MEDICAL SURGICAL NURSING
FLUIDS, ELECTROLYTES, AND ACID-BASE IMBALANCES
 Not used for renal or cardiac disease.
BODY FLUIDS
Water= most important nutrient for life.
Water= primary body fluid.
Adult weight is 55-60% water.
Loss of 10% body fluid = 8% weight loss
SERIOUS
Loss of 20% body fluid = 15% weight loss
FATAL
Fluid gained each day should = fluid lost
each day
(2 -3L/day average)
What is the minimum output per hour
necessary to maintain renal function?
30ml/hr
FUNCTIONS OF BODY FLUID
 Medium for transport
 Needed for cellular metabolism
 Solvent for electrolytes and other
constituents
 Helps maintain body temperature
 Helps digestion and elimination
 Acts as a lubricant
HYPERTONIC FLUIDS
 Hypertonic fluids have a higher
concentration of particles (high osmolality)
than ICF
 This higher osmotic pressure shifts fluid
from the cells into the ECF
 Therefore Cells placed in a hypertonic
solution will shrink
 Used to temporarily treat hypovolemia
 Used to expand vascular volume
 Fosters normal BP and good urinary output
(often used post operatively) Used to treat
severe hyponatremia and cerebral edema.
 Monitor for hypervolemia!
 THINK – Why not? Pulmonary Edema
 D5% 0.45% NS
 D5% NS
 D5% LR
HYPOTONIC FLUIDS
 Hypotonic fluids have less concentration of
particles (low osmolality) than ICF
 Cells placed in a hypotonic solution will
swell
 Hypotonic solutions
 0.45% Saline (1/2 NS)
 0.225% Saline (1/4 NS)
 0.33% saline (1/3 NS)
 Hypotonic solutions are used when the cell
is dehydrated, and fluids need to be put back
intracellularly.
 This happens when patients develop diabetic
ketoacidosis (DKA) or hyperosmolar
hyperglycemia.
 Never give hypotonic solutions to patient
who are at risk for increased cranial pressure
(can cause fluid to shift to brain tissue),
extensive burns, trauma (already
hypovolemic) etc. because you can deplete
their fluid volume.
ISOTONIC FLUID
Isotonic fluids have the same concentration
of particles (osmolality) as ICF
Osmotic pressure is therefore the same
inside & outside the cells
Cells neither shrink nor swell in an isotonic
solution, they stay the same
ICF intracellular fluid - fluid inside the cell
D5W isotonic /Normal saline solution is
isotonic because it has almost the same
concentration of sodium as blood.
Expands both intracellular and extracellular
volume
 Used commonly for: excessive vomiting,
diarrhea, blood loss, BURNS, Fluid Isotonic dehydration
Resuscitation, Traumas H20 & electrolyte loss in equal amounts;
0.9% Normal saline diarrhea and vomiting
D5W
Ringer’s Lactate Hypertonic dehydration
H20 loss greater than electrolyte loss;
IV FLUIDS
excessive perspiration, diabetes insipidus
Isotonic
ASSESSMENT FVD - HYPOVOLEMIA
 0.9% Saline (normal saline)
 Lactated Ringers (LR) Cardiovascular:
 5% Dextrose in Water  Diminished peripheral pulses; quality 1+
Hypotonic (thready)
 0.45% Saline (1/2 NS)  Decreased BP & orthostatic hypotension
 0.225% Saline (1/4 NS)  Increased HR
 0.33% Saline (1/3 NS)  Flat neck & hand veins in dependent
Hypertonic position
 3% Saline  Elevated Hematocrit (Hct)
 5% Saline
 10% Dextrose in Water (D10W) Gastrointestinal:
 5% Dextrose in 0.9% Saline  Thirst
 5% Dextrose in 0.45% Saline  Decreased motility, diminished bowel
 5% Dextrose in Lactated Ringer’s sounds, possible constipation

FLUID VOLUME DEFICIT FVD Neuromuscular:

(HYPOVOLEMIA)  Decreased CNS activity (lethargy to coma)
 Loss of both H20 and electrolytes from  Possible fever
ECF.  Skeletal muscle weakness
 Causes include:  Renal:
 Increased output, Hemorrhage, vomiting,  Decreased output
diarrhea, burns or  Increased specific gravity of urine
 Fluid shifts out of vascular space (“third  Weight loss
spacing”) into interstitial spaces  Hypernatremia
