Fluid and Electrolytes: Balance and Disturbance

Chapter 13
Fluid and Electrolytes: Balance and

Disturbance
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Fluid and Electrolyte

Balance
Necessary for life, homeostasis
Nursing role: help prevent, treat fluid,
electrolyte disturbances
Fluid
Approximately 60% of typical adult is fluid
Varies with age, body size, gender
Intracellular fluid
Extracellular fluid
Intravascular
Interstitial
Transcellular
Third spacing: loss of ECF into space that

does not contribute to equilibrium
Electrolytes
Active chemicals that carry positive
(cations), negative (anions) electrical
charges
Major cations: sodium, potassium,
calcium, magnesium, hydrogen ions
Major anions: chloride, bicarbonate,
phosphate, sulfate, and proteinate ions
Electrolyte concentrations differ in

fluid compartments
Regulation of Fluid
Movement of fluid through capillary
walls depends on
Hydrostatic pressure: exerted on walls of
blood vessels
Osmotic pressure: exerted by protein in
plasma
Direction of fluid movement depends

on differences of hydrostatic,
osmotic pressure
Regulation of Fluid
Osmosis: area of low solute concentration to
area of high solute concentration
Diffusion: solutes move from area of higher
concentration to one of lower concentration
Filtration: movement of water, solutes
occurs from area of high hydrostatic
pressure to area of low hydrostatic pressure
Active transport: physiologic pump that
moves fluid from area of lower concentration
of one of higher concentration
Active Transport
Physiologic pump that moves fluid
from area of lower concentration to
one of higher concentration
Movement against concentration
gradient
Sodium-potassium pump: maintains
higher concentration of extracellular
sodium, intracellular potassium
Requires adenosine (ATP) for energy
Question
Tell whether the following statement
is true or false:
Osmosis is the movement of a
substance from an area of higher
concentration to one of lower
concentration.
Answer
False.
Rationale: Diffusion is the movement of a
substance from an area of higher
concentration to one of lower concentration.
The concentration of dissolved substances
draws fluid in that direction. Osmosis is the
movement of fluid, through a semipermeable
membrane, from an area of low solute
concentration to an area of high solute
concentration until the solutions are of equal
concentration.
Routes of Gains and Losses

Gain
Dietary intake of fluid, food or enteral
feeding
Parenteral fluids
Routes of Gains and Losses (contd)

Loss
Kidney: urine output
Skin loss: sensible, insensible losses
Lungs
GI tract
Other
Question
What is the average daily urinary
output in an adult?
0.5 L
1.0 L
1.5 L
2.5 L
Answer
C. 1.5 L
Rationale: Vital to the regulation of
fluid and electrolyte balance, the
kidneys normal filter 170 L of plasma
every day in the adult, while
excreting only 1.5 L of urine.
Gerontologic Considerations
Reduced homeostatic mechanisms:
cardiac, renal, respiratory function
Decreased body fluid percentage
Medication use
Presence of concomitant conditions
Fluid Volume Imbalances

Fluid volume deficit (FVD):
hypovolemia
Fluid volume excess (FVE):
hypervolemia
Fluid Volume Deficit

Loss of extracellular fluid exceeds
intake ratio of water
Electrolytes lost in same proportion as
they exist in normal body fluids
Dehydration: loss of water along with

increased serum sodium level
May occur in combination with other
imbalances
Fluid Volume Deficit (contd)

Dehydration
Causes: fluid loss from vomiting,
diarrhea, GI suctioning, sweating,
decreased intake, inability to gain
access to fluid
Risk factors: diabetes insipidus, adrenal
insufficiency, osmotic diuresis,
hemorrhage, coma, third space shifts

Manifestations: rapid weight loss,
decreased skin turgor, oliguria,
concentrated urine, postural
hypotension, rapid weak pulse,
increased temperature, cool clammy
skin due to vasoconstriction,
lassitude, thirst, nausea, muscle
weakness, cramps
Laboratory data: elevated BUN in
relation to serum creatinine,

