Ms. Ida Anitha Lecturer College of Nursing CMC, Vellore


Water is found everywhere on earth including human body In an adult 60% of the weight is water Two third of the body’s water is found in the cell

Body fluids are distributed in two distinct compartments: 1.Extracellular fluids[ECF] Which includes interstitial fliud & intravascular fluid 2.Intracellular fluids[ICF]

Electrolytes 2.Cells .COMPOSITION OF BODY FLUIDS The fluids circulating throughout the body in extracellular and intracellular fluid spaces contain 1.Minerals 3.

MOVEMENT OF BODY FLUIDS Diffusion Osmosis Filtration Active transport .

REGULATION OF BODY FLUIDS Fluid intake Fluid output Hormonal influence Lymphatic influences Neurologic influences Renal influences .

ACID-BASE BALANCE Chemical regulation Biologic regulation Physiological regulation 1.Lungs 2.Kidneys .


FLIUD IMBALANCES The five types of fluid imbalances that may occur are: Extracellular fluid imbalances(EVFVD) Extracellular fluid volume excess(ECFVE) Extracellular fluid volume shift Intracellular fluid vloume excess(ICFVE) Intrcellular fluid volume deficit(ICFVD) .

is a decrease in intravascular and interstitial fluids An ECFVD can result in cellular fluid loss if it is sudden or severe .EXTRACELULLAR FLUID VOLUME DEFICIT An ECFVD. commonly called as dehydration .

water loss is greater than the electrolyte loss Isosmolar fluid volume deficit – equal proportion of fluid and electrolyte loss Hypotonic fluid volume deficit – electrolyte loss is greater than fluid loss .THREE TYPES OF ECFVD Hyperosmolar fluid volume deficit.

pertonial and joint cavities] Fever Gatrointestinal suction Ileostomy Fistulas Burns Hyperventilation Decresed ADH secretions Diabetes insipidus Addison’s disease or adrenal crisis Diuretic phase of acute renal failure Use of diuretics . pleural.ETIOLOGY AND RISK FACTORS Severe vomiting Diaphoresis Traumatic injuries Third space fluid shifts [percardial.

ELDERLY ARE HIGH RISK OF ECFVD DUE TO Decreased thirst response Decreased renal concentration of urine Altered ADH response Increased drug – drug interaction Multiple chronic diseases Decreased access to fluids due to financial or transportation barriers Debilitation Chemical or physical restraint Changes in mental status .

5 to 10 L of water loss or 8% of weight loss .CLINICAL MANIFESTATION In Mild ECFVD. 1to 2 L of water or 2% of the body weight is lost In Moderate ECFVD. 3 to 5L of water loss or 5%weight loss IN Severe ECFVD .

CLINICAL MANIFESTATION Thirst Muscle weakness Dry mucus membrane.dry cracked lips or furrowed tongue Eyeballs soft and sunken (severe deficit) Apprehension . confusion. with pulse increases > 30 Narrowed pulse pressure. decreased CVP&PCWP Flattened neck veins in supine position Weight loss Oliguria(< 30 mlper hour) Decreased number and moisture in stools . restlessness. coma in severe deficit Elevated temperature Tachycardia. headache . weak thready pulse Peripheral vein filling> 5 seconds Postural systolic BP falls >25mm Hg and diastolic fall > 20 mm Hg .

030) .LABORATORY FINDINGS Increased osmolality(> 295 mOsm/ kg) Increased or normal serum sodium level (> 145mEq/ L ) Increase BUN (>25 mg / L ) Hyperglycemia ( >120 mg /dl ) Elevated hematocrit (> 55%) Increased specific gravity ( > 1.

MANAGEMENT Mild fluid volume loss can be corrected with oral fluid replacement -if client tolerates solid foods advice to take 1200 ml to 1500ml of oral fluids -if client takes only fluids. increase the total intake to 2500 ml in 24 hours .

Management of Hyperosmolar fluid volume deficit Administration of hypotonic IV solution . such as 5% dextrose in 0.2 %saline If the deficit has existed for more than 24 hours.5 to 0.avoid rapid correction of fluid [sodium solution to be infused at the rate of 0.1m Eq/ L/ hr] .

