Care of Clients with Problems in
LP1 | INTRODUCTION TO FLUID, ELECTROLYTES, AND
ACID BASE IMBALANCES
Rheajane A. Roselas, D.M., R.N.
Transcribers: Calley, Christine O.
Fluid Imbalances
A. Fluid Volume Deficit
 Dehydration in which the body’s fluid intake is not sufficient to
meet the body’s fluid needs.
o Types of Fluid Deficits
1. Isotonic Fluid Deficit (FVD)
 Body loses both water and electrolytes from
the ECF in similar proportions
 Fluid is initially lost from the intravascular
compartment, so it is often called
hypovolemia
 Results in decreased circulating blood
volume and inadequate tissue perfusion
2. Hypertonic Dehydration
 Water loss exceeds electrolyte loss
 Results from alterations in concentrations of
specific plasma electrolytes
 Fluid moves from intracellular compartment
into the plasma and interstitial fluid spaces,
causing cellular dehydration and shrinkage
3. Hypotonic Dehydration
 Electrolyte loss exceeds water loss
 Result from fluid shifts between
compartments, causing a decrease in plasma
volume
 Fluid moves from the plasma and interstitial
fluid space into the cells, causing a plasma
volume deficit and causing the cell to swell
o Causes for the Types of Fluid Deficits
1. Isotonic Fluid Deficit
 Inadequate intake of fluids and solutes
 Fluid shifts between compartments
 Excessive loss of isotonic body fluids
2. Hypertonic Dehydration
 Conditions that increases fluid loss, such as
excessive perspiration, hyperventilation,
ketoacidosis, prolonged fever, diarrhea,
early stage renal failure, and diabetes
insipidus
3. Hypotonic Dehydration
 Chronic illness
 Excessive fluid replacement
 Renal failure
 Chronic malnutrition
o Third space syndrome
 Large quantities of fluid from the intravascular
compartment shift into the interstitial space;
inaccessible to the body
 May be caused by lowered plasma proteins,
increased capillary permeability & lymphatic
blockage
 Can be seen with trauma, inflammation, disease
 Fluid remains in the body but is essentially
unavailable for use
 Client with TSS has an isotonic fluid deficit but may
not manifest apparent fluids or weight loss
1. Nursing Assessment, Management and Interventions for
Fluid Volume Deficit
o Nursing Assessment - Signs and Symptoms
 Dry mucous membranes
 Weight loss
Mild Deficit 2%
Moderate Deficit 5%
Severe Deficit 8%
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Oxygenation, Fluid and Electrolytes,
Infectious, Inflammatory and
Immunologic Response, Cellular
Aberrations (Acute and Chronic)
 Orthostatic hypotension and increase in pulse rate
a form of low blood pressure that happens when
standing after sitting or lying down
 Body temperature usually subnormal
 Flat neck veins and decrease in CVP central venous
pressure
 Decreased urinary output and altered sensorium
 Hypotonic Dehydration
- skeletal muscle weakness
 Hypertonic Dehydration
- hyperactive deep tendon reflexes
- increased sensation of thirst
- pitting edema
GRADING EDEMA
2mm depression, barely detectable.
1+
Immediate rebound.
4mm deep pit.
2+
A few seconds to rebound.
6mm deep pit.
3+
10-12 seconds to rebound.
8mm very deep pit
4+
>20 seconds to rebound
o Goal of Treatment
 To restore fluid volume, replace electrolytes as
needed, and eliminate the cause of the FVD
o Nursing Management
 Measure all fluids that enter and leave the body
– I&Os
 Check electrolytes, CBC, and urine-specific gravity
– Laboratory values
 Assess for hypotension and weak pulses
– Cardio-vascular
 Assess respiratory system and tissue perfusion
– Respiratory
 Check orientation, vision, hearing, reflexes, and
muscle strength
– Assess
 Check for weight changes
– Daily weights
 Check for skin breakdown and good oral care
– Oral and skin care
o Nursing Interventions
 Monitor cardiovascular, respiratory, neuromuscular,
renal, integumentary, and GI status
 Prevent further fluid losses and increase fluid
compartment volumes to normal ranges
 Provide oral rehydration therapy if possible; IV fluid
replacement if the dehydration is severe
 Generally, isotonic dehydration is treated with
isotonic fluid solutions; hypertonic dehydration is
treated with hypotonic solutions; and hypotonic
dehydration is treated with hypertonic fluid solutions
 Administer medications as prescribed to correct the
cause, such as antidiarrheal, antimicrobial,
antiemetic, or antipyretic
 Administer oxygen as prescribed
 Monitor electrolyte values, and prepare to
administer medications to treat an imbalance if
present
B. Excess Fluid Volume
 Fluid intake or fluid retention exceeds the body’s fluid needs.
