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Tamara M. Kear
D
Copyright 2017 American Nephrology Nurses Association.
are common in patients across
the lifespan. Many factors have Kear, T.M. (2017). Fluid and electrolyte management across the age continuum.
been found to be associated with Nephrology Nursing Journal, 44(6), 491-496.
the development of these imbalances.
Dehydration, over-hydration, and salt Optional function of body systems depends upon fluid and electrolyte balance; however,
and water deficits and overload have across the lifespan, disorders of fluid and electrolytes offset this, and the causative factors
been associated with morbidity and are varied. Nurses play a major role in the management of fluid and electrolyte balance.
mortality with populations at each end This article focuses on the role total body water content, plasma proteins, kidney function,
of the lifespan experiencing an and drug metabolism have on the age-related physiology impacting fluid and electrolyte
balance, and on nursing implications.
increased risk (El-Sharkawy, Sahota,
Maughan, & Lobo, 2014). This article Key Words: Fluid and electrolyte balance, body water content, plasma proteins, kidney
focuses on the role total body water con- function, drug metabolism.
tent, plasma proteins, kidney function,
and drug metabolism have on the age-
related physiology impacting fluid and
electrolyte balance. lymph system, joints, glandular secre- mately 70% of their body weight
tions, and eyes. There is no significant (Metheny, 2012). Infants also have
daily gain or loss of transcellular fluid. more ECF, which makes them more
Total Body Water Content ICF is located inside the cells and vulnerable to fluid volume losses and
Total body water varies with body comprises approximately 40% of an deficits. By the end of the second year
fat content, age, and sex. Body water adult’s body weight (Metheny, 2012). of life, the total body fluid percentages
represents approximately 60% of While capillary walls and cell mem- near those of adults. At puberty, total
body weight in young, lean males and branes separate ICF and ECF, ECF body water composition is attained,
50% of body weight in females must be balanced with ICF. ECF is and the onset of sex differences relat-
(Metheny, 2012). Body water is divid- more readily lost from the body than ed to body weight percentages occurs
ed into two major compartments: ICF (McLafferty, Johnstone, Hendry, (Metheny, 2012).
extracellular fluid (ECF) and intracel- & Farley, 2014).
lular fluid (ICF). ECF is further divid- Age Considerations:
ed into intravascular fluid (also Adulthood
known as plasma) and interstitial Fluid Losses
After age 40 years, mean total
fluid. The interstitial fluid surrounds Fluid losses are categorized as sen- body water decreases in relation to
the cells. ECF comprises approxi- sible or insensible losses. Sensible loss- body weight, yet sex difference body
mately 20% of an adult’s body weight es are those that can be measured and weight percentages remain. Between
(Gooch, 2015; Metheny, 2012). include urine, feces, blood, wound ages 40 to 60 years, total body water
Transcellular fluids are also a compo- and gastric drainage, and emesis. decreases to 55% in the male popula-
nent of ECF and are found in the Insensible losses cannot be measured tion and 47% in women (Metheny,
cerebrospinal column, pleural cavity, and include perspiration and fluid 2012). By age 60 years, the male pop-
losses through breathing. Fever, ulation has a total body water percent-
Tamara M. Kear, PhD, RN, CNS, CNN, is an
Associate Professor of Nursing, Villanova
increased respiratory rate and depth, age of approximately 52%, with 46%
University, Villanova, PA, and a Nephrology and humidity impact the loss of fluid in the female population (Metheny,
Nurse, Fresenius Kidney Care. She is a member of in individuals (McLafferty et al., 2014). 2012; Severs, Rookmakker, & Hoorn,
the American Nephrology Nurses Association Board 2015).
of Directors, the Nephrology Nursing Journal Age Considerations: Birth
Editorial Board, and ANNA’s Keystone Chapter.
to Puberty
Plasma Proteins
Statement of Disclosure: The author reported The body surface area of an infant
no actual or potential conflict of interest in rela- is greater than that of an adult, relative Plasma proteins (albumin, fibrino-
tion to this continuing nursing education activity.
