FLUIDS AND ELECTROLYTES:

BALANCE AND DISTURBANCE

Fluid and electrolyte balance is essential to your
body’s homeostasis.
Body Fluids
• Refers to body water in which electrolytes are
dissolved.
• Been described as “a sea within”
• Water is the largest single constituent of the
body, representing 45% - 75% of the body
weight
Body Fluids
FACTORS THAT INFLUENCE AMOUNT OF BODY
FLUIDS
• Age
• Gender
• Body fat
Functions of Body Fluids
• Transport nutrients to the cells and carries
waste products away from the cells.
• Maintains blood volume.
• Regulates body temperature.
• Serves as aqueous medium for cellular
metabolism.
Functions of Body Fluids
• Assists in digestion of food through hydrolysis.
• Acts as solvents in which solutes are available
for cell function.
• Serves as medium for the excretion of waste
products.
Body fluids are distributed in the body in two
compartments:
1. Intracellular fluid compartment (ICF)
• Fluid inside the cells
• Contains 2/3 of body fluids
• Located primarily in skeletal muscle mass
Body fluids are distributed in the body in two
compartments:
2. Extracellular (ECF)
• Outside the cell
• Contains 1/3 of body fluids
• maintains blood volume and serves as the
transport system to and from the cells
Body fluids are distributed in the body in two
compartments:
ECF subdivided further into:
I. Interstitial fluid
II. Intravascular fluid
III. Transcellular
Body fluids are distributed in the body in two
compartments:
I. Intravascular
• Fluid within blood vessels
• Contains plasma (3 L out of the average 6 L
blood volume)
II. Interstitial
• Fluids that surrounds the cells (11 to 12 L)
• Ex: lymph
Body fluids are distributed in the body in two
compartments:
III. Transcellular
• 1-3% of body weight
• Approximately 1-2 L
• Cerebrospinal fluid, pericardial fluid, synovial
fluid, pleural fluids
• Sweat
• Digestive secretions
Note:
• There is a continuous exchange of fluid between
the fluid compartment, of these spaces, only the
plasma is directly influenced by the intake or
elimination of fluid from the body.
• third-space fluid shift or “third spacing” where
there is a loss of ECF into a space that does not
contribute to the equilibrium between ICF and
ECF.
Note:
“Third spacing” occurs in:
• ascites
• burns
• peritonitis
• bowel obstruction
• massive bleeding into a joint or body cavity.
ELECTROLYTES
• Chemical compounds in solution that have the
ability to conduct an electrical current.
• They break into ions:
Cations carry positive charges;
Anions carry negative charges
Sodium – primary cation in the ECF; important in
regulating fluid volume
Chloride – primary anion in the ECF
Potassium – primary cation in the ICF
Phosphates and sulfates – primary anions in the
ICF
General Functions of electrolytes:
promote neuromuscular irritability
maintain body fluid volume and osmolality.
distribute body water between compartments
regulate acid-base balance
Movements of Water and Electrolytes
1. PASSIVE TRANSPORT
a. Diffusion
b. Osmosis
c. Filtration
2. ACTIVE TRANSPORT
Movements of Water and Electrolytes
Passive transport
a. Diffusion
• movement of particles from an area of higher to
lower concentration within one compartment.
• occurs through the random movement of ions and
molecules.
• particles will distribute themselves evenly.
• an example is the exchange of O2 and CO2 between the
pulmonary capillaries and alveoli.
Movements of Water and Electrolytes
1. Passive transport
b. Osmosis
• movement of fluid from an area of lower
concentration to higher concentration across the
semi-permeable membrane.
• normal serum osmolality is 280-300mOsm/kg.
• osmolality of ECF and ICF is always equal.
Movements of Water and Electrolytes
• Important terms:
Tonicity
is the ability of all the solutes to cause an osmotic driving force
that promotes water movement from one compartment to
another
• Osmolality
• reflects the concentration of fluid that affects the
movement of water between fluid compartments by
osmosis.
• Also measures the ability of a solution to create
osmotic pressure and affect movement of water.
(mOsm/kg)

