Fluid, Electrolyte, and Acid–Base Balance

Homeostasis – the tendency of the body to maintain a state

of balance or equilibrium while continually changing; a
mechanism in which deviations from normal are sensed and
counteracted
 60% of the average healthy adult’s weight is water,
the primary body fluid
 a person’s weight varies by less than 0.2 kg (0.5 lb)
in 24 hours
Water serves as:
1. A medium for metabolic reactions within cells
2. A transporter for nutrients, waste products, and other
substances
3. A lubricant
4. An insulator and shock absorber
5. A means of regulating and maintaining body
temperature.

 Age, sex, and body fat affect total body water.

 Infants have the highest proportion of water, accounting
for 70% to 80% of their body weight.
 The proportion of body water decreases with age.
 Older than 60 years of age only about 50% of total body
COMPOSITION OF BODY FLUID
weight.
 Women generally have a lower percentage of body water sodium chloride – salt that breaks up into one ion of sodium
than men, due to lower levels of muscle mass and a (Na+) and one ion of chloride (Cl
greater percentage of fat tissue. )
 water makes up a greater percentage of a lean person’s
body weight than an obese person’s. Electrolytes – charged particles; capable of conducting
electricity; measured in milliequivalents per liter (mEq/L) or
DISTRIBTION OF BODY FLUIDS milligrams per 100 milliliters (mg/100 mL).
Intracellular fluid (ICF) – is found within the cells of the body;  Cations – ions that carry a positive charge Should be
it constitutes approximately 2/3 of the total body fluid in adults;
Eg. sodium (Na+), potassium (K+), calcium equal in
transports wastes from cells by way of the lymph system, as
well as directly into the blood plasma through capillaries. (Ca2+), and magnesium (Mg2+). number

