LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE

Rebecca De Asis, MAN, RN

Description
OUTLINE • ECF fluid that contains colloids, proteins, and is
I. Review of Common Terms related to Fluid,
the liquid part of the blood along with the RBC.
Electrolyte, and Acid-Base
II. Terms related to Fluid and Electrolyte Movement • It maintains blood volume, which makes 5% of
III. Hormones that regulate Fluid and Electrolyte the body water.
Balance
IV. Terms related to Hydrogen Ions ELECTROLYTE
V. Basic Concepts about Body Description
VI. Basic Concepts about Fluid and Electrolyte • A substance when placed in solvent like water
Imbalance breaks up into separately charged particles called
VII. Alterations in Fluid Balance ions.
VIII. Electrolyte Imbalance • Electrolytes contain ions that may be positive or
IX. Acid-Base Imbalance negative electrical charges.
X. Defense Mechanism against Imbalances
XI. Four Major Acid-Base Imbalances ION
XII. Nursing Experiencing Burns Description
Link: • Atom having positive or negative electrical
https://drive.google.com/drive/u/0/folders/182xHZYSv charge.
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Book: CATION
Kozier & Erb's Fundamentals of Nursing: Concepts, Description
Process, and Practice.
• Is positively charged ion like sodium (Na+),
potassium (K+), magnesium (Mg2+), calcium
(Ca2+), hydrogen (H2).
REVIEW OF COMMON TERMS RELATED TO
FLUID, ELECTROLYTE, AND ACID-BASE ANION
Description

BODY WATER • Is negatively charged particles like chloride (Cl-),

Description
phosphate (PO43-), sulfate (SO42-), bicarbonate
(HCO3-).
• The aqueous medium of the body minus the
electrolytes, the major component in the body. COLLOIDS
Description
BODY FLUID
Description
• Macronutrients of protein, that are located within
the plasma.
• Body fluid in which electrolytes are dissolved.
• Colloids maintain the intravascular pressure. A
• e.g. ECF, ICF, Interstitial Fluid
decrease in colloids like albumin would allow
• Other fluids include cerebrospinal, pericardial,
movement of fluids from the intravascular space
pancreatic, pleural, intraocular, biliary, peritoneal,
into the interstitial spaces.
and synovial fluids.
MILLIEQUIVALENT (mEq)
INTRACELLULAR FLUID
Description
Description
• The measure of the combining power of an ion.
• Body fluid located within the cells.
• The capacity of cations to combine with anions to
• 70% of total body weight is normally within the
form molecules.
cells.
• It constitutes approximately two third of the total
body fluids in adults. TERMS RELATED TO FLUID AND
ELECTROLYTE MOVEMENT
EXTRACELLULAR FLUID
Description
• Body fluid located outside the cells. OSMOLALITY
Description
• 30% of the total body weight.
• It accounts for about one third of total body • The total number of dissolved particles/ liter of
fluids. solvent.
• Two main compartments of ECF are intravascular • Osmolality increases when you are
and interstitial. dehydrated and decreases when you have too
much fluid in your blood.
• Other components of ECF include the lymph and
transcellular fluids. • It would decrease because a solvent is a solution
that would dilute the particles that are dissolved
• Example of transcellular fluid include
in it.
cerebrospinal, pericardial, pancreatic, pleural,
intraocular, biliary, peritoneal, and synovial fluids. HYPEROSMOLALITY
Description
INTERSTITIAL FLUID
Description • Decrease in water in relative to solvent.
• Fluid found in between the cells. • Kun hyperomolar, mas damo an imo solute
compared to your water.
• 25% of total body water in the interstitial space.

PLASMA or INTRAVASCULAR FLUID HYPO-OSMOLAR

Description

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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN
• Increase in water relative to solute concentration.
• Kun hypo-osmolar, guruguti an solute kaysa han
water.
ACTIVE TRANSPORT
Description
• An energy requiring process that transport ions
across cell membrane.
• Example of active transport that takes place in the
body is the sodium-potassium pump wherein the
sodium may be transported from one
compartment to another in exchange of
potassium.
BLOOD HYDROSTATIC PRESSURE
Description
• Pressure of the blood within the capillaries.
• It depends on the:
o Level of arterial BP. An increase in
arterial blood pressure will allow
movement of fluids from the intravascular
into the interstitial space.
o Rate of blood flow through the
capillaries
o Venous pressure
COLLOID OSMOTIC PRESSURE
Description
• Also called oncotic pressure.
• There is movement of fluids towards or inside.
• Pressure exerted by the plasma proteins which
hold water within the vessels and draws back
water that escapes from the vessels.
• If there is a decrease in osmotic pressure, fluid
will move into the interstitial space because it
lacks large proteins to hold water within the blood
vessels.
• It also allows to push back water that escapes
from the vessels to maintain the oncotic pressure
within the intravascular space.
FILTRATION PRESSURE
Description
• The net pressure that forces fluid out of vessels.
• For example, in the glomerulus, only small
solutes could pass through the intact membrane
of the glomerulus. Some solutes are filtered and
they could not pass through the membrane.
HORMONES THAT REGULATE FLUID AND
ELECTROLYTE BALANCE
ANTIDIURETIC HORMONE (ADH)
Description
• Hormone released from the posterior pituitary
gland which controls water reabsorption by the
kidneys and regulates fluid osmolality.
• Water is reabsorb by the kidney tubules.
• If ADH is released due to the hyperosmolality of
the fluid, the urine output will decrease.
• Conditions where ADH is stimulated to be release
is when there is low blood pressure or a decrease
in intravascular volume.
• An increase in the osmolality of the intracellular
fluid will stimulate the ADH to be released which
will result to water reabsorption until it would
normalize the osmolality.
• Factors that stimulate ADH release:
o Hyperosmolality of body fluid.
Conditions such as high blood sugar
levels cause hyperosmolality because
the blood is within the extracellular
compartment. Another condition is
hypernatremia or too much sodium in the
intracellular space.
o Reduced circulating blood volume.
ALDOSTERONE
Description
• Hormone secreted by adrenal cortex.
• It increases renal absorption of sodium and
water, thus regulates fluid volume in the ECF.
• Since sodium goes with water, as sodium is
reabsorb, water is also reabsorb.
PARATHYROID HORMONE (PTH)
Description
• Secreted by the parathyroid gland to maintain
serum calcium level.
THYROID HORMONE
Description
• Thyroxine (T4)
• Triiodothyronine (T3)
• Patients who undergone thyroidectomy should be
monitored for signs and symptoms of
hypocalcemia since the parathyroid gland may
have been damaged.
CALCITONIN
Description
• Secreted by the thyroid gland, enhance calcium
shift to the bones.
• If there is increased in serum calcium levels,
calcitonin is released by the thyroid gland to
increase movement or shifting of calcium into the
bones. Calcitonin will then antagonize the effects
of parathormone.
TERMS RELATED TO HYDROGEN IONS
ACID
Description
• A hydrogen ion donor.
• An acid gives ions to a base, thereby neutralizing
the base.
• Hydrogen is an acid. To prevent acidosis, excess
hydrogen ion should be donated and be accepted
by an alkali or base.
BASE
Description
• A hydrogen ion acceptor.
