Basic concepts
o skin 75%
◼ Total Body Water: 50-60% of total
body weight
◼ Lean individuals: greater %age of
body weight is water.
◼ Lower %age of TBW in females
correlates with a higher %age of
adipose tissue and lower %age of
muscle mass.
FLUID COMPARTMENTS
Functions of Body water
ECF
- Maintains blood volume
- Transport system to and from the
cell
- Chemical composition of the ICF
o Na = primary cations
o Cl and bicarbonate =
principal anions
ICF
- Internal aqueous medium for
cellular chemical function
- Maintenance of normal body
temp.
- Elimination of waste products
- Chemical composition of the ICF
o K, Mg = primary cations
o Phosphates and proteins =
principal anions
Classification of body fluid changes
Normal exchange of fluid & electrolytes
• 2000ml of water/day
o 75% oral intake, 25% solid
foods
Daily losses:
• 1 L urine
• 250ml stool
• 600ml insensible losses
o lungs 25%
o insensible losses in
▪ fever
▪ hypermetabolism
▪ hyperventilation
Internal regulation of body water and
electrolytes
Na and K
1. Thirst → major control of actual fluid
intake
2. Kidney → major organ controlling
output
3. ADH → ↑ water reabsorption
4. RAAS
Volume control
Volume changes are sensed by both
osmoreceptors & baroreceptors
• OSMORECEPTORS (Surface of
Hypothalamus)- detects even small
changes in fluid osmolality
THIRST MECHANISM
Decreased volume → plasma
osmolality (increased solute
concentration → increased ADH →
Thirst stimulated → increased
water consumption
• Baroreceptors modulate volume in
response to changes in pressure
and circulating volume
• Located in the aortic arch & carotid
sinuses
Volume Deficit
ECF
• Most common fluid disorders
• Deficient fluid volume or
hypovolemia
 • Loss of GI fluids eg.Vomiting, NGT • Hypertonic IVF)
secretion diarrhea, fistula drainage • I&O, weight, Na levels
• Rapid losses= CNS and CVS • Neuro status → promote safety
changes
• Thermal regulation
ELECTROLYTE IMBALANCES
HYPEROSMOLAR IMBALANCE
(DEHYDRATION)
SODIUM
Etiology:
o Excess loss of water
o ↓ intake of water Major ECF cation → most abundant
o ↑ solute intake w/o • Controls ECF osmotic pressure,
sufficient water(High CHON ECF volume
tube feedings) o Controls water distribution
DHN → loss of water w/o electrolyte loss throughout the body
Hypovolemia/ Fluid volume deficit → lost o Loss/ Gain of Na = Loss/
of water and electrolytes in the same gain of water
proportion as they exist in normal tissues • Nec. For neuromuscular fx. IC
chemical rxn
Assessment: • Maintains acid-base balance
• Thirst, wt. loss, dry skin and 2 gm/ day
mucous membranes CONCENTRATION CHANGES
Management: • Changes in serum sodium are
• Fluid replacement → Oral (safest inversely proportional to total
route) body water
• Oral care NA K PUMP
• Safety measures • Regulates concentration of Na and
K in the ICF and ECF
HYPOOSMOLAR IMBALANCE (Water • Na → Diffusion → ICF
intoxication) • Na → Active Transport → ECF
Causes: • K → Diffusion → ECF
• Excess intake of electrolyte • K → Active Transport → ICF
• Na deficit
• ↑ ADH HYPONATREMIA/ Na Deficit
Assessment: Na level < 134-145
• Changes in mental status (cerebral Causes:
edema), weight gain (edema), • GI losses
Hyperventilation, warm moist skin, • Diuretics
↑ ICP (↓HR, ↑ SBP, ↓DBP) • Low Na intake
Management: • ↓ Aldosterone
• Fluid restriction • Diaphoresis
• Diuretics Assessment:
 •↓ECF ↑ ICF o Thirst is such a strong