 Also called OVERHYDRATION or FLUID OVERLOAD.
[NCM 112] LP1 INTRODUCTION TO FLUID, ELECTROLYTES, AND ACID BASE IMBALANCES – Rheajane A. Roselas, D.M., R.N.
o Types of Excess Fluid Volume
1. Isotonic Overhydration
 Known as hypervolemia and results
from excessive fluid in the extracellular
fluid in the extracellular fluid
compartment
 Only the ECF compartment is expanded
and fluid does not shift between the
ECF and IC compartments
 Causes circulatory overload and
interstitial edema; when severe or
when it occurs in a client with poor
cardiac function, CHF Congestive
Heart Failure and pulmonary edema
can result
2. Hypertonic Overhydration
 Occurrence is rare and is caused by an
excessive sodium intake
 Fluid is drawn from the ICF
compartment; the ECF volume expands
and the ICF volume contracts
3. Hypotonic Overhydration
 Known as water intoxication
 Excessive fluid moves into the
intracellular space and all body fluid
compartments expand
 Electrolyte imbalances occur as a result
of dilution
o Causes for the Types of Fluid Deficits
1. Isotonic Overhydration
 Poorly controlled IV therapy
 Kidney failure
 Long Term Corticosteroid Therapy
2. Hypertonic Overhydration
 Excessive sodium ingestion
 Rapid infusion of hypertonic saline
 Excessive sodium bicarbonate therapy
3. Hypotonic Overhydration
 Early renal failure
 Congestive heart failure
 SIADH Syndrome of Inappropriate
Antidiuretic Hormone
 Replacement of isotonic fluid loss with
hypotonic fluids
 Poorly controlled IV therapy
 Irrigation of wounds and body cavities
with hypotonic solution
1. Nursing Assessment, Management and Interventions for
Fluid Volume Deficit
o Nursing Assessment
 Neurologic
- Changes in LOC level of consciousness
- Confusion
- Headache
- Seizures
- Skeletal muscle weakness
- Paresthesia, pins and needles sensation
 Cardiovascular
- Bounding pulse, increased PR
- Full peripheral pulses
- High blood pressure, obvious jugular vein
distention
- Elevated BP, decreased pulse pressure
- Elevated central venous pressure
- Engorged venous and varicosities
- Presence of S3
- Tachycardia
 Respiratory
- Pulmonary congestion
- Increased RR
- Shallow respirations
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- Dyspnea
- Moist crackles on auscultation
 Integumentary
- Pitting edema in dependent areas
- Skin pale and cool to touch
 Gastrointestinal
- Increased motility
1. Isotonic Overhydration
- Liver enlargement
- Ascites
2. Hypotonic Overhydration
- Polyuria body makes more pee than normal
- Diarrhea
- Nonpitting edema
- Dysrhythmias abnormal or irregular heartbeat
- Projectile vomiting vomit forcefully that the
vomit lands several feet away from the person
o Nursing Care
 Monitor cardiovascular, respiratory,
neuromuscular, integumentary, gastrointestinal
status
 Prevent further fluid overload and restore normal
fluid balance
 Administer diuretics; osmotic diuretics are
typically prescribed first to prevent severe
electrolyte imbalances
osmotic diuretic – inhibits reabsorption of water
and sodium
 Restrict fluid and sodium intake
 Monitor I&O and weight
 Monitor electrolyte values and prepare to
administer medication to treat an imbalance if
present
Fluid and Electrolyte Balance
o Definition of Terms
Fluid – body fluids contain water and electrolytes
Water – the main component of blood which delivers O2,
nutrients, hormones
Electrolytes – minerals in your body have an electric
charge, in blood, urine and body fluids
Solvent – substance dissolved
Solvent – solution in which the solute is dissolved
Selectively Permeable Membranes – found throughout
body cell membranes & capillary walls; allow
water and some solutes to pass through them
freely
A. Methods of Fluid & Electrolyte Movement
o Diffusion
 Process by which a solute in solution moves
 Involves gas or substance
 Movement of particles in a solution
 Molecules move from area of higher concentration
