Fluid and Electrolytes,

Balance and Disturbances

FLUID

#
#
 AVENUES BY WHICH WATER
ENTERS AND LEAVES THE BODY

#
 ANTIDIURETIC HORMONE REGULATION MECHANISMS

Osmolarity Osmoreceptors
in
hypothalamus
Blood Volume
Hypothala
volume receptor mus ADH Kidne
or BP y
Atria and great tubule
veins
Posterior H2Os
pituitary reabsorpti
Narcotics, Stress, gland on
Anesthetic agents, vascular
Heat, Nicotine, volume
Antineoplastic and
agents, Surgery osmolari
#
ty
 ALDOSTERONE-RENIN-ANGIOTENSIN SYSTEM

Serum Sodium Juxtaglomerular RENI Angiotensinog

N
Blood volume cells-kidney en in plasma

Angiotens
in I Angiotensin-
converting
Via vasoconstriction of arterial smooth muscle enzyme
Sodium Angiotensi
resorption Kidney ALDOSTERONE n II
(H2O tubules Adrenal
resorbed Cortex
with Intestine,
sodium); sweat
Blood glands, S #
volume
 Fluid Types
Fluids in the body generally arent
found in pure forms
Isotonic, hypotonic, and hypertonic
types
Defined in terms of the amount of
solute or dissolve substances in the
solution
Balancing these fluids involves the
shifting of fluid not the solute involved
#
 Isotonic Solutions
No net fluid shifts
occur between isotonic
solutions because the
solution are equally
concentrated
Ex. NSS or 0.9SS

#
 Hypotonic Solutions
Has a lower solute
concentration than
another solution
Fluid from the
hypotonic solution
would shift into the
second solution until
the two solutions had
equal concentrations
Ex. Half normal or
0.45%SS
#
 Hypertonic Solutions
Has a higher solute
concentration than
another solution
Fluid from the second
solution would shift
into the hypertonic
solution until the two
solutions had equal
concentrations
Ex. D5NSS

#
 Fluid Movements
Fluids and solutes constantly move
within the body, which allows the body
to maintain homeostasis
Fluids along with nutrients and waste
products constantly shift within the
bodys compartments from the cell to
the interstitial spaces, to the blood
vessels and back again
#
Fluid Movements
Types of Transport
A. Active transport
B. Passive transport
Diffusion
Osmosis
Filtration

#
 FLUID BALANCE
The desirable amount of fluid intake and loss in adults ranges from
1500 to 3500 mL each 24 hours. Ave= 2500 mL
Normally INTAKE = OUTPUT
FLUID IMBALANCE
Changes in ECF volume = alterations in sodium balance
Change in sodium/water ratio = either hypoosmolarity or
hyperosmolarity
Fluid excess or deficit = loss of fluid balance
As with all clinical problems, the same pathophysiologic change is
not of equal significance to all people
For example, consider two persons who have the same viral
syndrome with associated nausea and vomiting

#
 FLUID DEFICIT/HYPOVOLEMIA
May occur as a result of:
Reduced fluid intake
Loss of body fluids
Sequestration (compartmentalizing) of body fluids
Pathophysiology and Clinical Manifestations

DECREASED FLUID VOLUME

Stimulation of thirst ADH Secretion Renin-Angiotensin-

center in hypothalamus Aldosterone System
Activation
Water resorption
Person complains of thirst
Sodium and
Urine Output
Water Resorption

Urine specific gravity

#
 Pathophysiology and Clinical Manifestations
UNTREATED FLUID VOLUME DEFICIT

Depletion of fluids available

Cells become unable to continue BODY TEMPERATURE

providing water to replace ECF
losses
Dry mucous membranes

Signs of circulatory collapse

Difficulty with speech
blood pressure
heart rate
respiratory rate

Restlessness and Apprehension

#
 Hypovolemia
Nursing Intervention
Monitor fluid intake and output
Checked daily weight (a 1lb(0.45kg) weight loss equals a
500 ml fluid loss)
Monitor hemodynamic values such as CVP
Monitor results of laboratory studies
Assess level of consciousness
Administer and monitor I.V. fluids
Apply and adjust oxygen therapy as ordered
If patient is bleeding, apply direct continuous pressure to the
area and elevate it if possible
Assess skin turgor
Assess oral mucous membranes
Turn the patient at least every 2 hours to prevent skin
breakdown #
Encourage oral fluids
 Hypovolemia
Warning Signs
Cool pale skin over the arms and legs
Decreased central venous pressure
Delayed capillary refill
Deterioration in mental status flat jugular veins
Orthostatic hypotension
Tachycardia
Urine output initially more than 30ml/min, then
dropping below 10ml/hour
Weak or absent peripheral pulses
Weight loss