•Anorexia, n/v, muscle weakness, defender of serum Na in
lethargy healthy people → HyperNat
• Confusion, headache, ↓HR, ↑ SBP, does not occur unless
↓DBP patient is unconscious or
• Seizures, coma denied water
• Muscle twitching, cramps • Red swollen tongue, dry sticky
• Dry skin., mucous membranes mucous membranes
MANAGEMENT: • Oliguria
• Fluid restriction - 800 ml/day • ↑ temp. ↑ BP ↑ Pulse
• Na replacement • Tachycardia, Fatigue, lethargy
o IV 0.9 NaCl • Neurologic: restlessness,
o ↑ Na in diet → Broth beef disorientation, hallucinations,
cubes, tomato juice seizures
• Treatment of shock • Hyperreflexia, muscle twitching
o Plasma expanders → MANAGEMENT:
Colloids • Restrict Na in diet
o Dextran, Haes Steril • Hydrate
• Safety Precautions o Oral fluids, non-saline IVF
o Elderly → ↑ risk due to (D5W) → indicated if water
changes in renal function needs to be replaced w/o
o → confusion Na
o Offer fluids at regular
HYPERNATREMIA intervals
Na Excess o Sufficient fluids after
Na level > 135-145 enteral feeding
Causes: • Diuretics
• More water than Na is lost from • Dialysis
the body • Desmopressin Acetate (DDAVP) →
o Hyperventilation, diarrhea D. Insipidus
• High Na intake • Monitor I&O, LOC, Behavioral
o Hypertonic Enteral feedings changes
w/o sufficient water intake
• Salt tablets
• Rapid infusion of IV saline POTASSIUM
• Water deprivation: Unconscious
client → cannot communicate • Normal levels: 3.5-5.5 meq/L
thirst • Major intracellular cation
Assessment: • Maintains ICF osmotic pressure
• Usually neurologic → consequence • 2% is ECF, 98% ICF
of cellular DHN • critical in cardiac & neuromuscular
• Extreme thirst function
 o Influences both cardiac and
skeletal muscle activity
• Maintains Acid-base balance and
normal kidney function
o K excess = alkalosis; K
deficit = acidosis
o 80% of K excreted → urine
o 20% → bowel and sweat
o Kidneys → primary
regulators of K balance
o ↑serum K = ↑ K excretion in
the urine
o Aldosterone → promotes
release of K
• Influenced by: surgical stress,
injury, acidosis & tissue anabolism
& catabolism
HYPOKALEMIA
Serum K <3.5 meq/L
Causes:
• GI losses → diarrhea, vomiting,
gastric suction
• ↓ intake, starvation
o Elderly, anorexic, bulimics,
alcoholics, debilitated
Drugs:
• Diuretics, Corticosteroids (↑
aldosterone), Digoxin (toxicity),
Penicillin
Metabolic alkalosis
Hypertonic Enteral feedings → ↑ insulin
Mg. losses → ↑ renal K loss
More common in surgical patients
Etiology:
• Inadequate intake
o Dietary
o potassium free IVF (D5 0.3,
D5 0.45, D5 0.9 NaCl)
• Excessive excretion
o hyperaldosteronism
o medications
▪ penicillin- promote
renal tubular loss of
K
▪ amphotericin,
aminoglycosides,
foscarnet, cisplatin,
ifosfamide – induce
magnesium
depletion which will
cause renal K
wastage
SUCTION
• S – Skeletal muscle weakness
• U – U wave
• C – Constipation → Ileus
• T – Toxicity of Digoxin
• I – Irregular/ weak pulse
• O – Orthostasis → dizziness
• N – Numbness
ECG CHANGES
• SA Node → AV Node → Bundle of
His → Purkinje Fibers → Ventricles
• ↓ K ➔ ↓ SA Node firing (Intrinsic
Rate-= 60-100) → AV node (40-60)
takes over → Ectopic beats → AV
node fails → Purkinje Fibers/
Ventricles (20-40) → impulse firing
not compatible w/ life
ASSESSMENT:
• GIT:
o Anorexia, n/v, abdl
distention → paralytic ileus
• CNS
o Lethargy, ↓ DTR, Confusion,
depression
• Muscles
o Flaccid paralysis, weakness
→ Resp. Arrest
• Cardiovascular
 o ↓ BP, dysrythmias, ECG