to an area of lower concentration
 Evenly distributes the solute in the solution
 Passive transport & requires no energy
o Facilitated Diffusion
 Involves carrier system that moves substance
across a membrane faster than it would with simple
diffusion
 Substance can only move from area of higher
concentration to one of lower concentration
 Example is movement of glucose with assistance
of insulin across cell membrane into cell
o Osmosis
 Movement of the solvent or water across a
membrane
 Involves solution or water
 Equalizes the concentration of ions on each side of
membrane
 Movement of solvent molecules across a
membrane to an area where there is a higher
concentration of solute that cannot pass through the
membrane
 Low concentration | Semipermeable membrane |
Higher concentration
o Osmotic Pressure
 Pull that draws solvent through the membrane to
the more concentrated side
[NCM 112] LP1 INTRODUCTION TO FLUID, ELECTROLYTES, AND ACID BASE IMBALANCES – Rheajane A. Roselas, D.M., R.N.
 Amt. determined by relative number of particles of
solute on side of greater concentration
 Proportional to number of particles per unit volume
solvent
o Osmolality
 Measure of solution’s ability to create osmotic
pressure and thus affect movement of water
 Number of osmotically active particles of water
 Plasma osmolality is 200-300 mOsm/kg
 ECF osmolality is determined by sodium
 MEASURE used in clinical practice to evaluate serum
& urine
o Osmolality in Clinical Practice
 Serum 280-300mOsm/kg; Urine 50-1400mOsm/kg
 Serum osmolality can be estimated by doubling
serum sodium
 Urine specific gravity measures the kidneys’ ability to
excrete or conserve water
 Normal range 1.010 to 1.025 (compared to weight of
distilled water with sp g of 1.000)
o Filtration
 Movement of fluid through a selectively permeable
membrane from an area of higher hydrostatic
pressure to an area of lower hydrostatic pressure
 Arterial end of capillary has hydrostatic pressure >
than osmotic pressure so fluid & diffusible solutes
move out of capillary
o Hydrostatic Pressure
 Force of the fluid pressing outward against vessel wall
 With blood not only refers to weight of fluid against
capillary wall but to force with which blood is
propelled with heartbeat
 “Fluid- pushing pressure inside a capillary”
o Kidney Function
 The kidneys perform the essential function of
removing waste products from the blood and
regulating the water fluid levels
1. Fluids
 It transport gases, nutrients and wastes
 Help generate the electrical activity needed to power
body function
 Take part in the transforming of food into energy and
other wise maintain overall function of the body
o Body Fluids
 60% body weight in typical adult
 Water is largest single component
 Dec. to 45-50% body weight in elderly
 Variations occur based on age, gender and amount of
body fat
 70-80% in neonate is water
o Major Compartments for Fluids
 Intracellular Fluid (ICF)
- Inside cell
- Most of body fluid here – 40% weight
- Decreased in elderly
 Extracellular Fluid (ECF)
- Outside cell
 Intravascular fluid – within blood vessels
(5%)
 Interstitial fluid – between cells & blood
vessels – (15%)
 Transcellular fluid – cerebrospinal,
pericardial, synovial
o Routes of Gains and Loses
 Kidneys
 Skin
 Lungs
 GI Tract
o Water Steady State
 Amount ingested = amount eliminated
AMOUNT INGESTED AMOUNT ELIMINATED
Ingested
1500 Skin
liquids
Lungs through
Water in foods 800
expired air
Water from
300 Feces
oxidation
Kidneys
TOTAL 2600 TOTAL
Table example for Input and Output
2. Homeostatic Mechanisms
KIDNEY HEART &BLOOD VESSELS
 Because of their role in  Failure of this pumping
filtering fluids and waste action interferes with renal
through the body, your perfusion and thus with
kidneys are considered a water and electrolyte
major homeostatic organ of regulation.
your body.
