Fluid and Electrolytes

A. Body fluids
I. water
a. the most important nutrient of life
b. humans can only survive for a few days without water
II. primary function of water in the body
a. provides a medium for transporting nutrients to cells and waste from cells and for
transporting substances such as hormones, enzymes, blood platelets, and red and white
blood cells
b. facilitates cellular metabolism and proper cellular chemical functioning
c. acts as a solvent for electrolytes and nonelectrolytes
d. helps maintain normal body temperature
e. facilitates digestion and promotes elimination
f. acts as a tissue lubricant
B. Body fluid compartments
I. intracellular fluid (ICF) compartment
a. contains fluid within the cells
b. constitutes about
i. 40% of an adult's body weight
ii. 70% of an adult's total-body water
II. extracellular fluid (ECF) compartment
a. contains fluid outside the cells
b. constitutes about:
i. 20% of an adult's body weight
ii. 30% of an adult's total-body water
b. includes:
i. intravascular fluid
a. fluid found within the vascular system
i. e.g., plasma
ii. interstitial fluid
a. fluid that surrounds tissue cells
II. total-body water
a. refers to the total amount of water in the body expressed as a percentage of body weight
b. in the normal adult, total-body water:
i. represents 50% - 60% of the body weight of a normal adult
 ii. total-body water is divided as follows:
a. cell fluids = 35% - 45%
b. ECF = 15% - 20%
c. plasma = 5%
d. interstitial fluid = 10% - 15%
B. Variations in fluid content
I. total-body water varies according to:
a. a person's age
i. infants
a. total-body water = 77%
ii. adults
a. total-body water = 50% - 60%
ii. elderly
a. total-body water = 45%
ii. risk factors:
a. since infants have considerably more body fluid and ECF than adults,
they are more at risk for problems with fluid balance compared to adults
b. lean body mass
i. fat cells
a. contain little water
ii. lean tissue
a. is rich in water
ii. risk factors:
a. since fat cells contain little water, obese people are more at risk for
problems with fluid balance compared to thin people
b. gender
i. females
a. tend to have proportionally more body fat than males
ii. males
a. tend to have proportionally less body fat than females
ii. risk factors:
a. since women have more body fat than males, women are more at risk for
problems with fluid balance compared to males
B. Electrolytes
I. electrolytes
a. definition
 i. substances capable of breaking down into electrically charged ions when
dissolved in solution
II. ion
a. definition
i. atom or molecule carrying an electrical charge
b. types of ions
i. cations
a. carry a positive charge
ii. anions
a. carry a negative charge
II. nonelectrolytes
a. definition
i. substances incapable of breaking down into electrically charged ions when
dissolved in solution and, consequently, remain intact
b. types of nonelectrolytes
i. urea
ii. glucose
II. measurement of electrolytes
a. how measured
i. measured in terms of their chemical combining power, or chemical activity
b. unit of measurement of electrolytes
i. the milliequivalent (mEq)
a. describes the chemical activity of electrolytes
b. 1 mEq of either a cation or anion is chemically equivalent to the activity
of 1 mg of hydrogen
c. 1 mEq of any cation is equivalent to1 mEq of any anion
d. mEqs for each electrolyte in the body vary within a relatively narrow
range
e. total cations in the body are normally equal to the total anions in the body
in homeostasis
II. regulation of electrolytes
a. sodium (Na+)
i. chief electrolyte in the ECF
ii. functions:
a. regulating ECF volume and distribution
b. maintaining blood volume
c. transmitting nerve impulses and contracting muscles
 ii. average daily requirement:
a. average daily requirement
i. not known
b. intake of 500 mg or 0.5 g maintains balance
ii. sodium-rich foods:
a. bacon
b. ham
c. sausage
d. catsup
e. mustard
f. relish
g. processed cheese
h. canned vegetables
i. bread
j. cereal
k. salted snack foods
l. table salt (about 46% sodium)
ii. losses:
a. eliminated primarily by the kidneys
b. small amounts are lost in the feces and perspiration
ii. regulation:
a. renal absorption or excretion
b. aldosterone increases Na+ reabsorption in the collecting ducts of the
tubules
ii. normal range for serum sodium:
a. 35 - 145 mEq (mmol/L)
b. potassium (K+)
i. chief electrolyte in the ICF
ii. functions:
a. maintaining ICF osmolality
b. transmitting nerve and other chemical impulses
c. regulating cardiac impulse transmission and muscle contraction