#
 Collaborative Care Management
Identification of vulnerable patients and
risk factors:
* Compromised mental state
* Physical limitations
* Disease states
* LimitedDevelopment of a plan offood
access to adequate care and
fluids
Ongoing assessment and Collaboration with the Family members should
detailed action plan of nurse, patient, family be educated about the
fluid and serum members, and other importance of fluid and
electrolyte balance. health care providers nutrition intake
Factors such as for continued
medications (particularly assessment and
diuretics), treatment of problems
hyperventilation, fever,
burns, diarrhea, and
diabetes with
appropriate referral #
 Collaborative Care Key Points
1 Liter of water = 1 kg of water by weight
Fluid replacement are calculated according to this ratio plus 1.5 L to
fulfill the current daily needs
For example, JUAN, a one-year-old, lost 1 kg of water from diarrhea as
weighed from his diaper over the last 24 hours. Therefore, since 1
kg=1 L, fluid replacement therapy for him will involve 1 L of fluids +
1500 L.
Oral fluid resuscitation is preferable but if the patient is unable to
tolerate fluids, IV Therapy may be ordered
Vital signs should be assessed regularly
Postural hypotension is common for postural persons with fluid
volume deficit. How do we assess this?
For example, in the care of LOIDA, a 31 year old with severe DHN, you
take her blood pressure (130/80) and pulse (75) while shes lying
down. Then you ask her to sit at the edge of bed. When you take her
blood pressure again, you get 115/80 and when you take her pulse,
you get 80. This is consistent with intravascular volume depletion.
Daily weighing is also useful to monitor fluid and electrolyte balance
Laboratory results should be reviewed for various fluid and electrolyte
disturbances so that appropriate adjustments to therapy can be
initiated
#
 Fluid Replacement Therapy
Aimed at restoring and maintaining
homeostasis
Methods:
Oral and gastric feeding
Parenteral therapy
Choice of therapy affected by several
factors
Type and severity of imbalance
Patients overall health status, age, renal and
cardiovascular status
Usual maintenance requirements #
 Fluid
Advantages
Replacement Therapy
Provides the patient with life-sustaining
fluids, electrolytes, and drugs
Immediate and predictable therapeutic
effects
Preferred for administering fluids,
electrolytes, and drugs in emergency
situations
Allows fluid intake when a patient has GI
malabsorption
Permits accurate dosage titration for
analgesics and other drugs
#
 Fluid Replacement Therapy
Disadvantages
Solution incompatibility
Adverse reactions
Infection

#
 Fluid Replacement Therapy
Administration routes

Oral route : oral ingestion of fluids and electrolytes as

liquids or solids administered directly into the GI tract

Nasogastric route: instillation of fluids and electrolytes

through feeding tubes, such as NG, gastrostomy and
jejunostomy tubes

I.V. route: administration of fluids and electrolytes

directly into the bloodstream using continuous
infusion, bolus, or I.V. push injection through
peripheral or central venous site
#
 Fluid Replacement Therapy
ISOTONIC SOLUTION
Facts Examples Uses

-same osmolality as plasma Dextrose 5% in -Fluid loss and

(app. 275 to 295 mOsm/kg) water, dehydration
-vascular space osmolality not -Hypernatremia
altered by infusion
-expand intracellular and Normal Saline -Blood transfusion,
extracellular space equally; Solution, fluid challenges,
degree of expansion correlates resuscitation, shock,
with amount of fluid infused metabolic alkalosis,
-no solution-related shifting hypercalcemia,
between ICF and ECF spaces hyponatremia
-cells neither shrink nor swell
with fluid movement
Lactated Ringers -Acute blood loss,
Solution
#
burns, dehydration,
hypovolemia
 Fluid Replacement Therapy
HYPOTONIC SOLUTION
Facts Examples Uses

