5.

1 Fluid and Electrolyte Imbalances NCM 112 A

Professor Sandra M. Covarrubias || September 23, 2021 MEDSURG
Transcribed by: Edding, Shaznei Raiyan B.
References: PPT, Books, Internet

TOPIC OUTLINE muscle contractions, acid balance, and fluid

I. General Concepts in Fluid and regulation.
Electrolytes
II. Movement of Fluid and Electrolytes How do you restore fluid and electrolytes
III. Mechanism of Regulating Fluid and normally?
Electrolytes o Fluid and electrolytes can be restored through diet
IV. Fluid Imbalance and fluid intake.
V. Electrolyte Imbalances
VI. Nursing Care FLUIDS
o Body fluid is a solution of water, electrolytes, and
OBJECTIVES non-electrolytes. An average healthy adult is 60%
1. Discuss the different composition of body made up of fluids.
fluids. o Functions of the body fluid:
2. Describe the movement of fluid and ✓ Transport nutrients, hormones, and
electrolytes in the human body. electrolytes
3. Identify the role of different organ system: ✓ Remove waste products in the body
kidney, endocrine, cardiovascular, ✓ Responsible in regulating body temperature
gastrointestinal, lung & integumentary in (Thermoregulation)
regulating fluid and electrolyte balance. ✓ Component of body cavities that protects and
4. Discuss the different fluid and electrolyte cushion joints and organs (e.g., pleural
imbalances. space, peritoneum cavity, pericardial space)
5. Identify appropriate nursing care to patients ✓ Medium for metabolism
with fluid and electrolyte imbalances. o Body fluids are divided into two compartments:
1. Intracellular (ICF) – Fluids within the cell and
Can you identify how your body systems lose fluid is composed of water, electrolytes, nucleic
and electrolytes? acids, lipids, and polysaccharides. These
o Integumentary System cellular contents are enclosed by a
✓ Sensible and insensible fluid loss (e.g., semipermeable membrane.
sweating) 2. Extracellular (ECF) – Fluids outside the cell,
✓ Sensible fluid loss refers to body fluid lost that it is further divided into interstitial,
can be perceived and measured (sweat) intravascular, transcellular fluid. ECF is
✓ Insensible fluid loss refers to body fluid lost that composed of electrolytes, water, proteins,
cannot be perceived and measured (sweat that RBCs, WBCs, and Platelets.
evaporated in the skin)
o Respiratory System
✓ Insensible fluid loss from breathing
✓ When breathing out, the breath has little
amount of water since both the mouth and
lungs are moist. When exhaling, the water
turns into a water vapor. Various factors like
respiratory rate (hyperventilation), humidity
and temperature affect the rate of the
respiratory fluid loss.
o Cardiovascular System
✓ Fluid shift in the blood vessels where there is an
increase in permeability allowing movements of ELECTROLYTES
fluid and electrolytes causing imbalance or fluid o Electrolytes are chemicals that are cations and
loss. anions.
✓ Bleeding or hemorrhage ✓ Cations are positively charged ions.
o Gastrointestinal System ✓ Anions are negatively charged ions.
✓ Sensible fluid losses such as diarrheal stools o Examples:
and vomiting Major electrolytes found in the body that is
o Genitourinary System responsible in the movement of fluid and
electrolytes:
✓ Sensible fluid loss through urination (urine)
✓ Sodium: Na+ a cation, the major ECF
What happens when your body are low in fluid and electrolyte.
electrolytes? Normal Values: 135 – 145 mEq/L
o Body processes are disrupted resulting to ✓ Potassium: K+ a cation, major ICF electrolyte.
homeostatic imbalance. Normal Values: 3.5 – 5.0 mEq/L
o When your body becomes low on electrolytes, it can ✓ Calcium: Ca+
impair your body's functions, such as blood clotting, Normal Values: 4.5 – 5.3 mEq/L

