Fluids and Electrolytes Balance

A. Body Fluids
1. Adults
a. Women: 50-55% body weight is water
b. Men: 60-70% body weight is water
c. Infant: 75-80% body weight is water
d. Elderly: 47% body weight is water
2. Intracellular: 80% of total body water
3. Extracellular: 20% of total body water
a. Interstitial
b. Intravascular (plasma)
c. Other: cerebrospinal fluid, intraocular fluid, bone water, gastrointestinal secretions

B. Electrolytes (normal values may vary slightly between institutions and laboratories)
1. Extracellular
a. Na+ 135-145 mEq/1
b. Ca++ 8-10mg/dl
c. Cl- 85-115 mEq/1
d. HCO3- 22-29 mEq/1
2. Intracellular
a. K+ 3.5-5.5 mEq/1
b. PO4 2.5-4.5 mg/dl
c. Mg+ 1.3-2.0 mEq/l
3. Electrolytes Functions
a. Promote neuromuscular excitability
b. Maintain fluid volume
c. Distribute water between fluid compartments
d. Regulate acid-base balance

C. Movement of Fluids and Electrolytes

1. Diffusion: molecules move from an area of higher concentration to an area of lower
concentration
2. Osmosis: water moves from an area of lower concentration of particles to an area of
higher concentration
3. Filtration: water and dissolved substances move from an area of greater hydrostatic
pressure to an area of lower hydrostatic pressure.
4. Types of solution
a. Isotonic 0.9% NaCl

1. Same osmolarity as plasma

2. Example: D5W: To replace fluid volume or increase ADH activity
b. Hypertonic 3.0% NaCl
c. Hypotonic 0.45% NaCl
2. Types of pressures
a. Osmotic
b. Hydrostatic

D. Mechanisms of Fluid Balance

1. Kidneys: regulate fluids and electrolytes, secrete renin
2. Lungs: regulate CO 2 levels, water vapor
3. Skin: regulate fluid losses (sweat)
4. Types of solution
a. ADH (antidiuretic hormone)
b. Aldosterone

Assessment of Fluids

a. Daily Weight
b. Skin Turgor
c. Intake and Output
d. Fontanel
e. Orbits of Eyes
f. Urine Specific Gravity

1. Fluid volume deficit: water and electrolytes lost in same proportion (blood and urine become
concentrated)
a. Causes
1. Fever
2. Vomiting
 3. Diarrhea or ostomy losses
4. Increased urine output
5. Increased respirations
6. Use of diuretics
7. Insufficient IV fluid replacement
8. Draining fistulas
9. Third spacing (burns, ascites)

b. Manifestations
1. Weight loss
2. Poor skin turgor
3. Urine: decrease in volume, dark, odorous, increased specific gravity
4. Increased respirations
5. Dry mucous membrane
6. Increased heart rate
7. Increased hematocrit (hemoconcentration)
8. Decreased central venous pressure (CVP)

c. Nursing Interventions
1. Weigh client daily
2. Monitor intake and output
3. Replace fluid-P.O. or IV (Lactated Ringers, 0.9% NS) per order
4. Measure urine specific gravity
5. Correct underlying cause

2. Fluid volume excess

a. Causes
1. Excessive IV fluids
2. Decreased kidney function, congestive heart failure (CHF), cirrhosis
3. Excessive ingestion of table salt

b. Manifestations (same as CHF)

1. Cough, dyspnea, crackles, tachypnea
2. Increased blood pressure, pulse
3. Decreased hematocrit (hemodilution)
4. Headache
5. Weight gain (1 liter of water = 1 kg of weight gain)
6. Increased CVP
7. Flushed skin
8. Late Signs
a. Neck vein distention
b. Tachycardia
c. Pitting edema

c. Nursing Interventions
1. Administer diuretics - furosemide (Lasix) as per order
2. Restrict fluids, monitor intake and output
3. Weigh client daily
4. Provide skin care
5. Use Semi-Fowler's position
6. Maintain low-sodium diet

Regulation of Body pH

1. Normal value is 7.35-7.45

2. Mechanisms regulating pH
a. Chemical buffers: protein molecules, phosphate
b. Lungs: control carbon dioxide levels
c. Kidneys: bicarbonate

Perfusion Incentive

1. Increase in Heart Rate - Tachycardia

2. Increase in Respiration - Tachypnea
3. Decrease in Circulation in Lower extremities - Vasoconstriction
4. Decreased urine output - Oliguria
5. Increased Bone marrow production - Thick Blood

A. Acid-Base Imbalance
1. Metabolic acidosis
a. Definition: Base Bicarbonate Deficit - increase in hydrogen ion concentration
 b. Causes
1. Long-Term Diarrhea
2. Renal failure
3. Systemic infections
4. Diabetic acidosis
5. Starvation, malnutrition, ketogenic (high-fat) diet

c. Manifestations
1. Headache
2. Confusion, stupor
3. Loss of consciousness
4. pH below 7.35
5. HCO3-below 22
6. Tachypnea (increased respirations) or Kussmaul's respirations

d. Nursing Interventions
1. Promote good air exchange
a. Semi-Fowler's Position
b. Incentive Spirometer
c. Coughing and Deep Breathing
2. Monitor K+ level
3. Give sodium bicarbonate, as ordered