-lower osmolality than 0.45% sodium -DKA after initial NSS and
plasma (usually less chloride (half- before dextrose infusion
than 275 mOsm/kg) normal saline -gastric fluid loss from
-hypo-osmolality solution) nasogastric suctioning or
possible with infusion vomiting
because solutions have 0.3% sodium -hypertonic dehydration
a lower concentration of chloride -sodium and chloride
electrolytes than plasma depletion
does
-water replacement
-transcend all
membranes from
vascular space to tissue
to cell
-cell swells
#
 Fluid Replacement Therapy
HYPERTONIC SOLUTION
Facts Examples Uses

-higher osmolality than Dextrose 5% in half DKA

plasma (usually > 295 normal saline solution
mOsm/kg)
-Infusion can Dextrose 5% in normal Addisonian crisis
significantly raised saline solution
plasma osmolality Hypotonic dehydration
-can cause vascular SIADH
volume expansion and
ICF deficit Dextrose 10% in water Water replacement
-Cell shrinks

#
 FLUID EXCESS/HYPERVOLEMIA
Psychiatric Dietary Sodium Renal and endocrine
Disorders, Indiscretion disturbances,
SIADH, Certain malignancies,
head injuries adenomas
Failure of renal
Excessive Sodium or hormonal
Overhydration Intake regulatory
functions

FLUID VOLUME
EXCESS/HYPERVOLEMIA

#
 Since ECF becomes hypoosmolar, fluid moves into the cells to equalize
the concentration on both sides of the cell membrane

Thus there, is an increase in intracellular fluid

The brain cells are particularly sensitive to the increase of intracellular
water, the most common signs of hypoosmolar overhydration are
changes in mental status. Confusion, ataxia, and convulsions may also
occur.
Other clinical manifestations include: hyperventilation, sudden weight
gain, warm, moist skin, increased ICP: slow bounding pulse with an
increase in systolic and decrease in diastolic pressue and peripheral
edema, usually not marked #
 Hypervolemia

Evaluating pitting edema

Press your fingertip firmly into the patients skin over a
bony surface for a few seconds. Then note the depth of
the imprint your finger leaves on the skin
A slight imprint indicates +1 pitting edema
A deep imprint, with the skin slow to return to its original
contour, indicates a +4 pitting edema
When the skin resists pressure and appears distended, the
condition is called brawny edema, which causes the skin to
swell so much that fluid cant be displaced

#
 Hypervolemia
Diagnostic Findings:
Decreased hematocrit resulting from hemodilution
Normal serum Na level
Low serum K and BUN levels
either due to hemodilution or higher levels may indicate
renal failure
Low oxygen level
Abnormal chest x-ray
Indicates fluid accumulation
May reveal pulmonary edema or pleural effusions

#
 Hypervolemia
Treatment
Na and fluid intake restriction
Diuretics to promote excess fluid excretion
Morphine and nitroglycerin (Nitro-Dur) for
pulmonary edema
Dilate blood vessels
Reduce pulmonary congestion and amount of
blood returning to the heart
Digoxin for heart failure
Strengthens cardiac contractions
#
 Hypervolemia

Treatment
Supportive measures
Oxygen administration
Bed rest
Hemodialysis or continuous renal
replacement therapy for renal dysfunction

#
 Hypervolemia
Nursing Interventions
Monitor fluid intake and output
Monitor daily weight
Monitor cardiopulmonary status
Auscultate breathe sounds
Assess for complaints of dyspnea
Monitor chest x-ray results
Monitor arterial blood gas values
Assess for peripheral edema
Inspect the patient for sacral edema
Monitor infusion of I.V. solutions
Monitor the effects of prescribed medications
#
ELECTROLYTES

#
cations

#
 sodium potassium

calcium magnesium

#
Electrolytes are measured
milliequivalent per litre
of water
(mEq / L)
#
 Equivalent refers to the chemical
combining power of a substance or
the power of cations to unite with
anions to form molecules

#
#
 most abundant cat ion in the
extracellular fluid
sodium is regulated by

Salt intake Aldosterone

Urinary output

#
 functions
Maintain balance of extracellular fluid, thereby
it controls the movements of the water between
fluid compartments