changes, myocardial
damage, Cardiac Arrest
• Renal
o Anorexia, ↓ capacity to
concentrate waste, thirst →
kidney damage
MANAGEMENT:
• Diet → ↑ K in the diet
o Fruits, mushrooms, carrots,
spinach, fish, beef, pork,
raisins/ dried fruits,
tomatoes, potatoes
• Potassium supplement
o K Citrate (Acalka)
o KCl IV → very irritating to
veins → CENTRAL LINE
▪ √ U.O./ Kidney
function → NO PEE,
NO K!!!
▪ 20-40 meq/H
▪ Dilute in IVF (0.9
NaCl) → shake IV
bottle
▪ Never given IM or IV
push → Infusion
pump
• K sparing diuretics
• Monitor K levels if pt. on Digoxin
o Maintain K level > 3.5
o √ ECG, changs in Pulse and
BP
HYPERKALEMIA
K > 5.5 meq/L
Less common than hypoK but more
dangerous
Causes:
• ↓ renal excretion of K
• Hypoalderosteronism
• Addison’s Dse
• Increased intake
o → K supplementation
o → blood transfusions
o → endogenous load:
hemolysis, crush injury, GI
hemorrhage
• Acidosis
o K moves out of cells into
ECF; H ions moves in
Signs and Symptoms:
• Cardiac s/sx → K 7 meq/L ↑
o ECG changes, bradycardia,
dysrhythmias
• Muscle weakness, paresthesia,
• Intestinal colic, cramps, irritability,
anxiety
Diagnostics:
• Serum K
• ECG → detect changes in cardiac
function
Management:
• ↓/ restrict K in the diet
• Diuretics
• Insulin + Glucose
• Ca Gluconate
o antagonizes action of K in
the heart
o Myocardial protective effect
is transient
▪ Effects last for 30
minutes
o Caution if w/ Digoxin
therapy
▪ Ca → sensitizes
heart to Digoxin →
toxicity
o √ BP → hpn; √ ECG
• IV NaHCO3
 o alkalinize plasma → K →
cells
o ↑ Na → antagonizes cardiac
effects of K
• Kayelexate exchange resin
o → binds w/ K and other
electrolytes and promotes
excretion into feces
o CAUTION: HypoMg,
HypoCal, Na retention, fluid
overload
• Dialysis
Nursing Management:
• Avoid K rich foods, K sparing
diuretics
• REST
• Monitor ECG and Cardiac function
• Monitor K levels, WOF hypoKal
CALCIUM
• Majority within bone matrix
(Skeletal system)
• <1% ECF, absorbed in the G.I. (acid
+ Vit.D, PTH)
• Excreted in the feces → urine
• Controlled by PTH and calcitonin
• ↓ Ca → PTH → ↑ Ca reabsorption
from GI and kidneys →Ca released
from bons
• ↑ serum Ca → suppresses PTH
• Excessive Ca → Calcitonin →
inhibits Ca reaborption bones
• Serum calcium
o protein bound (40%)
o complexed to PO4 & other
anions (10%)
o Ionized (50%)→ can be
measured directly
▪ can be used for NM
activity and clotting
Instrumental in:
1. transmission of nerve impulses
2. helps regulate muscle contraction/
relaxation → Cardiac muscles
3. Activates enzymes that stimulates
chemical reactions
4. Blood coagulation
5. Bone and teeth function
HYPOCALCEMIA
Causes:
• ↓ Ionized Ca
o Large transfusion w/
citrated blood (Infants),
alkalosis
• Excess Losses
o Kidney disease (↑PO4 =
↓Ca), Draining fistula,
• Inadequate Intake
• ↓ in GIT and Bone absorption
o ↓ Vit. D, ↓ PTH. ↑ Mg ↑
Calcitonin
• Severe injury and infection →
Burns
• Surgery → Thyroidectomy,
Parathyroidectomy
Signs and Symptoms:
• Bones → Osteoporosis
o Fracture
• GIT → ↑ Peristalsis
o n/v, diarrhea
• Cardiovascular → Dysrhythmias
o Cardiac arrest
• CNS → Tingling → Inc. irritability
o Convulsions
• Muscles → Muscle spasm
o Tetany (+) Trousseau,
Chvostek Sign
 • Others → abnormal deposits of Ca
in body tissues
Management:
• Monitor breathing
o Laryngeal stridor → post
Thyroid Sx
• IV Ca Gluconate → D5W
o → 0.9NaCl → promotes Ca
loss
o DO NOT USE IVF containing