 Dehydration: Fluid intake is not sufficient to
meet the body’s needs. Integumentary:
 Dehydration - if water isn’t adequately  Dry mouth & skin
replaced dehydration results  Poor turgor (tenting)
 Dx Tests  Pitting edema
 Elevated HCT  Sunken eyeballs
 Elevated NA
 Sp. Gravity above 1.030 Respiratory:
 Monitor lab work  Increased rate and depth
 Cause- unless unconscious
NURSING DIAGNOSIS - FVD
 Sudden weight change is a major indicator
of fluid loss Deficient Fluid Volume
Related to loss of GI Fluids via vomiting
DEHYDRATION
As evidenced by elevated Hct, dry mucous
membranes, decreased output, thirst Causes:
Increased Na/H2O retention
PLANNING - FVD Excessive intake of Na (PO or IV)
Client will demonstrate fluid balance as evidenced Excessive intake of H2O (PO or IV)
by moist mucous membranes, balanced I & O (Water intoxication)
measurements, Hct Within normal limits Syndrome of inappropriate antidiuretic
hormone (SIADH)
INTERVENTIONS FOR Renal failure, congestive heart failure
FVD
Deficient Fluid - HYPOVOLEMIA
Volume
Retention
Intake - Poorly controlled IV therapy/ rapid
hypertonic solution/ excessive sodium
bicarb / excessive Na intake
INTERVENTIONS FOR
FVE - HYPERVOLEMIA
CV:
 Elevated pulse; 4+ bounding, elevated BP,
distended neck & hand veins, ventricular
gallop (S3)
 Hyponatremia
 Oral - keep fluids at bedside, offer Resp:
frequently  Dyspnea, Moist Crackles, Tachypnea
 IV fluids, blood & other parenteral measures
Hyperal etc. Integumentary:
 Meds- depending on the cause  Periorbital edema
 Diarrhea give anti diarrhea meds  Pitting or Non-pitting edema
 Vomiting give anti emetics GI:
 Vasopressors if pt. In shock cause  Increased motility
vasoconstriction and increase BP  Stomach cramps
FLUID VOLUME EXCESS  Nausea & Vomiting
FVE - HYPERVOLEMIA
Renal:
 Fluid overload is an excess of body fluid -  Weight gain
overhydration  Decreased spec grav of urine
 Excess fluid volume in the intravascular
area-hypervolemia Neuromuscular:
 Excess fluid volume in interstitial spaces  Altered LOC, headache, skeletal muscle
edema twitching
 Increase in vascular blood
 Third spacing could be in the abdomen- NURSING DIAGNOSIS - FVE
ascites
 Fluid volume excess
 pleural effusion in the lungs
 Related to excessive H20 intake
FLUID VOLUME EXCESS
  AEB confusion, headache, muscle twitching, -Negatively charged
abdominal cramps, elevated BP and HR,  Chloride Cl-
hyponatremia.  Phosphate PO4-
 Bicarbonate HCO3-
PLANNING - FVE Each will be discussed except Bicarbonate as that
Client will demonstrate fluid balance by balanced I plays a role in acid base balance which will be
& O measurements, Serum Na WITHIN NORMAL covered in NR33
LIMIT
ELECTROLYTE FUNCTIONS
INTERVENTIONS FOR Regulate water distribution
FVE - HYPERVOLEMIA Muscle contraction
Nerve impulse transmission
 Restore normal fluid balance, prevent Blood clotting
further overload Regulate enzyme reactions Regulate acid-
 Drug therapy: diuretics base balance
 overhydration increases excretion of
SODIUM NA+
water and sodium
 Diet therapy: decrease Na & fluids  135-145mEq/L
 restricting fluid and sodium intake  Major Cation
 Monitor lab work  Chief electrolyte of the ECF
 Regulates volume of body fluids
 Monitor intake and output (I & O)
 Na concentrations effected by water
 Monitor weights intake and salt untake
 Monitor electrolytes  Needed for nerve impulse & muscle fiber
 Monitor CV, Resp, Renal systems transmission (Na/K pump)
 Regulated by kidneys/ hormones
SUMMARY  Hormones -Aldosterone
Hyper and Hypo Natremia are the most
ELECTROLYTES common electrolyte disturbances. Why do
Work with fluids to keep the body healthy you think that is?
It is most abundant in the EXTRACELLULAR
and in balance
FLUID and therefore more prone to fluctuation.