to weight. Thus, infants generally lose gen, prothrombin, and gamma globu-
Note: The Learning Outcome, additional state- a greater portion of water from the lins) constitute approximately 6% to
ments of disclosure, and instructions for CNE skin than adults. Infants have a high 7% of the blood plasma. Plasma
evaluation can be found on page 497. body fluid content that is approxi- proteins maintain osmotic pressure,
increase blood viscosity, and assist in um, excrete hydrogen ions, retain Assessment of Fluid Volume
maintaining blood pressure (McGloin, sodium, and reabsorb water resulting Excess
2015). The liver synthesizes all plasma in dysnatremia and hypovolemia Compromised regulatory systems,
proteins except for gamma globulins, (Lindner, Pfortmüller, Leichtle, such as heart failure, kidney failure,
thus explaining the rationale for coag- Fiedler, & Exadaktylos, 2014). The cirrhosis, and steroid use, may con-
ulopathies and proteins imbalances older adult also experiences decreas- tribute to fluid volume excess. High-
commonly found in patients with liver es in renal blood flow, glomerular fil- sodium diets and drugs, or prepara-
dysfunction and failure. Albumin tration, creatinine clearance, and the tions rich in sodium, such as Fleet®
plays an important role in maintaining ability to concentrate urine. In the enema, sodium bicarbonate, and
fluid homeostasis. When fluid filters presence of dehydration or hypov- Alka-Seltzer®, lead to fluid retention
through a capillary, albumin remains olemia, decreased blood flow to the and fluid volume excess. Further,
in the decreasing volume of water kidney also places the individual at overzealous administration of 0.9%
because the large molecular size of risk for acute kidney injury (AKI). sodium chloride or Ringer’s lactate
albumin does not pass through the solution can contribute to fluid vol-
capillary membrane with ease. This ume excess and may be compounded
Drug Metabolism
increased concentration of albumin if cardiac, kidney, or liver function is
pulls fluid back into the capillaries The cytochrome P-450 enzyme sys- impaired. Assessment findings in an
(plasma colloid osmotic pressure). tem in the small bowel and liver is the individual with fluid volume excess
Essentially, albumin plays the role of a most important known system for drug are found in Table 1 (McGloin, 2015).
“fluid magnet.” metabolism (Metheny, 2012). Drug
metabolism and elimination vary with Assessment of Fluid Volume
age, and with kidney and liver func- Deficit
Kidney Function
tion, and depend upon the drug, route The loss of fluid can be related to
The kidneys play a vital role in of administration, and dose. many pathophysiological causes or a
fluid, electrolyte, and acid-base bal- decrease in oral intake. Gastrointestinal
ance. A healthy kidney filters approx- Age Considerations (GI) fluids may be lost due to vomiting,
imately 180 liters of plasma a day and Phenytoin, barbiturates, anal- diarrhea, excessive ostomy drainage,
produces approximately 1.8 liters of gesics, and cardiac glycosides have or gastric suctioning. Polyuria is anoth-
urine a day (McGloin, 2015). As kid- plasma half-lives two to three times er etiological factor that leads to fluid
ney function declines in patients with longer in neonates than adults volume deficit. Polyuria may be related
chronic kidney disease (CKD), indi- (Lindner et al., 2014). As liver and to diuretic, kidney failure, hyperosmo-
viduals lose the ability to filter the kidney elimination decrease with age, lar tube feedings, diabetes insipidus,
plasma, and fluid and electrolyte drug levels increase, and toxicity may and diabetes mellitus (Metheny, 2012).
imbalances result. The greatest elec- slowly develop. Diuretics are of par- Conditions such as excessive sweating
trolyte concerns for patients with ticular concern and will be discussed and fevers result in increased fluid
CKD are imbalances in potassium later in this article. losses.
and calcium levels due to the impact Fluid loss from a process called
on cardiac function. third-spacing may also occur when
Nursing’s Role in Fluid
and Electrolyte Balance fluid accumulates in areas that nor-
Age Considerations: Birth to mally have little to no fluid. In third-
Early Childhood Nurses must employ several spacing, fluid shifts from the intravas-
Infants and young children excrete strategies to optimize fluid and elec- cular space into the interstitial space
urine at a higher rate than adults trolyte balance in individuals entrust- between cells. Third-spacing of fluid
because the higher metabolic rates in ed to their care. Such strategies results in decreased fluid in the vascu-
children produce more waste. include assessment of fluid and elec- lar space as plasma is shifted into the
Additionally, an infant’s kidneys can- trolyte status, prevention strategies, interstitial space. Third-spacing of
not concentrate urine until around 3 and fluid and electrolyte replacement. fluid may occur in the presence of
months of age and remain less effi- These strategies focus on managing trauma, surgery, burns, sepsis, pan-
cient than adult kidneys until around fluid volume excess and fluid volume creatitis, GI obstruction, and liver fail-
age of 2 years (Bekhof, van Asperen, deficit because fluid balance is deter- ure that leads to ascites. Assessment
& Brand, 2013). mined by daily gains and losses. Most findings in an individual with fluid
daily intake of water is oral, with a volume deficit are found in Table 2
Age Considerations: small percentage coming from food (McGloin, 2015).
Adulthood and metabolic processes. The majori-
As the adult ages, the kidney ty of body fluid losses comes from the Electrolyte Balance
loses function. This leads to an formation of urine. There are several electrolytes in
impaired ability to secrete potassi- the human body, and each electrolyte
• Weight gain
cellular spaces and move to maintain
• Peripheral edema
balance and electroneutrality. The
• Generalized edema
extracellular electrolytes include sodi-
• Crackles in the lungs upon auscultation
um, chloride, calcium, and sodium
• Dyspnea
bicarbonate. The intracellular elec-
• Orthopnea
trolytes include potassium, phos-
• Cough
phate, and magnesium.