• A base accepts hydrogen ion from an acid,
thereby neutralizing the acid.
• To maintain acid-base balance, they should
accept the excess hydrogen from an acid.
pH
Description
• Signifies the chemical concentration of hydrogen
ion, describes the alkalinity or acidity of a
solution.
• Its normal value is 7.35 to 7.45.
• Below 7.35 is acidic. Above 7.45 is alkali.
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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN
• If there is a decreased in pH, the hydrogen ion
concentration will increase. This is because a
hydrogen ion is acid and blood pH is below 7.35.
• If the blood pH is above 7.45, there is a decrease
in hydrogen ion.
BUFFERS
Description
• Pair of chemicals that donate or accept hydrogen
ions.
• They are buffer system wherein they could
correct acidosis or alkalosis.
BODY WATER: BASIC CONCEPTS
A. VOLUME OF BODY WATER
• The normal human body consists of 47% to 87%
water, varies with age, sex, and individual body
physical characteristics.
• Body water as a percentage of body weight
declines with age.
• Infant’s body is 77% to 80% water.
• Elder adult’s body is 47% water.
• Based on sex, male has greater percentage of
water (60% to 70% of their body weight)
compared to females which has 50 to 54% of
their body weight is water.
• A decrease in regulatory mechanisms may be a
factor as to why elderlies have lower percentage
of body water.
• In both women and older adults, this is due to
lower levels of muscle mass and a greater
percentage of fat tissue. Fat tissue is essentially
free of water, whereas lean tissue contains a
significant amount of water.
• Therefore, water makes up a greater percentage
of a lean individual’s body weight than of an
individual who is obese.
B. DISTRIBUTION OF BODY WATER
• 70% of total body water is located in the
intracellular compartment.
• 30% is distributed in the extracellular
compartment.
• 24% is in the interstitial space.
• 6% is in the intravascular space, as plasma.
C. FUNCTIONS OF WATER
• Provides aqueous medium for cellular
metabolism.
• Acts as solvent for solutes for cell function.
• Transports substances to and from cells.
• Aids in regulation of body temperature and
digestion.
D. FLUID TRANSPORT OR MOVEMENT
1. Osmosis
• The movement of fluid from lower to a higher
concentration.
• e.g. Administration of hypotonic solutions
• Hypotonic solutions have a lower concentration
compared to plasma. If infused in large amounts,
it would allow movement of fluid from the
intravascular into the intracellular compartment
causing the cell to swell. With the administration
of hypotonic solution, it makes the extracellular
fluid hypoosmolar.
• Osmosis occurs in the body when the
concentration of solutes is higher on one side of
a selectively permeable membrane, such as the
capillary membrane, than on the other side.
2. Diffusion
• Movement of solute particles from a higher
concentration to a lower concentration.
• For example, an increase in blood glucose will
make the blood hyperosmolar so glucose should
be transported into the cell with the help of insulin.
• Fluids will diffuse into the semipermeable
membrane of the glomerulus as long as it is intact
and smaller particles could pass through except
the large particles including protein.
• The rate of diffusion of a solute varies according
to the size of the molecules, the concentration of
the solution, and the temperature of the solution.
• Larger molecules move less quickly than smaller
ones,
• Molecules move from a solution of higher
concentration to a solution of lower concentration,
and
• Increases in temperature increase the rate of
motion of molecules and therefore the rate of
diffusion.
3. Hydrostatic Pressure
• There is pressure that is exerted to move fluid
pushing outward against the boundaries.
• Hydrostatic pressure is exerted by the pumping
action of the heart so that blood will be pumped
into the blood vessels.
• The hydrostatic pressure of blood is the force
exerted by blood against blood vessel walls.
4. Filtration Pressure
• Fluid achieve its equilibrium by moving from the
space with higher pressure across a semi-
permeable membrane.
• Smaller electrolytes move along with H2O, larger
solutes remain on the other side of the
membrane.
• Filtration pressure is the difference between the
hydrostatic pressure and the osmotic pressure.
E. BALANCE AND IMBALANCE OF WATER
• Balance of water depends on balance between I
& O at normal environment and at normal activity
of an individual.
• Normally, a person must have balance of intake
and output of 2600 ml/day.
• Average sources of water intake:
o 1200 ml water in beverages
o 1100 ml hidden water in foods
o 300 ml water from oxidation
o 2600 ml/day total
• Average water losses:
o 1500 ml losses from urine output
o 1000 ml from skin and lungs
o 100 ml from GIT or feces
o 2600 ml/day total
• Insensible fluid losses occur through the skin and
the lungs. They are called insensible because it
is usually not noticeable and cannot be measured.
• Insensible fluid loss through the skin occurs in
two ways, diffusion and perspiration.
• Another type of insensible loss is the water in
exhaled air. When respiratory rate accelerates,
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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN
for example, due to exercise or an elevated body
temperature, this loss can increase.
F. NORMAL BODY REQUIREMENT FOR WATER
• Normally, an adult person needs 2600 ml
fluid/day to meet body’s fluid requirements.
• Adults can live 10 days without water, while in
children 5 days, provided weather conditions are
moderate.
G. HOMEOSTATIC REGULATION OF WATER
1. ADH
• Increase water reabsorption.
• ADH is released by the posterior pituitary gland.
As water is reabsorbed in the kidney tubules, it
would result to a decreased osmolality in the
extracellular fluid.
• The main hormone of water regulation is ADH.
2. Kidneys
• Maintain concentration and volume of urine.
• Aldosterone is released in the proximal
convoluted tubules of the kidneys though the
adrenal cortex of the adrenal glands. As sodium
is reabsorbed, water is also reabsorbed, and
potassium is excreted.
• The main hormone that regulates sodium
reabsorption is aldosterone.
3. Thirst Mechanism
• The hypothalamus is activated by an increased in
body fluid osmolality results to increase water
intake.
• The initial response of the body towards the need
of water.
• The main regulator of water intake is the thirst
mechanism.
FLUID AND ELECTROLYTE IMBALANCES:
BASIC CONCEPTS
A. DISORDERS OF FLUID AND ELECTROLYTE
IMBALANCES
• Disorders that can be caused by a deficit or
excess of essential body substances.
• Disorders caused by protein deficiency.
o Kwashiorkor, a severe protein
deficiency, causes fluid retention and a
protruding abdomen.
o Marasmus, which results from severe
calorie deficiency, leads to wasting and
significant fat and muscle loss.
o Cachexia, occurs through increased rate
of skeletal muscle protein breakdown
and a reduction in the rate of muscle
protein synthesis.
o Nephrotic Syndrome, where there is
loss of protein in the urine.
o Liver Dysfunction, in which the liver
fails to synthesize proteins leading to
protein deficiency.
• Fluid shifts to the interstitial and/or fluids shifts
into the plasma.
o Third spacing or movement of body
fluids from the blood into the spaces
between the cells or body cavities that
normally contain little fluid. (e.g. edema,
ascites, pleural effusion)
B. CAUSES OF FLUID AND ELECTROLYTE
IMBALANCES
• Deficiency of F & E due to insufficient dietary
intake.
o Prolonged starvation
o Prolonged dieting
• Increased excretion or loss.
o Diarrhea
o High fever through insensible fluid loss
o Diabetes Mellitus due to polyuria
o Liver Cirrhosis manifested by ascites,
which is related to the increase of
pressure in the portal vein
• Compartmental shifts or electrolytes.
o Ascites where fluid accumulate in
spaces within the abdomen
o Edema due to increase in capillary
permeability which allows movement of
fluid into the interstitial spaces. (i.e.
congestive heart failure, right or left-sided
heart failure)
C. EXCESS OF FLUID AND ELECTROLYTES
• Intake is greater than excretion.