d. skeletal and smooth muscle function
e. regulating acid-base balance
ii. average daily requirement:
 a. average daily requirement
i. not known
b. intake of 50 - 100 mEq maintains K+ balance
ii. potassium rich foods:
a. bananas
b. peaches
c. kiwi
d. figs
e. dates
f. apricots
g. oranges
h. prunes
i. melons
j. raisins
k. broccoli
l. potatoes
ii. losses:
a. excreted primarily by the kidneys
i. kidneys have no effective means of conserving potassium
ii. potassium deficits develop rapidly if it is excreted in excess
without being replaced simultaneously
b. gastrointestinal excretions
c. some perspiration and saliva
ii. regulation:
a. renal excretion and conservation
b. aldosterone increases K+ excretion
c. movement into and out of cells
d. insulin helps K+ move into cells
e. tissue damage and acidosis shifts K+ out of cells into the ECF
ii. normal range for serum potassium:
a. 3.5 - 5 mEg/L (mmol/L)
b. calcium (Ca++)
i. most abundant electrolyte in the human body
a. 99% is in the bones
b. 1% is in the ECF
 ii. functions:
a. forming bones and teeth
b. transmitting nerve impulses
c. regulating muscle contractions
d. maintaining cardiac pacemaker (automaticity)
e. blood clotting
f. activating enzymes such as pancreatic lipase and phospholipase
ii. average daily requirement:
a. average daily requirement
i. 1 g for adults
ii. higher amounts are required for:
a. children
b. pregnant and lactating women
c. post-menopausal women not taking estrogen
d. people over 65
ii. calcium rich foods:
a. milk
b. cheese
c. dried beans
d. green vegetables
a. e.g., broccoli, kale, turnip greens shrimp
b. canned salmon or sardines
c. black strap molasses
d. calcium-fortified tofu
e. almonds
ii. losses:
a. urine
b. feces
c. bile
d. digestive secretions
e. perspiration
ii. regulation:
a. redistribution between the bones and ECF
b. parathyroid hormone (PTH) and calcitriol (Vitamin D) increase serum
Ca++ levels
 c. calcitonin decreases serum Ca++ levels
ii. normal range for serum calcium:
a. 4.5 - 5.5 mEg/L (mmol/L)
b. magnesium
i. second most important cation in the ICF
a. primarily found in the ICF
b. also present in the heart, bone, nerve, and muscle tissues
ii. functions:
a. intracellular metabolism
b. operating the sodium-potassium pump
c. relaxing muscle contractions
d. transmitting nerve impulses
e. regulating cardiac function
ii. average daily requirement:
a. average daily requirement
i. 18 - 30 mEq for adults
ii. higher amounts are required for:
a. children
ii. magnesium rich foods:
a. vegetables
b. nuts
c. fish
d. whole grains
e. peas
f. beans
ii. losses:
a. excreted by the kidneys
ii. regulation:
a. conservation and excretion by the kidneys
b. intestinal absorption increased by vitamin D and parathyroid hormone
ii. normal range for serum magnesium:
a. 1.3 - 2.1 mEg/L (mmol/L) with 1/3 of that bound to plasma proteins
b. chloride (CL-)
i. chief electrolyte in the ECF
 a. present in the blood, interstitial fluid, lymph, and in minute amounts in the
ICF
ii. functions:
a. hydrochloric acid (HCL) production
b. regulating ECF balance and vascular volume
c. regulating acid-base balance
d. buffer in oxygen-carbon dioxide exchange in red blood cells (RBCs)
ii. average daily requirement:
a. average daily requirement
i. not known
ii. chloride rich foods:
a. foods high is sodium
b. dairy products
c. meat
ii. losses:
a. excreted by the kidneys
ii. regulation:
a. normally paired and excreted and reabsorbed along with sodium in the
kidneys
b. aldosterone increases chloride reabsorption with sodium
ii. normal range for serum chloride:
a. 95 - 105 mEg/L (mmol/L)
b. bicarbonate (HC03-)
i. chief chemical base buffer within the body
a. present in both the ECF and ICF
ii. functions:
a. chief chemical base buffer involved in acid-base balance
b. essential component of the carbonic acid-bicarbonate buffering system
ii. average daily requirement:
a. average daily requirement
i. not known
ii. bicarbonate rich foods:
a. unlike other electrolytes that must be consumed in the diet, adequate
amounts of bicarbonate are produced through metabolic processes to
meet the body's needs
ii. losses:
 a. excreted by the kidneys
ii. regulation:
a. excretion and reabsorption by the kidneys
b. regeneration by the kidneys
ii. normal range for serum bicarbonate:
a. 25 - 29 mEg/L (mmol/L)
b. phosphate (PO4-)
i. chief anion in the ICF
a. present also in the ECF, bone, skeletal muscle, and nerve tissue
ii. functions:
a. forming bones and teeth
