FLUIDS AND

ELECTROLYTES
(NCM-3114a)

References:

Textbook of Medical-Surgical Nursing, 14th Ed.

By: Brunner & Suddarth

Medical-Surgical Nursing, Patient Centered Collaborative Approach, 6th Ed.

By: Ignativicius & Workman
BASIC CONCEPTS:

 Fluid and Electrolyte Balance is a dynamic process that is crucial for life and
homeostasis. Potential and actual disorders of fluid and electrolyte balance occur in
every setting, with every disorder, and with a variety of changes that affect healthy
people (ex. Increased fluid and sodium loss with strenuous exercise and high
environmental temperature, inadequate intake of fluid and electrolytes) as well as those
who are ill.

1) Physiologic Homeostasis depends on normal fluid and electrolyte balance.

Homeostasis = is the ability of the internal processes of the body. It is the maintenance of
a constant internal equilibrium in a biologic system that involves positive and negative
feedback mechanisms.
= It is the body’s tendency to maintain a state of physiologic balance in the presence of
constantly changing condition.

 One very important area of homeostasis is maintaining the body’s normal fluid volume
and composition.

2) It is important in both health promotion and treatment of disorders.

· Fluids and electrolytes imbalances commonly accompany illness.
· Severe imbalances may result in death.
· Such imbalances affect also clients with faulty diets or those who take selected
medications such as: Diuretics and glucocorticoid preparations.

3) So as nurses, we should understand the process of F & E balance; identify patient at risk
for imbalances; recognize early S/S; intervene as appropriate and evaluate the outcomes.

I. OVERVIEW OF ANATOMY AND PHYSIOLOGY

AMOUNT and COMPOSITION of BODY FLUIDS

Body Fluids:
 An adult human body consists of approximately 60% water.

Percentage varies with the influence of the following factors:

1) Body fat: Fat cells contain little water.

2) Gender or Sex: Women have less body water because they are rich in adipose tissue
while men have proportionately more body fluid.

3) Age: In general, younger people have a higher percentage of body fluid than older
people.

 75%-80% infant’s weight is H2O.

 This water (fluid) is divided into 2 spaces or compartments such as:

1. Extracellular Fluid - space contains about one third (15 L) of total body water.

 These spaces consist of:

a. Intravascular Space – the fluid within the blood vessels contains the plasma,
approximately 3L of the average 6L of blood volume is made up of plasma. The
remaining 3L is made up of erythrocytes, leukocytes, and thrombocytes.
 b. Interstitial Space – contains the fluid that surrounds the cell and totals about 11 to 12
L in an adult.
 Lymph is an interstitial fluid.

c. Transcellular Space – is the smallest division of ECF compartment and contains

approximately 1 L. Examples include cerebrospinal, pericardial, synovial,
intraocular, and plural fluids; sweats; and digestive system.

 Fluids move between the intracellular, intravascular, and interstitial compartments to

maintain fluid balance.

 Loss of fluid from the body can disrupt the equilibrium.

 Intravascular fluid – are the most changeable, quickly lost or gained by intake of fluids or
by loss of fluids.

 Interstitial fluids – are the reserve fluids replacing fluids in the cells or intravascular area.

2. Intracellular Fluids – are fluid inside the cells and the most stable compartment which
are fairly resistant to major fluids shift. Approximately two thirds of body fluid are in the
ICF compartment and are located primarily in the skeletal muscle mass.

 Body fluid normally moves between the 2 major compartments or spaces in an effort to
maintain equilibrium between the spaces.

 Loss of fluid from the body can disrupt this equilibrium. Sometimes fluid is not lost from
the body but is unavailable for use by either the ICF or ECF.

Fluid spacing – is a term used to classify the distribution of body water.

 First spacing – is a normal accumulation of fluid in both ECF & ICF compartments.

 Second spacing – refers to an excess accumulation of interstitial fluid.

 Third spacing – refers when fluid accumulates in areas that normally have less or no
fluid.

Regulation of Body Fluid Compartments:

1. Osmosis and Osmolality

Osmosis – is the process by which fluid moves across a semipermeable membrane from an
area of low solute concentration to an area of high solute concentration, the process continues
until the solute concentrations are equal on both sides of the membranes.

Osmolality – is the concentration of fluid that affects the movement of water between fluid
compartments by osmosis. It is the number of dissolved particles contained in a unit of fluid.
Osmolality measures the solute concentration per kilogram in blood and urine.
 Serum Osmolality – primarily reflects the concentration of sodium, although BUN and
glucose also play an important role in determining the serum osmolality.
 Osmolality is reported as milliosmoles per kilogram of water (mOsm/kg).

 In healthy adults, serum osmolality is 280 to 300 mOsm/kg.

  Urine Osmolality – is determined by urea, creatinine, and uric acid.
 Normal urine osmolality is 200 to 800 mOsm/kg.

 Water moved by osmosis from the ECF to the ICF based on the osmolality of the fluid
compartment.

 ICF osmolality increases water shifts from ECF into ICF.

 ECF osmolality increases water shifts from ICF into ECF.

Osmotic Movement of Fluids:

1. Cells are affected by the osmolality of fluids that surrounds them
2. Normally the ECF and ICF are isotonic to one another: no gain or loss.
3. If a cell is surrounded by hypotonic fluid, water moves into the cell causing it to swell
and possibly to burst.
4. If a cell is surrounded by hypertonic fluid, water leaves the cell to dilute the ECF, the cell
shrinks and may eventually die.

