XAVIER UNIVERSITY – ATENEO DE CAGAYAN

BACHELOR OF SCIENCE IN NURSING

In partial fulfillment of

NCM 112 – Care of Clients on Oxygenation, Fluid and Electrolyte, etc.

Fluid and Electrolyte

Submitted by:

Jan Levin B. Dagumbal

BS Nursing - 3 NB

Submitted to:

Gemma Panal, RN, MN, LPT

1. Differentiate between osmosis, diffusion, filtration and active transport.
a. Osmosis is the movement or shift of water across a semi-permeable cell
membrane. The fluid shifts from an area of lesser solute concentration to
an area with a greater solute concentration. This type of fluid movement is
a passive transport and does not require any energy for it to occur. Three
other terms are associated with osmosis and these are the following:
i. Osmotic pressure is the amount of hydrostatic pressure required to
halt the flow of water by Osmosis. This type of pressure is
determined by the concentration of solutes.
ii. Oncotic pressure is the osmotic pressure exerted by proteins such
as Albumin.
iii. Osmotic diuresis refers to the increase in urine ouput due to the
excretion of substances into the urine.
b. Diffusion is the movement of solutes from an area of high concentration to
a low concentration resulting in equal distribution of solutes among the
fluids. This occurs due to concentration of solutes and its rate of diffusion
varies according to the size of molecules, the concentration of the solution
and the temperature of the solution. It is also a passive transport,
therefore it does not require energy for it to happen.
c. An example of filtration is when blood pushes the walls of the capillaries
forcing fluids and solutes through the capillary wall and into the interstitial
space. Movement of fluids is usually from an area with greater hydrostatic
pressure to an area of lower hydrostatic pressure.
d. Active Transport refers to the movement of solutes from an area of lower
concentration to an area of higher concentration with the use of the energy
provided by adenosine triphosphate (ATP) across a concentration
gradient. The concentration of sodium in the ECF is greater than in the
ICF this leads to sodium entering the cell by diffusion. However, this is
 offset by the sodium-potassium pump that actively moves sodium from the
cell into the ECF, the high intracellular potassium concentration is then
maintained by pumping potassium into the cell.
2. Describe the role of kidneys and lungs in regulating the body’s fluid
composition and volume

Kidneys

The kidneys are vital to the regulation of fluid and electrolyte balance, it usually filter
up to 180 L of plasma every single day in the adult and typically excretes 1 to 2 L of
urine. They both act independently and according to bloodborne messengers such as
aldosterone and vasopressin.

Major functions of the kidneys in maintaining normal fluid balance include the
following:

 Regulates the volume and osmolality of ECF by selective retention and

excretion of body fluids.
 Regulates normal electrolyte levels in the ECF by excretion and retention of
electrolytes.
 Excretes metabolic wastes and toxic substances.

Lungs

The adult lungs remove in average about 300 mL of water daily through
exhalation. However certain abnormal conditions such as hypercapnea or continuous
coughing increase this loss. On the other hand, this can be decreased due to
mechanical ventilation with excessive moisture.

3. Identify the effect of aging on fluid and electrolyte regulation

The effects of aging on fluid and electrolyte regulation are vast and cover several
organ systems. A reduced cardial, renal and respiratory & alterations of body fluids to
muscle mass ratio can alter the response of an elderly to fluid and electrolyte changes
and acid-base disturbances.
 Decreased respiratory function impairs pH regulation in elderly clients with maor
illnesses or trauma. Due to a decrease in age-related muscle mass, elderly have a
lower concentration of body fluid which can affect several physiologic responses. To
add, due to the number of medications an elder client may be taking, this may lead to
an altered renal and cardiac function increasing the chance of fluid and electrolyte
disturbances.
Clinical manifestations of fluid and electrolyte disturbances in many elderly
clients may be subtle or atypical. Dehydration may cause delirium in an elderly client
whereas the first common sign of dehydration in younger client may be increased thirst.
Rapid infusion of an excessive volume of fluids must be closely monitored as it can
cause fluid overload and cardiac failure in elderly clients. Dehydration in the elderly is
common as a result of decreased kidney mass, decreased glomerular filtration rate,
decreased renal blood flow, decreased ability to concentrate urine, inability to conserve
sodium, decreased excretion of potassium, and a decrease of total body water.

4. Explain the role of the lungs, kidneys and chemical buffers in maintaining
acid-base Balance

Kidneys – the bicarbonate levels in the ECF is regulated by the kidneys as they
regenerate bicarbonate ions and at the same time can reabsorb them from the renal
tubular cells. When experiencing respiratory acidosis and most cases of metabolic
acidosis, kidneys excrete hydrogen ions and conserve bicarbonate ions to maintain
homeostasis. Finally, the kidneys can retain hydrogen ions and excrete bicarbonate
ions in respiratory and metabolic alkalosis.