If heamorrhage is the cause for ECFVD Packed red cells followed by hypotonic IV fluids is administered In situations where the blood loss is less than 1 L normal saline or ringer lactate may be used clients with severe ECFVD accompanied by severe heart . or kidney disease cannot tolerate large volumes of fluid and sodium . liver.

EXTRACELLULAR FLUID VOLUME EXCESS ECFVE is increased fluid retention in the intravasular and interstitial spaces .

ETIOLOGY AND RISK FACTORS Heart failure Renal disorders Cirrhosis of liver Increased ingestion of high sodium foods Excessive amount of IV fluids containing sodium Electrolyte free IV fluids SIADH.Sepsis decreased colloid osmotic pressure lymphatic and venous obstruction Cushing’s syndrome & glucocorticoids .

pleural fffusion Neck vein obstruction Bounding pulse &elevated BP S3 gallop Pitting & sacral edema Weight gain Increased CVP& PCWP Change in level of consiousness .CLINICAL MANIFESTATION Constant irritating cough Dyspnea & crackles in lungs Cyanosis.

LAB INVESTIGATION serum osmolality <275mOsm/ kg Low . normal or high sodium Decreased hematocrit [ < 45%] Specific gravity below 1.010 Decreased BUN [< 8mg/ dl] .

MANAGEMENT Diuretics [combination of potassium sparing and potassium depleting diuretics] In people with CHF. ACE inhibitors and low dose of beta blockers are used A low sodium diet .

pleural cavity. peritoneal cavity and pericardial sac .VOLUME SHIFT: THIRD SPACING Fluid that shifts into the interstitial spaces and remain there is called as third space fluid Common sites are abdomen .

RISK FACTORS Crushing injuries. major tissue trauma Major surgery Extensive burns Acid –base imbalances and sepsis Perforated peptic ulcers Intestinal obstruction Lymphatic obstruction Autoimmune disorders Hypoalbunemia GI tract malabsorption .

CLINICAL MANIFESTATION skin pallor Cold extremities Weak and rapid pulse Hypotension Oliguria Decreased levels of consiousness LAB INVESTIGATION Elevated hematocrit & BUN level .

For burns and tissue injuries large volume of isosmolar IV fluid is administered 2. Paracentesis for ascitis . IV fluid intake is maintained after major surgery to maintain kidney perfusion 4.MANAGEMENT Treat the cause 1. Albumin is administered for protein deficit 3. Pericardiocentesis if pericarditis is the result 5.

VOULME EXCESS:WATER INTOXICATION ICFVE is increase in amount of water inside the cells .

45%saline or 5%dextrose in water] Consumption of excessive amount of tap water without adequate nutritional intake SIADH Schizophrenia[compulsive water consumption] .ETIOLOGY Administration of excessive amount of hyposmolar IV fluids[0.

delirium. projectile vomiting. disorientation and confusion Increased ICP – pupillary changes and decreased motor and sensory function Bradycardia. Papilledema. elevated BP.CLINICAL MANIFESTATIONS Headaches Behavioral changes Apprehension Irritability. Babinski’s response flaccidity. widened pulse pressure & altered respiratory patterns. convulsions &coma .

LABORATORY FINDINGS High serum sodium level.125 mEq/L decreased hamatocrit .

MANAGEMENT Early administration of IV fluids containing sodium chloride cam prevent SIADH oral fluids such as juices or soft drinks can be given orally every hour Perform neurologic checks every hour to see if cranial changes are present Monitor fluid intake . IV fluids and fluid output hourly and weight daily Administer antiemetics for food and fluid retention .