Extracellular fluid (ECF) – is found outside the cells and
accounts for about 1/3 of total body fluid; the transport system
that carries oxygen and nutrients to, and waste products from,
body cells
a. Intravascular fluid (plasma) – accounts for
approximately 20% of ECF and is found within
the vascular system; protein-rich fluid containing
large amounts of albumin
b. Interstitial fluid – accounting for approximately
75% of ECF, surrounds the cells; vital to normal
cell functioning; contains solutes such as
oxygen, electrolytes, and glucose, and it
provides a medium in which metabolic
processes of the cell take place; contains little or
no protein
c. Lymph
d. Transcellular fluids
 Anions – ions that carry a negative charge
Eg.chloride (Cl), bicarbonate HCO3, phosphate
PO42–, and sulfate SO42–
milliequivalent – refers to the chemical combining power of
the ion, or the capacity of cations to combine with anions to
form molecules
milligram – refers to the weight of the ion
selectively permeable - substances other than water move
across them with varying degrees of ease
Solutes - substances dissolved in a liquid (sugar in coffee)
 crystalloids - salts that dissolve readily into
true solutions
 colloids -substances such as large protein
molecules that do not readily dissolve into true
solutions
solvent - is the component of a solution that can dissolve a
solute (coffee is the solvent for the sugar)
osmolality - concentration of solutes in body fluids;
determined by the total solute concentration within a fluid
compartment and is measured as parts of solute per kilogram
of water; reported as milliosmoles per kilogram (mOsm/kg.
Sodium is by far the greatest determinant of the
osmolality of plasma, or serum osmolality,
although glucose and urea also contribute.
Potassium, glucose, and urea are the primary
determinants of the osmolality of intracellular fluid.
tonicity - refer to the osmolality of one solution in relation to
another solution
Solutions may be termed as:
1. Isotonic - solution has the same osmolality as ECF;
Normal saline, 0.9% sodium chloride, is an example
of an isotonic solution
2. Hypertonic - have a higher osmolality than ECF; 3%
sodium chloride
3. Hypotonic - have a lower osmolality than ECF;
0.45% sodium chloride
Osmotic pressure - is the power of a solution to pull water
across a semipermeable membrane
colloid osmotic pressure or oncotic pressure – plasma
proteins that exert osmotic pressure in the body holding water
in plasma, and when necessary pulling water from the
interstitial space into the vascular compartment; an important
mechanism in maintaining vascular volume
Diffusion - occurs when two solutes of different
concentrations are separated by a semipermeable
membrane; larger molecules move less quickly than smaller
ones, molecules move from a solution of higher concentration
to a solution of lower concentration, and increases in
temperature increase the rate of motion of molecules and
therefore the rate of diffusion.
Osmosis - is a specific kind of diffusion in which water moves
across cell membranes, from the less concentrated solution
(the solution with less solute and more water) to the more
concentrated solution (the solution with more solute and less
water); , water moves toward the higher concentration of
solute in an attempt to equalize the concentrations of both
water and solute.
Filtration - is a process whereby fluid and solutes move
together across a membrane from an area of higher pressure
to an area of lower pressure. An example of filtration is the
movement of fluid and nutrients from the capillaries of the
arterioles to the interstitial fluid around the cells.
filtration pressure - pressure that results in the movement of
the fluid and solutes out of a compartment is called filtration
pressure; difference between the hydrostatic pressure and the
osmotic pressure
Hydrostatic pressure - pressure exerted by a fluid within a
closed system on the walls of the container in which it is
contained. The hydrostatic pressure of blood is the force
exerted by blood against blood vessel walls.
Active transport - is the movement of solutes across cell
membranes from a less concentrated solution to a more
concentrated one; a substance combines with a carrier on the
outside surface of the cell membrane, and they move to the
inside surface of the cell membrane. Once inside, they
separate, and the substance is released to the inside of the
cell. A specific carrier is required for each substance.
REGULATING BODY FLUIDS
Fluid intake - average adult drinks about 1,500 mL per day
even though they need 2,500 mL per day for normal
functioning
Water - as a by-product of food metabolism accounts for most
of the remaining fluid volume required. This quantity is
approximately 200 mL per day for the average adult
thirst mechanism - is the primary regulator of fluid intake;
thirst center is located in the hypothalamus of the brain
Fluid Output – fluid losses from the body includes:
 Urine - formed by the kidneys and excreted
from the urinary bladder, and is the major
route of fluid output
 Feces – chyme that passes from the small
intestine into the large intestine contains