Medical management: provide fluids
to meet body needs
Oral fluids
IV solutions
Fluid Volume Deficit - Nursing

Management
I&O, VS
Monitor for symptoms: skin and
tongue turgor, mucosa, UO, mental
status
Measures to minimize fluid loss
Oral care
Administration of oral fluids
Administration of parenteral fluids
Question
What is a major indicator of
extracellular FVD?
Full and bounding pulse
Drop in postural blood pressure
Elevated temperature
Pitting edema of lower extremities
Answer
B. Drop in postural blood pressure
Rationale: FVD signs and symptoms include acute
weight loss; decreased skin turgor; oliguria;
concentrated urine; orthostatic hypotension due to
volume depletion; a weak, rapid heart rate; flattened
neck veins; increased temperature; thirst; decreased or
delayed capillary refill; decreased central venous
pressure; cool, clammy, pale skin related to peripheral
vasoconstriction; anorexia; nausea; lassitude; muscle
weakness; and cramps. Clinical manifestations of FVE
result from expansion of the ECF and include edema,
distended neck veins, and crackles (abnormal lung
sounds).
Fluid Volume Excess

Due to fluid overload or diminished homeostatic
mechanisms
Risk factors: heart failure, renal failure, cirrhosis of liver
Contributing factors: excessive dietary sodium or
sodium-containing IV solutions
Manifestations: edema, distended neck veins, abnormal
lung sounds (crackles), tachycardia, increased BP, pulse
pressure and CVP, increased weight, increased UO,
shortness of breath and wheezing
Medical management: directed at cause, restriction of
fluids and sodium, administration of diuretics
Fluid Volume Excess - Nursing

Management
I&O and daily weights; assess lung sounds,
edema, other symptoms; monitor responses to
medications- diuretics
Promote adherence to fluid restrictions, patient
teaching related to sodium and fluid restrictions
Monitor, avoid sources of excessive sodium,
including medications
Promote rest
Semi-Fowlers position for orthopnea
Skin care, positioning/turning
Electrolyte Imbalances
Sodium: hyponatremia,
hypernatremia
Potassium: hypokalemia,
hyperkalemia
Calcium: hypocalcemia,
hypercalcemia
Magnesium: hypomagnesemia,
hypermagnesemia
Phosphorus: hypophosphatemia,
hyperphosphatemia
Hyponatremia
Serum sodium less than 135 mEq/L
Causes: adrenal insufficiency, water intoxication, SIADH
or losses by vomiting, diarrhea, sweating, diuretics
Manifestations: poor skin turgor, dry mucosa,
headache, decreased salivation, decreased BP, nausea,
abdominal cramping, neurologic changes
Medical management: water restriction, sodium
replacement
Nursing management: assessment and prevention,
dietary sodium and fluid intake, identify and monitor atrisk patients, effects of medications (diuretics, lithium)
Hypernatremia
Serum sodium greater than 145mEq/L

Causes: excess water loss, excess sodium
administration, diabetes insipidus, heat stroke,
hypertonic IV solutions
Manifestations: thirst; elevated temperature; dry,
swollen tongue; sticky mucosa; neurologic
symptoms; restlessness; weakness
Note: thirst may be impaired in elderly or the ill
Medical management: hypotonic electrolyte
solution or D5W
Nursing management: assessment and
prevention, assess for OTC sources of sodium,
offer and encourage fluids to meet patient needs,
provide sufficient water with tube feedings
Hypokalemia
Below-normal serum potassium (<3.5 mEq/L), may