• Osmolarity
• reflects the concentration of solutions. (mOsm/L)
• Oncotic pressure
• is the osmotic pressure exerted by proteins (ex.
albumin)

• Osmotic diuresis
• occurs when the urine output increases due to the
excretion of substances such as glucose, mannitol,
or contrast agents in the urine.
Movements of Water and Electrolytes
1. Passive transport
c. Filtration
• is the process by which water and diffusible
substances move together in response to fluid
pressure. This process is active in capillary beds.
• an example is the passage of water and electrolytes
from the arterial capillary bed to the interstitial fluid.
• Hydrostatic pressure
• blood entering the capillaries does so at a
pressure greater that the interstitial pressure, so
fluid and solutes move out of capillaries. At the
venous end of the capillary bed, hydrostatic
pressure is less than the interstitial pressure and
fluid and waste products move back into
capillaries.
Movements of Water and Electrolytes
2. Active transport
• movement of ions from an area of lesser to
greater concentration with an ion pump.
• (Na –K pump)
Concentration of Fluids
a. Isotonic
b. Hypotonic
c. Hypertonic
Concentration of Fluids
• Isotonic
• Exerts the same osmotic pressure as that found in
plasma. Osmolarity is 240-340mOsm/L.
• Hypotonic
• Exerts less osmotic pressure than that of blood plasma.
Osmolarity is less than 240 mOsm/L
• Hypertonic
• Exerts a higher osmotic pressure than that of blood
plasma. Osmolarity is more than 340mOsm/L.
REGULATION OF BODY FLUIDS AND
ELECTROLYTES
Kidneys
• Daily urine volume: 1 to 2 L
• Normal output should be 1 mL/kg/hr
Skin
• Insensible water loss through the skin: 600 mL
REGULATION OF BODY FLUIDS AND
ELECTROLYTES
Adrenal glands
• The adrenal glands secrete aldosterone.
REGULATION OF BODY FLUIDS AND
ELECTROLYTES
Aldosterone:
• Retains sodium and water.
• Excretes potassium at the same time.
sodium and potassium have an inverse
relationship.
REGULATION OF BODY FLUIDS AND
ELECTROLYTES
Aldosterone:
• Retains sodium and water.
• Excretes potassium at the same time.
• Builds up vascular volume, which makes the BP
to increase
Remember, more vascular volume means more
blood pressure.
REGULATION OF BODY FLUIDS AND
ELECTROLYTES
Lungs
• The lungs regulate fluid by releasing water as
vapor with every exhalation. Every time you
exhale, water is lost
• Gastrointestinal tract
• Usual loss is around 100 to 200 mL
REGULATION OF BODY FLUIDS AND
ELECTROLYTES
• Cardiovascular system
• Pumps and carries fluids and other good stuff
throughout the body, to the vital organs,
especially to the kidneys
REGULATION OF BODY FLUIDS AND
ELECTROLYTES
Pituitary gland
• antidiuretic
hormone (ADH),
which causes
retention of
water.
REGULATION OF BODY FLUIDS AND
ELECTROLYTES
Parathyroid glands
• The parathyroid glands secrete parathyroid
hormone (PTH).
REGULATION OF BODY FLUIDS AND
ELECTROLYTES
Parathyroid glands
• The parathyroid glands secrete parathyroid
hormone (PTH).
• This causes an increase in serum calcium by
pulling it from the bones and placing the
calcium in the blood.
REGULATION OF BODY FLUIDS AND
ELECTROLYTES
Thyroid gland
The thyroid gland releases thyroid hormones.
• Providing energy
• Increasing pulse rate
• Increasing cardiac output
• Increasing renal perfusion
• Increasing diuresis
• Ridding of excess fluid
REGULATION OF BODY FLUIDS AND
ELECTROLYTES
Hypothalamus
• thirst response
• AGE matters
REGULATION OF BODY FLUIDS AND
ELECTROLYTES
Small intestine
• absorbs 85% to 95% of fluid from ingested food
• delivers it into the vascular system
REGULATION OF BODY FLUIDS AND
ELECTROLYTES
Lymphatic system
• moves water and protein back into the vascular
space
How do we lose fluid?

