FLUID AND ELECTROLYTES: intraocular, and pleural fluids, sweat,

BALANCE AND DISTURBANCE and digestive secretions

Amount and Composition of Body Loss of ECF into a space that does not
Fluids contribute to equilibrium between the ICF
and the ECF is referred to as a third-space
 Approximately 60% of a typical fluid shift, or third spacing
adult’s weight consists of fluid
Early evidence of a third-space
 Younger people have a higher fluid shift
percentage of body fluid than older
adults 1. Decrease in urine output despite
adequate fluid intake. Urine
 Men have proportionately more body output decreases because fluid
fluid than women shifts out of the intravascular
 People who are obese have less fluid space; the kidneys then receive
than those who are thin, because fat less blood and attempt to
cells contain little water. compensate by decreasing urine
output.
 The skeleton also has low water
content. Muscle, skin, and blood Signs and symptoms of third
contain the highest amounts of water spacing that indicate an
intravascular fluid volume deficit
Body fluid is located in two fluid (FVD)
compartments:
1. Increased heart rate
1. Intracellular space (fluid in the cells)
located primarily in the skeletal 2. Decreased blood pressure
muscle mass.
3. Decreased central venous
2. Extracellular space (fluid outside the pressure
cells)
4. Edema
The ECF compartment is further
divided into the intravascular, 5. Increased body weight
interstitial, and transcellular fluid 6. Imbalances in fluid intake and
spaces: output (I&O).
1. The intravascular space (the fluid ELECTROLYTES
within the blood vessels) contains
plasma, the effective circulating  Electrolytes in body fluids are active
volume. Approximately 3 L of the chemicals. (cations that carry
average 6 L of blood volume in positive charges and anions that
adults is made up of plasma. The carry negative charges).
remaining 3 L is made up of Milliequivalents (mEq); measured
erythrocytes, leukocytes, and thru chemical activity
thrombocytes. The major cations in body fluid
2. The interstitial space contains the 1. Sodium; important in regulating the
fluid that surrounds the cell and volume of body fluid. Retention of
totals about 11 to 12 L in an adult. sodium is associated with fluid
Lymph is an interstitial fluid. retention, and excessive loss of
3. The transcellular space is the sodium is usually associated with
smallest division of the ECF decreased volume of body fluid
compartment and contains 2. Potassium
approximately 1 L. Examples of
transcellular fluids include 3. Calcium
cerebrospinal, pericardial, synovial,
 4. Magnesium area of higher concentration to
one of lower concentration.
5. Hydrogen ions
 Filtration - The kidneys filter
approximately 180 L of plasma
The major anions per day.

1. Chloride  Sodium–Potassium Pump -

active transport implies that
2. Bicarbonate energy must be expended for the
3. Phosphate movement to occur against a
concentration gradient
4. Sulfate, and Proteinate ions.

Hydrostatic pressure - The pressure exerted

by the fluid on the walls of the blood vessel.