 Contain special cells called
juxtaglomerular cells that
monitor your blood pressure
as blood flows through the
kidneys for filtration.
o Pituitary Functions
 ADH Antidiuretic Hormone
- Made in hypothalamus
- Called water conserving hormone
- Stored in posterior pituitary gland
- Acts on renal collecting tubule to regulate
reabsorption or elimination of water
o Parathyroid Functions
PTH influences bone resorption (a process involving the
breakdown of bone by specialized cells knowns as
osteoclasts, thus releases minerals from the bone to the
stream), calcium absorption from the renal tubules.
o Baroreceptor
 Are small nerve receptors that detect changes in
pressure within blood vessels and transmit this
information to the central nervous system
 A decrease in impulses stimulates the sympathetic
nervous system and inhibits the parasympathetic
nervous system.
 The outcome is increase in cardiac rate,
conduction, and contractility and circulating blood
volume.
 Sympathetic stimulation constricts renal arterioles.
This increases the release of aldosterone,
decrease glomerular filtration, and contractility
and increases Na and water reabsorption.
o Aldosterone
 Produced by adrenal cortex
 Released as part of RAA mechanism
 Acts on renal distal convoluted tubule
 Regulates water reabsorption by increasing sodium
uptake from the tubular fluid into the blood but
potassium is excreted
 Responsible for reabsorption of sodium & water
into the vascular compartment
 (Na reabsorption, Potassium wasting)
o Atrial-Natriuretic Factor
 Action is direct opposite from renin angiotensin
 Released from the cells in the atrium of the heart in
response to increase blood volume and stretching of
the atrial walls.
 Promotes Na wasting
 Acts as diuretic, thus reducing vascular volume
 Inhibits thirst reducing fluid intake
o Thirst Mechanism
 Primary regulator of fluid intake
 Conscious desire for water
 Initiated by the osmoreceptors in hypothalamus
that are stimulated by increase in osmotic
pressure of body fluids to initiate thirst
 Also stimulated by a decrease in the ECF volume
 Only temporary and returns 15 minutes
 Immediately relieved after drinking a small amount of
fluid even if it is absorbed from the GIT.
 The mechanism protects the individual from drinking
too much because it takes 30 mins-1 hour for the fluid
to be absorbed and distributed throughout the body.
600
300
200
1500
2600
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[NCM 112] LP1 INTRODUCTION TO FLUID, ELECTROLYTES, AND ACID BASE IMBALANCES – Rheajane A. Roselas, D.M., R.N.
o Risk Factors that Contribute to Problems in F&E  Is used because it provides a truer reflection of gas
 Acute or chronic Diarrhea exchange in the pulmonary system than venous
 Vomiting blood.
 Uncontrolled diabetes  Because a high pressure is used to obtain blood, it is
 Addison’s disease important to apply pressure to the puncture site
 Heat exhaustion for 5 minutes after the procedure to reduce the
 Elderly people with inadequate diet risk of bleeding or bruising
 Diseases of kidney  Six Measurements are commonly used to Interpret ABG
 Cushing’s syndrome pH measure of the relative acidity or alkalinity of the blood
pressure exerted by oxygen dissolved in the plasma of arterial
 Aldosteronism PaO2
blood; an indirect measure of blood oxygen content
 Certain medications such as Diuretics PaCO2
partial pressure of carbon dioxide in arterial plasma; respiratory
 Loss of body fluids leading to DHN component of acid-base determination
Bicarbonate
 Excessive alcohol consumption HCO3
measure of the metabolic component of acid-base balance
 High fever Base calculated value of bicarbonate levels, also reflective of the
 Hypertension Excess (BE) metabolic component of acid-base balance
Oxygen
3. Physical Examination Saturation percentage of hemoglobin saturated (combined) with oxygen
(SaO2)
o Inspection
 Is the visual examination, that is, assessing by using
the sense of sight. Nurses frequently use visual  Normal ABG Values
pH 7.35 – 7.45
inspection to assess moisture, color, and texture of
PaO2 80 – 100 mm Hg
body surfaces. Observation can be combined with
PaCO2 35 – 45 mm Hg
other techniques. Bicarbonate HCO3 22 – 26 mEq/L
o Skin Turgor Base Excess (BE) -2 to +2 mEq/L
 Skin turgor is the skin's elasticity. It is the ability of skin Oxygen Saturation (SaO2) 95 – 99 %
to change shape and return to normal.