occur with normal potassium levels with alkalosis
due to shift of serum potassium into cells
Causes: GI losses, medications, alterations of acidbase balance, hyperaldosterism, poor dietary intake
Manifestations: fatigue, anorexia, nausea, vomiting,
dysrhythmias, muscle weakness and cramps,
paresthesias, glucose intolerance, decreased
muscle strength, DTRs
Medical management: increased dietary potassium,
potassium replacement, IV for severe deficit
Nursing management: assessment, severe
hypokalemia is life-threatening, monitor ECG and
ABGs, dietary potassium, nursing care related to IV
potassium administration
Hyperkalemia
Serum potassium greater than 5.0 mEq/L
Causes: usually treatment related, impaired renal
function, hypoaldosteronism, tissue trauma, acidosis
Manifestations: cardiac changes and dysrhythmias,
muscle weakness with potential respiratory
impairment, paresthesias, anxiety, GI manifestations
Medical management: monitor ECG, limitation of
dietary potassium, cation-exchange resin (Kayexalate),
IV sodium bicarbonate , IV calcium gluconate, regular
insulin and hypertonic dextrose IV, -2 agonists,
dialysis
Hyperkalemia (contd)
Nursing management: assessment of serum
potassium levels, mix IVs containing K+ well,
monitor medication affects, dietary potassium
restriction/dietary teaching for patients at risk
Hemolysis of blood specimen or drawing of blood
above IV site may result in false laboratory result
Salt substitutes, medications may contain
potassium
Potassium-sparing diuretics may cause elevation
of potassium
Should not be used in patients with renal dysfunction
Question
Tell whether the following statement
is true or false:
The ECG change that is specific to
hyperkalemia is a peaked T wave.
Answer
True.
Rationale: The ECG changes that are
specific to hyperkalemia are peaked
T wave; wide, flat P wave; and wide
QRS complex. The ECG changes that
are specific to hypokalemia are
flatted T wave and the appearance of
a U wave.
Hypocalcemia
Serum level less than 8.5 mg/dL, must be
considered in conjunction with serum albumin
level
Causes: hypoparathyroidism, malabsorption,
pancreatitis, alkalosis, massive transfusion of
citrated blood, renal failure, medications, other
Manifestations: tetany, circumoral numbness,
paresthesias, hyperactive DTRs, Trousseaus
sign, Chovstek's sign, seizures, respiratory
symptoms of dyspnea and laryngospasm,
abnormal clotting, anxiety
Hypocalcemia (contd)
Medical management: IV of calcium
gluconate, calcium and vitamin D
supplements; diet
Nursing management: assessment,
severe hypocalcemia is lifethreatening, weight-bearing
exercises to decrease bone calcium
loss, patient teaching related to diet
and medications, and nursing care
related to IV calcium administration
Trousseaus Sign
Hypercalcemia
Serum level above 10.5 mg/dL

Causes: malignancy and hyperparathyroidism, bone
loss related to immobility
Manifestations: muscle weakness, incoordination,
anorexia, constipation, nausea and vomiting,
abdominal and bone pain, polyuria, thirst, ECG
changes, dysrhythmias
Medical management: treat underlying cause, fluids,
furosemide, phosphates, calcitonin, biphosphonates
Nursing management: assessment, hypercalcemic
crisis has high mortality, encourage ambulation, fluids
of 3 to 4 L/d, provide fluids containing sodium unless
contraindicated, fiber for constipation, ensure safety
Hypomagnesemia
Serum level less than 1.8 mg/dL, evaluate in

conjunction with serum albumin
Causes: alcoholism, GI losses, enteral or parenteral
feeding deficient in magnesium, medications, rapid
administration of citrated blood; contributing
causes include diabetic ketoacidosis, sepsis, burns,
hypothermia
Manifestations: neuromuscular irritability, muscle
weakness, tremors, athetoid movements, ECG
changes and dysrhythmias, alterations in mood
and level of consciousness
Medical management: diet, oral magnesium,
magnesium sulfate IV
Hypomagnesemia (contd)
Nursing management: assessment, ensure
safety, patient teaching related to diet,
medications, alcohol use, and nursing care
related to IV magnesium sulfate
Hypomagnesemia often accompanied by
hypocalcemia
Need to monitor, treat potential hypocalcemia
Dysphasia common in magnesium-depleted

patients
Assess ability to swallow with water before
administering food or medications
Hypermagnesemia
Serum level more than 2.7 mg/dL