both water and electrolytes
 Insensible losses - occur through the skin
and the lungs.; loss through the skin occurs
in two ways, diffusion and perspiration
obligatory losses - fluid losses that required to maintain
normal body function.
MAINTAINING HEMEOSTASIS
Kidneys - primary regulator of body fluids and electrolyte
balance. They regulate the volume and osmolality of ECF by
regulating water and electrolyte excretion; 1.5 of urine is
excreted
Hormones - help control fluid and electrolyte balance
 Antidiuretic Hormone (ADH) - regulates water
excretion from the kidney, is synthesized in the anterior
portion of the hypothalamus and acts on the collecting
ducts of the nephrons.
 Renin-Angiotensin-Aldosterone System - increases
blood volume
Renin causes the conversion of
angiotensinogen to angiotensin I, which is
then converted to angiotensin II by
angiotensin-converting enzyme. Angiotensin II acts
directly on the nephrons to promote sodium and
water retention. In addition, it stimulates the release
of aldosterone from the adrenal cortex. Aldosterone
also promotes sodium retention in the distal nephron
 Atrial natriuretic factor (ANF) - is released from cells in
the atrium of the heart in response to excess blood
volume and stretching of the atrial walls. Acting on the
nephrons, ANF promotes sodium wasting and acts as a
potent diuretic, thus decreasing blood volume. ANF also
inhibits thirst, reducing fluid intake.
Regulating Electrolytes
Electrolytes are important for:
1. Maintaining fluid balance
2. Contributing to acid–base regulation
3. Facilitating enzyme reactions
4. Transmitting neuromuscular reactions.
NOTE: SEE TABLE 52.3
Sodium - is the most abundant cation in ECF and a major
contributor to serum osmolality. Normal serum sodium levels
are 135 to 145 mEq/L (bacon, ham, processed cheese, and
table salt)
Potassium - is the major cation in ICF, with only a small
amount found in the ECF. ICF levels of potassium are usually
125 to 140 mEq/L, while normal serum potassium levels are
3.5 to 5.0 mEq/L. The ratio of intracellular to extracellular
potassium must be maintained for neuromuscular response to
stimuli (fruits and vegetables, meat, fish, and other foods
contain potassium)
Calcium - The vast majority (99%) of calcium (Ca2) in the
body is stored in the skeletal system, with a relatively small
amount in extracellular fluid. The total serum calcium level
(normal range: 8.5 to 10.5 mg/dL) represents both bound and
unbound calcium. The ionized serum calcium level (normal
range: 4.0 to 5.0 mg/dL) represents free, or unbound, calcium.
(milk products)
Magnesium - is found primarily in the skeleton and ICF,
where it is the second most abundant intracellular cation. Only
about 1% of the body’s magnesium is in ECF, and it has a
normal serum level of 1.5 to 2.5 mEq/L. In ECF it is involved
in regulating neuromuscular and cardiac function. (Cereal
grains, nuts, dried fruit, legumes, and green leafy
vegetables are good sources of magnesium in the diet, as
are dairy products, meat, and fish.)
Chloride - is the major anion of ECF, and normal serum levels
are 95 to 108 mEq/L. Chloride functions with sodium to
regulate serum osmolality and blood volume. (bacon, ham,
processed cheese, and table salt)
Phosphate - is the major anion of ICF. It also is found in ECF,
bone, skeletal muscle, and nerve tissue. Normal serum levels
of phospate in adults range from 2.5 to 4.5 mg/dL. Phosphate
is absorbed from the intestine (meat, fish, poultry, milk
products, and legumes)
Bicarbonate - is present in both ICF and ECF. Excreted when
too much is present; if more is needed, the kidneys both
regenerate and reabsorb bicarbonate ions. Unlike electrolytes
that must be consumed in the diet, adequate amounts of
bicarbonate are produced through metabolic processes
REGULATION OF ACID–BASE BALANCE
1. Buffers - prevent excessive changes in pH by
binding with or releasing hydrogen ions (bicarbonate
HCO3; carbonic acid H2CO3)
Acidosis – increased acidity
Alkalosis - excessively alkaline condition
2. Respiratory Regulation - the lungs help regulate
acid–base balance by eliminating or retaining carbon
dioxide (CO2).
3. Renal Regulation – kidneys are the ultimate long-
term regulator of acid–base balance. They are
slower to respond to changes, requiring hours to
days to correct imbalances, but their response is
more permanent and selective than that of the other
systems. Normal serum bicarbonate is 22 to
26mEq/L.
FACTORS AFFECTING BOY FLUID, ELECTROLYTES,
AND ACID-BASE BALANCE
1. Age
2. Sex
3. Body Size
4. Environmental temperature
5. Lifestyle
fluid volume deficit (FVD) - occurs when the body loses both
water and electrolytes from the ECF in similar proportions;
occurs as a result of:
a) abnormal losses through the skin, gastrointestinal
tract, or kidney
b) decreased intake of fluid
c) (c)bleeding
d) movement of fluid into a third space syndrome
third space syndrome - fluid shifts from the vascular space
into an area where it is not readily accessible as extracellular
fluid. This fluid remains in the body but is essentially
unavailable for use, causing an isotonic fluid volume deficit.
Hypovolemia - fluid is initially lost from the