 The body functions best when the osmolarity of the fluids in all body fluid spaces is close
to 300 mOsm/L.
 Isotonic – having an equal osmotic pressure, 275 to 295 mOsm / kg., such as 0.9% NaCl
in water, Ringer’s in water.

 Hypotonic – has a lower osmotic pressure, less than 270 mOsm / kg., such as 0.45%
NaCl, 0.25% NaCl, Normosol M in D5W.

 Hypertonic – having a higher osmotic pressure, more than 300 mOsm / kg., such as
D10W, D50W, and 0.3 NaCl.

2. Diffusion – is the natural tendency of a substance to move from an area of higher

concentration to one of lower concentration.
 Examples: The exchange of oxygen and carbon dioxide between the pulmonary
capillaries and alveoli and the tendency of sodium to move from the ECF compartment,
where its concentration is low.

3. Filtration – hydrostatic pressure in the capillaries tends to filter fluid out of the intravascular
compartment into the interstitial fluid. Movement of water and solutes occurs from an area of
high hydrostatic pressure to an area of low hydrostatic pressure. Filtration allows the kidneys to
filter 180 L of plasma per day.
 Example: The passage of water and electrolytes from the arterial capillary bed to the
interstitial fluid; in this instance, the hydrostatic pressure results from the pumping action
of the heart.
There are some conditions in which this system does not work smoothly and fluids remains
in tissue space:
1. Low level of plasma protein.
2. Less water is absorbed into the vascular space.

4. Sodium – Potassium Pump –as previously stated, the sodium concentration is greater in the
ECF than in the ICF, and because of this, sodium tends to enter the cell by diffusion and actively
moves sodium from the cell into the ECF. Conversely the high intracellular potassium
concentration is maintained by pumping potassium into the cell.
  Water and solutes distributed throughout the body’s compartment.
 Normal cell function maintained by constancy of the body’s compartments.
 Maintained by constant movement and continuous exchange of water and solutes.
 Disrupted when water and solute concentrations are altered within the body.

Functions of H2O to ICF H2O:

1) Provides the cell with the internal aqueous medium necessary for its chemical functions.

ECF H2O:

1) Transports nutrients, electrolytes, and oxygen to cells.

2) Transports waste products for excretion.
3) Regulates heat.
4) Lubricates and cushions joints and membranes.
5) Hydrolyzes food for digestive processes.

Balance and Imbalance of H2O= is maintained in the body because the intake of fluids equals
the excretion of fluids.

 Water and electrolytes are gained in various ways. Healthy people gain fluids by drinking
and eating, and their daily average intake and output of water are approximately equal.

 Nursing alert: When fluid balance is critical, all routes of systemic gain and loss must be
recorded and all volumes compared. Organs of fluid loss include the kidneys, skin, lungs,
and GI tract.

Intake: 0utput:

Oral liquids 1,300 Urine 1500

Water in food 1000 Stool 200

Water produced Insensible:

by metabolism 300 Lungs 300

Skin 600

Total gain = 2,600 Total loss = 2,600

Systemic Routes of Fluid Loss:

1) Skin = sensible perspiration refers to visible water and electrolyte loss through the
skin (sweating). The chief solutes in sweat are sodium, chloride, and potassium.
Actual sweat losses can vary from 0 to 1000 ml or more every hour, depending on the
factors such as the environmental temperature.

2) Lungs = the lungs normally eliminate water vapor at a rate of approximately 400 ml
every day. The loss is much greater with increased respiratory rate or depth, or in a
dry climate.

3) Kidneys = the usual daily urine volume in the adults is 1 to 2 L. In general is that the
output is approximately 1ml of urine per kilogram of body weight per hour
in all age group.
 4) G. I. = the usual loss through GI tract is only 100 to 200 ml daily, diarrhea and
fistulas cause large losses.
Kidneys = of all water loss routes, the kidneys are by far the most important and most sensitive,
serving as the major adjustment mechanism to preserve Fluids and Electrolytes.

 Minimum amount of urine per day needed to dissolve and excrete the toxic waste
products of metabolism ranges between 400-600 ml.
 If the volumes falls below the obligatory urine output metabolic waste are retained and
homeostasis can be disrupted.

Excessive H2O loss is due to the ff:

a) Profuse perspiration
b) Vomiting
c) Diarrhea
d) GI suctioning
e) Intestinal fistula
f) Ostomies
g) Burns
h) Wounds or ulcer exudates
i) Hemorrhage
j) Draining fistulas
k) Paracentesis, Thoracentesis

ELECTROLYTES:
= Are substances found in ECF and ICF that dissociate into electrically charged particles
known as ions.
 Cations = (+) charges
= Na, K, Ca, Mg
 Anions = (-) charges
= Cl, PO4, HCO3, SO4
 ICF = K, Mg, PO4
 ECF = Na, Ca, Cl

General Functions of Electrolytes:

1) Regulation of H2O distribution
2) Transmission of nerve impulses
3) Contraction of muscle
4) Regulation of Acid-Base balance
5) Clotting of blood

Measurement of Electrolytes:
The concentration of electrolytes can be expressed in:
1) Milligrams per deciliter (mg/dl)
2) Millimoles per liter (mmol/L)
3) Milliequivalents per liter (mEq/L)
 mmol/L= the international standard for measuring electrolytes.

1. Sodium (Na+) – is the major cation in the ECF and is responsible for maintaining ECF
osmolality. The normal plasma sodium level ranges between 135-145 mEq/L or
mmol/L.