REGULATION OF BODY FLUIDS

COMPARTMENT
 Osmosis - is the diffusion of water
across a membrane in response to
osmotic pressure caused by an
imbalance of molecules on either
side of the membrane.
SYSTEMIC ROUTES OF GAINS AND
 Osmolality - The number of LOSSES
dissolved particles contained in a
1. Kidney - A general rule is that the
unit of fluid determines the
output is approximately 1 mL of
osmolality of a solution, which
urine per kilogram of body weight
influences the movement of fluid
per hour (1 mL/kg/h) in all age
between the fluid compartment
groups
 Tonicity - is the ability of all solutes
2. Skin – Sensible perspiration refers to
to cause an osmotic driving force
visible water and electrolyte loss
that promotes water movement from
through the skin (sweating).
one compartment to another.
3. Lungs - normally eliminate water
 Osmotic pressure is the amount of
vapor (insensible loss) at a rate of
hydrostatic pressure needed to stop
approximately 300 mL every day
the flow of water by osmosis. It is
primarily determined by the 4. GI tract
concentration of solutes.
LABORATORY TESTS FOR EVALUATING
 Oncotic pressure is the osmotic FLUID STATUS
pressure exerted by proteins (e.g.,
albumin). 1. Urine - specific gravity - measures
the kidneys’ ability to excrete or
 Osmotic diuresis is the increase in conserve water. The specific gravity
urine output caused by the excretion of urine is compared to the weight of
of distilled water, which has a specific
gravity of 1.000. The normal range of
substances, such as glucose, mannitol,
urine specific gravity is 1.010 to
or contrast agents in the urine.
1.025.
 Diffusion is the natural tendency
of a substance to move from an
 2. BUN - made up of urea, which is an zona glomerulosa (outer zone) of the
end product of the metabolism of adrenal cortex, has a profound effect
protein. It measures the amount of on fluid balance. Increased secretion
urea nitrogen that's in your blood. of aldosterone causes sodium
The normal BUN is 10 to 20 mg/dL retention (and thus water retention)
(3.6 to 7.2 mmol/L). and potassium loss.
3. Creatinine - is the end product of f) Parathyroid Functions - regulate
muscle metabolism. It is a better calcium and phosphate balance by
indicator of renal function than BUN means of parathyroid hormone
because it does not vary with protein (PTH).
intake and metabolic state. The
g) Baroreceptors - The baroreceptors
normal serum creatinine is
are located in the left atrium and the
approximately 0.7 to 1.4 mg/dL
carotid and aortic arches. These
(62 to 124 mmol/L);
receptors respond to changes in the
4. Hematocrit - measures the volume circulating blood volume and
percentage of red blood cells regulate sympathetic and
(erythrocytes) in whole blood parasympathetic neural activity
Conditions that increase the
h) RAAS system - Renin is released by
hematocrit value are dehydration a
the juxtaglomerular cells of the
polycythemia, and those that
kidneys in response to decreased
decrease hematocrit are
renal perfusion. Renin is an enzyme
overhydration and anemia
that converts angiotensinogen, a
5. Urine Sodium - Normal urine substance formed by the liver, into
sodium levels range from 75 to 200 angiotensin I. Angiotensin-converting
mEq/24 hours (75 to 200 enzyme (ACE) converts angiotensin I
mmol/24 hours) to angiotensin II. Angiotensin II, with
its vasoconstrictor properties,
HOMEOSTATIC MECHANISMS
increases arterial perfusion pressure
a) Kidney Function - Excretion of and stimulates thirst.
metabolic wastes and toxic
i) ADH and Thirst - Oral intake is
substances
controlled by the thirst center
b) Heart Blood Vessel Function - located in the hypothalamus blood
Failure of this pumping action volume decreases, neurons in the
interferes with renal perfusion and hypothalamus are stimulated by
thus with water and electrolyte intracellular dehydration; thirst then
regulation. occurs, and the person increases
their intake of oral fluids.
c) Lung Function - Through
exhalation, the lungs remove j) Osmoreceptors - Located on the
approximately 300 mL of water daily surface of the hypothalamus,
in the normal adult osmoreceptors sense changes in
sodium concentration.
d) Pituitary Function - The
hypothalamus manufactures ADH, k) Natriuretic Peptides - Natriuretic
which is stored in the posterior peptide hormones affect fluid volume
pituitary gland Functions of ADH and cardiovascular function through
include maintaining the osmotic the excretion of sodium (natriuresis)
pressure of the cells by controlling
FLUID VOLUME DISTURBANCES
the retention or excretion of water by
the kidneys and by regulating blood Hypovolemia - It occurs when water and
volume electrolytes are lost in the same proportion
as they exist in normal body fluids;
e) Adrenal Function - Aldosterone, a
dehydration, which refers to loss of water
mineralocorticoid secreted by the
alone.
Pathophysiolgy: o Antiemetic
 FVD results from loss of body fluids
and occurs more rapidly when
coupled with decreased fluid intake.

HYPERVOLEMIA
Gerontologic Consideration :
 Refers to an isotonic expansion of
 Assessment of skin turgor is not as the ECF caused by the abnormal
valid in older adults because the skin retention of water and sodium.
has lost some of its elasticity; Hypervolemia occurs when
therefore, other assessment aldosterone is chronically stimulated.
measures (e.g., slowness in filling of
Pathophysiology:
veins of the hands and feet).
o Simple fluid overload
Medical Management:
o Lactated Ringer solution, 0.9% o Diminished homeostatic mechanisms
sodium chloride) are frequently the o Hearrt failure
first-line choice to treat the
hypotensive patient with FVD o Kidney injury
because they expand plasma volume
o Cirrchosis of the liver
o 0.45% sodium chloride as soon as
o Excessive amounts of table or
the pt becomes normotensive;
sodium salts.
provide both electrolytes and water
for renal excretion. Pharmacologic Therapy:
o Frequent assessments of I&O, o Diuretics
weight, vital signs, central venous
pressure, level of consciousness, o Thiazide diuretics to block sodium
breath sounds, and skin color reabsorption in distal tubule.