intravascular compartment
Fluid volume excess (FVE) - occurs when the body retains
both water and sodium in similar proportions to normal ECF.
causes of FVE include:
a) excessive intake of sodium chloride
b) administering sodium-containing infusions too
rapidly, particularly to clients with impaired regulatory
mechanisms
c) disease processes that alter regulatory mechanisms,
such as heart failure, renal failure, cirrhosis of the
liver, and Cushing’s syndrome.
Hypervolemia – increased blood volume
Edema - excess interstitial fluid; caused by three main
mechanisms are:
(a) increased capillary hydrostatic pressure
(b) decreased serum osmotic pressure
(c) increased capillary permeability
Pitting edema - is edema that leaves a small depression or
pit after finger pressure is applied to the swollen area. The pit
is caused by movement of fluid to adjacent tissue, away from
the point of pressure
Dehydration (hyperosmolar fluid imbalance) - occurs when
water is lost from the body, leaving the client with excess
sodium.
Overhydration (hypo-osmolar fluid imbalance) - occurs when
water is gained in excess of electrolytes, resulting in low
serum osmolality and low serum sodium levels. Water is
drawn into the cells, causing swelling.
ELECTROLYTES IMBALANCES
1. Sodium
a) Hyponatremia - is a sodium deficit, or serum
sodium level of less than 135 mEq/L, and is, in
acute care settings, a common electrolyte
imbalance.
b) Hypernatremia - is excess sodium in ECF, or a
serum sodium of greater than 145 mEq/L.
2. Potassium
a) Hypokalemia - is a potassium deficit, defined as
a serum potassium level of less than 3.5
mEq/L
b) Hyperkalemia - is a potassium excess, defined
as a serum potassium level greater than 5.0
mEq/L. Hyperkalemia is less common than
hypokalemia, and rarely occurs in clients with
normal renal function. More dangerous than
hypokalemia
3. Calcium
a) Hypocalcemia - is a calcium deficit, defined as
a total serum calcium level of less than
8.5mg/dL or an ionized calcium level of less than
4.5 mEq/L. Severe depletion of calcium can
cause tetany with muscle spasms and
paresthesias (numbness and tingling around the
mouth, hands, and feet), and can lead to
seizures
b) Hypercalcemia - is a calcium excess, defined
as a total serum calcium level greater than 10.5
mg/dL, or an ionized calcium level of greater
than 5.5 mEq/L, most often occurs when
calcium is released in excess from the bony
skeleton. This is usually due to malignancy or
prolonged immobilization.
4. Magnesium
a) Hypomagnesemia - is a magnesium
deficiency, defined as a serum magnesium level
of less than 1.5 mEq/L. It occurs more frequently
than hypermagnesemia. Chronic alcoholism is
the most common cause of hypomagnesemia.
Magnesium deficiency also may aggravate the
manifestations of alcohol withdrawal, such as
delirium tremens (DTs).
b) Hypermagnesemia - is a magnesium excess,
defined as a serum magnesium level above 2.5
mEq/L, due to increased intake or decreased
excretion. It is often iatrogenic, meaning caused
by medical treatment; usually the cause is over
supplementation with magnesium.
5. Chloride
a) Hypochloremia - is a chloride deficit, defined as a
serum chloride level below 95 mEq/L, and is usually
related to excess loss of chloride through the GI
tract, kidneys, or sweating. Hypochloremic clients
are at risk for alkalosis, and may experience muscle
twitching, tremors, or tetany.
b) Hyperchloremia - is a chloride excess, defined as a
serum chloride level above 108 mEq/L. Excess
replacement of sodium chloride or potassium
chloride is a risk factor for high serum chloride levels,
as are conditions that lead to hypernatremia. The
manifestations of hyperchloremia include acidosis,
weakness, and lethargy, with the risk of
dysrhythmias or coma.
6. Phosphate
a) Hypophosphatemia is a phosphate deficit,
defined as a serum phosphate level of less than
2.5 mg/dL. Glucose and insulin administration
and total parenteral nutrition can cause
phosphate to shift into the cells from extracellular
fluid compartments.
b) Hyperphosphatemia is a phosphate excess,
defined as a serum phosphate level greater than
4.5 mg/dL, and occurs when phosphate shifts out
of the cells into extracellular fluids (e.g., due to
tissue trauma or chemotherapy), in renal failure,
or when excess phosphate is administered or
ingested.
ACID-BASE IMBALANCES - usually classified as respiratory
or metabolic by the general or underlying cause of the
disorder.
Compensation – correcting acid–base imbalances.
Respiratory Acidosis - causes carbonic acid levels to
increase and pH to fall below 7.35
Respiratory Alkalosis - pH rises to greater than 7.45
Metabolic Acidosis -bicarbonate levels are low in relation to
the amount of carbonic acid in the body, pH falls
Metabolic Alkalosis - the amount of bicarbonate in the body
exceeds the normal 20-to-1 ratio
Fluid Intake and Output. Measurement and recording of all
fluid intake and output (I & O) during a 24-hour period provides
important data about a client’s fluid and electrolyte balance.
Generally, I & O are measured for hospitalized clients,
particularly those at increased risk for fluid and electrolyte
imbalance.