 Maintaining this difference in sodium levels is vital for the following functions:
a. Skeletal muscle control
b. Cardiac contractions
c. Nerve impulse transmission
 d. Normal ECF osmolality
e. Normal ECF volume
 The ECF sodium level determines whether water is retained, excreted, or moved from
one fluid space to another.

 Serum sodium balance is regulated by the kidney under the influences of aldosterone,
antidiuretic hormone (ADH), and natriuretic peptide (NP).

Food Sources of Sodium: Table salt, cheddar/cottage/American cheese, whole/skim milk,

butter, white bread, whole-wheat bread, soy sauce, ketchup, mustard, lean beef, fresh lean pork,
cured pork, light meat/dark meat chicken.

2. Potassium (K+) is the cation in ICF. The normal plasma potassium level ranges from
3.5 – 5.0 mEq/L or mmol/L.
 The normal ICF potassium level is about 140mEq/L (mmol/L).

 Functions of Potassium include the following:

a. Regulation of protein synthesis
b. Regulation of glucose use and storage
c. Maintenance of action potentials in excitable membranes

 Almost all foods contain potassium. Potassium intake is about 2 to 20g/day.

Food Sources: Corn flakes, Cooked oatmeal, egg, raw codfish, pink raw salmon, tuna fish, apple
raw w/ skin, banana, grapefruit, orange, raisins, watermelon, white bread, whole-wheat bread,
beef, beef liver, fresh/cured pork, chicken, ham, whole/skim milk, avocado, carrot, corn,
cauliflower, celery, green beans, mushrooms, onions, peas, potato, tomato.

 Some potassium control also occurs through kidney function. The kidney is the excretory
route for ridding the body of ECF potassium (80% of potassium removed from the body
occurs via the kidney).

3. Calcium (Ca+) is a mineral with functions closely related to those of phosphorous and
magnesium. Cacium is a divalent cation (an ion having 2 positive charges) that exists in
the body in 2 forms: bound and ionized (unbound or free).
 Bound calcium is normally attached to serum proteins, especially albumin.
 Ionized calcium is present in the blood and other ECGF as free calcium and is the active
form and must be kept within a narrow range in the ECF.
 The body functions best when blood calcium levels are maintained between 9.0 and
10.5 mg/dL, or between 2.25 and 2.75 mmol/L.

Calcium is important in the following actions:

a. Bone strength and density
b. Activation of enzymes or reactions
c. Skeletal muscle contraction
d. Cardiac muscle contraction
e. Nerve impulse transmission
f. Blood clotting

 Calcium enters the body by dietary intake and absorption through the intestinal tract.
Absorption of dietary calcium requires the active form of vitamin D. Calcium is stored in
the bones.

Food Sources: Cheddar/cottage/american cheese, whole/skim milk, low-fat yogurt, raw

broccoli, carrot, green beans, tofu.
4. Phosphorous (P) is in the body in both inorganic and organic forms. Normal serum levels of
phosphorous range from 3.0 to 4.5 mg/dL, or 0.97 to 1.45 mmol/L.

 Most phosphorous (80%) can be found in the bones. Phosphorous is the major anion in the
ICF, and its concentration inside cells is much higher than in the ECF.

 Phosphorous is needed for the following actions:

a. Activating B-complex vitamins
b. Forming and activating adenosine triphosphate (ATP)
c. Assisting in cell division
d. Cooperating in carbohydrate metabolism
e. Cooperating in protein metabolism
f. Cooperating in lipid (fat) metabolism

 Other phosphorous functions include acid-base buffering and calcium homeostasis.

Phosphorous balance and calcium balance are intertwined.
 
Food Sources: Cooked oats, eggs, codfish, Tuna fish (white, canned), raisins, white/whole-
wheat bread, cheddar/American cheese, whole/skim milk, low-fat yogurt, beef, beef liver, fresh
pork, chicken, almonds and peanuts.

5. Magnesium (Mg2+) is a mineral that forms a cation when dissolved in water. Adults have an
average total body level of 25 g of magnesium, most of which (60%) is stored in bones and
cartilage. Little magnesium is present in the ECF.
Plasma levels of free magnesium range from 1.3 to 2.1 mg/dL, or 0.65 to 1.05 mmol/L.

 Magnesium is critical for the following intracellular reactions or activities:

a. Skeletal muscle function
b. Carbohydrate metabolism
c. Adenosine triphosphate (ATP) formation
d. B-complex vitamin activation
e. Deoxyribonucleic acid (DNA) synthesis
f. Protein synthesis

 Extracellular magnesium regulates blood coagulation and skeletal muscle contractility.

 The daily magnesium requirement for adults is about 300 mg.

Food Sources: Cooked oats, tuna fish (white, canned), Raisins, beef, pork, chicken,
whole/skim milk, low-fat yogurt, peanut butter, avocado, broccoli, peas, potato.

6. Chloride (Cl ) – is the major anion of the ECF and works with sodium to maintain ECF
osmotic pressure. Chloride is important in the formation of hydrochloric acid in the stomach. The
normal plasma concentration of chloride ranges from 98 to 106 mEq/L or mmol/L.
Bicarbonate (HCO3 ) is the anion most commonly exchanged with chloride.
Chloride enters the body through dietary intake.

HOMEOSTATIC MECHANISMS:

1. Kidney function – the kidneys normally filter 170 L of plasma every day in the adult,
while excreting only 1.5 L of urine.

Major functions of the kidneys in maintaining normal fluids balance include the ff:
- Regulation of ECF volume and osmolality by selective retention and excretion of body
fluids
 - Regulation of electrolyte levels in the ECF by selective retention of needed substances
and excretion of unneeded substances.
- Regulation of ph of the ECF by retention of hydrogen ions.
- Excretion of metabolic wastes and toxic substances.