• Decreased excretion due to kidney disease or
impaired homeostatic regulation.
• Sequestration of fluid and/or electrolytes in one
compartment,
• e.g. Ascites, Anasarca or the general swelling of
the whole body seen in patients with ESRD
D. PERSONS SUSCEPTIBLE TO FLUID AND
ELECTROLYTES IMBALANCES
1. Conditions contributing to imbalances
• Vomiting. It contains food particles and the liquid
part of vomitus which is hydrochloric acid. Patient
become at risk for metabolic alkalosis.
• Diarrhea, renal or cardiac disease. Potassium is
loss through diarrhea as well as alkali from the
intestinal secretions. Patient become at risk for
metabolic acidosis.
• Burns.
• Hormonal disorders like DM.
• Cirrhosis of the liver. Normally, if a liver disorder
is present, the liver would inactivate aldosterone.
In cases of liver cirrhosis, liver fails to inactivate
aldosterone resulting in sodium excretion.
• Severe insensible fluid losses and
hyperventilation. This is due to the loss of water
vapor through exhalation.
• Patients who will undergo surgery. This is
because of the blood loss during surgery.
• Patients who needs blood transfusion.
o Patients who are anemic. This can be
corrected through administration of
packed RBCs.
o Patients with bleeding disorders or
hematemesis. This can be corrected
through administration of whole blood.
2. Interventions contributing to imbalances
• IVF therapy
o Isotonic solutions has the same
osmolality as ECF (e.g. normal saline
[NSS], 0.9% sodium chloride, lactated
ringer’s solution [PLR], 5% dextrose in
water [D5W]). Because the IV fluid is
similar to the blood, the fluid stays in the
intravascular space and osmosis does
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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN
not cause fluid movement between
compartments.
o Hypotonic solutions have a lower
osmolality than ECF (e.g. 0.45% sodium
chloride). It causes osmotic movement of
water from the intravascular
compartment into the intracellular space
resulting for the cell to swell.
o Hypertonic solutions have a higher
osmolality than ECF (e.g. 3% sodium
chloride, 5% dextrose in ringer’s lactate
[D5LR]). It causes the osmotic movement
of water out of the cells and into the
intravascular space to dilute the solutes
in the blood resulting for the cell to shrink.
o These solutions are called crystalloids
which are composed of water and small
solutes such as electrolytes and glucose.
• Diuretics
o Osmotic diuretics which increase
urinary flow by osmotic retention of water
throughout the nephron.
▪ Mannitol which is used to
decrease intracranial pressure
and edema.
o Loop diuretics have their effects in the
ascending limb of the loop of Henle.
▪ Furosemide is one of the first-
line therapy for acute relief of
pulmonary and peripheral edema
due to heart failure but are also
used to treat edema associated
with liver cirrhosis, and renal
disease, including nephrotic
syndrome.
o Potassium sparing diuretics increase
nephron reabsorption of potassium by
interrupting sodium reabsorption in the
collecting duct.
▪ Spironolactone is typically used
with a thiazide or loop diuretic to
enhance its action, as
potassium-sparing diuretics
have weak diuretic and
antihypertensive effects when
used alone.
o Thiazide diuretics inhibit sodium
chloride reabsorption in the distal
convoluted tubule.
▪ Hydrochlorothiazide is one of
the first-line agents for the
treatment of hypertension and
are often used together with loop
diuretics for their synergistic
diuretic effects in heart failure.
o Regardless of the age of a person, the
normal urine output is 1ml/kg/hr or at
least 30ml/hr.
o If the environment is warm, there is
lesser urine output because of the
increase in insensible fluid loss. The
more concentrated the urine, the darker
it is in color.
• Dietary management
o Dilute 1ml per kcal of water for
blenderized foods.
• Surgical procedures
o Paracentesis in which ascitic fluid is
drained from the patient’s abdomen
through a hollow needle.
o Lumbar puncture to obtain CSF for
examination.
o Thoracentesis to treat pleural effusion
or presence of fluid in the lungs.
• Medications to treat main causes of imbalances
o Sodium chloride is used to treat
hyponatremia.
o Potassium chloride is used to treat
hypokalemia. If the serum postasium
levels is below 3.5 mmol/L, potassium
chloride will be administered through IV
drip. It comes in a vial or ampule which is
labeled 2 mEq/ml. It is administered as
20 mEq dissolved in 90 cc PNSS via
soluset to run for 1 hour for 3 series. Drop
factor should be 60 ugtts/ml.
o Calcium gluconate is used to manage
hypocalcemia.
o Magnesium sulfate is used to treat
hypomagnesemia.
• Administration of blood transfusion, if condition is
due to blood loss
o If whole blood is use, the patient is at
risk for hyperkalemia because prolonged
administration may result in hemolysis of
RBC which is converted into potassium.
o Some patients may be at risk for
hypocalcemia because of the
preservatives used on the blood bank
which contains citrate. One it is infused,
the albumin or protein in the blood will
die.
ALTERATIONS IN FLUID BALANCE
A. FLUID VOLUME DEFICIT
• Is called hypovolemia, is decreased in fluid
volume or blood volume
• Maybe isotonic, hypotonic, hypertonic
B. FLUID VOLUME EXCESS
• Commonly called hypervolemia, fluid intake
excess loss, or excess adm of hypotonic
solutions, inc ADH released
• Its danger is it may result to CHF
• Maybe isotonic, hypotonic, hypertonic
ISOTONIC VOLUME DEFICIT
Causative Factors
• Due to excessive loss of isotonic body fluids from
vomiting, diarrhea, NGT suctioning
• Losses from the kidneys through diuresis in renal
disease
• Fluid loss through excessive diaphoresis
• Hemorrhage
• Lack of intake of fluids & electrolytes due to
inability to ingest orally
• Shift of fluids into body spaces like in ascites,
edema, fluid is not readily available for exchange
(third space fluid shift)
Assessment Findings
• Acute weight loss (esp.if greater than 5% of total
body weight
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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN
• Changes in cardiac function ( increased HR,
dec.BP, signs of postural hypotension, increased
RR.
• Decreased hydration of the skin & mucous
membrane, dry oral cavity.
• Decreased & concentrated urine output
• Increased Hematocrit
• Sunken eyeballs
• If dehydration is severe, patient may be irritable
Potential Nursing Diagnosis
• Fluid Volume Deficit
• Altered tissue perfusion
• High Risk for Injury
• Ineffective Breathing Pattern
• Decreased Cardiac Output
• Altered Nutrition, less than Body Requirements
• Altered Oral Mucous Membrane
• Fatigue
• Risk for activity intolerance
Interventions
• Medical Interventions:
o IVF replacement with isotonic solutions
o Adm.of BT if deficit is due to blood loss
o Treatment for contributory underlying
cause. (vomiting, diarrhea, blood loss ).
o Removal of third space fluid shift (
paracentesis in ascites, insertion of peri-
cardiac tube if pericardial effusion,
thoracostomy tube ).
o Mobilization of interstitial fluids into the
vascular system with caution.