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[NCM 112 A MEDSURG] Fluid and Electrolyte Imbalance – Prof. Sandra M. Covarrubias
✓ Magnesium: Mg+, second abundant
electrolyte in the ICF
Normal Values: 1.3 – 2.1 mEq/L
✓ Chloride: Cl- a major anion of the ECF
Normal Values: 98 – 106 mEq/L
✓ Phosphorus: P- major anion of the ICF
Normal Values: 2.5 – 4.5 mEq/L
✓ Bicarbonate: HCO3-
Normal Values: 22 – 28 mEq/L
✓ Sulfate
NON-ELECTROLYTES
o Electrically neutral solutes
✓ Vitamins
✓ Creatinine
✓ Protein
✓ Glucose
✓ Lipids
How to maintain electrolyte balance?
o REMEMBER: There should be equal amount of
anion and cation in the ICF and ECF to maintain
balance.
MOVEMENTS OF FLUIDS AND ELECTROLYTES
o Passive Transport is a mechanism that does not
involve expenditure of energy.
1. Diffusion – “Brownian motion” is the
movement of particles from an area of a
greater concentration to an area of lesser
concentration as a part of random activity.
Net movement of molecules stops when the
concentrations are equal in both areas.
2. Osmosis – the passive movement of water
molecule across a semipermeable
membrane from an area of higher to lover
concentration until equilibrium is achieved.
3. Filtration – is a physical process that pushes
fluids through a biologic membrane by
unequal pressure exerted by the fluids.
Filtration is another passive process of
moving material through a cell membrane.
While diffusion and osmosis rely on
concentration gradients, filtration uses a
pressure gradient. Molecules will move from
an area of higher pressure to an area of lower
pressure. Filtration is non-specific.
o Active Transport is the movement of particles
across cell membranes against a concentration
gradient, expends energy to do so.
✓ An example is the sodium-potassium pump.
Both molecules differ in concentration
intracellularly and extracellularly. To
maintain this concentration difference, the
cell uses active transport to move sodium
out of the cell and potassium into the cell.
This requires energy which is the
adenosine triphosphate (ATP).
REMEMBER: Passive and active transport
differentiate in energy expenditure.
PROPERTIES EXERTED BY SOLUTIONS
o Osmotic Pressure
✓ The semipermeable membrane present
extracellularly.
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✓ Osmotic pressure is the pressure that needs
to be applied to a solution to prevent the
inward flow of water across a semipermeable
membrane.
o Hydrostatic Pressure
✓ The outward push from capillary to
extracellular spaces.
✓ It is the force of fluid in a compartment
pushing against a cell membrane or vessel
wall.
✓ The blood pressure generated by the heart’s
contraction. It gradually decreases as the
blood moves through the arteries until it is
about 30 mm Hg in the capillaries.
✓ At the capillary level, it is the major force that
pushes water out of the vascular system and
into the interstitial space.
o Oncotic Pressure
✓ The osmotic pressure (colloidal osmotic
pressure) exerted by proteins (plasma
colloids) in solution present intravascularly.
MECHANISMS OF REGULATING FLUID AND
ELECTROLYTES
o Thirst Center
✓ Hypothalamic – Pituitary Regulation
✓ A body fluid deficit or increase in plasma
osmolality activates osmoreceptors in the
hypothalamus. This stimulates thirst and the
release of ADH from the posterior pituitary
gland.
✓ ADH (Antidiuretic Hormone) acts on the
distal tubules and collecting ducts in the
kidney by making them more permeable to
water. The result is increased water
reabsorption from the tubular filtrate into the
blood and decreased excretion in the urine.
✓ ADH is only able to regulate how much water
the body holds onto; an intact thirst
mechanism is our main protection against
developing dehydration or hyperosmolality.
Thirst causes us to increase the amount of
water we drink.
✓ Together these result in increased free water
in the body, decreasing plasma osmolality
and restoring fluid volume. Many factors
influence ADH secretion and thirst.
Decreased BP, nausea, pain, hypoglycemia,
and hypoxemia stimulate ADH release.
o Renal Regulation
✓ Extracellular, renin-angiotensin system and
sodium – potassium pump, ADH, and
aldosterone.
✓ The primary function of the kidneys is to
regulate fluid and electrolyte balance by