INTRACELLULAR FLUID VOLUME DEFICIT Severe hypernatremia and dehydration can cause ICFVD Relatively rare in healthy adults common in elderly people and in those conditions that result in acute water loss Symptoms include confusion. coma. and cerebral hemorrhage .

sodium is easily accomplished through normal diet *For those unable to eat.Sodium imbalances Definiti on Risk factors/ etiology Clinical manifestation Laboratory findings management Kidney diseases Hyponatr -aemia It is defined as a plasma sodium level below 135 mEq/ L Adrenal insufficiency Gastrointestinal losses Use of diuretics (especially with along with low sodium diet) Metabolic acidosis •Weak rapid pulse •Hypotension •Dizziness •Apprehension and anxiety •Abdominal cramps •Nausea and vomiting •Diarrhea •Coma and convulsion •Cold clammy skin •Finger print impression on the sternum after palpation •Personality change •Serum sodium less than 135mEq/ L • serum osmolality less than 280mOsm/kg •urine specific gravity less than 1.3%Nacl may be indicated *water restriction in case of hypervolaemia . by NG tube or parenterally *For patients who are able to eat & drink.010 •Identify the cause and treat *Administration of sodium orally.Ringer’s lactate solution or isotonic saline [0.9%Nacl]is given *For very low sodium 0.

45%] *Rapid lowering of sodium can cause cerebral edema *Slow administration of IV fluids with the goal of reducing sodium not more than 2 mEq/L for the first 48 hrs decreases this risk *Diuretics are given in case of sodium excess *In case of Diabetes insipidus desmopressin acetate nasal spray is used *Dietary restriction of sodium in high risk clients .3 or 0.Sodium imbalan -ce Definit ion causes Clinical manifestation Lab findings management Hypernat -remia It is defined as plasma sodium level greater than 145mE q/L *Ingestion of large amount of concentrated salts *Iatrogenic administration of hypertonic saline IV *Excess alderosterone secretion  Low grade fever  Postural hypertension  Dry tongue & mucous membrane  Agitation  Convulsions  Restlessness  Excitability  Oliguria or anuria  Thirst  Dry &flushed skin *high serum sodium 135mEq/L *high serum osmolality295m O sm/kg *high urine specificity 1.030 *Administration of hypotonic sodium solution [0.

heart blocks . fatigue. decreased muscle tone intestinal obstruction Lab findings Management It is defined as plasma potassium level of less than 3. depressed ST.5] can be managed by oral potassium replacement Moderate hypokalemia *K-3. taller U wave * K – less than 2mEq/L cause widened QRS. vomiting or other GI losses *Alkalosis *Cushing’s syndrome *Polyuria *Extreme sweating *excessive use of potassium free Ivs * K – less than 3mEq/L results in ST depression . flat T wave.Potassium imbalances Hypokalemia Definition Causes Clinical manifestation *weak irregular pulse *shallow respiration *hypotesion *weakness.0 mEq/L *Use of potassium wasting diuretic *diarrhea.3to 3. decreased bowel sounds.less than 3.4mEq/L need 100to 200mEq/L of IV potassium for the level to rise to 1mEq/ Severe hypokalemia K. paresthesia.0mEq/L need 200to 400 mEq/L for the level to rise to l mEq/L *Dietary replacement of potassium helps in correcting the problem[1875 to 5625 mg/day] .0to 3. inverted T wave Mild hypokalemia[3.

hypotension.0mEq/L Renal failure . *High serum potassium 5. giving IV saline or potassium wasting diuretics *Severe hyperkalemia is managed by 1. Adrenal insufficiency Use of potassium retaining diuretics & rapid infusion of stored blood irritability. Hypertonic dehydration.infusion of insulin and glucose or sodium bicarbonate to promote potassium uptake 3.3mEq/L results in peaked T wave HR 60 to 110 *serum potassium of 7mEq/L results in low broad Pwave *serum potassium levels of 8mEq/L results in no arterial activity[no pwave] *Dietary restriction of potassium for potassium less than 5.infusion of calcium gluconate to decrease the antagonistic effect of potassium excess on myocardium 2.Definition Causes Clinical manifestation Lab findings Management Hyperkal emia It is defined as the elevation of potassium level above 5.sodium polystyrene sulfonate [Kayexalate] given orally or rectally as retention enema Large amount of IV administration of potassium. paresthesia. anxiety. weakness . Burns& trauma Irregular slow pulse.5 mEq/L *Mild hyperkalemia can be corrected by improving output by forcing fluids.