• Nursing Interventions:
o Assess cardiovascular, respiratory, &
neurologic status.
o Assess skin turgor & condition of oral
mucous membrane.
o Monitor laboratory values.
o Measure & monitor I&O, minimum 30
ml/hr of urine output
o Monitor body weight daily, weight loss of
more than 0.5 lb/d is considered fluid
loss.
o Provide teaching about medication
regimen, prescribed diet, & foods to
avoid.
o Monitor signs of cardiac overloading
during IVF replacement.
Evaluation
• Patient’s v/s are within normal.
• Characteristics of urine output are normal; urine
output is 30 ml/hr
• Breaths sounds clear.
• With good skin turgor.
• Patient is free from injury
• With I&O balance.
HYPOTONIC VOLUME DEFICIT
• There is the loss/decrease solute concentration
with water volume remaining normal
• Due to loss of solutes in the ECF, fluid shifts into
the cell by osmosis.
Causes
• GI fluid losses through diarrhea, vomiting
• Renal loss of electrolytes like in Na wasting
• Iatrogenic fluid replacements with hypotonic
solutions
Clinical Symptoms
• Same with isotonic fluid volume deficit
• Additional symptoms:
o Fatigue
o Weakness
o Muscle cramps
o Postural hypotension
o Confusion if deficit is severe
Medical Interventions
• Same interventions with Isotonic Volume Deficit
• Additional:
o Replacement of electrolyte losses like
Na, potassium, if below normal.
Evaluation
• Same evaluation with isotonic volume deficit
FLUID VOLUME EXCESS
• Fluid volume excess is an increase in water
volume & solute concentration in the ECF.
Causes
• Excessive intake of sodium & water, or through
IVF replacement.
• Iso-osmolar fluid retention due to compromised
regulatory mechanisms
• Use of corticosteroids.
• Chronic Liver Disease
Signs and Symptoms
• Increased BP, HR, RR due to circulatory overload
• Interstitial edema
• Rapid weight gain esp.if more than 5% of total
body weight
• In severe cases, condition not resolve, patient’s
condition may progress into CHF, and pulmonary
edema which makes the condition life
threatening.
• Excretion of diluted urine
• Low serum sodium level
Potential Nursing Diagnosis
• Fluid Volume Excess
• Decreased Cardiac Output If heart fails to
function
• Ineffective Breathing Pattern
• Anxiety
• If fluid will shift into the cells, it will result to
swelling of the brain cells, wherein patient
manifests neurologic symptoms like lethargy,
headache, seizures, irritability, nausea.
Medical Interventions
• Restriction of water intake to a volume less than
urine output
• Increase salt in the diet
• Administration of IVF with sodium. Observe for
rebound effect of sodium administration.
Nursing Interventions
• Nursing interventions are the same with isotonic
fluid volume excess.
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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN

HYPERTONIC VOLUME EXCESS • The intravascular has the same amount of

• An increase in sodium concentration with water electrolytes with that of the interstitial, but the
volume remaining normal. intravascular fluids is the only measurable fluid to
• ICF shifts into ECF determine the serum sodium level of the body
fluid.
Causes
• Excess intake of hypertonic fluids or adm.of Excretion of Electrolytes
hypertonic solutions through IV. • They are lost during excretion of body fluids.
• It is manifested by neurologic symptoms such as • Renal excretion of electrolytes are abnormal with
muscle twitching, possible seizure, with the use of diuretics.
subsequent dehydration of cerebral cells. • GIT excretion of electrolytes occur during
• Hypernatremia, where Na is retained or in excess vomiting, & diarrhea. During vomiting, potassium
from abnormal sources, increase aldosteronism. & HCL acid is excreted.
• In lower GI elimination, hydrogen & potassium
Nursing Diagnosis are lost.
• Fluid Volume Excess • Excessive diaphoresis contributes to Na & Cl
• Impaired neurologic function, lethargy losses.
• Risk for injury • Surgical drains also contribute to electrolyte loss.
• Ineffective Breathing Pattern
Electrolyte Regulation
Interventions 1. Renal Regulation
• Treat underlying cause of the disease. • In the kidneys, electrolytes are balanced by
• Adm of potassium sparing diuretics glomerular filtration, tubular reabsorption, and
• Monitor I & O, v/s, body weight secretion.
• Provision of safety • In the distal & collecting tubules, water is
reabsorbed only in the presence of ADH.
• Electrolyte secretion occurs when an electrolyte
ELECTROLYTES moves from the blood into the tubule.
Description
2. Endocrine Regulation
• These are solutes found in body fluids • The pituitary adrenocorticotropic hormone
• They developed an electrical charges once stimulation enhances adrenal release of
dissolved in water. aldosterone.
• Major Body Electrolytes: • It enhances sodium reabsorption , another
o Sodium positively charged electrolyte- K+ is secreted into
o Potassium the tubules for excretion
o Magnesium 3. GI Regulation
o Calcium • Electrolytes are secreted, absorbed across the
o H+ small intestines same way in the kidneys
o Chloride
o Phosphorous
o Bicarbonate SODIUM:
NORMAL AND ALTERED BALANCE
Sources of Electrolytes
• Normal sources are intake from foods and fluids.
A. NORMAL BALANCE
• Abnormal sources:
• It is the major cation in the ECF
o Medications
• Normal serum Na: 135 to 145 mEq/L
o IVF solutions
• Most Na is found in the ECF where it can be
o Hyperalimentation
measured by serum tests
Functions of Electrolytes • It can be taken from the foods we eat, &
• Maintain osmolality of body fluids; & cellular beverages we drink
osmolality • The normal requirement for an adult individual is
• Regulate acids & bases 2 gms daily
• Aid in neurologic & neuromuscular conduction
Functions
Electrolyte Distribution and Excretion • Facilitate transmission of impulse in nerves &
1. ICF Electrolytes muscle fibers
• Potassium – major intracellular electrolyte • Assist in acid-base balance by combining with
• Phosphorous – the chief or major anion HCO3 & Cl
• Large amount of CHON • It determines the volume & osmolality of the ECF,
• Small amount of magnesium, calcium, S04, & thereby regulates body water
HCO3
Regulation of Sodium to Maintain Balance
• Extremely small amount of sodium & chloride
• The kidneys through filtration, reabsorption in the
2. ECF Electrolytes
presence of ADH
• Sodium – the chief/major cation
• Through endocrine regulation, secretes
• Chloride – the chief anion
aldosterone & ADH
• HCO3
• Small amounts of potassium, calcium, Mg, SO4,
PO4
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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN

B. SODIUM IMBALANCE • Altered nutrition: Less than body requirements

Interventions
b.1. HYPONATREMIA
• Serum sodium level below 135 mEq/L • Identify risk individuals; those receiving
hypertonic solutions, TPN
Causes • Monitor I & O, monitor body weight
• Prolonged use of diuretic therapy ( impairs Na • Monitor v/s
reabsorption in the loop of Henle) • Provide safety
• Excessive burns in which it results to loss of Na • Administer hypotonic solution with caution;
in the ECF, Na leak into the burned areas of the hypotonic Na solutions
body.