• Distention of peripheral veins Sodium. The role of sodium is to
• Bounding pulse
• Engorged carotid vessels
attract fluid and preserve ECF vol-
Table 2
certain drugs. Drug-induced hypo-
natremia may result from the use of
Fluid Volume Deficit – Assessment Findings
non-steroidal anti-inflammatory drugs
(NSAIDs), selective serotonin reup-
• Decreased skin and tongue turgor
take inhibitors, cyclophosphamides,
• Decreased oral cavity moisture
omeprazole, desmopressin, and oxy-
• Decreased urine output and urine specific gravity tocin. Drug-induced hypernatremia
• BUN rises out of proportion to serum creatinine
• Changes in vital signs (increased heart rate, respiratory rate, and tempera-
may result from 3% and 5% hyperton-
• Thirst may be present, but often absent in the older adult population
sodium chloride (Lindner et al., 2014).
• Decreased weight
Chloride. Chloride is mainly pro-
• Dry, cracked, mucous membranes
duced in the stomach as hydrochloric
• Dizziness, syncope
acid, so chloride levels may be impact-
• Orthostatic hypotension
ed by GI disorders because most of it is
absorbed in the intestines, with a small
Sources: Metheny, 2012; Reid et al., 2004; Severs, Rookmaaker, & Hoorn, 2015.
portion lost in the feces. Chloride and
bicarbonate have an inverse relation-
Table 3
ship. Diuretics increase the risk of chlo-
Sodium Imbalances
ride loss and deficiencies.
Calcium. Ninety-nine percent
Hyponatremia Hypernatremia
(99%) of calcium is found in the
bones, while 1% is in the teeth and
• Gastointestinal losses • Water deprivation
soft tissues (McLafferty et al., 2014).
• Adrenal insufficiency • Insensible water loss
Serum protein abnormalities can
• Sweating • Watery diarrhea
influence total serum calcium levels.
• Drug-induced • Excessive sodium intake Ionized calcium levels measure the
• Head trauma • Diabetes insipidus (polyuria and various forms of calcium located in
• Excessive water intake polydipsia)
• Syndrome of Inappropriate • Treat by adding water or removing
the extracellular fluid. Calcium and
Table 4
Calcium Imbalances
Bicarbonate. Bicarbonate plays
an important role in respiratory func-
Hypocalcemia Hypercalcemia
tion. Lack of bicarbonate causes aci-
dosis, and the respiratory rate increas-
• Surgical hypoparathyroidism • Malignancies
• Acute pancreatitis • Primary hyperparathyroidism
es to blow off more carbon dioxide.
Table 5
base balance (Crawford, 2014). Small
Hypokalemia Hyperkalemia
functions. Kidney disease, injury,
drugs, treatments, GI losses, cellular
• Decreased dietary intake • Increased dietary intake
shifts, sweating, and nutritional intake
• Excess fluid loss • Rapid infusion of potassium
affect potassium levels (see Table 5)
• Kidney losses (diuretics, steroids, containing solution (Crawford, 2014; Eliacik et al., 2015;
diuretic phase of acute kidney • Salt substitutes (potassium chloride)
injury) • Decreased kidney function
Metheny, 2012). Medications that
Table 6
1% in the ECF. Alcoholism, burns,
• Antibiotics (penicillin G)
breastfeeding or formula can elevate
• Cyclosporine
phosphate levels.
• Digoxin
Magnesium. Magnesium does
• Aldosterone antagonist
not get a great deal of attention as an
• Heparin
electrolyte. It plays an important role
• Hypertonic solutions (mannitol, glucose)
in carbohydrate metabolism and pro-
• Non-steroidal anti-inflammatory drugs (NSAIDs)
tein synthesis. Magnesium and albu-
• Pentamidine min are linked. Low serum albumin
• Tacrolimus
• Potassium sparing diuretics
levels (often from poor dietary intake
or liver disease) result in low magne-
to provide fluid (McGloin, 2015). This fluid volume excess unless contraindi- McLafferty, E., Johnstone, C., Hendry,
population may include patients with cated. Careful monitoring for changes C., & Farley, A. (2014). Fluid and
sepsis, diuresis from AKI, respiratory in fluid and electrolyte status, com- electrolyte balance. Nursing Standard,
acidosis, burns, and excessive gas- fort, vital signs, and physical assess- 28(29), 42-49.
Metheny, N.M. (2012). Fluid and elec-
trointestinal or wound losses because ment findings are essential nursing
trolyte balance: Nursing considerations
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