They are solutes that are found in various
concentrations and measured in terms of HYPONATREMIA
milliequivalent (mEq) units  Serum Na+ <135mEq/L
 1 mEq MILLIEQUIVALENT  Results from excess of water or loss of Na+
= 1 MG OF HYDROGEN  Water shifts from ECF into cells
Can be negatively charged (anions) or  S/S: abd cramps, confusion, NAUSEA/V,
positively charged (cations) pitting edema
For homeostasis body needs:  Fluid excess- osmotic diuretics ordered to
Total body ANIONS = Total body promote excretion of water rather than
CATIONS sodium (mannitol)
Cations  Fluid restriction till Na returns to norm
- Positively charged  Lop diuretics to remove excess fluid
 Assess: VS skin integrity, seizures, I & O/
 Sodium Na+
monitor lytes
 Potassium K+
 Calcium Ca++ Causes
 Magnesium Mg++
Anions
Poor IV therapy- IV therapy increased water in
blood Na is diluted
CHF
 Renal Failure
 GI: vomiting diarrhea drainage
 Skin: sweating burns
 diuretic drugs
TX
 Diet- foods high in sodium
 IV solutions ordered if hypovolemia (low
volume)
NURSING INTERVENTIONS
(HYPONATREMIA)
 Restrict or limit water intake
 Administer normal saline solution IV (3%
NSS with extreme caution)
 Monitor cardio-pulmonary status.
 Obtain BP lying down, sitting, & standing
 Daily weighing
 Monitor serum sodium levels
HYPERNATREMIA
 Serum Na+> 145mEq/L
 Results from Na+ gained in excess of H2O
OR Water is lost in excess of Na+
 Water shifts from cells to ECF
 S/S: thirst, dry mucous membranes & lips,
oliguria, increased temp & pulse, flushed
skin, confusion
Causes
increased Na intake- rapid infusion of saline
solution/po intake
Loss of water
diarrhea/DM/decreased water intake/ impaired thirst
center/can’t swallow
Fluid shift from ICF to ECF …. (Na pulls h2o out
of cells, kidneys excrete Na and water follows)
Tx
if caused by fluid loss Need slow gradual return to
normal Na+ by IV hypotonic solution 0.45% NS
Pt. Teaching avoid high Na foods, canned soups,
processed foods, ketchup AVOID antacids high in
sodium bicarb
I&O, review diet, meds,
Monitor weight, note change LOC
NURSING INTERVENTIONS
(HYPERNATREMIA)
 Daily weighing
 Strict I & O recording
 Assess skin and degree of edema
 Measures to prevent skin breakdown
 Sodium-restricted diet
 Vital signs & neurologic assessment
 Monitor laboratory test
POTASSIUM K+
 3.5-5.0 mEq/L
 Chief electrolyte of ICF
 Major mineral in all cellular fluids
 Aids in muscle contraction, nerve &
electrical impulse conduction, regulates
enzyme activity, regulates IC H20 content,
assists in acid-base balance
 Regulated by kidneys/ hormones
 Inversely proportional to Na
HYPOKALEMIA
 Serum level < 3.5mEq/L
 Results from decreased intake, loss via
GI/Renal & potassium depleting diuretics
 Life threatening-all body systems affected
 S/S muscle weakness & leg cramps,
decreased GI motility, cardiac arrhythmias
 Laboratory & diagnostics:
 ECG: depress ST segment, flattened T
waves
Effects
skeletal/cardiac/smooth muscle
Causes:
 Inadequate intake
 Alcoholism/Diuretics
 Excessive Vomiting & diarrhea
Tx
 ID cause
 High K diet (oranges, broccoli, meat protein
foods, banana, apricots)
 PO supplements common
 IV therapy always diluted

NURSING INTERVENTIONS
(HYPONATREMIA)
 Administer KCL (potassium chloride) Oral
or IV to replace losses
 Monitor ABG for acid-base imbalances
 Monitor pulse, respirations, BP & ECG.
 Assess urine output prior to giving K.
 Oral potassium is given with orange juice.
HYPERKALEMIA
 Serum level >5 mEq/L
 Results from excessive intake, trauma, crush
injuries, burns, renal failure
 S/S muscle weakness, cardiac changes, N/V,
paresthesia of face/fingers/tongue
 Shallow or Kussmaul's breathing
 Laboratory & diagnostics:
 ECG: prolong P-R interval, wide QRS
complex
 tented T wave (tented T waves is an
indication of eventual cardiac arrest)
(False rise due to tight tourniquet or hemolyzed
specimen occurs)
 Poor elimination by kidneys
 Paresthesia -tingling
Tx
 Depends on cause
 Hold Kmeds, low K diet ordered
 Kayexalate administered to increase
excretion of K
IV therapy add volume to dilute K+
Monitor for fluid overload.