o Isotonic fluids o Furosemide block in ascending limb

of Henle loop.
Nursing Management:
Dialysis:
o Monitor and measures fluid I&O q8h
 Hemodialysis or peritoneal dialysis
o Observes for weak, rapid pulse and may be used to remove nitrogenous
orthostatic hypotension. wastes and control potassium and
acid–base balance, and to remove
o Skin and tongue turgor are
sodium and fluid.
monitored.
Nutritional Therapy:
Prevention:
o Dietary restriction of sodium
o Replacement fluids
o Sodium Chloride contributes to
o Antidiarrheal medications
edema
o Small volumes of oral fluids at
o Lemon juice, onions, and garlic are
frequent intervals.
excellent substitute flavorings
 o Distilled water if local water supply is  Sodium has a major role in
very high in sodium. controlling water distribution
throughout the body,
o Avoid water softeners
 Sodium is regulated by ADH, thirst,
o Protein intake may be increased and the renin–angiotensin–
Nursing Management: aldosterone system.

o Measure I&O at regular intervals  When there is a decrease in the

circulating plasma osmolality, blood
o Weighed daily volume, or blood pressure, arginine
vasopressin (AVP) is released from
o Breath sounds are assess
the posterior pituitary.
o Monitor degree of edema  Oversecretion of AVP can cause
Pitting edema is assessed by pressing a SIADH (Syndrome of Inappropriate
finger into the affected part, creating a pit Secretion of Antidiuretic Hormone)
or indentation that is evaluated on a scale
of 1+ (minimal) to 4+ (severe)
Preventing Hypervolemia:
o Promoting rest

o Restricting sodium intake

o Monitoring parenteral fluid therapy

o Administering appropriate SODIUM DEFICIT (HYPONATREMIA):

medications
 Hyponatremia refers to a serum
o Regular rest periods sodium level that is less than 135
mEq/L (135 mmol/L)
Educating about Edema:
 Acute hyponatremia, Chronic
 Edema can be localized (e.g., in the
hyponatremia exercised-
ankle, as in rheumatoid arthritis) or
associated hyponatremia; which
generalized (as in cardiac failure and
is more frequently found in
kidney injury).
women and those of smaller
 Severe generalized edema is called stature. It can occur during
anasarca. extreme temperatures, because
of excessive fluid intake before
 Ascites is a type of edema in which exercise.
fluid accumulates in the peritoneal
cavity. Pathophysiology:

 Application of antiembolism o A deficiency of aldosterone, as

stockings, paracentesis, dialysis, and occurs in adrenal insufficiency, also
continuous renal replacement predisposes to sodium deficiency.
therapy in cases of kidney injury or
life-threatening fluid volume
overload.
ELECTROLYTES IMBALANCES
SODIUM IMBALANCES
 Sodium (Na+) is the most abundant
electrolyte in the ECF.
 significant hypervolemic and
euvolemic hyponatremia.
Nursing Management:
o Monitor I&O as well as daily body
weight
o Marathon runners may use salt
tablets to decrease sweating.
Detecting and Controlling
Hyponatremia:
o Monitor I&O

o Neurologic signs are associated with

very low sodium levels.
o Observes for lithium toxicity

o For all patients on lithium therapy,

Assessment: normal salt and oral fluid intake (2.5
o SIADH, it may be lower than 100 L/day) should be encouraged and a
mEq/L sodium restricted diet should be
avoided
o Specific gravity is low (1.002 to
When administering fluids to patients with
1.004)
cardiovascular disease, the nurse assesses
Medical management: for signs of circulatory overload (e.g.,
cough, dyspnea, puffy eyelids, dependent
o As a general rule, treating the
edema, excess weight gain in 24 hours).
underlying the condition is essential. The lungs are auscultated for crackles
Sodium Replacement:
o Careful administration of sodium by SODIUM EXCESS (HYPERNATREMIA)
mouth, nasogastric tube, or a  Hypernatremia is a serum sodium
parenteral route. level higher than 145 mEq/L (145
o The usual daily sodium requirement mmol/L)
in adults is approximately 100 mEq,  With a water loss, the patient loses
Water Restriction: more water than sodium