All of the following fluids need to be recorded:

1. Oral fluids
2. Ice chips
3. Foods that are or become liquid at room
temperature
4. Tube feedings
5. Parenteral fluids
6. IV medications
7. Catheter or tube irrigants
8. Urinary output
9. Vomitus and liquid feces
10. Tube drainage
11. Wound and fistula drainage
Laboratory Tests
1. Serum Electrolytes
2. Complete Blood Count
Hematocrit - is a measure of the volume of cells in relation to
plasma and is, therefore, affected by changes in plasma ENTERAL FLUID AND ELECTROLYTE
volume; hematocrit increases with dehydration and decreases REPLACEMENT
with overhydration. Normal hematocrit values are 40% to 54%
in men and 37% to 47% in women. a) Fluid Intake Modifications
b) Dietary Changes
3. Osmolality - measure of the solute concentration of c) Oral Electrolyte Supplements
blood.
4. Urine Specific Gravity - an indicator of urine
concentration that correlates with urine osmolality PARENTERAL FLUID AND ELECTROLYTE
and it can be measured quickly and easily by nursing REPLACEMENT
personnel. Normal specific gravity ranges from 1.005
to 1.030 (usually 1.010 to 1.025). IV fluid therapy is essential when clients are unable to
5. Urine pH - Normally the pH of the urine is relatively take sufficient food and fluids orally. It is an efficient and
acidic, averaging about 6.0, but a range of 4.6 to 8.0 effective method of supplying fluids directly into the
is considered normal. intravascular fluid compartment and replacing electrolyte
6. Arterial blood gases (ABGs) - are performed to losses.
evaluate a client’s acid–base balance and
a) Intravenous Solutions - IV solutions can be
oxygenation.
classified as isotonic, hypotonic, or hypertonic
(NOTE: SEE TABLE)
Volume expanders are used to increase
the blood volume following severe loss of
blood (e.g., from hemorrhage) or loss of
plasma (e.g., from severe burns, which
draw large amounts of plasma from the
bloodstream to the burn site). Examples of
volume expanders are dextran, plasma,
and albumin.
b) Venipuncture Sites - metacarpal, basilic, and
cephalic veins are common venipuncture sites
 c) Intravenous Equipment - IV catheters, Intravenous Filters – IV filters are used to remove air and
catheter stabilization devices, solution particulate matter from IV infusions and to reduce the risk of
containers, infusion administration sets, complications (e.g., infusion-related phlebitis) associated with
IVfilters, and IVpoles. routine IV therapies
Intravenous Poles – IV poles (rods) are used to hang the
Intravenous Catheters
solution container.
1. peripheral-short catheter is less than or equal to
7.6 cm (3 in.) in length drop factor - number of drops delivered per milliliter
2. Butterfly, or wing-tipped, needles with plastic flaps of solution varies with different brands and types of
attached to the shaft are sometimes used The flaps infusion sets. Macrodrops commonly have drop
are held tightly together to hold the needle securely factors of 10, 12, 15, or 20 drops/mL; the drop factor
during insertion; after insertion, they are flattened for microdrip sets is always 60 drops/mL
against the skin and secured with tape. The butterfly
needle is most frequently used for short-term therapy
(e.g., less than 24 hours) such as with single-dose
therapy, IV push medications, or blood sample
retrieval
3. peripherally inserted central venous catheter
(PICC) is inserted in the basilic or cephalic vein just
above or below the antecubital space of the right
arm. The tip of the catheter rests in the superior vena
cava. These catheters frequently are used for long-
term IV access when the client will be managing IV
therapy at home.
4. Central venous catheters usually are inserted into
the subclavian or jugular vein, with the distal tip of
the catheter resting in the superior vena cava just
above the right atrium; long-term IVtherapy or
parenteral nutrition is anticipated, or a client is
receiving IVmedications that are damaging to Devices to Control Infusions
vessels (e.g., chemotherapy) 1. Electronic infusion devices (EIDs) regulate the
5. Implantable venous access devices are used for infusion rate at preset limits
clients with chronic illness who require long-term IV 2. The Dial-A-Flo in-line device is a manual regulator
therapy (e.g., intermittent medications such as that controls the amount of fluid to be administered;
chemotherapy, total parenteral nutrition, and may be used in situations where a pump is not
frequent blood samples) available or required, but prevention of fluid overload
is important.
Catheter Stabilization Devices - securing or stabilizing an IV BLOOD TRANSFUSIONS
catheter helps decrease movement of the catheter in and out
of the insertion site and the catheter is less likely to be Blood Groups - A, B, AB, and O.
dislodged. Historically, nonsterile tape was used to secure
Antigens - promote agglutination or clumping of blood cells,
peripheral IV catheters.
they are also known as agglutinogens. (A, B, and Rh)
Solution Containers - Solution containers are available in The A antigen is present on the RBCs of people with
various sizes (50, 100, 250, 500, or 1,000 mL); the smaller blood group A, the B antigen is present on the RBCs
containers are often used to administer medications. of people with blood group B, and A and B antigens
are both present on the RBCs in people with group
Infusion Administration Sets - Infusion administration sets AB blood. Neither antigen is present on the RBCs of
(also called administration infusion sets), consist of an people with group O blood.
insertion spike, a drip chamber, a roller valve or screw clamp,
tubing with secondary ports, and a protective cap over the Antibodies – present in plasma often called agglutinins
connecter to the IV catheter. People with blood group A have B antibodies
(agglutinins); A antibodies are present in people with
blood group B; and people with blood group O have
antibodies to both A and B antigens. People with
 group AB blood do not have antibodies to either A or
B antigens

