Imbalance Contributing Factors Signs/Symptoms and

Laboratory Findings

Fluid volume deficit Loss of water and electrolytes, Acute weight loss, decrease
(hypovolemia) as in vomiting, diarrhea, skin turgor, oliguria,
fistulas, fever, excess concentrated urine, weak
sweating, burns, blood loss, rapid pulse, capillary filling
gastrointestinal suction, and time prolonged, low CVP,
third-space fluid shifts; and decrease blood pressure,
decreased intake, as in flattened neck veins,
anorexia, nausea, and inability dizziness, weakness, thirst
to gain access to fluid. and confusion, increase pulse,
Diabetes insipidus and muscle cramps, sunken eyes
uncontrolled diabetes mellitus Labs indicate: increase
also contribute to a depletion hemoglobin and hematocrit,
of extracellular fluid volume. increase serum and urine
osmolality and specific
gravity, decrease urine
sodium, increase BUN and
creatinine, increase urine
specific gravity and osmolality
Fluid volume excess Compromised regulatory Acute weight gain, peripheral
(hypervolemia) mechanisms, such as renal edema and ascites, distended
failure, heart failure, and jugular veins, crackles,
cirrhosis; overzealous elevated CVP, shortness of
administration of sodium- breath, increase blood
containing fluids; and fluid pressure, bounding pulse and
shifts (ie, treatment of burns). cough, increase respiratory
Prolonged corticosteroid rate
therapy, severe stress, and Labs indicate: decrease
hyperaldosteronism augment hemoglobin and hematocrit,
fluid volume excess. decrease serum and urine
osmolality, decrease urine
sodium and specific gravity
Sodium deficit Loss of sodium, as in use of Anorexia, nausea and
(hyponatremia) diuretics, loss of GI fluids, vomiting, headache, lethargy,
Serum sodium renal disease, and adrenal dizziness, confusion, muscle
_135 mEq/L insufficiency. Gain of water, cramps and weakness,
as in excessive administration muscular twitching, seizures,
of DW and water supplements papilledema, dry skin,
for patients receiving increase pulse, decrease BP,
hypotonic tube feedings; weight gain, edema
disease states associated with Labs indicate: decrease serum
 SIADH such as head trauma and urine sodium, decrease
and oat-cell lung tumor; urine specific gravity and
medications associated with osmolality
water retention (oxytocin and
certain tranquilizers); and
psychogenic polydipsia.
Hyperglycemia and heart
failure cause a loss of sodium.