2. Heart and Blood Vessel Functions

 The pumping action of the heart circulates blood through the kidneys under sufficient
pressure to allow for urine formation. Failure of this pumping action interferes with renal
perfusion and thus with water and electrolyte regulation.

3. Lung Functions

 The lungs are also vital in maintaining homeostasis. Through exhalation, the lungs
remove approximately 300 ml of water daily in the normal adult.

4. Pituitary Functions

 The hypothalamus manufactures ADH, which is stored in the posterior pituitary gland.
Functions of ADH include maintaining the osmotic pressure of the cells by controlling
the retention and excretion of water by the kidneys and by regulating blood volume.

ADH – promotes water reabsorption from the renal tubules (distal and collecting tubules).

 Factors that stimulates ADH productions:

1. Increased plasma osmolality
2. ECF fluid depletion
3. Pain
4. Stress

5. Adrenal Functions

Aldosterone – a mineralcorticoid secreted by the adrenal cortex, has a profound effect on fluid
balance. Increased secretion of aldosterone causes sodium retention and potassium loss.
Conversely, decreased secretion of aldosterone causes sodium and water loss and potassium
retention

Cortisol – another adrenocortical hormone, when secreted in large quantities it can also produce
sodium and fluid retention.

6. Parathyroid Functions

 The Parathyroid Glands, embedded in the thyroid gland, regulate calcium and
phosphate balance by means of parathyroid hormone. PTH influences bone resorption,
calcium absorption from the intestines, and calcium reabsorption from the renal tubules.

7. Baroreceptors

 The Baroreceptors are small nerve receptors that detect changes in pressure within blood
vessels and transmit this information to CNS. They are responsible for monitoring the
circulating volume.

 Sympathetic stimulation constricts renal arterioles, this increases the release of

aldosterone, increases sodium and water retention, decreases GFR.
 Glomerular Filtration Rate (GFR) – is a test used to check how well the kidneys are working.
Specifically, it estimates how much blood passes through the tiny filters in the kidneys, called
glomeruli, each minute. The GFR test measures how well your kidneys are filtering a waste
called creatinine, which is produced by the muscles. When the kidneys aren’t working as well as
they should, creatinine builds in the blood. Recommended for people with chronic kidney
disease and those at risk for it due to: Diabetes, Family history of kidney disease, Frequent UTI,
High BP and Urinary blockage.

8. Renin – Angiotensin – Aldosterone System

1. When arterial blood flow is decreased to the kidneys, renin is released by the
juxtaglomerular apparatus of the kidney.
 Renin – is a protein (enzyme) released by special kidney cells when you have
decreased salt (sodium levels) or low blood volume.
2. In the blood, renin converts angiotensin to angiotensin 1.
 Angiotensin – is a peptide hormone that causes vasoconstriction and a subsequent
increase in blood pressure.
3. Angiotensin 1 is further converted to angiotensin 2
4. The presence of angiotensin 2 stimulates secretion of aldosterone from the adrenal cortex.
5. This mechanism help maintain a balance of Na and water and a healthy blood volume
and pressure.

9. Antidiuretic Hormone (ADH) and Thirst

 Oral intake is controlled by the thirst center located in the hypothalamus. As

serum concentration or osmolality increases or blood volume decreases, neurons
in the hypothalamus are stimulated by intracellular dehydration, thirst then occurs,
and the person increases his or her oral intake of oral fluids.

 Water excretion is controlled by ADH. The presence or absence of ADH is the

most significant factor in determining whether the urine that is excreted is
concentrated or diluted.

10. Release of Atrial Natriuretic Peptide (ANP)

= Is a cardiac hormone. It involved in the homeostatic control of body water, sodium,
potassium and fat (adipose tissue). It is released by muscle cells in the upper chambers (atria) of
the heart in response to high blood pressure.

 The action of ANP opposes those of RAAS (Renin – Angiotensin – Aldosterone

System)
 ANP decreases blood pressure and reduces intravascular blood volume.
 Atrial stretching increases the amount of ANP released.

11. Lymphatic System

= Plasma protein and fluid that escapes from the tissue’s spaces cannot be directly
reabsorbed into the blood vessels. The lymphatic system plays an important role in returning
excess fluid and protein from the interstitial spaces to the blood.
ASSESSMENT OF FLUID AND ELECTROLYTE BALANCE

NURSING PROCESS
A. ASSESSMENT
1. HISTORY

 One way of organizing history data to assess the client’s fluid and electrolyte status is to
use Gordon’s Functional Health Patterns. The patterns that most affect fluid and
electrolyte status are the Nutritional-Metabolic Pattern and the Elimination Pattern.

Using Gordon’s Functional Patterns

 Nutritional-Metabolic Pattern
= What is your typical daily food intake? Describe a day’s meals, snacks, and vitamins.
= How much salt do you typically add to your food? Do you use salt substitutes?
= How is your appetite?
= Do you have any difficulty chewing or swallowing?
= What is typical daily fluid intake? What types of fluids (water, juices, soft drinks,
coffee, tea)? How much?
= Have you had any recent change in your weight? Weight gain? Weight loss? How
much?
= Have you noticed a change in tightness of your rings or shoes? Tighter? Looser?

 Elimination Patterns
= What is your usual bowel elimination pattern? Frequency? Character? Discomfort?
Laxatives?
= What is your usual urinary elimination pattern? Frequency? Amount? Color? Odor?
Control?
= Have you noticed a change in the amount of urine?
= Do you have any problem with excessive perspiration?
= Do you have any other type of drainage?