NURSING INTERVENTIONS
Administer Kayexalate as ordered
Administer & monitor IV glucose & insulin
infusion
Anticipate hemodialysis if potassium levels
become severe
Administer sodium bicarbonate with caution
(calcium level drops with bicarbonate)
Provide cardiac monitoring
Discontinue any potassium IV or oral
supplements
CALCIUM CA++
 4.5-5.5mEq/L
 Most abundant in body but:
99% in teeth and bones
 Needed for nerve transmission, vitamin B12
absorption, muscle contraction & blood
clotting
 Inverse relationship with Phosphorus
 Vitamin D needed for Ca absorption
 8.5-10.5mg/deciliter dL
 Vit D needed for Ca absorption
HYPOCALCEMIA
 Serum Ca < 4.3mEq/L
 Results from low intake, loop diuretics,
parathyroid disorders, renal failure
 S/S osteomalacia, EKG changes,
numbness/tingling in fingers, muscle cramps
/ tetany, seizures, Chvostek Sign &
Trousseau Sign, 
 ECG: prolong Q-T interval
Common after thyroid surgery
Chvostek sign
Tap facial nerve in front of ear = facial spasm
Trousseau
carpal spasm after BP cuff inflated due to increased
neuromuscular excitability
TX
Ca supplements dietary. Dairy green vegetables,
sardines, salmon
If severe - IV calcium gluconate

NURSING INTERVENTIONS
(HYPOCALCEMIA)
 Administer oral calcium (calcium lactate), or
IV calcium (calcium gluconate or calcium
chloride)
 Calcium gluconate is used as a
cardioprotective agent in high blood
potassium. Calcium gluconate is the antidote
for magnesium sulfate toxicity.
 Seizure precaution & Safety measures: pad
side rails, bed free from sharp object, never
leave patient unattended
 Provide diet rich in calcium
 Institute bleeding precautions.
 Monitor electrolyte levels
HYPERCALCEMIA
 Serum Ca > 5.3mEq/L  memory loss
 Results from hyperparathyroidism, some
cancers, prolonged immobilization  
 S/S muscle weakness, renal calculi, fatigue,
altered LOC, decreased GI motility,
NAUSEA, VOMITING  
Remember it’s in the blood not the bones
Causes-high intake
TX
 Depends on cause encourage mobility,
immobilization causes demineralization of
bones leading to fractures remove
parathyroid tumors
 encourage fluids to prevent renal calculi
 Lower Ca by IV therapy causes diuresis
encouraging kidney excretion
 Calcium binding meds given to promote
excretion of calcium.
NURSING INTERVENTIONS
(HYPOCALCEMIA)
 Encourage mobilization
 Limit vitamin D & calcium intake
 Administer diuretics (Lasix)
 Administer IV normal saline
 Administer calcitonin
 Provide safety measures
 Monitor/review electrolyte levels
MAGNESIUM MG2+
 1.5-2.5mEq/L
 Most located within ICF
 Needed for activating enzymes, electrical
activity, metabolism of carbs/proteins, DNA
synthesis
 Regulated by intestinal absorption and
kidney
HYPOMAGNESEMIA
 Serum < 1.5mEq/L
 Results from decreased intake, prolonged
NPO status, chronic alcoholism &
nasogastric suctioning
 S/S: muscle weakness, cardiac changes,
mental changes, hyperactive reflexes &
other hypocalcemia S/S.
 Flushed face
 Changes in LOC: confusion, hallucinations,
 Tetany
Convulsion
 Ataxia, tremors
 Hyperactive reflexes
Laryngeal stridor due to muscle spasm
 Trousseau’s and Chvostek’s sign
 Common in critically ill patients
 Associated with high mortality rates
 Increases cardiac irritability and ventricular
dysrhythmias - especially in patients with
recent MI
 Maintenance of adequate serum Mg has
been shown to reduce mortality rates post
MI
NURSING INTERVENTIONS
(HYPOMAGNESEMIA)
 Provide dietary food rich of magnesium
(green leafy- Spinach) 
 Monitor cardiac & respiratory status
 Monitor electrolyte levels
Administer magnesium replacement slowly and with
extreme caution
 Infuse 10% Mg at a rate no more than 1.5
ml/minute.
 Seizure precaution
 Assess for difficulty in swallowing
NURSING FAST FACTS!
Rapid administration of magnesium can cause
cardiac arrest.
 HYPERMAGNESEMIA
 Serum>2.5mEq/L
 Results from kidney failure, increased intake
of magnesium, end stage liver disease
 S/S: flushing, lethargy, cardiac changes
(decreased HR), decreased resp, loss of deep
tendon reflexes, hypotension
Flushing due to peripheral vasodilation
Resp. deep shallow and slow

NURSING INTERVENTIONS
(HYPERMAGNESEMIA)
 Peritoneal dialysis- can be an option
 Calcium gluconate
 Diuretics/ water pill (Lasix, Furosemide)