PO4, HC03 → precipitation
• High Ca intake → 1,000-1,500
mg/day
o Dairy Products, Green
vegetables, Broccoli, Nuts,
legumes, whole grains,
carrots, seafoods
• Al(OH)3 / CaCo3
o ↓ PO4
Vit. D/ PTH supplements
Nursing Consideration:
• Monitor patient during IV Ca
Gluconate infusion
o Infuse slowly → prevent
cardiac arrest
o Monitor for digoxin toxicity
▪ Ca exert similar
action as Digoxin
o Observe IV site for
infiltration
• Suction Precaution
• Emphasize need for ↑ Dietary Ca
• Regular weight bearing exercises
• Health teaching for people at risk
for Osteoporosis
HYPERCALCEMIA
↑ Serum Ca < 10 mg/dl
Very dangerous when severe
Causes:
• Loss from Bones
o Immobilization, Carcinoma
w/ bone metastases
• Excess Intake
o ↑ Ca in diet (milk), Ca
Antacids
• ↑ PTH → ↑ release of Ca from
bones, ↑ renal and intestinal
reabsorption of Ca
• ↑ Vit. D
• Thiazide Diuretics → potentiates
effects of PTH on kidneys, ↓ Ca
excretion
Signs and Symptoms:
• Reduce neuromuscular irritability
→ suppresses activity at the
myoneural junction
• CNS → ↓ DTR, Lethargy, Coma
• CV → Depressed activity,
dysrhythmias, Cardiac arrest
• Muscles → fatigue, hypotonia, ↓
GIT
• Bones → Bone pain, osteoporosis,
fractures
• Kidneys → stones, kidney damage,
polyuria, polydipsia, DHN
ECG Changes
• prolonged QT
• T wave inversion
• Heart blocks
• Ventricular fibrillation
Management:
• ↑ Fluid intake (3-4L/day)
o Reduce risk of stone
formation
o relieves thirst
• Acid-ash fruit juices, Vit. C
o inhibits stone formation
• Protect from injury → confused
Pharmacology:
• IVF containing Na
• Diuretics
o Furosemide
• Mithramycin (Mithracin) -
↓Cytotoxic antibiotic
o inhibits bone resorption →
dec. Ca levels
• IV Phosphate → cause a reciprocal
drop in Ca levels
o use cautiously → severe
calcification, hpn, ARF
• CALCITONIN → ↓ bone resorption,
↑ deposition of Ca and PO4 in
bones, ↑ urinary excretion of Ca
and P
• Biphosphonates → inhibits
osteoclast activity
o Pamidronate (Aredia)
Hypercalcemic Crisis
• Serum Ca > 16
• Severe thirst, polyuria, DHN
• Cardiac Arrest
• Calcium Abnormalities
• ECG changes
o shortened QT
o prolonged PR, QRS
o Increased QRS voltage
o T wave flattening
o AV block
Correction
Parenteral
• Calcium gluconate 10%= 100
mg/ml (9 mg elemental)
• Calcium Chloride 10% (27mg
elemental)
Oral
• Calcium Carbonate (Tums) 40%
elemental
MAGNESIUM
• Acts as an activator in many
intracellular enzyme system
• CHO/ CHON Metabolism
• Impt. In neuromuscular function
• Acts directly on myoneural
junction
o variation in Mg levels affect
NM irritability and
contractility
▪ ↑Mg → diminished
excitability
▪ ↓ Mg → NM
irritability and
contractility
• Inhibits AcH
• Peripheral vasodilator → ↓ PVR
HYPOMAGNESEMIA
Causes:
• Alcoholism
• TPN, Enteral feeding
• ↓ intake
o Prolonged starvation,
malnutrition, starvation
• Impaired absorption from GIT
o HyperCal, Diarrhea, GIT
Draining Fistulas,
Disruption in small bowel
function (IBD, Int.
Resection)
• Excessive excretion
o Aldosterone, polyuria,
Signs and Symptoms
• Hyperexitability of the muscles
• Assoc. w/ HypoNat HypoKal
• CNS
 o Convulsions, paresthesias, o arrhythmias
tremors, ataxia
• CV Correction
oTachycardia, hpn, • ORAL
dysrhythmias o Protein- Magnesium Tablets
• Muscles (133mg elemental)
o Cramps, spasticity, tetany o DOSE: 6-15 mg elemental
(+) Trousseau/ Chvostek mg/kg/24h QID
• Mental changes
o Agitation, depression,
confusion PHOSPHORUS