 The guidelines for obtaining a thorough fluid and electrolyte history do not differ from
those for assessing any other system; however, the information collected is more specific.
For example: Exact intake and output volumes are important, as are serial daily weight
measurements.  Guide the client in reporting accurately the amount of fluid ingested
and changes in urine patterns.
= Also assess the types of fluids and foods ingested to determine the amount and
osmolality. Many clients do not know that solid foods contain liquid. Solid foods such as
ice cream, gelatine, and ices are liquids at body temperature, and these must be included
when calculating fluid intake.

 Output includes losses not only as urine but also as sweat, diarrhea, and insensible loss
during fevers. Ask specific questions about prescribed and over-the-counter drugs and
check the dosage, the length of time taken, and the client’s adherence with the drug
regimen.

 Other important areas of the client history include: Body weight changes, thirst or
excessive drinking, exposure to hot environments, and the presence of other disorders,
such as kidney or endocrine diseases (ex. Cushing’s disease, Addison’s disease, diabetes
Mellitus, and diabetes insipidus).  Address the client’s level of consciousness and
mental status, because changes in mental status occur with fluid imbalance.
= In such cases, you may need to check the accuracy of information with family
members.
 2. PHYSICAL ASSESSMENT

 Hydration is the state of fluid balance.

= A normally hydrated adult is alert, has moist eyes and mucous membranes, has a urine
output nearly the same as the amount of fluid ingested (with a urine specific gravity of
about 1.015), and good skin turgor.
 Assess skin turgor
= Decreased turgor, a sign of dehydration, is present when the fold remains in a
pinched shape after being released and rebounds slowly (tenting).
= Skin turgor is best assessed in body areas that have little fat tissue (sternum, on
the forehead, or on the back of the hand.)
= An older person has poor skin turgor on the hands and feet because of loss of
tissue elasticity related to aging
= The best areas for assessing turgor in the older adult are over the sternum and
on the forehead.

 Skin hydration assessment also includes an examination for dryness.  The

mucous membranes and the conjunctiva are normally moist.

 Assessment of fluid balance always includes: An assessment of the eyes, nose,

and oral mucous membranes.
= A dry, sticky, “cottony” mouth; absence of tearing; weight loss; and decreased
urine output  all indicate deficient fluid volume.

 Accurate measurement of fluid intake and output is needed to assess fluid and
electrolyte status. Use volumetric devices to accurately measure actual fluid
intake and output.
Vital Signs:
 Pulse – bounding; rapid; weak thread; weak irregular, rapid pulse; weak irregular, slow
pulse.

 BP – hypotension/hypertension

 Respiration – deep, rapid breathing; shallow, slow irregular breathing; shortness of

breath; moist crackles; restricted airway.

 Skeletal muscles – cramping of exercise muscles; carpal spasms (Trousseau’s sign);

flabby muscles, positive Chvostek’s sign (spasm of the facial muscles elicited by tapping
the facial nerve in the region of the parotid gland; seen in tetany).

 Include behavioural and neurological assessment in fluid assessment because fluid

imbalance can change neurologic function.
 In hypertonic state, neuron shrinkage may induce serious nervous system
excitability and hyperactivity, and convulsions may occur.
 Another variable to assess is the degree of thirst, but this may be difficult to
gauge in a confused older client.
 Estimate insensible water loss (ex. Sweat) in every client.
 Consider possible fluid loss from other routes, including the following:
a. Fluid losses from wounds
b. Gastric or intestinal drainage
c. Blood loss from hemorrhage
d. Drainage of body secretions, such as bile, and pancreatic juices through
fistulas
  Electrolyte assessment includes: A complete neuromuscular assessment of muscle tone
and strength, movement, coordination, and tremors.

 Assessment of other systems, including: The cardiac system (heart rate, the strength of
contractions, and the presence of dysrhythmias) and gastrointestinal system (peristalsis)
 may indicate changes of excitable membrane function.

 Assessment must also focus on changes from previous findings including: Mental status,
physical examination data, and laboratory data.

3. PSYCHOLOGICAL ASSESSMENT

 Psychological assessment includes both psychological and cultural factors that

might influence balance.
 Depressed client may refuse fluids or drink adequate fluids.
 Clients with bulimia or anorexia nervosa (eating disorders) may abuse laxatives or
may induce vomiting, causing fluid and electrolyte imbalances.

 Also assess social practices. For example: Alcohol or drug abuse may cause
fluid or electrolyte imbalance.

4. DIAGNOSTIC ASSESSMENT

 Laboratory
 Serum electrolytes

 Other laboratory values are helpful in assessing fluid and electrolyte

status includes: Blood Urea Nitrogen (BUN), Blood glucose level,
Creatinine level, pH, Bicarbonate level, Osmolality, Hemoglobin, and
Hematocrit.

 Urine test results may be helpful in assessing fluid status.

 If a laboratory report is unavailable, you can perform some test using a

dipstick to help determine fluid and electrolyte status, including detecting
substances normally not present in the urine, such as glucose, acetone,
protein and blood.

 Urine pH and specific gravity also can be determined in this way.

