normal in such patient without questioning what exactly the doc was drinking the night before :)

And that's the tricky part, "sweating in a desert" can result in either hypernatremia or hyponatremia based on additional information. Sweat contains about a third of the sodium per liter that blood does, so sweating without drinking any water will eventually result in hypernatremia, sweating and drinking water but not enough to match water losses will result in hyponatremia.

NurseNurseNurseNurse · May 29, 2018

The questions is very reminiscent of nursing school, it gives you too little info, and the "best answer" isn't actually the correct answer.

That is so great to hear you say! I have been thinking this a lot, especially with out case studies that are based off only 2-3 sentences of backstory. Oy.

Thanks!