Fluid and Electrolyte Imbalance

Prepared By

Dr/ Shimaa Abd Elhady Badawy

 Outlines

• Introduction
• Water balance
• Body water composition and changes with gestational and
postnatal age
• Fluid Compartment and Homeostasis
• I- Alteration in Fluid Volume
• Fluid volume deficit (Hypovolemia)
• Fluid volume excess (Hypervolemia)
• II- Alteration in Electrolyte Balance
• 1-Sodium
• 2- Potassium
• Dehydration
 Introduction

• The kidneys are essential for regulating the volume and

composition of bodily fluids. The main fluid in the bod
y is water. Total body water is 60% of body weight. Th
e water is distributed in three main compartments separ
ated from each other by cell membranes. The intracellu
lar and the extracellular compartment consist of the inte
rstitial area (between and around cells) and the inside o
f the blood vessels (plasma). Electrolytes are the chemi
cals dissolved in the body fluid.
Body water composition and changes with
gestational and postnatal age
 Water Requirement

• Water Requirement in children less than 10 kg =

100ml/kg
• Water Requirement in children10-20kg =1000m
l+50 ml for each kg above 10kg/24 hours
• Water requirement for child above 20 kg =1500
ml+20ml for each kg /24hours
 Alteration in Fluid Volume:-

• Fluid volume deficit (Hypovolemia)

• Fluid volume excess (Hypervolemia)
 1- Fluid volume deficit (Hypovol
emia)

• Causes of Hypovolemia
• Failure to absorb or reabsorb water.
• Complete sudden cessation of intake or prolonged diminis
hed intake.
• Neglect of intake by self or caregiver.
• Loss from gastrointestinal tract; vomiting, diarrhea, nasoga
stric suction.
• Inappropriate anti diuretic hormone (ADH) secretion.
• Loss through skin or lung as excessive perspiration or eva
poration.
• Hemorrhage.
• Clinical Manifestation:
• Thirst.
• Variable temperature-increased.
• Dry skin and mucous membrane.
• Poor skin turgor.
• Poor perfusion (decreased pulse, slowed capillary refill tim
e)
• Weight loss.
• Fatigue.
• Diminished urinary output.
• Altered level of consciousness, disorientation
• Nursing Management:
• Give ringer lactate 10-20ml/kg
• Fluid resuscitation 40ml/kg
• Monitor vital signs (Blood pressure, peripheral p
erfusion, heart rate, and output) are monitored to
determine child’s responses to therapy
• Determine and correct cause of water depletion.
• Measure intake and output.
• Monitor urine specific gravity
 2- Fluid volume excess (Hyperv
olemia)

• Causes:
• Water intake in excess of output:
• Excessive oral intake.
• Hypertonic fluid overload.
• Plain water enemas.
• Failure to excrete water in presence of normal intak
e:
• Kidney disease.
• Congestive heart failure.
• Malnutrition.
• Clinical manifestation:
• Generalized edema.
• Pulmonary crackles.
• Hepatomegaly.
• Slow, bounding pulse.
• Weight gain.
• Increased spinal fluid pressure and venous press
ure
• Nursing Management:
• Fluid and sodium restriction
• Administer diuretics.
• Monitor vital signs.
• Determine and treat the underlying cause.
• Analyze laboratory electrolyte measurement frequently.
II- Alteration in Electrolyte Balan
ce
 1-Sodium

• Is a major cation of extra cellular compartment,

play a major role in acid –base balance through
osmolarity, and regulate actions of skeletal musc
les, nerves, and myocardium.
• Concentration:-
• In Extra Cellular Fluid (E C F):- 135 - 145 m
Eq/l
• In Intra Cellular Fluid (I C F ): 3 - 5 m Eq/l
 Hyponatremia

• Decrease of sodium in the extra cellular fluid less than 130

mEq/l
• Causes
• Prolonged low-sodium diet.
• Fever.
• Excess sweating.
• Vomiting, diarrhea
• Renal disease.
• Diabetic ketoacidosis (DKA).
• Increased water intake without electrolyte.
• Clinical manifestation:
• Clinical manifestation is similar to water loss-dehydration, (
weakness, dizziness, nausea, abdominal cramps, and app
rehension.
• Mild- apathy, weakness, nausea, weak pulse.
• Moderate- decreased blood pressure, lethargy
• Nursing Management:
• Hyper tonic infusion with 3% saline over 30 minutes throug
h large vein
• Monitor serum sodium frequently
• Determine and treat cause.
 Nursing Management

• Determine and treat cause.