We lose fluid by 2 ways:

1. Sensible
2. Insensible
How do we lose fluid?
1. Sensible fluid loss:
loss that is SEEN
urine, sweat, and feces.
Kidneys--800 to 1500 mL/day
NGT
How do we lose fluid?
2. Insensible fluid loss:
loss that is NOT SEEN
• Occurs through the intestinal tract, lungs, and
skin.
• Skin—water evaporation
• Lungs- approximately 500 mL/day
• GI-100 to 200 mL/day
Abnormal fluid loss
Abnormal fluid loss results from a physiologic
imbalances.
Examples include:
Fever or an increased room temperature
Severe burns
Hemorrhage
Emesis
Abnormal fluid loss
Abnormal fluid loss results from a physiologic
imbalances.
Fistulas
Secretions
Wound exudates
Paracentesis
Thoracentesis
Diaphoresis
DEHYDRATION
The 2 types of dehydration are:
1. Mild dehydration:
2% loss of body weight, which equals 1 to 2 L of
body fluid.
2. Marked dehydration:
5% loss of body weight, which equals 3 to 5 L of
body fluid.
How do we measure electrolytes?
1. mg/dL (deciliter)
• measures the weight of the particle in a certain
amount of volume.
2. mEq/L
• milliequivalent is one-thousandth of an equivalent
• the amount of a substance that will react with a
certain number of hydrogen ions. This is measured per
liter of fluid. Simply put, this is atomic weight.
How do we measure electrolytes?
3. mmol/L (millimoles/liter)
• millimole is one-thousandth of a mole per liter of
fluid.
• Basically, this measurement offers an in-depth analysis
of the electrolyte being evaluated.
Where do electrolytes live in the body?
Electrolytes can be found all over the body.
1. Potassium: found inside the cell; the most
plentiful electrolyte in the body.
2. Magnesium: found inside the cell; second most
plentiful electrolyte in the body.
3. Sodium: numero uno electrolyte in the
extracellular fluid.
Where do electrolytes live in the body?
Electrolytes can be found all over the body.
4. Phosphorus: found inside the cell and in the
bones.
5. Calcium: found mainly in bones and teeth;
some floats around in the blood as well.
6. Chloride: found inside the cell, the blood, and
the fluid between cells.
Hormones
Hormones help keep electrolytes within normal
range.
1. Insulin
• moves potassium from the blood to the inside of
the cell, causing the serum K to drop.
Hormones
Hormones help keep electrolytes within normal
range.
2. Parathyroid hormone (PTH)
• moves calcium from the bone into the blood
when serum calcium levels are low.
• causes the serum calcium to increase.
Hormones
Hormones help keep electrolytes within normal
range.
3. Calcitonin:
moves calcium into the bones as needed.
When the serum calcium is too high, calcitonin
increases and moves calcium from the blood into
the bone.
This causes serum calcium to decrease.
How do we get rid of excess electrolytes?
Excess electrolytes are excreted by:
• Urine, feces, and sweat.
• Aldosterone:
• causes sodium and water retention while causing
potassium excretion through the urine.
• PTH:
• increases urine excretion of phosphorus and
decreases urine excretion of calcium.
What causes decreased oral electrolyte intake?
• Anorexia
• Feeling weak
• Shortness of breath
• GI upset
• Income
• Fad dieting (low in potassium)
Abnormal electrolyte losses
• Vomiting
• Nasogastric (NG) suction
• Intestinal suction
• Drainage
Abnormal electrolyte losses
• Paracentesis
• Diarrhea
• Diuretics
• Kidney trauma, illness,
CASE IN POINT
A common nursing order is “nothing by mouth”
(NPO).
What causes electrolyte excess in the blood?
• Kidney trauma, illness, or disease
• Massive blood transfusions