Causes: renal failure, diabetic ketoacidosis, excessive
administration of magnesium
Manifestations: flushing, lowered BP, nausea, vomiting,
hypoactive reflexes, drowsiness, muscle weakness,
depressed respirations, ECG changes, dysrhythmias
Medical management: IV calcium gluconate, loop
diuretics, IV NS of RL, hemodialysis
Nursing management: assessment, do not administer
medications containing magnesium, patient teaching
regarding magnesium containing OTC medications
Hypophosphatemia
Serum level below 2.5 mg/DL
Causes: alcoholism, refeeding of patients after
starvation, pain, heat stroke, respiratory alkalosis,
hyperventilation, diabetic ketoacidosis, hepatic
encephalopathy, major burns, hyperparathyroidism,
low magnesium, low potassium, diarrhea, vitamin D
deficiency, use of diuretic and antacids
Manifestations: neurologic symptoms, confusion,
muscle weakness, tissue hypoxia, muscle and bone
pain, increased susceptibility to infection
Medical management: oral or IV phosphorus
replacement
Nursing management: assessment, encourage foods
high in phosphorus, gradually introduce calories for
malnourished patients receiving parenteral nutrition
Hyperphosphatemia
Serum level above 4.5 mg/DL
Causes: renal failure, excess phosphorus, excess vitamin
D, acidosis, hypoparathyroidism, chemotherapy
Manifestations: few symptoms; soft-tissue calcifications,
symptoms occur due to associated hypocalcemia
Medical management: treat underlying disorder, vitaminD preparations, calcium-binding antacids, phosphatebinding gels or antacids, loop diuretics, NS IV, dialysis
Nursing management: assessment, avoid highphosphorus foods; patient teaching related to diet,
phosphate-containing substances, signs of hypocalcemia
Hypochloremia
Serum level less than 96 mEq/L
Causes: Addisons disease, reduced chloride intake,
GI loss, diabetic ketoacidosis, excessive sweating,
fever, burns, medications, metabolic alkalosis
Loss of chloride occurs with loss of other
electrolytes, potassium, sodium
Manifestations: agitation, irritability, weakness,
hyperexcitability of muscles, dysrhythmias,
seizures, coma
Medical management: replace chloride-IV NS or
0.45% NS
Nursing management: assessment, avoid free
water, encourage high-chloride foods, patient
teaching related to high-chloride foods
Hyperchloremia
Serum level more than 108 mEq/L
Causes: excess sodium chloride infusions with water
loss, head injury, hypernatremia, dehydration, severe
diarrhea, respiratory alkalosis, metabolic acidosis,
hyperparathyroidism, medications
Manifestations: tachypnea, lethargy, weakness, rapid,
deep respirations, hypertension, cognitive changes
Normal serum anion gap
Medical management: restore electrolyte and fluid
balance, LR, sodium bicarbonate, diuretics
Nursing management: assessment, patient teaching
related to diet and hydration
Maintaining Acid-Base
Balance
Normal plasma pH 7-35-7.45:
hydrogen ion concentration
Major extracellular fluid buffer
system;
bicarbonate-carbonic acid buffer
system
Kidneys regulate bicarbonate in ECF
Lungs under control of medulla
regulate CO2, carbonic acid in ECF
Maintaining Acid-Base
Balance (contd)
Other buffer systems
ECF: inorganic phosphates, plasma
proteins
ICF: proteins, organic, inorganic
phosphates
Hemoglobin
Question
What is the most common buffer
system in the body?
Plasma protein
Hemoglobin
Phosphate
Bicarbonate-carbonic acid
Answer
D. Bicarbonate-carbonic acid
Rationale: The bodys major
extracellular buffer system is the
bicarbonatecarbonic acid buffer
system, which is assessed when
arterial blood gases are measured.
Metabolic Acidosis
Low pH <7.35
Low bicarbonate <22 mEq/L
Most commonly due to renal failure
Manifestations: headache, confusion, drowsiness,
increased respiratory rate and depth, decreased blood
pressure, decreased cardiac output, dysrhythmias,
shock; if decrease is slow, patient may be
asymptomatic until bicarbonate is 15 mEq/L or less
Correct underlying problem, correct imbalance
Bicarbonate may be administered
Metabolic Acidosis (contd)