B. ANALYSIS:

COMMON NURSING DIAGNOSES:

1. Deficient Fluid Volume related to insufficient fluid intake, diarrhea, hemorrhage or third-
space fluid loss such as ascitis or burns
2. Excess Fluid Volume related to fluid retention secondary to heart, renal, or liver failure or
excess consumption
3. Impaired Oral Mucous Membrane
4. Risk for Injury
5. Risk for Activity Intolerance
6. Risk for Decreased Cardiac Output
7. Risk for Impaired Skin Integrity
8. Imbalanced Nutrition: Less than Body Requirements related to Insufficient Intake of
foods rich in potassium
 C. PLANNING

1. Planning for Health Promotion

 Preventing fluid and electrolyte loss
 Planning for client hydration
 Reducing the risk for injury

2. Planning for Health Restoration and Maintenance

 Fluid and electrolyte replacement
 Oral and intravenous fluid and electrolyte management

3. NURSING PROCESS WITH FLUID AND ELECTROLTE

IMBALANCES

1. FLUID IMBALANCES

A. FLUID VOLUME DEFICIT (FVD), or Hypovolemia

 Occurs when loss of ECF volume exceeds the intake of fluid. It occurs when water and
electrolytes are lost in the same proportion as they exist in normal body fluids, so that the
ratio of serum electrolytes to water remains the same.
 FVD (Hypovolemia) should not be confused with dehydration, which
refers to loss of water alone, with increased serum sodium levels.
 FVD may occur alone or in combination with other imbalances, serum
electrolyte concentrations remain essentially unchanged.

PATHOPHYSIOLOGY:

 FVD results from loss of body fluids and occur more rapidly when coupled with
decreased fluid intake.
 FVD can also develop with a prolonged period of inadequate intake.

Causes of FVD include:

a. Abnormal fluid losses such as those resulting from vomiting, diarrhea, GI suctioning and
sweating.
b. Decreased intake as in nausea or lack of access to fluids.
c. Third-space fluid shifts or the movement of fluid from the vascular system to other body
spaces. Ex: with edema formation in burns, ascitis with liver dysfunction.

Additional Causes include:

a. Diabetes Insipidus – is a condition characterized by excessive thirst and excretion of
large amounts of severely diluted urine caused by deficiency of ADH.
b. Adrenal Insufficiency – is a condition in which the adrenal glands do not produce
adequate amounts of steroid hormones primarily cortisol but may also include impaired
production of aldosterone which regulates sodium conservation, potassium secretion and
water retention.
c. Osmotic Diuresis – is increased urination caused by the presence of certain substances in
the small tubes of the kidneys.
d. Hemorrhage
e. Coma
Clinical Manifestations:
 FVD can develop rapidly, and its severity depends on the degree of fluid loss.
a. Acute weight loss
b. Decreased skin turgor
c. Oliguria (<30cc/hr)
d. Concentrated urine
e. Orthostatic hypotension due to volume depletion
f. A weak, rapid heart rate
g. Flattened neck veins in supine position
h. Increased temperature
i. Thirst
j. Decreased or delayed capillary refill
k. Decreased CVP
l. Cool, clammy, pale skin related to peripheral vasoconstriction
m. Anorexia
n. Nausea
o. Lassitude (exhausted, fatigue)
p. Muscle weakness
q. Cramps

Assessment and Diagnostic Findings:

 Laboratory data useful in evaluating fluid volume status include BUN and its relation to
serum creatinine concentration.
 Elevated BUN because of dehydration or decreased renal perfusion and
function
 Hematocrit level is greater than normal because there is a decreased plasma
volume.
 Serum electrolyte changes  Potassium and sodium levels can be reduced
(hypokalemia, hyponatremia) or elevated (hyperkalemia, hypernatremia).
 Hypokalemia occurs with GI and renal losses.
 Hyperkalemia occurs with adrenal insufficiency.
 Hyponatremia occurs with increased thirst and ADH release.
 Hypernatremia results from increased insensible losses and diabetes
insipidus.
 Urine specific gravity is increased in relation to the kidneys’ attempt to
conserve water and is decreased with diabetes insipidus.
 Urine osmolality can be greater than 450 mOsm/kg because the kidneys try to
compensate by conserving water.

Medical Management:

 the primary health care provider considers the maintenance requirements of the patient
and other factors (ex. Fever) that can influence fluid needs.
 If the deficit is not severe  oral route is preferred, provided the patient can
drink.
 However, if the fluid losses are acute or severe  the IV route is required.
 Isotonic electrolyte solution (ex. Lactated Ringer’s solution, 0.9%
sodium chloride) – are frequently used to treat the hypotensive
patient with FVD because they expand plasma volume.
 As soon as the patient is normotensive  a hypotonic electrolyte
solution (ex. 0.45% sodium chloride) is often used to provide both
electrolyte and water for renal excretion of metabolic waste.

 Accurate and frequent assessment of I&O, weight, vital signs, CVP, LOC, breath sounds,
and skin color should be performed to determine when the therapy should be slowed to
avoid volume overload.
  The rate of fluid administration is based on severity of loss and patient’s hemodynamic
response to volume replacement.

 If the patient with severe FVD is not excreting enough urine and is therefore oliguric 
determine whether the depressed renal function is caused by reduced renal blood flow
secondary to FVD (prerenal azotemia – an excess of urea or other nitrogenous wastes
in the blood as a result of kidney insufficiency) or, more seriously, by acute tubular
necrosis from prolonged FVD  Fluid challenge test.
 During a fluid challenge test – volumes of fluids are administered at specific
rates and intervals while the patient’s hemodynamic response to this
treatment (Ex: vital signs, breath sounds, sensorium, CVP, urine output).
 Example: A typical fluid challenge involves administering 100 to 200 ml of
normal saline solution over 15 minutes.
 Goal: To provide fluids rapidly enough to attain adequate tissue
perfusion without compromising the cardiovascular system  the
response of patient with FVD but with normal renal function 
increased urine output and increased blood pressure and CVP.
Nursing Management:

 To assess for FVD, the nurse monitors and measures fluid I&O at least Q8 hours, and
sometimes, hourly.
 As FVD develops, body losses exceed fluid intake through excessive urination
(polyurea), diarrhea, vomiting or other mechanisms.
 Once FVD has developed, the kidneys attempt to conserve body fluids  leading
to a urine output <30 ml/h in an adult.