o Fluid – restriction Pathophysiology:

o A common cause of hypernatremia is
fluid deprivation in patients who
Highly hypertonic sodium solutions (2% to cannot respond to thirst.
23% sodium chloride) should be given
slowly and the patient monitored closely, o If the patient does not experience or
because only small volumes are needed to cannot respond to thirst, or if fluids
elevate the serum sodium concentration are excessively restricted.
from a dangerously low level. o Water moves out of the cell into the
Pharmacologic Therapy: ECF, resulting in cellular dehydration
and a more concentrated ECF
o AVP receptor antagonist
o A primary characteristic of
o Tolvaptan (Samsca) is an oral hypernatremia is thirst.
medication indicated for clinically
Medical Management:
 o hypotonic electrolyte solution (e.g., o Cushing Syndrome (increase
0.3% sodium chloride) or an isotonic secretion of Aldosterone).
nonsaline solution (e.g., dextrose 5%
o Heavy fluid Loss (NG suction,
in water [D5W]).
vomiting, diarrhea, wound drainage,
o D5W is indicated when water needs sweating).
to be replaced without sodium.
Other: K+ move from ECF to ICF, for
Nursing Management: alkalosis and hyperinsulinism in blood.
o Monitored in patients who are at risk Signs and Symptoms: (everything is slow
for hypernatremia. and low ); remember K+ plays a role in
muscle and nerve conduction, GI, renal,
o Assess for abnormal losses of water heart and lung muscle is affected.
or low water intake and for large
gains of sodium. Assessment and Diagnostic Findings

o Obtains a medication history o ECG changes include flat T waves or

inverted T waves, depressed ST
Preventing Hypernatremia: segments and elevated U waves is
o Providing oral fluid specific to hypokalemia.

o Decreased level of consciousness or

other disability interfering with
adequate fluid intake, parenteral
fluid replacement may be prescribed.

POTASSIUM DEFICIT (HYPOKALEMIA)

 3.5-5.0 mEq/L
 Potassium is responsible for nerve
impulse and conduction and muscle
contraction.
 The kidneys regulate potassium
balance by adjusting the amount of
potassium that is excreted in the
urine.
 Aldosterone also increases the
excretion of potassium by the
kidney.
 Large amounts of potassium are
contained in intestinal fluids.
 Severe hypokalemia can cause death
through cardiac or respiratory arrest.
Causes:
Body is trying to DITCH potassium
o Drugs (laxatives, diuretics,
corticorsteroid).
o Inadequate intake of K+

o Too much water intake (dilute K+) Medical management:

 o Increased intake in the daily diet or o Renal function should be monitored
by oral potassium supplements through BUN and creatinine levels
and urine output if the patient is
o Dietary intake of potassium in the
receiving potassium replacement.
average adult is 50 to 100 mEq/day.
Potassium is never given by IV push or
o Foods high in potassium include intramuscularly to avoid replacing
most fruits and vegetables, legumes, potassium too quickly. IV potassium must
whole grains, milk, and meat. be given using an infusion pump.
o The IV route is mandatory for
patients with severe hypokalemia.
POTASSIUM EXCESS (HYPERKALEMIA)
Nursing Management:
 Hyperkalemia (serum potassium
o Monitor for its early presence in level greater than 5 mEq/L [5
patients at risk. Fatigue, anorexia, mmol/L]).
muscle weakness, decreased bowel
motility, paresthesias, and  In adults, there is a increased in
dysrhythmias. hyperkalemia due to decreases in
renin and aldosterone.
o Monitored closely for signs of
digitalis toxicity because  Often caused by iatrogenic
hypokalemia potentiates the action (treatment-induced) causes.
of digitalis.  Cardiac arrest is more frequently
Preventing Hypokalemia: associated with high serum
potassium levels.
o Consumption of foods high in
potassium should be encouraged; Pathophysiology:
examples include bananas, melon, o Decreased renal excretion of
citrus fruits, fresh and frozen potassium, rapid administration of
vegetables (avoid canned potassium.
vegetables), lean meats, milk, and
whole grains. o Untreated kidney injury.