Transmission of nerve impulses

Neuro muscular and myocardial impulse

transmission
#
Normal concentration
of sodium

135 to 145
mEq/L
#
#
Main intracellular cat ion
Helps in maintaining fluid balance of
the intracellular fluid
Potassium is regulated by

#
 functions
Regulates neuromuscular excitability and muscle
contraction

Needed for glycogen formation and protein

sunthesis

Correction of acid base imbalances. Potassium

ion can be exchanged with hydrogen ion (H+)
#
Normal concentration
of potassium

3.5 to 5.3
mEq/L
#
#
Calcium is the most abundant element
in the body
Calcium is extracellular fluid
Regulated by the action of
Thyroid gland parathyroid gland

#
Parathyroid hormone (PTH) controls
the balance among bone calcium,
gastrointestinal absorption and
kidney excretion of calcium.

Thyrocalcitonin from the thyroid

gland inhibits the release of calcium
from bones, thus playing a minor
role in determining serum calcium
levels.
#
 functions
Maintenance of cell membrane, its integrity and
structure

Conduction of nerve impulses in the skeletal

muscle

Stimulation and depolarization and contraction

of cardiac muscles
#
 functions
Aids in blood coagulation

Growth and formation of bones

Muscle relaxation

#
Normal concentration
of calcium

4 to 5
mEq/L
#
#
Magnesium is the second most
important cat ion in the
intracellular fluid

It has an inhibitory effect on

skeletal muscles.

#
 functions
Precipitation of metabolic activities of cells

Enzyme activity

Neuro chemical activity

Muscular excitability

#
Normal concentration
of magnesium

1.5 to 2.4
mEq/L
#
anions

#
 chloride
phosphate

bicarbonate

#
#
Phosphate is a buffer anion in
extracellular and intracellular fluid

Phosphate absorption is through

gastrointestinal tract in a range of 3 to
12 mg/100 ml

Calcium and phosphate are inversely

proportional.

When one rises the other falls

#
Serum phosphate is regulated by

kidneys

Parathyroid hormone

#
Activated vitamin D

#
 functions
Development and maintenance of bones and
teeth

Promotes normal neuromuscular action

Participates in carbohydrate metabolism

Assist in acid base regulation

Maintains levels of ATP ( Adenosine

Triphosphate) and thus energy levels #
Normal concentration
of phosphate

2.5 to 4.5
mEq/L
#
#
Chlorides are found in extracellular and
intracellular fluids

The chloride ion balances the cations

within the extracellular fluid

The ion exchange helps to maintain the

electrical neutrality

#
Chloride is regulated through
kidneys

The dietary intake of chloride and

the amount excreted in urine are
closely related

#
Normal concentration
of chloride

100 to 106
mEq/L
#
#
Bicarbonate is found in extracellular
and intracellular fluids

It is a major chemical buffer in the

body

Regulation is through kidneys

It is an essential component of the

carbonic acid-bicarbonate buffering
system essential to acid base balance
#
 Normal arterial
bicarbonate value

22 to 26
mEq/L
#
 Normal venous
bicarbonate value
24 to 30
mEq/L
In venous blood, bicarbonate
is measured as
carbondioxide content

#
FLUID VOLUME
DISTURBANCES

#
 Fluid
volume deficit

hypovolemia
#
 Fluid Volume Deficit
Mild 2% of body weight loss

Moderate 5% of body weight loss

Severe 8% or more of body

weight loss

#
 Pathophysiology
results from loss of
body fluids and occurs
more rapidly when coupled
with decreased fluid
intake

#
 Clinical manifestations

Acute Weight loss

Decreased skin turgor

#
Concentrated urine

flattened neck veins

Postural hypotension

#
Weak, rapid, heart rate

Oliguria

Increased temperature

Decreased central venous pressure

#
 Nursing Diagnosis
Fluid volume Deficit r/t
Insufficient intake, vomiting, diarrhea,
hemorrage, m/b dry mucous membranes