 Skin turgor is a sign of fluid loss (dehydration). o Complete Blood Count (CBC)
Diarrhea or vomiting can cause fluid loss. Infants and  Hematocrit measures the volume (percentage)
young children with these conditions can rapidly lose of whole blood that is composed of RBC’s.
lot of fluid, if they do not take enough water. Fever Because the hematocrit is a measure of the volume
speeds up this process. cells in relation to plasma, it is affected in plasma
 To check for skin turgor, the health care provider volume.
grasps the skin between two fingers so that it is tented  Thus, the hematocrit increases with severe
up. Commonly on the lower arm or abdomen is dehydration and decreases with severe
checked. The skin is held for a few seconds then overhydration.
released.  Normal hematocrit values
 Skin with normal turgor snaps rapidly back to its - Men: 40% – 54%
normal position. Skin with poor turgor takes time to - Women: 37% – 47%
return to its normal position. o Osmolality
o Edema  Serum Osmolality – a measure of the solute
 Technique concentration of the blood. The particles included
 Inspect for visible swelling around eyes in are sodium ions, glucose, and urea blood urea
fingers, and in lower extremities nitrogen, BUN
 Compress the skin over the dorsum of the foot,  Serum osmolality can be estimated by
around the ankles, over the fibia, in the sacral doubling the serum sodium because
area sodium and its associated chloride ions
 Possible abnormal findings are the major determinants of serum
 Skin around eyes in puffy, lids appear swollen; osmolality
rings are tight; shoes leave impressions on feet  Serum osmolality values are used primarily
o Palpation to evaluate fluid balance
 Edema  An increase in serum osmolality indicates
 Ascites fluid volume deficit
 Neck vein filling  A decrease indicates fluid volume excess
 Hand vein filling  Urine Osmolality – a measure of the solute
 Neuromuscular irritability concentration of urine
 Characteristics of pulse  Particles included are nitrogenous wastes,
o Percussion such as creatinine, urea, and uric acid
 Abdomen for presence of air, fluid  Normal values are 500 to 800 mOsm/kg
o Auscultation  An increased urine osmolality indicates FVD
 Auscultate for the presence of rales  An decreased urine osmolality reflects FVE
4. Laboratory Tests o Urine PH
o Serum Electrolytes  Measurement of urine pH may be obtained by lab.
 Are often routinely ordered for any client admitted to Analysis or by using a dipstick on a freshly
hospital as a screening test for electrolyte and acid voided specimen.
base imbalances  Can be useful in determining whether the kidneys
 Normal Electrolyte Values for Adults are responding appropriately to acid-base
Sodium 135-145 mEq/L imbalances
Potassium 3.5-5.0 mEq/L  Normally the pH of the urine is relatively acidic.
Chloride 95-105 mEq/L  In metabolic acidosis, urine pH should decrease
Calcium (total) 4.5-5.5 mEq/L or 8.5-10.5 mg/dL as the kidneys excrete hydrogen ions
Calcium (ionized) 2.5 mEq/L or 4.0-5.0 mg/dL  In metabolic alkalosis, the pH should increase
Magnesium 1.5-2.5 mEq/L or 1.6-2.5 mg/dL
o Urine Specific Gravity
Phosphate (phosphorus) 1.8-2. mEq/L
 Specific gravity is an indicator of urine
Serum osmolality
*normal lab values vary from agency to 280-300 mOsm/kg water concentration that can be performed quickly and
agency easily by nursing personnel.
 Normal specific gravity ranges from 1.005 to 1.030
o Arterial Blood Gases (ABGs) (usually 1.010 to 1.025).
 Are performed to evaluate the client’s acid base  When the concentration of solutes in the urine is
balance and oxygenation. high, the specific gravity rises
 In very dilute urine with few solutes, it is
abnormally low.
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