o Patient education may help alleviate o Infection or excessive intake of

the problem (abuse of laxatives or potassium in food or medications.
diuretics).
o Hypoaldosteronism or Addison
Correcting Hypokalemia: disease.
o Oral route is ideal to treat mild to o Medications; KCl, heparin, ACE
moderate hypokalemia inhibitors, NSAIDs, beta blockers,
cyclosporine (Neoral), tacrolimus
Oral potassium supplements can produce
(Prograf), and potassium-sparing
small bowel lesions; therefore, the patient
diuretics.
must be assessed for and cautioned about
abdominal distention, pain, or GI bleeding. o Improper use of potassium
supplements
Administering Intravenous Potassium:
o Pseudohyperkalemia (a false
o Potassium should be given only after
hyperkalemia) has several causes,
adequate urine output has been
including the improper collection or
established.
transport of a blood sample, a 858
o A decrease in urine volume to less traumatic venipuncture, and use of a
than 20 mL per hour for 2 tight tourniquet around an exercising
consecutive hours is an indication to extremity while drawing a blood
stop the potassium infusion and sample, producing hemolysis of the
notify the primary provider. sample before analysis
Potassium supplements are extremely o IV administration of regular insulin
dangerous for patients who have impaired and a hypertonic dextrose solution
renal function and thus decreased ability to causes a temporary shift of
excrete potassium. Even more dangerous is potassium into the cells.
the IV administration of potassium to such
patients, because serum levels can rise o Beta-2 agonists, such as albuterol
very quickly. Aged (stored) blood should (Proventil, Ventolin), are highly
not be given to patients with impaired renal effective in decreasing potassium;
function, because the serum potassium they can cause tachycardia and
concentration of stored blood increases chest discomfort.
due to red blood cell deterioration. It is Nursing Management:
possible to exceed the renal tolerance of
any patient with rapid IV potassium o Identified and closely monitored for
administration, as well as when large signs of hyperkalemia for pt that are
amounts of oral potassium supplements high risk.
are ingested.
o Monitors I&O and observes for signs
Clinical Manifestation: of muscle weakness and
dysrhythmias.
o When measuring vital signs, an
apical pulse should be taken.
Preventing Hyperkalemia:
Medical Management: o Potassium-rich foods to be avoided
o Serum potassium level should be include many fruits and vegetables,
obtained from a vein without an IV legumes, whole-grain breads, lean
infusing a potassium-containing meat, milk, eggs, coffee, tea, and
solution. cocoa

o Restriction of dietary potassium and o Conversely, foods with minimal

potassium containing medications. potassium content include butter,
margarine, cranberry juice or sauce,
o Administration, either orally or by ginger ale, gumdrops or jellybeans,
retention enema. hard candy, root beer, sugar, and
honey.
Emergency Pharmacologic Therapy:
Correcting Hyperkalemia:
o Administer IV calcium gluconate; If
serum potassium levels are o IV administration is via an infusion
dangerously elevated. pump
(calcium antagonizes the action of o Potassium-conserving diuretics,
hyperkalemia on the heart but does potassium supplements, and salt
not reduce the serum potassium substitutes should not be given to
concentration). patients with renal dysfunction.
Administration of calcium gluconate. CALCIUM IMBALANCES
The ECG should be continuously
monitored during administration; the  More than 99% of the body’s calcium
appearance of bradycardia is an (Ca++) is located in the skeletal
indication to stop the infusion. The system; it is a major component of
myocardial protective effects of bones and teeth.
calcium last about 30 minutes.  Calcium plays a major role in
o Monitoring the blood pressure is transmitting nerve impulses and
essential to detect hypotension helps regulate muscle contraction
and relaxation, including cardiac
muscle.
  Plays a role in blood coagulation. entire symptom complex induced by
increased neural excitability.
 The normal total serum calcium level
is 8.6 to 10.2 mg/dL (2.2 to 2.6 o Seizures; increases irritability of the
mmol/L). central nervous system as well as
the peripheral nervous system.
 Calcium exists in plasma in three
forms: ionized, bound, and complex. o Clinical signs and symptoms are
caused by spontaneous discharges of
 It is excreted primarily in the feces.
both sensory and motor fibers in
 As ionized serum calcium decreases, peripheral nerves.
the parathyroid glands secrete PTH.
o Respiratory effects with decreasing
This, in turn, increases calcium
calcium include dyspnea and
absorption from the GI tract,
laryngospasm
increases calcium reabsorption from
the renal tubule, and releases o Signs and symptoms of chronic
calcium from the bone. hypocalcemia include hyperactive
 When calcium increases excessively, bowel sounds, dry and brittle hair
the thyroid gland secretes calcitonin, and nails, and abnormal clotting.
which inhibits calcium reabsorption o Osteoporosis; most common in
from bone and decreases the serum postmenopausal women
calcium concentration.
CALCIUM DEFICIT (HYPOCALCEMIA)
 Hypocalcemia (serum calcium value
lower than 8.6 mg/dL [2.15 mmol/L]).
 People who spend an increased
amount of time in bed, have an
increased risk of hypocalcemia,
because bed rest increases bone
resorption.
Pathophysiology:
o Hypoparathyroidism and surgical
hypoparathyroidism
o Radical neck dissection