• Tumors
• Crushing injuries
• Chemotherapy
Substances that can alter fluid balance
1. Plasma protein.
2. Glucose.
Substances that can alter fluid balance
1. Plasma protein
Plasma protein holds on to fluid in the vascular
space.
Albumin
CASE IN POINT
• If a client is badly burned, malnourished
(decreased protein intake), or has a disease
where the liver is not making adequate amounts
of albumin, problems can occur.
• Adequate albumin needed to hold fluid in the
vessels may not exist; therefore, the fluid may
leak out of the vessels into the tissues and cause
shock.
Substances that can alter fluid balance
2. Glucose
• The vascular space likes the particle-to-water
ratio to be equal.
CASE IN POINT
• When the blood sugar is very high, as in
diabetics, the blood has too many glucose
particles compared to water in the vascular
space. This causes particle-induced diuresis
(PID), sometimes called osmotic diuresis.
Fluid volume deficit
Fluid volume excess
Fluid volume deficit
Fluid volume deficit (FVD) results when fluid loss
exceeds fluid intake.
sodium and water are lost in equal amounts
from the vascular space.
• Also called hypovolemia or isotonic
dehydration.
*Not the same as dehydration.
What causes it?
• Decreased intake or poor appetite
• Drugs that affect fluids and electrolytes
• Diuresis
• Forgetting to drink and eat
• Poor response to fluid changes
• Vomiting
What causes it?
• Diarrhea
• GI suction
• Diuretics
• Impaired swallowing
• Tube feedings
• Fever
What causes it?
• Laxatives
• Hemorrhage
• Third spacing
Signs and symptoms
• Acute weight loss
• Decreased skin turgor (tenting occurs)
• Postural hypotension (orthostatic hypotension)
• Increased urine specific gravity
Signs and symptoms
• Weak, rapid pulse
• Cool extremities
• Dry mucous membranes
• Decreased BP
Signs and symptoms
• Decreased peripheral pulses
• Oliguria
• Decreased vascularity in the neck and hands
• Decreased central venous pressure
• Increased respiratory rate
Diagnostic tests and treatments
Laboratory testing for FVD include:
• serum electrolytes
• BUN, and creatinine.
Treatment measures:
oral or IV fluid replacement
if is due to hemorrhage or blood loss---blood
products
Complications
Shock.
Poor organ perfusion, leading to acute tubular
necrosis and renal failure.
Multiorgan dysfunction due to poor perfusion.
Decreased cardiac output.
Fluid volume excess
fluid volume excess (FVE) results when fluid
intake exceeds fluid loss.
• Excessive retention of water and sodium in the
extracellular fluid (ECF).
• Also called hypervolemia or isotonic
overhydration.
Causes
• Renal failure
• CHF
• Cushing syndrome
• Excessive sodium: from IV normal saline or
lactated ringers or foods
• Blood product administration
• Increased ADH
Causes
• Medications
• Liver disease
• Hyperaldosteronism
• Burn treatment
Signs and symptoms
• Jugular vein distension ( JVD)
• Bounding pulse, tachycardia
• Abnormal breath sounds
• Polyuria
• Decreased urine specific gravity
• Dyspnea and tachypnea
• Increased BP
Signs and symptoms
• Increased central venous pressure (CVP)
• Edema
• Productive cough
• Weight gain
Diagnostic tests and treatments
Tests:
• Serum Electrolytes
• BUN and Creatinine
• Chest x-ray:
• If the heart is enlarged, as can be seen with an x-
ray, this could mean congestive heart failure.
Diagnostic tests and treatments
Treatments:
• Loop diuretics: Furosemide (Lasix)
• Potassium-Sparing Diuretics: Spironolactone
(Aldactone)
• Dietary Sodium Restrictions
• Treat the cause
Complications