#
 Nursing management
Restore fluids by oral or IV
Treat underlying cause
Monitor I & O at least every 8
hours
Daily weight
Vital signs
Skin turgor
Urine concentration
#
 Fluid
volume excess

hypervolemia
#
 Pathophysiology
may be related to
fluid overload or
diminished function of the
homeostatic mechanisms
responsible for regulating
fluid balance
#
Contributing factors

#
 Clinical manifestations

Edema

Distended neck veins

#
Tachycardia

Increased blood
Pressure

#
Increased weight

crackles

#
 Nursing Diagnosis
Fluid volume excess r/t
CHF, excess sodium intake,
renal failure

#
 Nursing management
Preventing FVE

Detecting and Controlling FVE

Teaching patients about edema

#
Electrolyte Imbalances

#
SODIUM

#
 Sodium
Normal range 135 to 145 mEq/L

Primary regulator of ECF

volume (a loss or gain of sodium is
usually accompanied by a loss or
gain of water)

#
HYPONATREMIA

Sodium level
less than 135
mEq/L
#
 causes
Vomiting Diarrhea

#
Sweating Diuretics

#
Clinical manifestations

Poor
skin Dry
turgor mucosa

Decreased
saliva Anorexia
production vomiting

#
Clinical manifestations

Nausea/
Orthostatic
abdominal
hypotension
cramping

Confusion
Altered &
mental lethargy
status

#
Nursing interventions
Assess clinical manifestations

Monitor fluid intake and output, vital

signs and lab data.

Encourage food and fluids high in Na

Limit water intake.

#
HYPERNATREMIA

Sodium level
more than 145
mEq/L
#
 CAUSES
Loss of fluids

Water deprivation

Excessive salt intake

Conditions like Diabetes

insipidus, heatstroke
#
 Pathophysiology
- Fluid deprivation in patients who
cannot perceive, respond to, or
communicate their thirst
- Most often affects very old, very
young, and cognitively impaired
patients

#
 Clinical manifestations
- Thirst

- Sticky mucous membranes

- Flushed skin

- Postural hypotension

- Dry, swollen tongue

#
Nursing interventions
Monitor intake and output

Monitor behavioural changes

Monitor lab findings

Encourage fluids

Monitor diet as ordered(salt

restriction)
#
POTASSIUM

#
 Normal serum potassium
concentration is 3.5 to 5.5 mEq/L

Major Intracellular electrolyte

and 98% of the bodys potassium is
inside the cells

#
HYPOKALEMIA

Potassium level
less than 3.5
mEq/L
#
 CAUSES
Loss of K+ in the form of
vomittings ,GI suction

poor K intake

diuretics

steroid administration

#
 Clinical manifestations
Muscle weakness
Leg cramps
Fatigue
Lethargy
Anorexia
Nausea, vomitting
Decreased bowel sounds
Decreased bowel motility
Cardiac dysrhythmias
Depressed deep tendon reflex #
 Nursing interventions

Monitor heart rate and rhythm

Monitor clients receiving DIGITALIS
Administer oral K+ as ordered with
food /fluids
Administer IV K+ as ordered ,flow
rate not more than 10-20 meq/hr
Teach patients about potassium rich
diet and to reduce potassium wastage
#
HYPERKALEMIA

Potassium level
more than 5.5
mEq/L
#
 Causes
Decreased renal potassium excretion as
seen with renal failure and oliguria

High potassium intake

Renal insufficiency

Shift of potassium out of the cell as

seen in acidosis #
 Clinical manifestations
Skeletal muscle weakness/paralysis
ECG changes such as peaked T waves,
widened QRS complexes
Heart block

#
 Nursing interventions
Monitor ECG changes telemetry

Administer Calcium solutions to

neutralize the potassium

Monitor muscle tone

Give Kayexelate

Give Insulin and D50W

#
CALCIUM

#
 Normal serum calcium level is 4
to 5 mEq/L

More than 99% of the bodys

calcium is located in the skeletal
system

#
HYPOCALCEMIA

Calcium level
less than 4
mEq/L
#
 Causes
- Vitamin D/Calcium deficiency
- Primary/surgical
hyperparathyroidism
- Pancreatitis
- Renal failure