o Inflammation of the pancreas

causes the breakdown of proteins

and lipids. It is thought that calcium
ions combine with the fatty acids
Chvostek sign: a contraction of the facial
released by lipolysis, forming soaps.
muscles elicited in response to light tap
o Hypocalcemia may be related to over the facial nerve in front of the ear.
excessive secretion of glucagon from
the inflamed pancreas, which results
in increased secretion of calcitonin.
o Kidney injury

Clinical Manifestations:
o Tetany; most characteristic
manifestation of hypocalcemia and
hypomagnesemia, refers to the
 o Increased dietary intake of calcium
Trousseau sign: a to atleast 1000 to 1500 mg/day.
carpopedal spasm
induced by o Calcium-containing foods include
inflating a blood milk products; green, leafy
pressure cuff vegetables; canned salmon; canned
above systolic sardines; and fresh oysters.
blood pressure (an Nursing Management:
adducted thumb,
flexed wrist and o Seizure precautions

o Airway is closely monitored.

o Safety precaution

o Educate about food rich in

metacarpophalangeal joints, extended calcium
interphalangeal joints with fingers
together) will occur as ischemia of the o Alcohol and caffeine inhibit
ulnar nerve develops calcium absorption
o Avoid overuse of laxatives and
antacids.
Medical Management/Emergency
Pharmocologic Therapy:
CALCIUM EXCESS (HYPERCALCEMIA)
o Acute symptomatic hypocalcemia is
given a Iv administration of calcium  Hypercalcemia (serum calcium value
salt preferably calcium gluconate greater than 10.2 mg/dL [2.6
mmol/L])
calcium chloride can cause
irritatation and can cause sloughing  Hypercalcemia reduces
of tissue if it infiltrates. neuromuscular excitability because it
suppresses activity at the myoneural
o IV administration of calcium is
junction.
contraindicated with patient taking
digitalis; can cause digitalis toxicity  Calcium enhances the inotropic
effect of digitalis; therefore,
o The nurse must clarify with the
hypercalcemia aggravates digitalis
primary provider and pharmacist toxicity
which calcium salt to administer,
because calcium gluconate yields 4.5 Pathophysiology:
mEq of calcium and calcium chloride
o Hyperparathyroidism
provides 13.6 mEq of calcium.
Too rapid IV administration of calcium can o Bone mineral lost in immobilization ;
cause cardiac arrest, preceded by it elevates calcium in bloodstream.
bradycardia. Therefore, calcium should be o Multiple fractures and spinal cord
diluted in D5W and given as a slow IV bolus injury
or a slow IV infusion using an infusion
pump o Thiazide diuretics

Nutritional Therapy: Clinical Manifestations:

o Vitamin D

o Aluminum hydroxide, calcium

acetate or calcium carbonate Pharmacologic Therapy:
antacid.
o Administer fluids; to dilute serum
calcium.
 o Restricting dietary calcium intake

o IV administration od 0.9% sodium

chloride
o Administering IV phosphate
therapy
o Furosemide; increase calcium
excretions
o Calcitonin can be used to lower
the serum calcium level.
Nursing Management:
o Monitor at-risk patients

o Increasing patient mobility and

encouraging fluids
o Encourage to ambulate ASAP

o Fluids containing sodium should

be given
o Encourage to drink 2.8-3.8L of
fluid daily
o Safety precautions