•CHF
•pulmonary edema
In fluid volume deficit and fluid volume excess,
the osmolarity and serum sodium are not
affected as the client loses fluid and sodium
proportionately.
Sodium imbalances
The following apply to the electrolyte sodium:
• Chief electrolyte in ECF.
• Assists with generation and transmission of
nerve impulses.
• An essential electrolyte of the sodium–
potassium pump in the cell membrane.
Sodium imbalances
Food sources: bacon, ham, sausage, catsup,
mustard, relishes, processed cheese, canned
vegetables, bread, cereals, snack foods.
Excess sodium is excreted by kidneys.
Excretion of sodium retains potassium.
Normal adult sodium level is 135 to 145 mEq/L.
Helps maintain the volume of body fluids.
• Sodium is the only electrolyte that is affected by
water.
• Sodium level decreases when there is too much
water in the body.
• Conversely, sodium level increases with less
water in the body.
Renin–angiotensin system

•ECF (vascular volume) decreased → Renin

produced by the kidneys →Angiotensin I
converted to angiotensin II →Aldosterone
secreted → Sodium and water retained.
•If sodium and water are retained or lost
equally then there will be no change in
serum sodium.
Hyponatremia
Serum sodium less than 135 mEq/L.
Hyponatremia is:
• Not enough sodium in the ECF (vascular space).
• Possibly, there is too much water diluting the
blood which makes serum sodium go down.
• Anytime there is a sodium problem there is a
fluid problem as well.
Causes
• Excessive administration of D5W
• Diuretics
• Wound drainage
• Psychogenic polydipsia
• Decreased aldosterone
• Low-sodium diet
Causes
• Syndrome of inappropriate antidiuretic hormone
(SIADH)
• Vomiting and sweating
• Replacing fluids with water only
• Muscle weakness
Signs and symptoms
• Decreased deep tendon reflexes (DTRs)
• Diarrhea
• Respiratory problems
Diagnostic tests and treatments

• Tests:
• hyponatremia is serum electrolytes
• Treatment:
• Depends on the cause
• 0.9% normal saline IV
• 3% Saline
Diagnostic tests and treatments
• Watch for FVE
• Increased dietary Sodium
• If appropriate, discontinue drugs/treatments
that could be causing sodium loss.
COMPLICATIONS
• Seizures and brain damage are the major
complications associated with hyponatremia.
• Also, consider what caused the hyponatremia
when determining what could harm your
patient.
Hypernatremia
• serum sodium greater than 145 mEq/L
• similar to dehydration:
• there is too much sodium and not enough water in
the body.
Causes
• Anything that causes an increased “water” loss
or excessive sodium intake can cause
hypernatremia.
Causes
• Administration of IV normal saline without
proper water replacement
• Hyperventilation
• Watery diarrhea
• Hyperaldosteronism
• Renal failure
Causes
• Heat stroke
• NPO status
• Infection
• Diabetes insipidus
• Tachycardia
Signs and symptoms
• Dry, sticky mucous membranes
• Thirst
• Changes in level of consciousness (LOC)
• Decreased heart contractility
• Seizure
• Muscle twitching
Signs and symptoms
• Muscle weakness
• Decreased DTRs
Diagnostic tests and treatments
• Tests:
• serum electrolytes
• Treatment:
individualized/specific depending on the cause.
• Restrict all forms of sodium: Foods can have
excess sodium as well as drugs and IV fluids.
COMPLICATIONS
• As with hyponatremia, seizures and brain
damage are the major complications associated
with hypernatremia.
Potassium imbalances
• Makes skeletal and cardiac muscle work
correctly.
• Major electrolyte in the intracellular fluid.
• Potassium and sodium are inversely related
(when one is up, the other is down).
• Plays a vital role in the transmission of electrical
impulses.
Potassium imbalances
• Food sources: peaches, bananas, figs, dates,
apricots, oranges, melons, raisins, prunes,
broccoli, potatoes, meat, dairy products.
• Excreted by the kidneys.
• Stomach contains large amount of potassium.
• Normal potassium level: 3.5 mEq/L to 5.0 mEq/L
Hypokalemia
• serum potassium below 3.5 mEq/L
• Paralytic ileus can occur from severe hypokalemia.
• Abdominal distension
• muscle cramps
• muscle weakness
Causes
• Diuretics
• Steroids
• GI suction
• Vomiting
• Diarrhea
• NPO status; poor oral intake
• Age
Causes
• Cushing syndrome
• Kidney disease
• Alkalosis
• IV insulin
Signs and symptoms
• Muscular weakness, cramps, flaccid paralysis
• Hyporeflexia
• Life–threatening arrhythmias
• Slow or difficult respirations
• Weak, irregular pulse
Signs and symptoms
• Decreased bowel sounds
• Decreased LOC
Diagnostic tests and treatments
Tests:
• serum electrolytes
• EKG (shows flattened T wave, depressed ST
segment, and a U-wave)
Diagnostic tests and treatments
Treatments:
• determine the cause
• High potassium diet
• IV or oral potassium chloride
• check for proper kidney function or good urine
output.
• A good rule to remember when administering IV K
is not to exceed 20 mEq/hour.
Diagnostic tests and treatments
• Clients taking a cardiac glycoside with a diuretic
should be monitored closely for hypokalemia,
which can potentiate the cardiac glycoside and
cause toxicity
• switched to a potassium-sparing diuretic
COMPLICATIONS
• life-threatening arrhythmias
• arrhythmias  decreased cardiac output 
resulting in hypotension.
• Respiratory depression may also occur.
Hyperkalemia
• serum potassium greater than 5.0 mEq/L.
• In severe hyperkalemia, ascending flaccid
paralysis of the arms and legs may be seen;
• this paralysis moves distal to proximal.
Causes
• Renal failure
• IV potassium chloride overload
• Burns or crushing injuries
• Tight tourniquets
• Hemolysis of blood sample
• Incorrect blood draws
Causes
• Salt substitutes
• Potassium-sparing diuretics
• Blood transfusions
• ACE inhibitors
• Tissue damage
• Acidosis
Causes
• Adrenal insufficiency (Addison’s disease)
• Chemotherapy
Signs and symptoms
• Begins with (1)muscle twitching associated with
tingling and burning; (2)progresses to
numbness, especially around mouth;
(3)proceeds to weakness and flaccid paralysis
• Excess potassium interferes with skeletal and
smooth muscle contraction, nerve impulse
conduction, acid–base balance, enzyme action,
and cell membrane function
Signs and symptoms
• Diarrhea
• Smooth muscles of the intestines hyper contract,
resulting in increased motility
• Dysfunctional nerve impulse conduction and smooth
muscle contraction
Signs and symptoms
• Cardiac arrhythmia;
• bradycardia; EKG changes: peaked T-wave, flat or
no P-wave, wide QRS complex; ectopic beats on
EKG leading to complete heart block, asystole,
ventricular tachycardia, or ventricular fibrillation
Diagnostic tests and treatments
Tests:
• serum electrolytes
• ECG will also be assessed
Diagnostic tests and treatments
Treatments:
• depends on the primary cause.
• IV insulin in conjunction with 10–50% glucose IV (IV
insulin will lower the serum K by pushing it into the
cell.
• Administration of sodium polystyrene sulfonate
(Kayexalate) with 70% sorbitol
• Kayexalate---serum sodium as hypernatremia can
occur.
Diagnostic tests and treatments