b. metabolizing carbohydrate, protein, and fat
c. cellular metabolism; producing ATP and DNA
d. muscle, nerve, and RBC function
e. buffer in the oxygen - carbon dioxide exchange in RBCs
ii. average daily requirement:
a. 1 g for adults
b. higher amounts are required for:
i. children
ii. pregnant and lactating women
iii. post-menopausal women not taking estrogen
iv. people over 65
ii. phosphate rich foods:
a. beef
b. pork
c. dried peas and beans
ii. losses:
a. excreted by the kidneys
ii. regulation:
a. excretion and reabsorption by the kidneys
b. parathyroid hormone decreases serum levels increasing renal excretion
c. reciprocal relationship with calcium
i. increasing serum calcium levels decreases phosphate levels
ii. decreasing serum calcium levels increases phosphate levels
ii. normal range for serum phosphate:
 a. 2.5 - 4.5 mEg/L (mmol/L)
B. Fluid and electrolyte movement
I. osmosis
a. movement of a solvent across a selectively permeable cell membrane from an area of
higher concentration of solutes to an area of lower concentration of solutes until
equilibrium is established
i. solvents
a. liquids that hold a substance in solution
i. e.g., when sugar is added to coffee, the coffee is the solvent
b. the primary solvent in the human body is water
ii. solutes
a. substances that are dissolved in a liquid
i. e.g., when sugar is added to coffee, the sugar is the solute
b. solutes may be crystalloids or colloids
i. crystalloids
a. salts that dissolve readily into true solutions
i. e.g., sodium
i. colloids
a. substances that do not readily dissolve into true
solutions
i. e.g., large protein molecules
i. osmolality
a. the concentration of solutes in body fluids
i. osmolality is:
a. determined by the total solute concentration within a fluid
compartment
b. measured as parts of solute per kilogram of water
c. reported as milliosmols per kilogram (mOsm/L)
i. osmolality of plasma is 275 - 295 mOsm/L
i. the greatest determinant of osmolality
within a fluid compartment is sodium
concentration
i. tonicity
a. may be used ro refer to the osmolality of a solution
b. isotonic solutions
i. have the same osmolality as body fluids
a. e.g., between 275 - 295 mOsm/L
 b. e.g., 0.9% normal saline
ii. with isotonic solutions:
a. water remains in the intravascular compartment without
any net flow across selectively permeable cell
membranes
b. hypertonic solutions
i. have a higher osmolality than body fluids
a. e.g., greater than 295 mOsm/L
b. e.g., 3 % normal saline
i. with a hypertonic solution in the intravascular
compartment:
a. water moves out of the intracelluar compartment (inside
the cells) and into the intravascular compartment that is
hypertonic causing cells to shrink
a. hypotonic solutions
i. have a lower osmolality than body fluids
a. e.g., less than 275 mOsm/L
b. e.g., 0.45 % normal saline
i. with hypotonic solutions:
a. water moves out of the intravascular compartment and
into the intracellular compartment (inside the cells) that
is hypertonic causing the cells to burst
II. diffusion
a. movement of solutes across a selectively permeable cell membrane from an area of
higher concentration of solutes to an area of lower concentration of solutes until
equilibrium is established
i. "coasting downhill"
b. diffusion is affected by:
i. the size of the solutes
a. larger solutes move less quickly and, consequently, have a lower rate of
diffusion
b. smaller solutes move more quickly and, consequently, have a higher rate
of diffusion
ii. the concentration of the solutes
a. solutes move from an area of higher concentration of solutes to an area
of lower concentration of solutes
ii. the temperature of the solutes
a. increases in temperature increase the rate of motion of solutes and,
consequently, leads to a higher rate of diffusion
 b. decreases in temperature decrease the rate of motion of solutes and,
consequently, leads to a lower rate of diffusion
II. active transport
a. movement of solutes across a selectively permeable cell membrane, usually against a
pressure gradient and with the expenditure of metabolic energy, from an area of higher
concentration of solutes to an area of lower concentration of solutes until equilibrium is
established
i. "pumping uphill"
b. in active transport:
i. a solute combines with a carrier on the outside surface of a cell membrane
ii. the solute and carrier move to the inside surface of the cell membrane
iii. once on the inside surface of the cell membrane, the solute and carrier separate
and the solute is released to the inside of the cell