•pathological fractures.Asymtomatic hypocalcemia is treated with oral calcium chloride. •neoplastic diseases.Calcium imbalanc es Definitio n Causes Clinical manifestation Lab findings Management hypocalc emia It is a plasma calcium level below 8.5 mg/dl •Rapid administration of blood containing citrate. •pancreatitis •Numbness and tingling sensation of fingers. •prolonged bleeding time Serum calcium less than 4. •Vitamin deficiency.3 mEq/L and ECG changes 1. •hyperactive reflexes. positive chvostek’s sign . •Hypothyroidism . •hypoalbuminemia.Tetany from acute hypocalcemia needs IV calcium chloride or calcium gluconate to avoid hypotension bradycardia and other dysrythmias 3.Chronic or mild hypocalcemia can be treated by consumption of food high in calcium . •muscle cramps. calcium gluconate or calcium lactate 2. • Positve Trousseau’s sign.

•elevated BUN 25mg/100ml.5mg /100ml 1. lethargy. •weakness . •low back pain from kidney stones.IV normal saline.5mEq/L.Plicamycin an antitumor antibiotics decrease the plasma calcium level 3. vomiting. •anorexia.Corticosteroid drugs compete with vitamin D and decreases intestinal absorption of calcium 5. given rapidly with Lasix promotes urinary excretion of calcium 2. •Metastatic bone tumors. •osteoporosis . •widened bone cavitation. •decreased level of consciousness & cardiac arrest •High serum calcium level 5. •paget’s disease.Calcium imbalance Definition Causes Clinical manifestation Lab findings Management Hypercalc emia It is calcium plasma level over 5. • x.5 mEq/l or 11mg/dl •Hyperthyro •idism. •urinary stones.Calcitonin decreases serum calcium level 4.ray showing generalized osteoporosis. •prolonged immobalisation •Decreased muscle tone. •nausea. •elevated creatinine1. If cause is excessive use of calcium or vitamin D supplements reduce or avoid the same .

syncope. coma PH lesser than 7. giddiness. neuromuscular disorder. Chemical stimulation of respiratory center. Respiratory center depression.Correct electrolyte imbalance 4. thickened alveolar – capillary membrane. late ARDS.Acid-Base imbalance Definition Causes Clinical manifestation Lab findings Management Respiratory acidosis Hypoventilation & excessive CO2 production It is a clinical disorder in which the pH is less than 7.35 PaCO2 lesser than 35 mmHg.Intravenous NaHCO3 Respiratory Alkalosis Hyperventilation It is a clinical condition in which the arterial Ph is greater than7. weakness. paresthesia. coma. tetany PH greater than 7. Hypokalemia.45 and the paCO2 is less than 38mmHg Hypoxemia.Treat underlying cause 2. dizziness. GuillianBarre syndrome. Dyspnea . convulsions. Hypoxemia 1. traumatic stimulation of respiratory center Tachypnea. Myssthenia gravis. Hypocalcemia Increase CO2 retention through CO2 rebreathing & sedation and mechanical hypoventilation .35. Drugs. Paco2 greater than 45mmHg. Hyperkalemia.Support ventilation 3. impaired lung expansion. disorientation.35 and the paCO2 is greater than 42mmHg COPD.

renal tubular acidosis Hyperventilation confusion. HCO3< 22mEq/L 1.Treat the underlying cause 2.35.45 Hypokalemia Hypocalcemia PaCO2 normal or increased 1. headache PH< 7.correct electrolyte imbalance Metabolic Alkalosis It is a clinical condition in which PH is raised Hypokalemia.Administer KCL 3. coma. ingested toxins.Treat the underlying cause 2. Overcorrection of acidosis with NaCO3 Hypoventilation Dysrythmias PH >7.Intravenous NaHCO3 3.intravenous acidifying salts[NH4CL] 4. massive correction of whole blood. Diabetic ketoacidosis. Lactic acidosis. gatric fluid loss.Administer acetazolamide .Definition causes Clinical manifestation Lab findings Management Metabolic Acidosis It is a clinical condition in which the HCO3 & pH is decreased Renal failure. drowsiness.