2. Metabolic alkalosis
a. Definition: Base Bicarbonate Excess - decrease in hydrogen ion concentration
b. Causes
1. Vomiting (excessive loss of chloride)
2. Gastric suction
3. Alkali ingestion (excessive bicarbonate)
4. Long-term diuretic therapy

c. Manifestations
1. CNS symptoms:
a. confusion
b. irritability
c. agitation
d. coma
2. Shallow Respiration
3. Tetany
4. pH below 7.45
5. HCO3- above 26

d. Nursing Interventions
1. Restore fluid volume
2. Prevent metabolic alkalosis
a. Monitor K+ level
b. Evaluate need for intravenous K+ replacement for clients on gastric
suction
c. Promote intake of K+ rich foods or oral replacement for clients on
long term diuretic therapy

3. Respiratory acidosis
a. Definition: Excess Carbonic Acid - increase in hydrogen ion concentration
b. Causes
1. Acute: respiratory suppression or obstruction due to pulmonary edema,
over-sedation, pneumonia
2. Chronic: chronic airflow limitation (CAL) Or COPD

c. Manifestations
1. Acute
a. Confusion
b. Restlessness
c. Weakness
d. Headache
e. Coma
f. pH below 7.35
g. pCO2 above 45 mm Hg
2. Chronic (These symptoms are classic signs of COPD)
a. pCO2 above 45 mm Hg
b. Tachypnea
c. Dyspnea
 d. Weight loss

d. Nursing Interventions
1. Administer sodium bicarbonate per order
2. Promote good respiratory exchange
3. Administer bronchodilators per order
4. Monitor arterial blood gases (ABGs)

4. Respiratory alkalosis
a. Definition: carbonic acid deficit; decrease in hydrogen ion concentration
b. Causes
1. Hyperventilation - secondary to pain, anxiety, thyroid toxicosis
2. Decreased O 2 (pneumonia, pulmonary edema)
3. Elevated body temperature
4. Salicylate intoxication

c. Nursing Interventions
1. Have client breathe into paper bag
2. Have client breathe into cupped hands
3. Provide oxygen, if hypoxic

d. Manifestations
1. Unconsciousness
2. Circumoral numbness
3. pCO2 below 35 mm Hg

B. Blood Gases
1. Arterial Blood Gases (ABG)s
a. Most accurate means of assessing respiratory function
b. Must be sterile, anaerobic
c. Drawn into heparinized syringe
d. Keep on ice and transport to lab immediately
e. Document amount of oxygen delivered
f. Document client's body temperature
g. Apply pressure to site for 5-10 minutes
2. Components

pH measure of acidity or alkalinity of blood

N = 7.35-7.45
pCO2 partial pressure of carbon dioxide respiratory parameter influenced by lungs
only
N = 35-45, remember this by taking the seven away from pH
Hypoventilation results in hypercapnia (high CO2)
Hyperventilation results in hypocapnia (low CO2)
pO2 partial pressure of oxygen measure of amount of oxygen delivered to the
lungs
N = 80-100
HCO3- bicarbonate, metabolic parameter influenced only by metabolic factors
N = 22-26

Respiratory & Metabolic Acidosis vs. Alkalosis

R - Respiratory
O - Opposite
High pH and Low in pCO2 = Alkalosis
Low in pH and High in pCO2 = Acidosis
M - Metabolic
E - -Equal
High in pH and High in HCO3 = Alkalosis
Low in pH and Low in HCO3 = Acidosis
 TABLE 1-2. ACIDOSIS/ALKALOSIS
pH pCO2 HCO3-
Respiratory Acidosis low high Normal or
high
Respiratory Alkalosis high low Normal or low
Metabolic Acidosis low low low
Metabolic Alkalosis high high high
RESPIRATORY RESPIRATORY
ACIDOSIS ALKALOSIS
pH 7.32pH 7.48
pCO2 48 pCO2 33
HCO3- 20 HCO3- 28
pO2 90 pO2 90
METABOLIC METABOLIC ALKALOSIS
ACIDOSIS
pH 7.32pH 7.48
pCO2 30 pCO2 38
HCCV 20 HCO3- 28
pO2 90 pO2 90

I.V. Safety Issues

a. Make sure pump is correct

b. Make sure it’s the correct solution at the correct rate
c. Make sure that the patient’s system are working

POINTS TO REMEMBER:

1. Clients with low sodium will present with acute on set of confusion.
2. Never give K+ to a client who is not voiding: no "P," no "K"
3. When a client has a high calcium level, phosphorus levels will be low and vice versa; works like a
see-saw