b. the sodium-potassium pump
i. important active transport mechanism:
a. under normal conditions:
i. sodium concentrations are higher in the ECF
ii. potassium concentrations are higher in the ICF
b. to maintain these conditions, the sodium-potassium
pump continually:
i. pumps sodium out of the cells into the ECF
ii. pumps potassium into the cells into the ICF
II. filtration
a. movement of solutes and solvent across a permeable cell membrane from an area of
higher concentration of solutes to an area of lower concentration of solutes until
equilibrium is established
b. influenced by two pressures
i. colloid osmotic, or oncotic, pressure
a. the pressure exerted by solutes in water
b. "water-pulling pressure"
i. major source in keeping water from moving out from a confined
space through a permeable cell membrane
ii. plasma proteins in the blood exert a colloid osmotic, or oncotic,
pressure that prevents water from moving out from the
intravascular to extravascular compartments to maintain vascular
volume
i. hydrostatic pressure
a. the pressure exerted by water within a closed system on the wall of a
container in which it is contained
b. "water-pushing pressure"
 i. major source in moving water outward from a confined space
through a permeable cell membrane
ii. plasma and blood cells exert hydrostatic pressure that moves
water outward from the intravascular to extravascular
compartments
i. filtration pressure
a. the difference between the colloid osmotic, or oncotic, pressure and
hydrostatic pressure
b. important concept at the capillary bed
i. on the arteriole side of the capillary bed hydrostatic pressure is
greater than colloid osmotic, or oncotic, pressure
a. helps force or filter water and dissolved substances into
the interstitial space
i. on the venule side of the capillary bed, colloid
osmotic, or oncotic, pressure is greated than
hydrostatic pressure
a. helps force or filter water and dissolved substances into
the capillary
B. Fluid balance
I. a person's fluid intake should normally be approximately balanced by fluid loss
a. fluid intake sources
i. ingested liquids
a. 1300 mL/24 hours
i. water in ingested food
a. 100 mL/24 hours
i. metabolic oxidation
a. 300 mL/24 hours
i. total
a. 2600 mL/24 hours
a. fluid losses
i. kidneys
a. 1500 mL/24 hours
i. skin
a. insensible loss
i. imperceptible losses
a. e.g., from evaporation and respiration
i. 200 - 400 mL/24 hours
a. sensible loss
 i. 300 - 500 mL/24 hours
i. lungs
a. 400 mL/24 hours
i. gastrointestinal
a. 100 mL/24 hours
i. total
a. 2500 - 2900 mL/24 hours
B. Acid-base balance
I. body fluids must maintain an acid-base balance to sustain health and life
II. acidity or alkalinity of a solution is determined by its concentration of hydrogen ions
a. an acid
i. a substance containing hydrogen ions that can be liberated or released, e.g.:
a. carbonic acid (H2CO3) releases a hydrogen ion to form a bicarbonate
base (HCO3-)
ii. strong versus weak acid
a. a strong acid is an acid that dissociates (separates) completely in
solution and releases all of its hydrogen ions
b. a weak acid is an acid that dissociates (separates) incompletely in
solution and releases only a small number of its hydrogen ions
b. an alkali, or base
i. a substance that can accept or trap hydrogen ions, e.g.:
a. bicarbonate base (HCO3-) traps a hydrogen ion to form carbonic acid
(H2CO3)
ii. strong versus weak base
a. a strong base is a base that binds or accepts hydrogen ions easily
b. a weak base is a base that binds or accepts hydrogen ions less easily
II. unit of measure of acid-base balance is pH
a. the pH scale ranges from 1 - 14
i. neutral solution
a. has a pH of 7
i. acid solution
a. has a pH of 1 - 6.9
b. as hydrogen ions increase and a solution becomes more acidic, the pH
becomes less than 7
i. alkaline solution
a. has a pH of 7.1 - 14
 b. as hydrogen ions decrease and a solution becomes more basic, the pH
becomes more than 7
b. the pH of blood
i. the normal pH of blood
a. 7.35 - 7.45
ii. acidosis
a. a condition characterized by an excess of hydrogen ions in the ECF and
a pH less than 7.35
ii. alkalosis
a. a condition characterized by a deficit of hydrogen ions in the ECF and a
pH more than 7.45
a. narrow range of the pH of blood is achieved through three major
homeostatic regulators of hydrogen ions
i. carbonic acid (H2CO3) - sodium bicarbonate (HCO3-) buffer system
a. when too much acid is in the blood:
i. the excess acid combines with the sodium bicarbonate (HCO3-)
part ot this system