 Monitor body weights daily; an acute loss of 0.5 kg (1 lb) represents a fluid loss of
approximately 500 ml. (1 liter of fluid weighs approximately 1 kg, or 2.2 lbs).

 Vital signs are closely monitored. The nurse observes for a weak, rapid pulse and
orthostatic hypotension (ex. A decrease in systolic pressure exceeding 15 mm Hg when
patient moves from a lying to a sitting position)
 A decrease in body temperature often accompanies FVD, unless there is a
concurrent infection.

 Skin and tongue turgor are monitored on a regular basis.

 In a person with severe FVD, the skin remains elevated for many seconds. Tissue
turgor is best measured by pinching the skin over the sternum, inner aspects of the
thigh or forehead.
 Tongue turgor – In a normal person, the tongue has one longitudinal furrow but in
persons with FVD, there are additional longitudinal furrows and the tongue is
smaller because of fluid loss.

 Assess the degree of oral mucous membrane moisture  a dry mouth may indicate either
FVD or mouth breathing.

 Monitor urine concentration by measuring the urine specific gravity.

 In a volume-depleted patient, the urine specific gravity should be greater than
1.020  indicating healthy renal conservation of fluid.

 Monitor mental functioning  it is eventually affected in severe FVD as a result of

decreasing cerebral perfusion  that can result in cold extremities.
 In patients with relatively normal cardiopulmonary function  low CVP 
indicative of hypovolemia.
 Patients with cardiopulmonary decompensation  require more extensive
hemodynamic monitoring of pressure in both sides of the heart to determine if
hypovolemia exists.
Preventing Hypovolemia
 To prevent FVD, the nurse identifies patients at risk and takes measures to minimize fluid
losses.
Example: If the patient has diarrhea, measures should be implemented to control
diarrhea and replacement fluids administered.
 Includes administering antidiarrheal medications and small volumes of oral fluids
at frequent intervals.

Correcting Hypovolemia
 When possible, oral fluids are administered to help correct FVD, with consideration
given to the patient’s likes and dislikes.
 If the patient is reluctant to drink because of oral discomfort, the nurse assists
with frequent mouth care and provided nonirritating fluids.
 Offer small volumes of oral rehydration solutions (Ex: Rehydratyte, Elete,
Cytomax)  these solutions provide fluid, glucose, and electrolytes in
concentrations that are easily absorbed.
 If nausea is present – antiemetic may be needed before oral fluid replacement can be
tolerated.

 If the deficit cannot be corrected by oral fluids, therapy – may need to be initiated by an
alternative route  enteral or parenteral until adequate circulating volume and renal
perfusion are achieved.
 Isotonic fluids are prescribed to increase ECF volume.

B. FLUID VOLUME EXCESS (FVE), or Hypervolemia

 Refers to an isotonic expansion of ECF caused by the abnormal retention of water and
sodium in approximately the same proportions in which they normally exist in the ECF.

 It is always secondary to an increase in the total body sodium content in which in turn 
leads to an increase in total body water but the serum sodium concentration remains
essentially normal because there is isotonic retention in the body.

Pathophysiology:

 FVE may be related to simple fluid overload or diminished function of the homeostatic
mechanisms responsible for regulating fluid balance.

 Contributing Factors include:

 Heart failure
 Renal failure
 Cirrhosis of the liver

 Another Contributing Factor:

 Consumption of excessive amounts of table or other sodium salts; Excessive
administration of sodium-containing fluids in a patient with impaired regulatory
mechanisms  predisposes him or her to a serious FVE.
Clinical Manifestations:

 Clinical manifestations of FVE result from expansion of the ECF and include:

Respiratory:
 Constant, irritating cough; dyspnea; crackles in lungs; cyanosis.

Cardiovascular:
 Neck vein engorgement in semi-fowler’s position; hand vein engorgement; bounding
pulse, elevated blood pressure; S3 gallop; pitting edema of the lower extremities; sacral
edema; weight gain
Neurologic:
 Change in level of consciousness.

Assessment and Diagnostic Findings:

 Laboratory data useful in diagnosing FVE include:

 BUN
 Hematocrit
 In FVE, both of these values may decrease because of plasma
dilution.
 Other causes of abnormalities in these values include: low protein
intake and anemia.
 In chronic renal failure – both serum osmolality and the sodium level are
decreased due to excessive retention of water.
 Increased urine sodium level – the kidneys are attempting to excrete excess
volume.
 Chest x-ray – may reveal pulmonary congestion.

 Hypervolemia occurs when aldosterone is chronically stimulated (ex: cirrhosis, heart

failure and nephritic syndrome) but the urine sodium level does not increase in these
conditions.

Medical Management:

 Management of FVE is directed at the causes, and if related to excessive administration

of sodium-containing fluids, discontinuing the infusion may be all is needed.

 Symptomatic treatment consists of administering diuretics and restricting fluids and

sodium.