Lungs – Under the supervision of the medulla, the lungs control the CO2 and thus the
carbonic acid content of the ECF. They are able to do so by adjusting ventilation in
response to the amount of CO2 in the blood. Respiration is greatly influenced by a rise
in the partial pressure of CO2 in arterial blood. The partial pressure of oxygen in arterial
blood (PaO2) also influences respiration but it is not as evident as that produced by the
PaCO2. In metabolic acidosis, the respiratory rate increases, influencing the lungs to
eliminate a greater amount of CO2 to reduce the acid load. On the other hand the
respiratory rate is decreased during metabolic alkalosis in or to retain CO2 thereby
increasing the acid load.

Chemical Buffers – Buffers remove or release H + thus preventing any major changes
in the pH of body. Hydrogen ions are buffered by both intracellular and extracellular
buffers. The bicarbonate-carbonic acid buffer system is the body’s major extracellular
buffer system. This system is assessed when arterial blood gases are measured.
Usually there are 20 parts of bicarbonate to one part of carbonic acid. However when
this ratio is altered, the normal pH will also change. The ratio of bicarbonate to carbonic
acid is extremely vital in maintaining pH. As CO2 is a potential acid it becomes carbonic
acid when dissolved in water. Therefore, when CO2 is increased, the carbonic acid
content is also increased, and vice versa. Acid imbalance results from a ratio that is no
longer retained. Less important buffer systems in the ECF include the inorganic
phosphates and the plasma proteins. Intracellular buffers include proteins, organic and
inorganic phosphates, and, in red blood cells, hemoglobin
 5. Compare the metabolic acidosis and alkalosis and respiratory acidosis and alkalosis with regards to causes, clinical
manifestation, diagnosis and management

DISORDER CAUSE CLINICAL DIAGNOSIS MANAGEMENT

MANIFESTATIONS
Metabolic acidosis is It primarily results The clinical manifestiations Diagnosis can be taken Treatment is directed at
characterized by a low from the direct loss of depend on the severity of the from arterial blood gas correcting the metabolic
pH and plasma bicarbonate such as in acidosis. However, it typicall measurements. Low imbalance. If it is the result of
bicarbonate conditions like involves headache, confusion, bicarbonate level and overconsumption of chloride,
concentration. It can diarrhea, drowsiness, increased low pH may signal treatment is focused at
be produced by a gain ureterostomies and respiratory rate and depth, metabolic acidosis. eliminating the source of
of hydrogen ion or a use of diuretics. It can nausea and vomiting. Hyperkalemia also Chloride.
loss of bicarbonate. It also be caused by Peripheral vasodilation and a accompanies due to Administration of bicarbonate
can be divided into two early renal decreased cardiac ouput the shift of potassium can be done if necessary.
forms, according to the insufficiency, occurs when the pH drops out of the cells. A Serum potassium levels must be
values of the serum excessive Chloride less than 7 decreased CO2 level is closely monitor for hypokalemia.
anion gap: high anion administration and vary with the the result of In chronic metabolic acidosis,
gap acidosis and parenteral nutrition severity of the acidosis but hyperventilation. An low serum calcium levels
normal anion gap administration without include headache, confusion, ECG can also detect are treated before the chronic
acidosis. bicarbonate or solutes drowsiness, increased dysrhythmias due to metabolic acidosis is treated, in
producing respiratory rate and depth, the increased order to prevent tetany due to an
bicarbonate. nausea, and potassium. increased pH and a decreased
vomiting. Peripheral ionize calcium.
vasodilation and decreased Alkalizing agents may also be
cardiac output occur when the given.
pH drops to less than 7. Hemodialysis or peritoneal
Additional physical dialysis
assessment findings include
decreased blood pressure,
cold and clammy skin,
dysrhythmias, and shock.
Chronic
metabolic acidosis is usually
seen with chronic renal
failure.
Metabolic alkalosis Vomiting is one of the Metabolic alkalosis is Evaluation of arterial Treatment of both acute and
Refers to a high pH most common cause manifested by tingly fingers blood gases reveals a chronic metabolic alkalosis is
and high plasma of metabolic alkalosis. and toes, dizziness and pH greater than 7.45 aimed at correcting the
bicarbonate It can also be caused hypertonic muscles. and a serum underlying acid–base disorder.
concentration. It can by gastric suction with Depressed respiratory rate is bicarbonate The nurse must monitor the fluid
be produced by a gain loss of hydrogen and a compensatory action by the concentration greater intake of the patient regularly
of chloride ions. lungs. than 26 mEq/L. and carefully.
bicarbonate or a loss Other causes may be Atrial tachycardia may also As the lungs attempt to Administer sodium chloride fluids
of hydrogen diuretic therapy that occur. compensate for the as instructed to restore normal
promotes excretion of Due to the increase of pH and excess bicarbonate, fluid volume.
potassium. development of hypokalemia, PaCO2 is increased. by H2 receptor antagonists, such as
Chronic metabolic ventricular disturbances may retaining CO2. cimetidine (Tagamet), reduce the
alkalosis may be due occur. Urine chloride levels production of gastric HCl,
to long-term diuretic Decreased motility and may help identify the thereby decreasing the
therapy, villous paralytic ileus may also be cause of metabolic alkalosis associated
adenoma, external present. metabolic alkalosis if with gastric suction.
drainage of gastric Symptoms of chronic the patient’s history Patients who cnnot tolerate rapid
fluids, significant metabolic alkalosis are the provides inadequate volume expansion may be
potassium depletion, same as for acute metabolic information. treated with Carbonic anhydrase
cystic fibrosis, and the alkalosis. Hypovolemia and inhibitors.
chronic ingestion of As potassium decreases, hypochloremia produce
milk and calcium premature ventricular urine chloride
carbonate. contractions or U waves are concentrations lower
frequently seen on the ECG. than 25 mEq/L.
Patients with alkali
loading do not exhibit
hypovolemia and urine
chloride concentration
exceeds 40 mEq/L.
The urine chloride
concentration should
be less than 15 mEq/L
when decreased
chloride levels and
hypovolemia occur.
Respiratory acidosis