ii. the above returns the pH of the blood to its normal range of 7.35
- 7.45
a. when too much base is in the blood:
i. the excess base combines with the carbonic acid (H2CO3) part of
this system
ii. the above returns the pH of the blood to its normal range of 7.35
- 7.45
a. ratio of carbonic acid (H2CO3) and sodium bicarbonate
(HCO3-) in the blood:
i. the amount of carbonic acid (H2CO3) and sodium bicarbonate
(HCO3-) in the blood varies
ii. a ratio of 20 parts of sodium bicarbonate (HCO3-) to 1 part of
carbonic acid (H2CO3) is typically maintained
iii. the ratio of 20 parts of sodium bicarbonate (HCO3-) to 1 part of
carbonic acid (H2CO3) maintains the pH of blood within its normal
range of 7.35 - 7.45
b. quickness of response of the carbonic acid (H2CO3) -
sodium bicarbonate (HCO3-) buffer system in restoring
acid-base balance
i. almost immediate
ii. almost instantaneously a normal blood pH is restored by the
carbonic acid (H2CO3) - sodium bicarbonate (HCO3-) buffer
system
ii. respiratory mechanisms
a. carbon dioxide (CO2) is constantly produced by cellular metabolism
i. carbon dioxide (CO2) can combine with water to form carbonic
acid (H2CO3), e.g.:
a. carbon dioxide (CO2) + water (H20) makes carbonic acid
(H2CO3)
ii. carbonic acid (H2CO3) can dissociate from water
to form carbon dioxide (CO2) (to be exhaled) and
water, e.g.:
a. carbonic acid (H2CO3) breaks down into carbon dioxide
(CO2) and water (H20)
b. the lungs help to regulate acid-base balance by
eliminating or retaining carbon dioxide (CO2)
and, thus, controlling the amount of carbonic
acid (H2CO3) available in the blood
c. when the pH of the blood is too acidic:
i. the respiratory center is stimulated
ii. rate and depth of respiration is increased
iii. carbon dioxide (CO2) is excreted
iv. carbonic acid (H2CO3) levels fall
v. pH of the blood returns to its normal range of 7.35 - 7.45
b. when the pH of the blood is too alkaline:
i. the respiratory center is depressed
ii. rate and depth of respiration is decreased
iii. carbon dioxide (CO2) is retained
iv. carbonic acid (H2CO3) levels rise
v. pH of the blood returns to its normal range of 7.35 - 7.45
b. quickness of response of respiratory mechanisms in
restoring acid-base balance
i. not immediate
ii. takes minutes for a normal blood pH to be restored by
respiratory mechanisms
ii. renal mechanisms
a. the kidneys help to regulate acid-base balance by excreting or retaining
hydrogen ions and forming or excreting sodium bicarbonate ions
b. when the pH of the blood is too acidic:
i. the kidneys excrete hydrogen ions
ii. the kidneys form sodium bicarbonate ions
iii. pH of the blood returns to its normal range of 7.35 - 7.45
b. when the pH of the blood is too basic:
 i. the kidneys retain hydrogen ions
ii. the kidneys excrete sodium bicarbonate ions
iii. pH of the blood returns to its normal range of 7.35 - 7.45
b. quickness of response of renal mechanisms in restoring
acid-base balance
i. response is not immediate
ii. takes hours to days for a normal blood pH to be restored by
renal mechanisms
B. Fluid imbalances
I. fluid volume deficit (FVD)
a. deficiency in both the amount of water and electrolytes in the ECF where water and
electrolyte proportions remain near normal
i. commonly known as hypovolemia
b. occurs as a result of:
i. abnormal losses through the skin, gastrointestinal tract, or kidney
ii. decreased intake of fluid
iii. bleeding
iv. a shift of fluid into a third space
a. the shift of fluid from the intravascular space into an area where it is not
readily accessible as ECF, e.g.:
i. sequestered in the bowel
ii. in the interstitial spaces as edema
iii. in inflamed tissue
iv. in potential spaces such as the peritoneal or pleural cavities
b. the patient with a shift of fluid into a third space may not
manifest signs/symptoms of fluid volume deficit
II. fluid volume excess (FVE)
a. excessive retention of water and sodium in similar proportions to normal ECF
i. commonly known as hypervolemia
b. occurs as a result of:
i. excessive intake of sodium chloride
ii. administering sodium-containing infusions too rapidly, particularly to patients with
impaired regulatory mechanisms
iii. disease processes that alter regulatory mechanisms, such as congestive heart
failure, renal failure, cirrhosis of the liver, and Cushing's syndrome
b. in FVE, both the intravascular and interstitial spaces have an increased
water and sodium chloride content
i. excess interstitial fluid is known as edema
 ii. edema can be found around the:
a. eyes
b. fingers
c. ankles
d. sacrum
ii. edema may result in a weight gain in excess of 5%
b. system for grading edema
i. 1+ pitting edema
a. slight indentation (2 mm)
b. normal contours
c. associated with interstitial fluid volume 30% above normal
ii. 2+ pitting edema
a. deeper pit after pressing (4 mm)
b. lasts longer than 1+
c. fairly normal contour
ii. 3+ pitting edema
a. deep pit (6 mm)
b. remains several seconds after pressing
c. skin swelling obvious by general inspection
ii. 4+ pitting edema
a. deep pit (8 mm)
b. remains for a prolonged time after pressing, possibly minutes
c. frank swelling
ii. brawny edema
a. fluid can no longer be displaced secondary to excessive interstitial fluid
accumulation
b. no pitting
c. tissue palpates as firm or hard
d. skin surface shiny, warm, moist
II. dehydration
a. deficiency in the amount of water in the ECF without a deficiency in electrolytes
b. because water is lost while electrolytes, particularly sodium, are retained:
i. serum osmolality increases
ii. serum sodium levels increase
II. overhydration
 a. an excess in the amount of water in the ECF without an excess in electrolytes
b. because water is lost while electrolytes, particularly sodium, are retained:
i. serum osmolality decreases
ii. serum sodium levels decrease
B. Electrolyte imbalances
I. hyponatremia
a. sodium deficit in the ECF, or serum sodium level less than 135 mEg/L
b. risk factors
i. loss of sodium, e.g.,
a. loss os GI fluids
b. use of diuretics
c. adrenal insufficiency
ii. gains of water, e.g.:
a. excessive administration of IV fluids
ii. disease states associated with SIADH
iii. pharmacologic agents than may impair water excretion
b. signs/symptoms
i. anorexia
ii. nausea and vomiting
iii. lethargy
iv. confusion
v. muscle cramps
vi. muscular twitching
vii. seizures
viii.coma
II. hypernatremia
a. sodium excess in the ECF, or serum sodium level greater than 145 mEg/L
b. risk factors
i. water deprivation
ii. increased sensible and insensible water loss
iii. ingestion of a large amount of salt
iv. excessive parenteral administration of sodium-containing solutions
v. profuse sweating
vi. diabetes insipidus
b. signs/symptoms
 i. thirst
ii. elevated body temperature
iii. tongue dry and swollen
iv. sticky mucus membranes
v. in severe hypernatremia:
a. disorientation
b. hallucinations
c. lethargy when undisturbed
d. irritable and hyperactive
e. focal or grand mal seizures
II. hypokalemia
a. potassium deficit in the ECF, or serum potassium level less than 3.5 mEg/L
b. risk factors
i. diarrhea
ii. vomiting or gastric suction
iii. potassium-wasting diuretics
iv. steriod administration and certain antibiotics
v. poor intake as in anorexia nervosa, alcoholism, potassium-free parenteral fluids
vi. polyruia
b. signs/symptoms
i. fatigue
ii. anorexia, nausea, and vomiting
iii. muscle weakness
iv. decreased bowel motility
v. cardiac arrythmias
vi. increased sensitivity to digitalis
vii. polyuria, nocturia, dilute urine
viii.postural hypotension
ix. ECG changes
x. paresthesias or tender muscles
II. hyperkalemia
a. potassium excess in the ECF, or serum potassium level greater than 5.0 mEg/L
b. risk factors
i. decreased potassium excretion, e.g.:
a. oliguric renal failure
 b. potassium-sparing diuretics
c. hypoaldosteronism
ii. high potassium intake, especially in the presence of renal
insufficiency
iii. shift of potassium out of cells, e.g.
a. acidosis, tissue trauma, malignant cell lysis
b. signs/symptoms
i. vague muscle weakness
ii. cardiac arrythmias
iii. paresthesias of the face, tongue, feet, and hands
iv. flaccid muscle paralysis
v. GI symptoms such as nausea, intermittent intestinal colic, or diarrhea may occur
II. hypocalcemia
a. calcium deficit in the ECF, or serum calcium level less than 8.5 mEg/L
b. risk factors
i. surgical hypoparathyroidism
ii. malabsorption
iii. vitamin D deficiency
iv. acute pancreatitis
v. excessive administration of citrated blood
vi. alkalotic states
b. signs/symptoms
i. Trousseau's and Chvostek's signs
ii. numbness and tingling of the fingers and toes
iii. mental changes
iv. convulsions
v. spasm of larygneal muscles
vi. ECG changes
vii. cramps in the muscles of the extremities
II. hypercalcemia
a. calcium excess in the ECF, or serum calcium level greater than 10.5 mEg/L
b. risk factors
i. hyperparathryroidism
ii. malignant neoplastic disease
iii. prolonged immobilization
 iv. large doses of Vitamin D
v. overuse of calcium supplements
vi. thiazide diuretics
b. signs/symptoms
i. muscular weakness