• Administer fluid as prescribed

• Measure intake and output

• Monitor laboratory status

• Monitor neurologic status.

 Potassium:

• Is an intracellular and have major role in the body related t

o action in nervous system, skin, smooth muscle, and hear
t through sodium potassium pump. (3.5 – 5.5mEq/l ).

• Hypokalemia
• Causes:
• Starvation.
• Malabsorption.
• Administration of diuretics.
• Potassium-losing nephritis.
• Administration of corticosteroids
• Clinical Manifestation:
• Muscle weakness, cramping, stiffness, paralysis, hyporefle
xia.
• Hypotension.
• Cardiac arrhythmias, gallop rhythm.
• Tachycardia or bradycardia.
• Apathy, drowsiness.
• Irritability, fatigue.
• Laboratory finding:
• Decreased serum potassium concentration ≤ 3.5 mEq/l.
• Abnormal ECG- notched or flattened T waves decreased S
T segment, premature ventricular contraction.
• Nursing Management:
• Determine and treat cause.
• Monitor vital signs, including ECG.
• Administer supplemental potassium.
• Assess for adequate renal output before administration.
• I.V; administer K+ slowly.
• Oral: offer high-potassium fluids and foods.
• Evaluate acid-base status.
 Hyperkalemia

• Causes:
• Renal disease.
• Renal failure.
• Severe dehydration.
• Too rapid administration of IV potassium chloride.
• Transfusion with old donor blood
• Clinical Manifestation:
• Muscle weakness, flaccid paralysis.
• Hyperreflexia.
• Bradycardia.
• Ventricular fibrillation and cardiac arrest.
• Oliguria
• Laboratory finding:
• High serum potassium concentration ≥ 5.5 mEq/l
• Variable urine volume.
• Flat P wave, peaked T waves, widened QRS complex, incr
eased PR interval.
• Nursing Management:
• Determine and treat cause.
• Monitor vital signs, including ECG.
• Administer IV fluids as prescribed.
• Administer IV insulin to facilitate movement of potassium in
to cells.
• Monitor serum potassium level.
• Evaluate acid-base status.
 Dehydration

• It is one the consequences of watery diar

rhea. It is caused by the loss of water and el

ectrolytes in liquid or loose stools and vomit

us.
 Types of dehydration:

• 1) Isonatraemic dehydration (serum Na 130-150 mmol

/l)
a- Loss of water and sodium is balanced •
b- Serum osmolality is normal (275-295 mOsmol/l) •
• 2) Hypernatraemic dehydration (serum Na > 150 mmql/
l)
a- Loss of water is greater than that of sodium •
b- Serum osmolality is raised (>295 mOsmol/l) •
c- Most common in young infants •
• 3) Hyponatraemic dehydration (serum Na < 130 mmql/l
)
a- Loss of sodium is greater than that of water •
b-Serum osmolality is lowered (<275 mOsmol/l) •
 Rehydration Therapy:

Composition of standard ORS

Ingredients Amount g/l Ions Concentration mmol/l

Sodium chloride 3.5 Sodium 90

Trisodium citrate dihydrate 2.9 Potassium 20

Potassium chloride 1 .5 Citrate 10

Glucose 20 Chloride 80
111
• Advantages of ORS:
1- Prevents and treats dehydration •
2- None of the complications of IV fluid therapy are seen •
3- Over hydration does not occur as most children will stop •
drinking once hydrated and will ask for food instead
4- Simple to use, can be used anywhere even at home •
5- Comforting to the child •
6- Cheap •
• 7- The mother takes an active role in managing her child.
• Limitations of ORS therapy:
ORS is ineffective or inappropriate in the following situat
ions:

1- Severe dehydration

2- Paralytic illus

3- Glucose malabsorption
 Classification of DEHYDRATION

• There are three possible classifications for the typ

e of diarrhea. These are:

1. SEVERE DEHYDRATION

2. SOME DEHYDRATION

3. NO DEHYDRATION
Two of the following signs:
Lethargic or unconscious
Sunken eyes
Not able to drink or drinking poorly
Skin pinch goes back very slowly.
Two of the following signs: Restless, irritab Yellow:
le
Sunken eyes
Drinks eagerly, thirsty
Skin pinch goes back slowly
Not enough signs to classify as some or sev
ere dehydration
Pink: 1. If child has no other severe classification:
SEVERE DEHYDRATIO  Give fluid for severe dehydration (Plan C) OR
N  If child also has another severe classification: Refe
r URGENTLY to hospital with mother giving frequ
ent sips of ORS on the way
 Advise the mother to continue breastfeeding
1. If child is 2 years or older and there is choler
a in your area, give antibiotic for cholera
1. Give fluid, zinc supplements, and food for some de
hydration (Plan B)
SOME DEHYDRAT 2. If child also has a severe classification:
ION  Refer URGENTLY to hospital with mother giving f
requent sips of ORS on the way
 Advise the mother to continue breastfeeding
1. Advise mother when to return immediately
2. Follow-up in 5 days if not improving
Green: 1. Give fluid, zinc supplements, and food to treat diarr
NO DEHYDRATIO hoea at home (Plan A)
N 2. Advise mother when to return immediately
3. Follow-up in 5 days if not improving
 Management of Dehydration:
1- How to assess a patient for dehydration

A B C
I-look at
1`-General condition Well, alert Restless or irritable Lethargic or
unconscious; floppy
2-Eyes Normal Sunken Very sunken and dry
3-Tears Present Absent Absent
4-Mouth and tongue Moist Dry Very dry

5-Thirst Not thirsty Thirst, drinks eagerly* Drinks poorly or unable to dri
nk

II- Feel skin pinch Goes back quickly * Goes back slowly* * Goes back very slowly*
III- Decide The patient has NO If the patient has two or m If the patient has two or more
Signs Of ore signs, including at least signs, including at least one
Dehydration one * sign* , there is * sign* there is
SOMe Severe Dehydration
Dehydration

IV- Treat Plan A Plan B Plan C urgently

Treatment Plan A Plan B Plan C
At home In OP rehydration c In hospital
Where
enter
1- Fluid th Give more fluid than usua Gives ORS Give IV fluids
erapy l
Home made fluids (rice, Pansol .Ringer's lactate.
water, tea without sugar, Normal saline.
What type soup, yogurt).

-Give after each loose sto 75ml/kg -100 ml/kg of body wt. gi
ol for child <2 years : 50 ven in 3 – 6 hrs.
– 100ml -1st 30 ml/kg given in 1/2
How muc
-For child > 2 years: 100 to 1 hr.
h
– 200 ml. -Next 70 ml/kg given in
2.5 – 5hrs, longer time is
used for infant < 1 year.
-Slowly (1 spoon 1-2 min) Slowly (1 spoon 1- I.V.
-By cup and spoon, 2 min) by cup &spo
How give dropper/syringe. on, dropper/syring
n e. Nasogastric tube
.
A) Advice the mother to B) Reassess the patient's condi
bring the child to a tion.
health facility if :
-Frequent large stools. -If no signs of dehydration shift to

-Repeated vomiting plan A.

-Increased thirst -Some dehydration shift to plan B

-No improvement after days -Severe dehydration shift to plan C.

-Bloody stools .
-Fever.
 Guidance during intervention :

• Mothers should be taught to give ORS (one teaspoonful ev

ery 1-2 minutes, the child should be in semi-sitting position
).

• Give ORS as much as he desires.

• If vomiting occurs, wait 10 minutes. Then continue giving

ORS solution but more slowly (one teaspoonful every 2-3
minutes).

• Watch for puffy eyes as a sign of over hydration. If this occ

urs, stop ORS solution, give breast feeding and water.