Management: • Primary intracellular anion

• Dietary supplement
o Fish, fruits, vegetables,
whole wheat grain, milk,
meat, nuts
• Mg Supplement → IV/Oral
o Monitor U.O before, during
and after
o Notify MD if U.O. falls <100
cc in 4 H
o Calcium Gluconate
• Promotion of safety
o Protect from injury →
SEIZURE PREC!
• WOF digitalis toxicity
• Monitor for laryngeal stridor →
laryngospasm
Magnesium abnormalities
• ECG changes
Hypermagnesemia
o increased PR interval
o widened QRS
o elevated T waves
Hypomagnesemia
o prolonged QT, PR
o ST depression
o Flattening/inversion of P
waves
o Torsades de pointes
• 85% bones/ teeth, 14% soft
tissues, 1% ICF
• Responsible for maintaining
energy production in the form of
glycolysis or high energy
phosphate products such as ATP
• Essential to the function. Of RBC’s
and muscles, critical to nerve and
muscle function. provides
structural support to bones and
teeth
• Higher in children → skeletal
growth; ↓ age
• Controlled by renal excretion
HYPOPHOSPHATEMIA
Causes
• Administration of calories, ↑ CHO
Diet, TPN
o Malnutrition, Alcoholism
• Prolonged Hyperventilation →
alkalosis
• Poor dietary intake
• Burns
↓ K, ↓ Mg, ↑ renal excretion, Diuretics
Hyperparathyroidism
Excess binding w/ antacids
↓ Vit. D → osteomalacia (brittle bones)

Signs and Symptoms:
• ATP deficiency → impairs cellular
energy resources, impairs O2
delivery to tissues
• CNS
o Paresthesia, seizures
• Muscles
o muscle weakness, bone
pain, tenderness
• Respiratory
o Respiratory failure
• CV
o Cardiomyopathy, Chest
pain, tissue hypoxia
• ↑ susceptibility to infection
• Vit. D → does not ↑ s. Ca
• Ca binding antacids
• PO4 binding antacids → Al(OH)3
• ↓ dietary PO4
• Dialysis
CHORIDE
• Major ECF anion
• Found in interstitial and lymph
fluid
• Produced in the GIT → HCl
• Direct proportion w/ Na
• HCO3 inverse rel. w/ Cl

Management: HYPOCHLOREMIA
• Dietary supplement Causes:
o ↑ oral PO4 • Addison’s
o IV PO4 → S. PO4< 1 mg + • GI drainage
Non-functional GIT o Vomiting, diarrhea
o S.E. Tetany, Calcification • Chronic Resp. Acidosis
from HyperPO4 • Salt restricted diet
o Rate: 10meq/H • water losses → diaphoresis,
diuretics
HYPERPHOSPHATEMIA o ↓ Cl → ↑ HCO3 → ↑ pH →
Causes: Alkalosis
• RENAL FAILURE
• Chemotherapy Signs and Symptoms:
• Hypoparathyroidism • Agitation, irrotability, cramps,
• Respiratory Acidosis hyperactive DTR , tetany, slow
• High PO4 intake shallow resp. seizures, s/sx of
• ↑ PO4 absorption alkalosis

Signs and Symptoms Management:

• usually r/t hypocalcemia • 0.9NaCl IV
• Tetany, tachycardia, anorexia, n/v, • ↑ Cl diet
muscle weakness o Tomato juice, broth, canned
vegetables, processed
Management: meats, fruits
• directed at underlying d/o • Limit intake of free water
 • Al(OH)3 → alkalosis from upper abdominal incision,
excessive use of narcotics
HYPERCHLOREMIA
Causes: RESPIRATORY ALKALOSIS
• Excessive NaCl infusion w/ water • Hypoxia, CNS injury, iatrogenic
loss ventilation injury
• Head injury • Hypokalemia and ventricular
• Hypernatremia tachyarrhythmias
• Renal failure • treatment= proper use of
• Severe Diarrhea, DHN ventilator, correcting k deficits,
• Metabolic acidosis appropriate sedation
• Overdose of aspirin
METABOLIC ACIDOSIS
Signs and Symptoms • Retention or gain of acids or the
• Tachypnea, lethargy, weakness, , loss of bicarbonates
deep rapid respirations, • E.g renal failure, diarrhea, small
tachycardia, ↓ CO, dysrythmias, bowel fistula, DKA
coma, s/sx of acidosis • Anion gap = useful in delineating
the etiology
Management • Shock= most common cause of
• Infusion w/ LRS elevated anion gap
• NaHCO3 • DKA, starvation, ethanol
• Diuretics intoxication poisoning excessive
• Na, Cl, fluid restriction amount of aspirin
• Treatment= bicarbonate

ACID BASE BALANCE METABOLIC ALKALOSIS

Buffering systems • Ph serum HCO3= elevated
• Blood Buffer system → ABG • Primary compensation= renal
• Lungs • Hypochloremic, hypokalemic
• Kidney metabolic alkalosis= from ECV
• Important buffers: deficits
o Intracellular CHON & PO4 • Mgt. With isotonic NaCl and
o Extracellular bicarbonate- replacement of K= indicated
carbonic acid system • Should be gradual 24 h

RESPIRATORY ACIDOSIS
IV FLUIDS
Retention of CO2 secondary to decreased
alveolar ventilation
• Airway obstruction, atelectasis, Na+ K+ Cl-
pneumonia, pleural effusion,pain D5LR 130 4 109
 D5 0.3 51 - 51 o Effective volume expanders
D5 0.45 75 - 75 compared to isotonic
D5 0.9 154 - 154 crystalloids
D5 NR 140 5 98 Due to their MW, they are
D5 IMB 25 20 22 confined to the
D5 NM 40 13 40 intravascular space and
PLR 130 4 109 infusion results into more
ECF 142 4 103 efficient plasma expansion

NORMAL VALUES OF ELECTROLYTES Correction of life-threatening electrolyte

Na = 135 - 145 meq/L abnormalities
K = 3.5- 5.1 HYPERNATREMIA
Cl = 99 - 106 • Hypovolemic patients
Ca = 90 - 105 o D5W
Phos = 0.93 - 2.26 o Water deficit(L)= serum
sodium- 140
Pediatric IV Fluids HYPONATREMIA
8% of body weight or 80cc/kg • Water restriction
• estimated blood volume of infants • (+) neurologic signs- D5 0.3%NaCl
and children • Rapid correction can lead to
Maintenance Fluid rates in children PONTINE MYELINOLYSIS
• >10kg = 50ml/kg o seizures,
o next 10kg= 25ml/kg weakness/paresis/akinetic
• 4cc/kg= 1st 10kg body wt movements,
o 2cc/kg= 2nd 10kg unresponsiveness
o 1cc/kg = every kilo over 20 HYPERKALEMIA
o e.g.25kg child 4x10=40 • Treatment = bicarbonate, glucose,
plus 2 x 10=20 plus 1x5=5 insulin administration
IVF rate of 65 cc/hr • Severe k= cation exchange
resins=Kayexalate/or hemodialysis
ALTERNATIVE RESUSCITATIVE FLUIDS • Fluid therapy
• Hypertonic saline (7.5%) has been • Special surgical patients
used as a treatment for closed • SIADH (Syndrome of Inappropriate
head injuries Antidiuretic Hormone Secretion)
o increased cerebral
perfusion
o decreased ICP
o decreased edema
• Colloids