ii. tiredness, lethargy
iii. constipation
iv. anorexia, nausea, vomiting
v. decreased memory and attention span
vi. polyuria and polydipsia
vii. renal stones
viii.neurotic behavior
ix. cardiac arrest
II. hypomagnesemia
a. magnesium deficit in the ECF, or serum magnesium level less than 1.3 mEg/L
b. risk factors
i. chronic alcoholism
ii. intestinal malabsorption
iii. diarrhea
iv. nasogastric suction
v. drugs, e.g.:
a. thiazide diuretics
b. aminoglycoside antibiotics
c. excessive doses of vitamin D
d. citrate preservative in blood
b. signs/symptoms
i. neuromuscular irritability
a. increased reflexes
b. coarse tremors
c. convulsions
ii. cardiac manifestations
a. tachyarrythmias
b. increases susceptibility for digitalis toxicity
ii. mental changes
i. disorientation
 ii. mood changes
II. hypermagnesemia
a. magnesium excess in the ECF, or serum magnesium level greater than 3.0 mEg/L
b. risk factors
i. renal failure
ii. adrenal insufficiency
iii. excessive administration during treatment of eclampsia
iv. hemodialysis with hard water or dialysate high in magnesium content
b. signs/symptoms
i. flushing a sense of skin warmth
ii. hypotension
iii. depressed respirations
iv. drowsiness, hypoactive reflexes, and muscular weakness
v. cardiac abnormalities
II. hypophosphatemia
a. phosphate deficit in the ECF, or serum phosphate level less than 2.5 mEg/L
b. risk factors
i. glucose administration
ii. refeeding after starvation
iii. hyperalimentation
iv. alcohol withdrawal
v. diabetic ketoacidosis
vi. respiratory alkalosis
b. signs/symptoms
i. cardiomyopathy
ii. acute respiratory failure
iii. seizures
iv. decreased tissue oxygenation
v. joint stiffness
II. hyperphosphatemia
a. phosphate excess in the ECF, or serum phosphate level greater than 4.5 mEg/L
b. risk factors
i. renal failure
ii. chemotherapy
iii. large intake of milk
 iv. excessive intake of phophate-containing laxatives, e.g.:
a. fleets phosphosoda
ii. large vitamin D intake
iii. hyperthyroidism
b. signs/symptoms
i. short term consequences:
ii. symptoms of tetany, e.g.:
a. tingling of the fingertips and around the mouth
b. numbness
c. muscle spasms
ii. long-term consequences:
i. precipitation of calcium phosphate in nonosseus tissue sites, e.g.:
a. kidneys
b. joints
c. arteries
d. skin
e. cornea
B. Acid-base imbalances
I. respiratory acidosis
a. a primary excess of carbonic acid in the ECF
b. cause of respiratory acidosis:
i. decreased alveolar ventilation, e.g.:
a. lung disease such as COPD
b. central nervous system depression due to anesthesia or narcotic
overdose
ii. consequent increase in carbon dioxide
b. lab findings in respiratory acidosis:
i. pH less than 7.35
ii. PaCO2 greater than 45 mm Hg
iii. HCO3-
a. normal or slightly elevated in acute cases
b. above 26 mEg in chronic cases
b. to compensate for a respiratory acidosis:
i. the lungs:
a. unable to participate in compensation since they are the source of the
problem
 ii. the kidneys:
a. retain more bicarbonate
b. excrete more hydrogen ions
II. respiratory alkalosis
a. primary deficit of carbonic acid in the ECF
b. cause of respiratory alkalosis:
i. increased alveolar ventilation, e.g.:
a. pyschogenic or anxiety-related hyperventilation
b. fever
ii. consequent decrease in carbon dioxide
b. lab findings in uncompensated respiratory alkalosis:
i. arterial pH greater than 7.45
ii. PaCO2 less than 35 mm Hg
b. to compensate for a respiratory alkalosis:
i. the lungs
a. unable to participate in compensation since they are the source of the
problem
ii. the kidneys
a. excrete more bicarbonate
b. retain more hydrogen ions
II. metabolic acidosis
a. primary deficit of bicarbonate ions in the ECF
b. cause of metabolic acidosis:
i. increase in hydrogen ions and/or excessive loss of bicarbonate ions, e.g.:
a. renal failure
b. diabetic ketoacidosis or starvation when fat tissue is used for energy
(forms acid ketone bodies as a by-product)
b. lab findings in metabolic acidosis:
i. pH less than 7.35
ii. PaCO2 greater than 38 mm Hg with respiratory compensation
iii. HCO3- less than 22 mmEg/L
b. to compensate for a metabolic acidosis:
i. the lungs
a. increase the rate and depth of respiration to increase the excretion of
carbon dioxide
ii. the kidneys
 a. retain more bicarbonate
b. excrete more hydrogen ions
II. metabolic alkalosis
a. primary excess of bicarbonate ions in the ECF
b. cause of metabolic alkalosis:
i. excessive loss of hydrogen ions and/or increase in bicarbonate ions, e.g.:
a. ingestion of bicarbonate of soda as an antacid