Rhesus (Rh) Factor. The Rh factor antigen is present on the

RBCs of approximately 85% of the people in the United
States.
a. Rh positive
b. Rh negative
In contrast to the ABO blood groups, Rh
blood does not naturally contain Rh antibodies. However,
after exposure to blood containing Rh factor. Subsequent
exposure to Rhblood places the client at risk for an antigen–
antibody reaction and hemolysis of RBCs.
Blood Typing and Crossmatching. To avoid transfusing
incompatible red blood cells, both blood donor and recipient
are typed and their blood crossmatched. Blood typing is done
to determine the ABO blood group and Rh factor status. This
test is also performed on pregnant women and neonates to
assess for incompatibility between their blood types
(particularly Rh factor incompatibilities). Blood Typing and
Crossmatching. To avoid transfusing incompatible red blood
cells, both blood donor and recipient are typed and their blood
crossmatched. Blood typing is done to determine the ABO
blood group and Rh factor status. This test is also performed
on pregnant women and neonates to assess for
incompatibility between their blood types (particularly Rh
factor incompatibilities).
Transfusion Reactions - transfusion of ABO- or Rh-
incompatible blood can result in a hemolytic transfusion
reaction, which causes destruction of the transfused RBCs
and subsequent risk of kidney damage or failure.

(NOTE: SO AYUN MALIPONG GAD HIYA HAHAHA

PARANG LOVE CHAR HAHAHA :<)
-SHERLOCK