• Excessive diaphoresis
• Prolonged vomiting, diarrhea, NGT suction POTASSIUM:
• Renal disease result to Na wasting NORMAL AND ALTERED BALANCE
• Excessive administration of water through IV
route A. NORMAL BALANCE
• SIADH where water is retained results to • Serum level of 3.5 to 5 mEq/L
hyponatremia • Major cation in the ICF
• Sources: fruits, vegetables, chocolates
Clinical Symptoms • Nutritional supplements of k+
• Vomiting, diarrhea, which maybe the cause of • IV infusion of K+
hyponatremia
• Neurologic & musculoskeletal symptoms like Functions
muscle cramps, muscle twitching, headache, • Regulates ECF osmolality by exchanging with
confusion, convulsion coma (due to shifting of Na.
fluid into the cells resulting to swelling of brain • Maintain normal neuromuscular contraction by
cells) participation in Na-K+ pump.
• Maintain muscular activity – with particular
Potential Nursing Diagnosis
sensitivity to cardiac muscle
• Potential for fluid volume excess • Regulate acid-base balance in exchange with
• High risk for injury hydrogen ion.
• Anxiety • It is needed for all metabolic processes ( CHO,
• Impaired physical mobility Glycogen, CHON )
Interventions Regulation of Potassium in the Body
• Early detection of signs & symptoms of • Renal System
hyponatremia by identifying risk patients for • Renin-aldosterone Mechanism
hyponatremia. • Regulated by plasma CHON
• Restrict fluid intake to allow Na & water to
balance naturally. B. POTASSIUM IMBALANCE
• Replace sodium through administration of IVF
solutions with Na. b.1. HYPOKALEMIA
• Monitor I & O • Serum K+ below 3.5 mEq/L
• Monitor v/s, & serum sodium levels.
Causes
b.2. HYPERNATREMIA • Prolonged used of osmotic diuretic like
• Serum level above 145 mEq/L furosemide
• Prolonged vomiting, diarrhea, laxative abuse,
Causes NGT suctioning
• Sodium gain in excess of water from adm of • Renal disease where potassium is not secreted
excessive IVF solutions containing sodium or by the kidney tubules for absorption
tube feedings • Excessive removal during dialysis.
• Excessive intake of sodium in the diet. • Inadequate intake during anorexia & alcoholism
• Water loss in excess like severe diarrhea, burns, • Adm of hypertonic glucose, shift of k+ from ECF
osmotic diuresis to ICF
• Fluid shifts out of the ICF into ECF to balance the • During administration of insulin, where k+ moves
excess ECF Na. into cell with glucose
Clinical Symptoms • During metabolic alkalosis where potassium
• Commonly associated with dehydration moves into the cell in exchange of hydrogen ion.
o Thirst • During hyperaldosteronism, increased Na
o Tachycardia enhances K+ excretion.
o Dry mucous membrane Signs and Symptoms
o Hyperactive reflexes
• Vomiting or diarrhea which may be the actual
o Seizures
cause of the imbalance.
Potential Nursing Diagnosis • Muscle weakness & cramps, hyporeflexia,
• Fluid volume deficit paresthesia, hypotension, cardiac dysrhythmia
• High risk for injury due to decrease muscular contraction

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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN
• Serum level below 3.5 mEq/L, increased bld pH,
elevated blood glucose
• ECG tracing appear inverted flat T-wave.
Potential Nursing Diagnosis
• Decreased cardiac output
• High risk for injury
• Impaired physical mobility
• Activity intolerance
• Risk for cardiac dysrhythmia
Interventions
• Identify high risk patients to prevent hypokalemia.
• Teach patients receiving diuretics to increase
intake of potassium rich-foods.
• Monitor I & O, keeping in mind diuresis increase
k+ loss.
• Caution patients receiving digitalis, digitalis
toxicity may occur along with the use of diuretic
furosemide.
• Replace potassium losses through dietary
interventions.
• Administer oral potassium supplements, note
these drugs are GI irritants, give with water.
• Administer IV solutions with potassium, note kCl
should not be given by IVP or in concentrated
forms. It can result to dysrhythmia
• Monitor v/s,
• Monitor serum potassium level, after IV K+
replacement.
Nursing Considerations in IV infusion of K+
• Concentrated use of potassium should not be
given by direct IVP, make sure to have adequate
solvent to administer by drip.
• Commonly potassium is ordered to dilute 20 mEq
dissolved in 90-100 cc of solvent given in 1 hour
drip for 3 doses depends on the ordered
medication to correct hypokalemia.
• It is recommended that IV cannula should be
inserted in a central vein, because drug is
irritating to the veins.
• Monitor urinary output while patient is given
potassium supplement to ensure excretion of
potassium.
Evaluation
• Serum potassium level is within normal range.
• Patient’s cardiac output is normal.
• Patient is free from injury.
• With balance intake & output.
• Vital signs within normal.
• Patient’s mobility improved, able to ambulate
without assistance.
b.2. HYPERKALEMIA
• Serum K+ above 5.0mEq/L
Causes
• IV replacement of potassium
• Potassium rich hyperalimentation
• Excessive use of salt substitutes
• Poor elimination of potassium due to kidney
failure.
• In metabolic acidosis where hydrogen ion enters
the cell in exchange of potassium.
• In cases of great cell damage like in burns,
chemotherapy to treat Cancer, potassium is
released into the serum.
• Adm of WB nearly of its expiry date
Signs and Symptoms
• Confusion, paresthesia, abdominal cramps,
muscle paralysis – hyperkalemia affects the
musculoskeletal system, smooth muscle
function, & nerve cell function.
• ECG changes which appears prolonged P-R
intervals, wide QRS & tented T-wave, which may
result to cardiac arrest.
Potential Nursing Diagnosis
• Decreased Cardiac Output
• Risk for Injury
• Impaired Physical Mobility
• Anxiety
Interventions
• Identify risk individuals those receiving IV
potassium replacement, patients with severe
burns, cellular damage, those with renal failure.
• Check patient’s urine output, and serum
potassium levels.
• Attach patient to cardiac monitor if they have
signs of hyperkalemia
• Administer sodium bicarbonate as ordered with
caution
• To patient with CKD, they may undergo dialysis
• Monitor I & O, report if urine output is below 30
ml/hour
CALCIUM:
NORMAL AND IMBALANCE
A. NORMAL BALANCE
• Serum level of 8.5mg/dL - 10.5mg/dL
• It is regulated with Mg & PO4
• Its sources: 99% found in the bones & teeth
• Calcium not bound to bone is either bound to
plasma proteins or ionized ( calcium that is not
attached to proteins)
• It is taken through the diet
Functions of Calcium
• Calcium that are bound to bones & teeth
maintains their strength & rigidity.
• Calcium is needed for nerve, muscle, and cardiac
conduction
• It is required for hormonal secretion
Regulation of Calcium Level
• It is absorbed in the small intestine & excreted in
the urine.
• Vit D in its active form 1,25-
dihydroxycholecalciferol is required in the
absorption of calcium in the S.I. Conversion
occurs in the kidneys
Renal Regulation of Calcium Level
• Calcium is filtered in the glomerulus and
absorbed in the tubules.