[NCM 112 A MEDSURG] Fluid and Electrolyte Imbalance – Prof. Sandra M. Covarrubias
adjusting urine volume and the excretion of
most electrolytes.
✓ Renal system is the major regulator of fluid
and electrolyte in the body.
✓ In the average adult, the kidneys reabsorb
99% of this filtrate, producing around 1.5 L
of urine per day.
✓ Under the influence of ADH, aldosterone,
and other hormones, selective reabsorption
and secretion of water and electrolytes in
the renal tubules result in urine that is
different in composition and concentration
from plasma. This process helps maintain
normal plasma osmolality, electrolyte
balance, blood volume, and acid-base
balance.
✓ Aldosterone is a mineralocorticoid with
strong sodium-retaining and potassium-
excreting capabilities. Decreased renal
perfusion or decreased sodium in the distal
part of the renal tubule activates the renin-
angiotensin-aldosterone system (RAAS),
resulting in aldosterone secretion.
✓ Increased serum potassium decreased
serum sodium, and adrenocorticotropic
hormone (ACTH) stimulate aldosterone
secretion. Aldosterone increases sodium
and water reabsorption in the renal distal
tubules, decreasing plasma osmolality and
restoring fluid volume.
o Endocrine Regulation
✓ Thirst center (primary regulator), ADH and
aldosterone, parathyroid hormone (calcium
balance)
o Cardiac Regulation
✓ Consist of pressure center or the
baroreceptors that is found in the large
blood vessels which are sensitive to blood
pressure changes.
✓ Baroreceptors are a type of
mechanoreceptor allowing for the relay of
information derived from blood pressure
within the autonomic nervous system. They
are spray-type nerve endings in the walls of
blood vessels and the heart that are
stimulated by the absolute level of, and
changes in, arterial pressure.
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✓ Increases pressure to increase blood
volume to kidney for urine output. Increased
blood volume causes increased in urine
output and atrial pressure.
✓ Natriuretic peptides, including atrial
natriuretic peptide (ANP) and b-type
natriuretic peptide (BNP), are hormones
made by cardiomyocytes. They are made in
response to increased atrial pressure
(increased volume, such as occurs in heart
failure) and high serum sodium levels. In
the renal tubules, peptides promote
excretion of sodium and water, decreasing
blood volume and BP.
✓ ANP works only for a short period of time
and on acute stages through positive
feedback.
o Gastrointestinal Regulation
✓ In addition to oral intake, the GI tract
normally secretes around 8000 mL of
digestive fluids each day.
✓ The GI tract normally reabsorbs most of this
fluid, with only a small amount eliminated in
feces. This is why diarrhea and vomiting,
which prevent GI reabsorption of secreted
fluid, can lead to significant fluid and
electrolyte loss.
o Pulmonary Regulation
✓ Regulate fluid and electrolyte through
breathing. Hyperventilation causes
insensible loss of fluids.
NURSING PROCESS
Physical Assessment
o Fluid Assessment Management
✓ Vital Signs
✓ Patterns of intake and output
• Intake – ice cream, oral fluid intake, IV
fluids, blood products, medication
administered through bolus, NGT
feeding, TPN
• Output – urine, profuse sweating
(diaphoresis /+1, +2 ratings), bleeding or
hemorrhage, diarrheal stools (diaper),
tube secretions, drainage from wounds,
vomiting, secretion from GI (GI
irrigation), NGT aspirate
• I&O – Monitor q1 - 2hr postoperatively
(esp. peripheral dialysis or kidney
surgery), depends on the order of
doctor.
✓ Weight loss or gain
• REMEMBER: Weigh patient daily using
the weighing scale, early prior breakfast
every day, on the same time and type of
clothing.
✓ Edema
• Assess for the type of edema such as
generalized, localized, and pitting edema.
✓ Abdominal Girth
• Especially, if there is fluid shift (fluid
retention in peritoneum) causing decrease
motility in the GI tract
✓ Level of Consciousness
• Monitor orientation and alertness of
patient. Use Glasgow Coma Scale (GCS)
✓ Cardiac and Respiratory Status
• Assess rate, depth, rhythms, and
regularity.
• Oxygen Saturation through pulse
oximeter.
[NCM 112 A MEDSURG] Fluid and Electrolyte Imbalance – Prof. Sandra M. Covarrubias