1. Pharmacologic Therapy
 Diuretics are prescribed when dietary restriction of sodium alone is insufficient
to reduce edema by inhibiting the reabsorption of sodium and water by the
kidneys.
 The choice of diuretic is based on the:
 Severity of the hypervolemic state
 The degree of impairment of renal function and
 The potency of the diuretic.
a. Thiazide diuretics – block sodium reabsorption in the distal tubule, where only 5% to
10% of filtered sodium is absorbed.
b. Loop diuretics – such as furosemide (Lasix), bumetamide (Bumex), or torsemide
(Demadex), can cause a greater loss of both sodium and water because they block sodium
reabsorption in the ascending limb of the loop of Henle, where 20% to 30% of filtered
sodium is normally reabsorbed.
  Generally, thiazide diuretics such as hydrochlorothiazide (HydroDIURIL) or
metolazone (Mykrox, Zarosolyn) are prescribed for mild to moderate
hypervolemia and
 Loop diuretics for severe hypervolemia.

 Electrolyte imbalances may result from the effect of diuretics.

 Hypokalemia can occur with all diuretics except those that work in the last distal
tubule of the nephrons  Potassium supplements can be prescribed to avoid this
complication.
 Hyperkalemia can occur with diuretics that work in the last distal tubule (ex.
Spironolactone [Aldactone]), especially in patients with decreased renal function.
 Hyponatremia occurs with dieresis due to increased release of ADH secondary to
reduction in circulating volume.
 Decreased magnesium levels occur with administration of loop and thiazide
diuretics due to decreased reabsorption and increased excretion of magnesium by
the kidney.
 Azotemia (increased nitrogen levels in the blood) can occur with FVE when urea
and creatinine are not excreted due to decreased perfusion by the kidneys and
decreased excretion of wastes.
 High uric acid levels (hyperuricemia) can also occur from increased reabsorption
and decreased excretion of uric acid by the kidneys.

2. Dialysis

 If renal function is so severely impaired that pharmacologic agents cannot act efficiently,
other modalities are considered to remove sodium and fluid from the body.
 Hemodialysis or peritoneal dialysis – may be used to remove nitrogenous
wastes and control potassium and acid-base balance, and to remove sodium and
fluid.
 Continuous renal replacement therapy may be required.

3. Nutritional Therapy

 Treatment of FVE usually involves dietary restriction of sodium.

 Diet: Low-sodium diet
 Foods high in sodium must be avoided.
 Protein intake may be increased for patients who are malnourished or who
have low serum protein levels in an effort to increase capillary oncotic
pressure and pull fluid out of the tissues into vessels for excretion by the
kidneys.

Nursing Management:

 To assess for FVE:

 The nurse measures I&O at regular intervals to identify excessive fluid retention.
 Weigh patient daily and note for any rapid weight gain.
 An acute weight gain of 2.2 lb (1kg) is equivalent to a gain of
approximately 1 L of fluid.
 Assessed breathe sounds at regular intervals in at-risk patients, particularly if
parenteral fluids are administered.
 Monitor the degree of edema in the most dependent parts of the body, such as the
feet and ankles in ambulatory patients and the sacral region in patients confined in
bed.
 Pitting edema is assessed by pressing a finger into the affected part,
creating a pit or indentation.
 Peripheral edema is monitored by measuring the circumference of the
extremity with a tape marked in millimetres.
1. Preventing Hypervolemia

 Most patients require a sodium-restricted diets and adherence to the prescribed diet is
encouraged.
 Patients are instructed to avoid over-the-counter medications without first checking with
a health care provider, because these substances may contain sodium.
 If fluid retention persists despite adherence to prescribed diet, hidden sources of
sodium, such as the water supply or use of water softeners, should be considered.

2. Detecting and Controlling Hypervolemia

 It is important to detect FVE before the condition becomes severe.

 Interventions include:
 Promoting rest – it favors diuresis of edema fluid. This mechanism is probably
related to diminish venous pooling and subsequent increase in effective
circulating blood volume and renal perfusion.
 Sodium and fluid restriction should be instituted as indicated. Because patient
with FVE require diuretics, the patient’s response to these agents is monitored.
 Monitoring parenteral fluid therapy – the rate of parenteral fluids and the patient’s
response to these fluids are also monitored.
 If dyspnea or orthopnea is present, place patient in a semi-fowler’s position – to
promote lung expansion.
 Turn and repositioned patient at regular intervals because edematous tissue is
more prone to skin breakdown than normal tissue.
 Because conditions predisposing to FVE are likely to be chronic, patients are
taught to monitor their response to therapy by documenting fluid I&O and body
weight changes.

3. Teaching Patients About Edema

 Because edema is a common manifestation of FVE, patients need to recognize its

symptoms and understand its importance.
 The nurse gives special attention to edema when teaching the patient with FVE.
 Edema can be localized (ex. In the ankle, as in rheumatoid arthritis) or
generalized (as in cardiac and renal failure).
 Severe generalized edema is called anasarca.
 A thorough medication history is necessary to identify any medications that could cause
edema, such as nonsteroidal anti-inflammatory drugs (NSAIDs), estrogrens,
corticosteroids, and antihypertensive agents.
 Ascitis is a form of edema in which fluid accumulates in the peritoneal cavity; it results
from nephrotic syndrome, cirrhosis, and some malignant tumors.
 Commonly, the patient reports shortness of breath and a sense of pressure
because of pressure in the diaphragm.
 In addition to treating the cause of edema, other treatments may include:
 Diuretic therapy
 Restriction of fluids and sodium
 Elevation of the extremities
 Application of anti-embolism stockings
 Paracentesis
 Dialysis and Continuous renal replacement therapy (CRRT) in cases of renal
failure or life-threatening fluid volume overload.