• If excessive calcium is present, it can precipitate
into stone.
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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN
Endocrine Regulation of Calcium Level
• The parathyroid gland responses to low calcium
level by releasing PTH, stimulates the release of
calcium from the bones until it becomes normal.
• If serum phosphorous level is higher than normal,
calcium binds with phosphorous.
B. CALCIUM IMBALANCE
b.1. HYPOCALCEMIA
• Serum Calcium level below 8.5mg/dL
Causes
• Inadequate intake of calcium in the diet due to
anorexia, dieting.
• In CKD, vit D is not activated or
dihydroxycalceferol is not activated.
• Vit D deficiency
• Inadequate exposure to sunlight, w/c hinders
activation of vit D
• Malabsorption of calcium due to GI disease, or
alcohol abuse.
• Acute pancreatitis which results to hypocalcemia
• Low PTH level, reduce calcium absorption.
Signs and Symptoms
• Tetany & seizures
• ECG result prolonged Q-T intervals
• Appearance of petechiae and easy bruising
observed on the skin.
• Hyperphosphatemia is noted
• Prolonged prothrombin time
Potential Nursing Diagnosis
• Decreased cardiac output
• Risk for bleeding
• Risk for injury
• Ineffective breathing pattern
• Impaired physical mobility
• Activity Intolerance
• Because calcium is a critical part in
neuromuscular contraction, low calcium levels
affect the contraction of the smooth, skeletal, &
cardiac muscles which include:
o Muscle cramps in arms & legs
o Muscle spasms ( spasms in bronchial &
laryngeal muscles which are dangerous
signs of hypocalcemia)
o Cardiac dysrhythmias ( prolonged Q-T
interval)
• It is also a critical part of nerve cell conduction,
w/c makes nerve cells more excitable results to
hyperactive deep tendon reflexes, paresthesia,
+Chvostek’s sign, +trousseaus sign.
Interventions
• Identify patients at risk for hypocalcemia; those
with thyroid disease or have undergone
thyroidectomy, or patients with GI disorders.
• Assist patient to restore serum calcium level to
normal
• Patient maybe prescribed of calcium
supplements, vit D, provide calcium rich foods.
• Provide safety always.
• Monitor v/s
• Administer calcium gluconate with caution & to
patients receiving digitalis, it may result to digitalis
toxicity.
• Ca gluconate is also use to antagonize
magnesium toxicity.
• Encourage patient to ambulate & do some
exercises as tolerated
b.2. HYPERCALCEMIA
• Serum Calcium level below 10.5mg/dL
Causes
• Over administration of calcium supplements.
• Increased vit D intake
• Hyperparathyroidism which accelerates PTH
effects on bones
• Increased in renal disease which decrease renal
regulation of electrolytes.
• Hypophosphatemia due to inverse relationship of
calcium with phosphorous
• Thyrotoxicosis accelerates release of calcitonin.
• Immobility, if bones are not used, calcium moves
out from the bones
• In cases of bone cancer, calcium moves out from
the bones.
Signs and Symptoms
• Assess level of serum calcium level especially to
patients who are at risk for hypercalcemia.
• Hypercalcemia affects the skeletal, cardiac &
smooth muscles which are manifested by dec
intestinal peristalsis, muscle weakness, cardiac
dysrhythmia manifested by shortened Q-T
interval.
• Excess calcium may result to formation of urinary
calculi manifested by hematuria, dysuria,
presence of calcium oxalate in the urinalysis.
• Patient is risk for pathologic fracture.
Potential Nursing Diagnosis
• Decreased cardiac output
• High risk for injury
• Altered nutrition: less than body requirements
• Risk for constipation R/T decreased GI function
from immobility.
• Impaired memory, confusion R/T altered
neurologic function.
Interventions
• Institute measures to prevent hypercalcemia to
high risk patients.
• Encourage patient to ambulate and do exercise
as tolerated.
• Institute measures to eliminate excess calcium
from the blood by administration of loop diuretics
as ordered
• Administer calcitonin as ordered enhance
movement of calcium into the bones.
• Monitor v/s, and electrolytes
MAGNESIUM:
NORMAL AND IMBALANCE
A. NORMAL BALANCE
Description
• The second most abundant cation in the ICF
• Normal serum Mg level – 1.5-2.5 mEq/L
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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN
Causes
• Increased intake of Mg rich-foods, or
administration of magnesium through IV route in
the treatment of eclampsia, IV supplements,
Hyperalimentation.
Functions
• Assists in the contraction of cardiac, & skeletal
muscles
• Has an effect of vasodilation, results to
decreased BP & cardiac output.
• Facilitates sodium & potassium transport across
cell membrane.
Regulation
• Mg is filtered along with other electrolytes in the
tubules
• Mg is reabsorbed in the renal tubules as the body
needs Mg. If serum Mg level is low, Mg is re-
absorbed, if high excreted.
• Osmotic diuretics can excrete excess Mg.
B. MAGNESIUM IMBALANCE
b.1. HYPOMAGNESEMIA
• Serum Calcium level below 1.5mEq/L
Causes
• Can be loss from vomiting, diarrhea, NGT suction
( more Mg is lost from the bowel compared to
vomiting)
• Administration of loop diuretics.
• Inadequate intake or absorption due to
malnutrition, starvation, excess dietary intake of
calcium or vit D
• Hypercalcemia
• Hypoparathyroidism
Signs and Symptoms
• Patient may be manifesting vomiting & diarrhea
which may be the cause of the Mg deficit.
• Hypotension, because Mg is required for
neuromuscular & cardiac muscle function
• Patient may manifest same manifestation with
that of a patient with hypocalcemia: tetany,
seizure, tremors, confusion, hyperactive deep
tendon reflex, positive Chvostek’s & trousseau’s
signs.
• Memory loss
• Lab results: Mg below normal, hypocalcemia,
hypokalemia
• ECG results; prolonged P-R interval, inverted T-
wave.
Potential Nursing Diagnosis
• Risk for injury
• Decreased cardiac output
• Altered nutrition: less than body requirement
• Altered memory
Interventions
• Prevent hypomagnesemia to high risk patients;
early detection of hypomagnesemia to high risk
patients.
• Monitor patients with hypokalemia for impending
hypomagnesemia
• Monitor patients with hypomagnesemia who are
receiving digoxin for signs of digitalis toxicity.
• Assess for deep tendon reflex, refer to physician
if noted.
• Monitor v/s, intake & output.
• Institute seizure precaution.
• Infuse MgSO4 with caution, can be given by IM,
IVP, IV infusion with caution. Assess patient’s
status: v/s, deep tendon reflex, RR, urine output
of patient.
b.2. MAGNESIUM EXCESS
• Serum Calcium level above 2.5mEq/L
Causes
• Mg gain from medication & hyperalimentation
• Inadequate excretion due to renal disease.
Signs and Symptoms
• Decreased cardiac output manifested by
hypotension.
• Since magnesium causes warm systemic
sensation, patient may appear flush, may
verbalized feeling of warmth.
• Hypoactive deep tendon reflexes or decreased
motor function of extremities; decreased neuro-
muscular activity.