pH is less than 7.35 May be a result of Sudden hypercapnia can Arterial blood gas Treatment is directed at
and the PaCO2 is inadequate CO2 cause increased analysis reveals: improving ventilation; exact
greater than 42 mm excretion with pulse and respiratory rate,  pH lower than 7.35 measures vary with the cause of
Hg inadequate ventilation, increased blood pressure,  PaCO2 greater than inadequate ventilation.
thus resulting to an mental 42 mm Hg  Bronchodilators help reduce
elevated plasma CO2 cloudiness, and a feeling of  Variation in the bronchial spasm
concentrations and fullness in the head. bicarbonate level.  Antibiotics are used for
increased levels of An elevated PaCO2 causes Depending on the respiratory infections
carbonic acid. cerebrovascular cause of respiratory  Thrombolytics or
In addition to an vasodilation and increased acidosis, other anticoagulants are used for
elevated PaCO2, cerebral blood flow. diagnostic tests pulmonary emboli
hypoventilation usually Ventricular fibrillation may be include: Pulmonary hygiene measures
causes a decrease in the first sign of respiratory  Serum electrolyte are initiated to clear the
PaO2. acidosis levels respiratory tract of mucus and
Emergency situations in anesthetized patients.  Chest x-ray purulent drainage.
such as acute Severe respiratory acidosis  Drug screen Adequate hydration (2 to 3
pulmonary edema, may cause increased ICP ECG is also conducted L/day) is indicated to keep the
foreigh object resulting in papilledema and to identify any cardiac mucous membranes moist and
aspiration, atelectasis, dilated conjunctival blood problems as a result of facilitate
pneumothorax, vessels. COPD. the removal of secretions.
sedative overdose, Chronic respiratory acidosis Supplemental oxygen is
sleep apnea, may occur with pulmonary administered as necessary.
administration of diseases such as chronic Mechanical ventilation may be
oxygen to a patient emphysema and bronchitis, used to improve pulmonary
with chronic obstructive sleep apnea, and ventilation. However,
hypercapnia, severe obesity. inappropriate mechanical
pneumonia and acute ventilation may cause rapid
respiratory distress excretion of CO2 that kidneys
dyndrome may cause are unable to eliminate excess
acute respiratory bicarbonate quickly enough to
acidosis. prevent alkalosis and
seizures. Because of this,
Diseases that impair PaCO2 must be decreased
respiratory muscles slowly.
may also cause Placing the patient in a semi-
respiratory acidosis. Fowler’s position also facilitates
 expansion of the chest wall.

Respiratory alkalosis

Arterial pH is greater It is mainly caused by Clinical signs consist of Analysis of arterial Treatment depends on the
than 7.45 and the hyperventilation, due lightheadedness due to: blood gases assists in underlying cause of respiratory
PaCO2 is less than 38 to the excessive  vasoconstriction the diagnosis of alkalosis. If the cause is anxiety,
mm Hg excretion of CO2  decreased cerebral blood respiratory alkalosis. the patient is instructed
leading to a decrease flow Evaluation of serum to breathe more slowly to allow
in plasma carbonic  inability to concentrate electrolytes is used to CO2 to accumulate or to
acid concentration.  numbness identify: breathe into a closed system
Causes of  tingling from decreased  Decrease in (such as a paper bag).
hyperventilation may calcium ionization potassium as In very anxious patients however
be due to extreme  tinnitus hydrogen is pulled a sedative may be administered
anxiety, hypoxemia, out of the cells in to relieve hyperventilation.
 loss of consciousness
early phase of exchange for Treatment of other causes of
Cardiac effects of respiratory
salicylate intoxication, potassium respiratory alkalosis is directed
alkalosis include:
gram(-) bactermia and  Decreased calcium at correcting the underlying
 Tachycardia
inappropriate as severe alkalosis problem.
ventilator settings.  Ventricular dysrhythmias
inhibits calcium
Chronic hypocapnia  Atrial dysrhythmias
ionization,
can cause chronic  Decreased
respiratory alkalosis phosphate,
entailing a decreased alkalosis causes an
in serum bicarbonate increased cell
levels. uptake of
Some risk factors phosphate
includes Chronic
hepatic insuffiency To rule out salicylate
and cerebral tumors. intoxication a
toxicology screen
should be performed.