With acidosis, hyperkalemia may
occur as potassium shifts out of cell
As acidosis is corrected, potassium
shifts back into cell, potassium levels
decrease
Monitor potassium levels
Serum calcium levels may be low
with chronic metabolic acidosis
Must be corrected before treating
acidosis
Metabolic Alkalosis
High pH >7.45
High bicarbonate >26 mEq/L
Most commonly due to vomiting or
gastric suction
May also be due to medications,
especially long-term diuretic use
Hypokalemia will produce alkalosis

Manifestations: symptoms related to
decreased calcium, respiratory
depression, tachycardia, symptoms
Metabolic Alkalosis (contd)

Correct underlying disorder, supply
chloride to allow excretion of excess
bicarbonate, restore fluid volume
with sodium chloride solutions
Respiratory Acidosis
Low pH <7.35
PaCO2 >42 mm Hg
Always due to respiratory problem
with inadequate excretion of CO2
With chronic respiratory acidosis,
body may compensate, may be
asymptomatic
Symptoms may be suddenly increased
pulse, respiratory rate and BP, mental
changes, feeling of fullness in head
Respiratory Acidosis (contd)

Potential increased intracranial
pressure
Treatment aimed at improving
ventilation
Respiratory Alkalosis
High pH >7.45
PaCO2 <35 mm Hg
Always due to hyperventilation
Manifestations: lightheadedness,
inability to concentrate, numbness
and tingling, sometimes loss of
consciousness
Correct cause of hyperventilation
Arterial Blood Gases

pH 7.35 - (7.4) - 7.45
PaCO2 35 - (40) - 45 mm Hg
HCO3 22 - (24) - 26 mEq/L
Assumed average values for ABG
interpretation
PaO2 80 to 100 mm Hg
Oxygen saturation >94%
Base excess/deficit 2 mEq/L
IV Site Selection
Complications of IV Therapy
Fluid overload
Air embolism
Septicemia, other infections
Infiltration, extravasation
Phlebitis
Thrombophlebitis
Hematoma
Clotting, obstruction

Fluid and Electrolytes: Balance and Disturbance

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Chapter 13

Fluid and Electrolytes: Balance and

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fluid and Electrolyte

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Third spacing: loss of ECF into space that

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Electrolyte concentrations differ in

Direction of fluid movement depends

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Routes of Gains and Losses

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Routes of Gains and Losses (contd)

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fluid Volume Imbalances

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fluid Volume Deficit

Dehydration: loss of water along with

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fluid Volume Deficit (contd)

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fluid Volume Deficit (contd)

Fluid Volume Deficit (contd)

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fluid Volume Deficit - Nursing

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fluid Volume Excess

Fluid Volume Excess - Nursing

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Serum sodium greater than 145mEq/L

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Below-normal serum potassium (<3.5 mEq/L), may

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Serum level above 10.5 mg/dL

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Serum level less than 1.8 mg/dL, evaluate in

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Dysphasia common in magnesium-depleted

Serum level more than 2.7 mg/dL

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Metabolic Acidosis (contd)

Hypokalemia will produce alkalosis

Metabolic Alkalosis (contd)

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Respiratory Acidosis (contd)

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Arterial Blood Gases

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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