Potential Nursing Diagnosis
• decreased cardiac output
• risk for injury
• Ineffective breathing pattern
Interventions
• Prevent hypermagnesemia to high risk patients
by identifying early signs of the deficit.
• Monitor v/s, urine output
• Administer calcium gluconate as ordered to
counter effect magnesium toxicity
ACID - BASE:
NORMAL AND IMBALANCE
A. HYDROGEN ION BALANCE (Basic Concepts)
Description
• Hydrogen ion is present in body fluids, both in the
ECF & ICF
• It determines the acidity or alkalinity of a solution
or body fluids.
• The greater the number of hydrogen ion the more
acid the solution is; the smaller the hydrogen ion
the more alkaline the solution.
• The acidity or alkalinity of body fluids or blood is
measured in terms of pH – normal blood pH –
7.35-7.45
• If blood pH drops to below 7.35, it is acidosis; if
blood pH is above 7.45 it is alkalosis.
• Hydrogen circulates within the body in 2 forms:
o Volatile hydrogen, when CO2 is
dissolved in water, it forms carbonic acid,
excreted in gaseous form by the lungs.
o Non-volatile hydrogen ion ( metabolic )
– produced as a result of metabolic
processes.
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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN
• Some are formed from organic acids like uric
acid; some are found in the form of sulfuric acid ,
phosphoric acids, some are formed from
catabolic processes from fats forming ketone
acids when glucose is elevated & not used by the
cells as source of energy.
• Excess metabolic acids formed as a result of
anaerobic metabolism like in severe tissue
damaged forming lactic acids in burns, or tissue
injury or trauma.
• Excretion of hydrogen ion
o The lungs primarily eliminate volatile
hydrogen ion of carbonic acid as CO2 &
water
o The kidneys eliminate volatile acids in the
form of:
▪ 60% is excreted in the urine as
NH4 chloride
▪ 40 % is excreted as weak acids
HYDROGEN IONS CONCENTRATION
REGULATION
• Dilution of EXCESS hydrogen ion in the ECF, first
line of defense
• Buffer by the following systems ; H2CO3- HCO3
buffer system; Protein Buffer System ;
Phosphorous Buffer System.
• Respiratory Buffer System
• Kidney Buffer System
a.1. Local Dilution of the Hydrogen Ion
• Kidney Buffer System
• Example: if you do exercise, hydrogen is build up
in the circulation, then automatically distributed
within the body with out any symptoms of
increased hydrogen ion, later it will have normal
distribution.
a.2. Buffer System
• The buffer system of the body is composed of
weak acid that coexists with a salt: ex. HCl
(strong acid) + NaHCO3 > H2CO3 (WEAK ACID)
+ NaCl (salt). Results to normal blood pH.
• It can buffer 90% of the hydrogen ion in the ECF.
• It is the most important buffer system in the ECF;
Lungs excrete H2C03 while the kidneys excrete
HCO3 ( alkali )
• There should be 1 part of H2CO3 & 20 parts of
HCO3 ( 1:20 ) ratio.
a.3. The Respiratory System
• The lungs removed CO2 from the body in
response to increase hydrogen ion concentration
in the blood.
• Arterial blood gases is measured by partial CO2
pressure (PaCO2), Normal is 35-45 mmHg.
• The partial pressure of oxygen (PO2) is called
oxygen tension. Normal is 75-100 mmHg.
FEEDBACK MECHANISM OF REGULATION OF
CO2
• The respiratory center in the medulla controls the
carbonic acid in the bicarbonate-carbonic acid
buffer system by means of a feedback
mechanism between the respiratory center & the
lungs.
• When H2CO3 decreases in the blood, blood pH
increased, the PCO2 is decreased which maybe
due to hyperventilation, the respiratory center will
decreased its function resulting to
hypoventilation.
• Hypoventilation results to retention of CO2,
combines with water to form carbonic acid until
blood pH returns to normal
• But if blood pH is decreased, H2CO3 is
increased, CO2 is retained maybe due to
hypoventilation from sedation, obstruction of air
passages, CO2 is not given off, reaction of the
medulla is to stimulate respiration through
hyperventilation to excrete the excess CO2 that
are retained until the H2CO3 & blood pH back to
normal level.
• Lungs limitation to correct acid-base imbalance is
they are only capable of excreting volatile acids.
a.4. The Renal System
• The kidneys regulate bicarbonate in the HCO3-
H2CO3 in the buffer system & eliminate non-
volatile hydrogen ions.
• It works slowly, takes several days to correct
imbalance.
• The kidneys work to correct acid-base
imbalances by:
o Reabsorption of filtered bicarbonate
o Hydrogen ion secretion in the kidney
tubules
o Production of NH3.
• Reabsorbing filtered bicarbonate- blood entering
the glomeruli contains bicarbonate ions, passes
through the tubules & reabsorbed if needed &
excreted if the body’s blood pH is normal.
• Net secretion of H+ - cellular metabolism
produces hydrogen ions that must be excreted in
the urine to keep the blood from too acidic.
• H+ entering the renal tubular fluids combines with
ammonia rather than with HCO3.
• NH3 Mechanism – when certain amino acids
break down, NH3 is formed w/in the distal tubular
cells. When NH3 diffuses from the cells into the
renal tubules, it reacts w/ H+ to form NH4,
excreted in the urine, this will increase the
bicarbonate level.
B. HYDROGEN ION IMBALANCES
Description
• Hydrogen ion balance depends on the normal
function of the buffer system, lungs & kidneys.
• Types of hydrogen imbalances:
o Acidosis – a condition where the
hydrogen ion concentration in the blood
is elevated, normal bicarbonate is
elevated, blood pH is decreased.
o Alkalosis – a condition where hydrogen
ion concentration in the blood is
decreased, bicarbonate is elevated,
blood pH is increased.
DEFENSE MECHANISM AGAINTS IMBALANCES
• Correction of the buffer system. The first line of
defense against hydrogen imbalance is through
buffer system
• The second line of defense is the respiratory
system
• The third line of defense is the renal system
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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN
• Assessment: all major manifestations are caused
by the CNS.
o In respiratory or metabolic acidosis, the
major problem is CNS depression
resulting in decreased respiratory & renal
function
o In respiratory or metabolic alkalosis, the
problem is CNS stimulation
Diagnosis of Hydrogen Ion Imbalances
• Blood pH – determines the acidity or alkalinity of
the blood; it does not indicate if imbalance is
respiratory or metabolic in nature.
o Normal – 7.35-7.45
o Below 7.35 – acidosis ; above 7.45 is
alkalosis
• PaCo2 determination – measures the amount of
CO2 pressure of arterial blood which its normal
value is 35-45 mmHg
• HCO3 – measures the bicarbonate level of the
arterial blood; normal level is 22-26 mEq/L.
• the above diagnostic exam is known as the ABG
exam
Interventions to Correct Acid-Base Imbalance
• Identify & treat cause of imbalance
• Assist the respiratory &/ or the renal system
through supportive interventions to correct &
compensate for the imbalance.
• Monitor the renal & respiratory functions.
• Asses for patient’s condition, ensure physiologic
& psychologic safety.
• Administer medications that neutralize excess
acids or base with caution; commonly
bicarbonate is given to correct acidosis, &
ammonium chloride to correct excess base or
alkali.