Sodium excess Water deprivation in patients Thirst, elevated body

(hypernatremia) unable to drink at will, temperature, swollen dry
Serum sodium hypertonic tube feedings tongue and sticky mucous
_145 mEq/L without adequate water membranes, hallucinations,
supplements, diabetes lethargy, restlessness,
insipidus, heatstroke, irritability, focal or grand mal
hyperventilation, watery seizures, pulmonary edema,
diarrhea, burns, and hyperreflexia, twitching,
diaphoresis. Excess nausea, vomiting, anorexia,
corticosteroid, sodium increase pulse, and increase
bicarbonate, and sodium BP
chloride administration, and Labs indicate: increase serum
salt water near-drowning sodium, decrease urine
victims sodium, increase urine
specific gravity and
osmolality, decrease CVP
Potassium deficit Diarrhea, vomiting, gastric Fatigue, anorexia, nausea and
(hypokalemia) suction, corticosteroid vomiting, muscle weakness,
Serum potassium administration, polyuria, decreased bowel
_3.5 mEq/L hyperaldosteronism, motility, ventricular asystole
carbenicillin, amphotericin B, or fibrillation, paresthesias,
bulimia, osmotic diuresis, leg cramps, decrease BP,
alkalosis, starvation, diuretics, ileus, abdominal distention,
and digoxin toxicity hypoactive reflexes. ECG:
flattened T waves, prominent
U waves, ST depression,
prolonged PR interval
Potassium excess Pseudohyperkalemia, oliguric Muscle weakness,
(hyperkalemia) renal failure, use of tachycardia bradycardia,
Serum potassium potassium-conserving dysrhythmias, flaccid
_5.0 mEq/L diuretics in patients with renal paralysis, paresthesias,
insufficiency, metabolic intestinal colic, cramps,
acidosis, Addison’s disease, abdominal distention,
crush injury, burns, stored irritability, anxiety.
bank blood transfusions, rapid ECG: tall tented T waves,
 IV administration of
potassium, and certain
medications such as ACE
inhibitors, NSAIDs,
cyclosporine
Calcium deficit Hypoparathyroidism (may
(hypocalcemia) follow thyroid surgery or
Serum calcium radical neck dissection),
_8.5 mg/dL malabsorption, pancreatitis,
alkalosis, vitamin D deficiency,
massive subcutaneous
infection, generalized
peritonitis, massive
transfusion of citrated
blood, chronic diarrhea,
decreased parathyroid
hormone, diuretic phase of
renal failure, c PO
, fistulas, burns, alcoholism
Calcium excess Hyperparathyroidism,
(hypercalcemia) malignant neoplastic disease,
Serum calcium prolonged immobilization,
_10.5 mg/dL overuse of calcium
supplements, vitamin D
excess, oliguric phase of renal
failure, acidosis,
corticosteroid therapy,
thiazide diuretic use,
increased parathyroid
hormone, and digoxin
toxicity
Magnesium deficit Chronic alcoholism,
(hypomagnesemia) hyperparathyroidism,
Serum magnesium hyperaldosteronism, diuretic
_1.8 mg/dL phase of renal failure,
malabsorptive disorders,
diabetic ketoacidosis,
refeeding after starvation,
parenteral nutrition, chronic
laxative use, diarrhea, acute
myocardial infarction, heart
failure, decreased serum K⁺
and Ca⁺⁺ and certain
pharmacologic agents (such
prolonged PR interval and
QRS duration, absent P waves,
ST depression
Numbness, tingling of fingers,
toes, and circumoral region;
positive Trousseau’s sign and
Chvostek’s sign; seizures,
carpopedal spasms,
hyperactive deep tendon
reflexes, irritability,
bronchospasm, anxiety,
impaired clotting time,
decrease prothrombin,
diarrhea, decrease BP. ECG:
prolonged QT interval and
lengthened ST
Labs indicate: Decrease Mg⁺⁺
Muscular weakness,
constipation, anorexia,
nausea and vomiting, polyuria
and polydipsia, dehydration,
hypoactive deep tendon
reflexes, lethargy, deep bone
pain, pathologic fractures,
flank pain, calcium stones,
hypertension. ECG: shortened
ST segment and QT interval,
bradycardia, heart blocks
Neuromuscular irritability,
positive Trousseau’s and
Chvostek’s signs, insomnia,
mood changes, anorexia,
vomiting, increased tendon
reflexes, and increase BP.
ECG: PVCs, flat or inverted T
waves, depressed ST
segment, prolonged PR
interval, and widened QRS
 as gentamicin, cisplatin, and
cyclosporine)
__
Magnesium excess Oliguric phase of renal failure
(hypermagnesemia) (particularly when
Serum magnesium magnesium-containing
_2.7 mg/dL medications are
administered), adrenal
insufficiency, excessive IV
magnesium administration,
diabetic ketoacidosis, and
hypothyroidism
Phosphorus deficit Refeeding after starvation,
(hypophosphatemia) alcohol withdrawal, diabetic
Serum phosphorus ketoacidosis, respiratory and
_2.5 mg/dL metabolic alkalosis,
decrease magnesium,
decrease potassium,
hyperparathyroidism,
vomiting, diarrhea,
hyperventilation, vitamin D
deficiency associated with
malabsorptive disorders,
burns, acid–base disorders,
parenteral nutrition, and
diuretic and antacid use
Phosphorus excess Acute and chronic renal
(hyperphosphatemia) failure, excessive intake of
Serum phosphorus phosphorus, vitamin D excess,
_4.5 mg/dL respiratory and metabolic
acidosis, hypoparathyroidism,
volume depletion,
leukemia/lymphoma treated
with cytotoxic agents,
increased tissue breakdown,
rhabdomyolysis
Chloride deficit Addison’s disease, reduced
(hypochloremia) chloride intake or absorption,
Serum chloride untreated diabetic
_96 mEq/L ketoacidosis, chronic
respiratory acidosis, excessive
sweating, vomiting, gastric
suction, diarrhea, sodium and
Flushing, hypotension, muscle
weakness, drowsiness,
hypoactive reflexes,
depressed respirations,
cardiac arrest
and coma, diaphoresis. ECG:
tachycardia bradycardia,
prolonged PR interval and
QRS, peaked T
waves
Paresthesias, muscle
weakness, bone pain and
tenderness,
chest pain, confusion,
cardiomyopathy, respiratory
failure, seizures, tissue
hypoxia, and increased
susceptibility to infection,
nystagmus
Tetany, tachycardia, anorexia,
nausea and vomiting, muscle
weakness, signs and
symptoms of hypocalcemia;
hyperactive reflexes; soft
tissue calcifications in lungs,
heart, kidneys, and cornea
Agitation, irritability, tremors,
muscle cramps, hyperactive
deep tendon reflexes,
hypertonicity, tetany, slow
shallow respirations, seizures,
dysrhythmias, coma
Labs indicate: decrease
 potassium deficiency,
metabolic alkalosis; loop,
osmotic, or thiazide diuretic
use; overuse of bicarbonate,
rapid removal of ascitic fluid
with a high sodium content,
intravenous fluids that lack
chloride (dextrose and water),
draining fistulas and
ileostomies, heart failure,
cystic fibrosis
Chloride excess Excessive sodium chloride
(hyperchloremia) infusions with water loss,
Serum chloride head injury (sodium
_108 mEq/L retention), hypernatremia,
renal failure, corticosteroid
use, dehydration, severe
diarrhea (loss of bicarbonate),
respiratory alkalosis,
administration of diuretics,
overdose of salicylates,
Kayexalate, acetazolamide,
phenylbutazone and
ammonium chloride
use, hyperparathyroidism,
metabolic acidosis
serum chloride, decrease
serum sodium, increase pH,
increase serum bicarbonate,
increase total carbon dioxide
content, decrease urine
chloride level, decrease serum
potassium
Tachypnea, lethargy,
weakness, deep rapid
respirations, decline in
cognitive status, decrease
cardiac output, dyspnea,
tachycardia, pitting edema,
dysrhythmias, coma
Labs indicate: increase serum
chloride, increase serum
potassium and sodium,
decrease serum pH, decrease
serum bicarbonate, normal
anion gap, increase urinary
chloride level