b. prolonged vomiting with loss of HCL from the stomach
b. lab findings in metabolic alkalosis:
i. pH greater than 7.35
ii. PaCO2 greater than 45 mm Hg with respiratory compensation
iii. HCO3- greater than 26 mEg
b. to compensate for a metabolic alkalosis:
i. the lungs
a. decrease the rate and depth of respiration to decrease the excretion of
carbon dioxide
ii. the kidneys
a. excrete more bicarbonate
b. retain more hydrogen ions
B. Assessing fluid and electrolyte imblances
I. measure fluid intake and output
II. daily weights
III. monitor laboratory studies
a. complete blood count
i. increased hematocrit values
a. dehydration
i. decreased hematocrit values
a. acute, massive blood loss
i. increased hemoglobin values
a. hemoconcentration of the blood
i. decreased hemoglobin values
a. anemia, severe hemorrhage
a. serum electrolytes
b. urine pH and specific gravity
c. arterial blood gasses
i. steps in reading arterial blood gasses
a. determine whether the pH is alkalotic or acidotic
b. determine the cause of the change of pH
i. in respiratory acid-base imbalances, the pH and PaCO2 values
are inversely abnormal (move in opposite directions)
a. in respiratory acidosis:
i. the pH is less than 7.35
ii. the PaCO2 is increased
iii. the HCO3- is normal
a. in respiratory alkalosis:
i. the pH is greater than 7.45
ii. the PaCO2 is decreased
iii. the HCO3- is normal
i. in metabolic acid-base imbalances, the
pH and HCO3- are both high or both low
a. in metabolic acidosis:
i. the pH is less than 7.35
ii. the HCO3- is decreased
iii. the PaCO2 is normal
a. in metabolic alkalosis:
i. the pH is greater than 7.45
ii. the HCO3- is increased
iii. the PaCO2 is normal
a. determine if there is a compensatory
attempt to return the pH to normal
i. in respiratory acidosis:
a. if the pH is less than 7.35
b. if the PaCO2 is increased
c. but the HCO3- is increased
i. the kidneys are attempting to retain HCO3- to
compensate
i. in respiratory alkalosis
a. the pH is greater than 7.45
b. the PaCO2 is decreased
c. the HCO3- is decreased
i. the kidneys are attempting to excrete HCO3- to
compensate
 i. in metabolic acidosis
a. the pH is less than 7.35
b. the HCO3- is decreased
c. the PaCO2 is decreased
i. the lungs are attempting to compensate by
excreting CO2
i. in metabolic alkalosis
a. he pH is greater than 7.45
b. the HCO3- is increased
c. the PaCO2 is increased
i. the lungs are attempting to compensate by
retaining CO2
a. determine if compensation has occurred
i. compensation is absent if:
a. the pH is abnormal
b. one component is abnormal
c. a second component within normal range
i. compensation is partial if:
a. the pH is abnormal
b. one component is abnormal
c. a second component is beginning to change
i. compensation is complete if:
a. the pH is within normal range
b. one component is abnormal
c. a second component is changed to move the pH within
normal range
B. Diagnosing
I. fluid volume excess
II. fluid volume deficit
III. risk for fluid volume deficit
IV. risk for fluid volume excess
B. Planning
I. patient goals/expected outcomes:
a. the patient will demonstrate fluid volume, electrolyte, and acid-base balance, as evidence
by:
i. maintaining an approximate balance between fluid intake and output
 ii. maintaining serum electrolytes within normal range
iii. maintaining pH within normal range
iv. maintaining arterial blood gases within normal range
v. maintaining a urine specific gravity within normal range
vi. maintaining body weight +/- 5 pounds of typical body weight
vii. reporting relief of symptoms of fluid, electrolyte, and acid-base disturbances
(specify) after implementation of appropriate treatment
B. Implementing
I. developing a dietary plan
II. modifying fluid intake
a. increasing fluids
b. restricting fluids
II. administering medications
a. mineral-electrolyte preparations
b. diuretics
II. admnistering intravenous therapy
B. Evaluating
I. evaluation strategies:
a. did the patient maintain an approximate balance between fluid intake and output?
b. did the patient maintain serum electrolytes within normal range?
c. did the patient maintain pH within normal range?
d. did the patient maintain arterial blood gases within normal range?
e. did the patient maintain a urine specific gravity within normal range?
f. did the patient maintain body weight +/- 5 pounds of typical body weight?
g. did the patient report relief of symptoms of fluid, electrolyte, and acid-base? disturbances
(specify) after implementation of appropriate treatment?