THE FOUR ACID - BASE IMBALANCES
A. Respiratory Acidosis
Causes
• Conditions that results to retention of CO2 results
to increased CO2 level of the blood, decreased
serum pH level.
• Any condition that obstruct the excretion of CO2
• Impaired neuromuscular function e.g. GBS, chest
trauma
• Depressed respiratory function
Assessment
• Dyspnea upon exertion, DOB, tachycardia,
restlessness, irritability, in severe cases patient
may become disoriented, confused, then coma
Interventions
• Goal: improve respiratory function, Provide
patient’s comfort and safety.
• Plan activities that patient able to have rest
periods in between activities
• Encourage deep breathing, coughing exercises
to improve exchange of CO2 & oxygen in the
respiratory system.
• Place patient in semi-fowler’s position.
Encourage change of position q 2 hrs.
• Institute chest physiotherapy
• Suction secretions if needed.
• Provide emotional support & reassure to allay
anxiety
• Monitor respiratory rate, depth, & rhythm.
• Monitor O2 saturation, indicate if room air, w/ O2
via nasal cannula,/ face mask
• Administer low flow of oxygen as ordered.
• Monitor ABG levels
• Force fluids as tolerated and if not
contraindicated.
• Administer nebulization, antibiotics as ordered
• Attach to mechanical ventilator if indicated
B. Respiratory Alkalosis
Causes
• Excessive CO2 excretion which results to
decreased in PaCO2, increased in H2CO3,
increased in blood pH.
• This may be the result of hyperventilation &
overstimulation of the respiratory center.
• Anxiety may result to hyperventilation
• After a series of exercises, a person
hyperventilates
• Hypoxia in high altitudes
• Defect in the adjustment of ventilators
• Conditions that causes overstimulation of the
respiratory center of the brain:
o Fever
o CNS infection like meningitis
o Intracranial surgery
o ASA toxicity
o The increased blood pH of the blood
increased neuromuscular irritability
manifested by hyperreflexia, positive
Chvostek’s sign, & muscular twitching,
seizures sometimes occur.
Interventions
• Identify patients at risk for respiratory alkalosis.
Identify early symptoms of the disease.
• Assist the patient to breath slowly or normally.
• Listen with sympathy to a patient with anxiety
having hyperventilation.
• Ask the person to re-breath his/her own exhaled
CO2 in a paper bag thus increasing the H2CO3
in the blood.
• Take precautions to prevent injury.
• Monitor v/s, I& O, record.
• Check adjustment of ventilators.
C. Metabolic Acidosis
• Increased in H2CO3 & Blood pH
Causes
• Overproduction of metabolic acids produced from
metabolism, such as DM, high fat, low CHO diet,
prolonged fasting.
• Excessive ingestion of acids like ASA, ferrous
SO4, ammonium chloride.
• Renal Disease – in renal disease, the kidneys are
unable to excrete the excess acids from the
blood, and decrease retention/ reabsorption of
HCO3.
• Abnormal losses of Alkali – losses from
pancreatic, biliary, & lower GI secretions through
diarrhea results to retention of acids.
• Severe tissue anoxia results to anaerobic
metabolism like in cases of burns, anemia,
cardiac disorders.
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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN
Interventions
• Goal: restore normal blood volume & osmolality;
Correct HCO3 deficit; Prevent electrolyte
imbalances; Maintain safety of patient.
• Restore normal blood volume & osmolality -
Commonly patients with acidosis are dehydrated,
monitor body weight, I & O, administer isotonic
solutions as ordered.
• Correct HCO3 deficit. Na HCO3 may be given
cautiously as ordere; It maybe add to IV solutions
or given by IVP slowly or IV drip through
volumetric set.
• Prevent electrolyte imbalances; Patients w/
metabolic acidosis may develop hyperkalemia as
k+ shifts from ICF to ECF in exchange of H+;
Observe for signs of hypocalcemia, because as
metabolic acidosis is corrected, calcium bind to
plasma protein, citrate, which contribute to
hypocalcemia. Observe for signs of tetany,
because calcium regulates neuromuscular
irritability.
• Protect patient from potential injury. Patients
w/ metabolic acidosis may have altered level of
consciousness like seizure, irritability; Always put
side rails up, don’t leave patient unattended.
D. Metabolic Alkalosis
• Blood pH above 7.45, HCO3 above 26 mEq/L
Causes
• It results to excessive loss of hydrogen ion or
excessive ingestion of alkali.
• Excessive use of hydrogen ion
o From severe vomiting where Hcl acid
stomach content is lost.
o Patients w/ GI suction where there is no
electrolyte replacement.
o Loss of chloride which causes the
kidneys to retain bicarbonate.
• Excessive ingestion of alkali - patients with peptic
ulcer & given antacids
Interventions
• Identify cause of imbalance, & correct the
imbalance.
• Patients treated with peptic ulcer disease should
be careful not to overdose the intake of antacid.
• Commonly patient is given PLR to replace fluid
losses like in vomiting, it contains 10 mEq of
chloride, an alkali.
• Correct water, cl-, Na, & potassium deficits,
important when correcting alkalosis.
• Monitor v/s, I & O, record.
• Observed signs of rebound effect of metabolic
alkalosis.
Evaluation
• Patient has normal breathing pattern.
• Vomiting is controlled, able to tolerate oral
feeding.
• Intake & output are within normal balance.
• Patient is free from injury.
NURSING EXPERIENCING BURNS
• Burns as defined caused by flames, chemicals,
radiation, or electrical current.
• Thermal burns is the most common, caused by
fires in home, vehicular accident, playing with
matches in children, poorly stored gasoline.
Functions of the Skin
• Protection against infection.
• Prevent loss of body fluids.
• For excretion, use for sensation
• Produce vit D
Pathophysiology of Burns
• Following burns, increased capillary permeability
results, plasma seeps into surrounding tissues,
causing edema.
• This leads to body fluid loss w/c is greatest within
18-36 hrs.
• In mild cases of burns, fluid leak into the burned
areas; while in severe cases, it leads to systemic
fluid loss.
• Factors determining burn severity:
o Burn depth
▪ First degree – affects superficial
part of the skin or the epidermis.
Skin appears pink & red, w/ small
thin blisters
▪ Second degree burn or partial
thickness, where only part of the
skin is damaged. Both dermis &
epidermis are affected. Large
thick-walled blisters develop,
commonly covering the burned
area.
▪ Third degree burn or full
thickness burn – all the skin,
dermis, epidermis are destroyed
including the subcutaneous,
muscle & bone. The color may
be deep red, white or black, or
brown.
▪ Full-thickness burn –
structures beneath the skin are
severely affected.
• Determining Burn Size: determine BSA affected
o It is determined by the “Rule of Nine” or
the “Lund and Browder” method. But
commonly the rule of nine is used in the
hospital.
o According to the rule of nine, the body is
divided into 9% of the total body areas
affected.
o Head & neck – 9% ; right upper ext. 9%;
left upper ext. 9%; anterior trunk – 18%;
posterior trunk – 18%; right lower ext.
18%; left lower ext. 18%; perineum 1%
NCA 1 ┃ NURSING COURSE APPRAISAL 1