#
Clinical Manifestations

Tetany and cramps in muscles of

extremities

#
Trousseaus sign carpal
spasms

#
Chvosteks sign cheek
twitching

#
Seizures, mental changes

#
ECG shows prolonged QT
intervals

#
 Nursing interventions
- IV/PO Calcium Carbonate or Calcium
Gluconate

- Encourage increased dietary intake

of Calcium

- Monitor neurlogical status

- Establish seizure precautions

#
HYPERCALCEMIA

Calcium level
more than 5
mEq/L
#
 Causes
- Hyperparathyroidism

- Prolonged immobilization

- Thiazide diuretics

- Large doses of Vitamin A and D

#
 Clinical manifestations
- Muscle weakness, nausea and
vomiting

- Lethargy and confusion

- Constipation

- Cardiac Arrest

(high level)
#
 Nursing interventions

- Eliminate Calcium from diet

- Monitor neurological status

- Increase fluids (IV or PO)

- Calcitonin

#
MAGNESIUM

#
Normal serum magnesium level
is 1.5 to 2.4 mEq/L

Thought to have a direct

effect on peripheral arteries
and arterioles

#
HYPOMAGNESEMIA

magnesium
level less than
1.5 mEq/L

#
 Causes
- Chronic Alcoholism

- Diarrhea, or any disruption in small

bowel function

#
- TPN

- Diabetic ketoacidosis

#
#
 Clinical manifestations
- Neuromuscular irritability
- Positive Chvosteks and Trousseaus
sign
- EKG changes with prolonged QRS,
depressed ST segment, and cardiac
dysrhythmias
- May occur with hypocalcemia and
hypokalemia

#
 Starved possible cause of
hypomagnesemia
Seizures
Tetany
Anorexia and arrhythmias
Rapid heart rate
Vomiting
Emotional lability
Deep tendon reflexes increased

#
Nursing interventions
- IV/PO Magnesium replacement,
including Magnesium Sulfate
- Give Calcium Gluconate if
accompanied by hypocalcemia
- Monitor for dysphagia, give soft
foods
- Measure vital signs closely

#
 Foods high in Magnesium:
Green leafy vegetables

#
 Nuts

Legumes

#
Seafood

Chocolate

#
HYPERMAGNESEMIA

magnesium
level more than
2.4 mEq/L

#
 Causes
- Renal failure
- Untreated diabetic ketoacidosis
- Excessive use of antacids and
laxatives

#
 Clinical manifestations
- Flushed face and skin warmth

- Mild hypotension

- Heart block and cardiac

arrest

- Muscle weakness and even paralysis

#
 RENAL
Reflexes decreased (plus weakness
and paralysis)
ECG changes (bradycardia and
hypotension)
Nausea and vomiting
Appearance flushed
Lethargy (plus drowsiness and
coma)
#
 Nursing interventions
- Monitor Mg levels
- Monitor respiratory rate
- Monitor cardiac rhythm
- Increase fluids
- IV calcium for emergencies

#
PHOSPHORUS

#
 Normal serum phosphorus
level is 2.5 to 4.5 mg/100 ml

- Phosphate levels vary inversely

to calcium levels

- High Calcium = Low Phosphate

#
 HYPO
PHOSPHOTEMIA

Phosphorus
level less than
2.5 mEq/L

#
 Causes
- Most likely to occurs with
overzealous intake or
administration of simple
carbohydrates

- Severe protein-calorie
malnutrition (anorexia
or alcoholism)
#
Clinical manifestations
- Muscle weakness
- Seizures and coma
- Irritability
- Fatigue
- Confusion
- Numbness
#
 Nursing interventions
- Prevention is the goal
- IV Phosphorus for severe
- Prevention of infection
- Monitor phosphorus levels
- Increase oral intake of
phosphorus rich foods
#
 Foods rich in phosphorus
- Milk and milk products
- Poultry
- Whole grains
- Organ meats
- Nuts
- Fish
#
 HYPER
PHOSPHOTEMIA

Phosphorus
level more than
4.5 mEq/L

#
 Causes
- Renal failure

- Chemotherapy

- Hypoparathyroidism

- High phosphate intake

#
 Clinical manifestations

- Tetany
- Muscle weakness
- Similar to Hypocalcemia because
of reciprocal relationship

#
#
 Nursing interventions
- Treat underlying cause

- Avoid phosphorus rich foods

#
#