o BUN (Blood Urea Nitrogen) – May be decreased
in fluid volume excess due to plasma dilution.
Normal values: 10 – 20 mg/dL
o Hematocrit (Hct) – Hct levels in fluid volume deficit
are greater than normal because there is a
decreased plasma volume
Normal Values: M – 42% - 52% F – 35% - 47%
o Serum Electrolyte Levels – Measurement of
electrolyte levels should be performed to check for
presence of imbalance.
o Electrocardiogram (ECG) – ECG changes can
also contribute to the diagnosis of fluid and
electrolyte imbalance. Electrolytes like calcium can
alter the cardiac functions.
o Arterial Blood Gas (ABG) Analysis – ABG
analysis may reveal acid – base imbalance. Shows
pH level, PaO2, PaCO2, HCO3.
NURSING DIAGNOSIS
o Fluid Volume Deficit or Excess
o Altered Mucous Membrane
o Imbalance Nutrition Less/More than
Requirements
MEDICAL MANAGEMENT
o Isotonic Electrolyte Solutions
✓ These solutions are used to treat the
hypotensive patient with fluid volume deficit
because they expand plasma volume.
✓ Fluid resuscitation through fluid electrolyte
solutions
o Accurate monitoring of Intake and Output
o Dialysis
✓ Indicated when there is fluid overload and
major electrolytes loss
o Nutritional Therapy
✓ Oral rehydration
✓ Diet of fluid and electrolyte-rich foods
administration is within one hour, and the
diuresis lasts about 6-8 hours.
o Electrolyte Replacement
✓ Monitor for weight gain and edema.
NURSING MANAGEMENT
o Fluid Assessment Management
✓ Intake and output
✓ Daily weight
✓ Vital signs
✓ Physical Exam
o Monitor skin turgor (less than 2 seconds)
o Urine Concentration
✓ Determined through specific gravity
Normal Values: 1.003 – 1.010 or 1.005 to
1.030
o Oral and parenteral fluids
o Oral rehydration solutions
o Monitor central nervous system changes
o Diet
EVALUATION
Body
o Maintained fluid volume at a functional level.
o Displayed normal laboratory results.
o Demonstrated appropriate changes in lifestyle and
behaviors including eating patterns and food
quantity/quality.
o Reestablished and maintained normal pattern and
GI functioning.

PHARMACOLOGICAL TREATMENT
o AVP (Arginine Vasopressin/Antidiuretic
Hormone) receptor antagonists
✓ Vasopressin antagonists are drugs that bind
to vasopressin receptors (V1A, V1B and V2)
and block the action of vasopressin
(antidiuretic hormone, ADH), which is a
hormone released by the pituitary gland.
Vasopressin causes vasoconstriction and
increases reabsorption of water by the
kidneys.
o Diuretics
✓ 3 types of diuretics: Loop-acting, potassium-
sparing, thiazide diuretics.
✓ Furosemide is the most common which is a
loop-acting diuretics. A diuretic makes the
body get rid of extra fluid through the kidneys.
A loop diuretic works on a specific part of the
kidney called the "loop of Henle" to increase
the salt and water excretion.
✓ Furosemide works by blocking the
absorption of sodium, chloride, and water
from the filtered fluid in the kidney tubules,
causing a profound increase in the output of
urine (diuresis). The onset of action after oral

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