• Diuretics to increase renal excretion of K.

• 10% calcium gluconate IV (to decrease myocardial
irritability).
• Hemodialysis
• Peritoneal dialysis
• Limit high potassium foods.
• Limit drugs which could cause retention of K
(aldactone).
Complications
• monitor clients for dehydration, neurological
changes, and life-threatening arrhythmias.
Calcium imbalances
• Acts like a sedative on muscles.
• Most abundant electrolyte in the body.
• Has an inverse relationship to phosphorus.
• Necessary for nerve impulse transmission,
blood clotting, muscle contraction, and
relaxation.
• Needed for vitamin B12 absorption.
Calcium imbalances
Promotes strong bones and teeth.
Who needs extra calcium?
• Children, pregnant women, lactating women.
Food sources: milk, cheese, dried beans.
Must have vitamin D present to utilize calcium.
Calcium imbalances
If blood levels of calcium decrease, the body takes
calcium from the bones and teeth. (to build the blood
level back up)
Parathyroid hormone (PTH) increases serum calcium by
pulling it from the bones and putting it in the blood.
Calcitonin decreases serum calcium by driving the
blood calcium back into the bones.
Normal calcium: 9.0 to 10.5 mg/dL
Hypocalcemia
• serum calcium level drops below 9.0 mg/dL.
Causes
• Decreased calcium intake
• Kidney illness
• Decreased vitamin D
• Diarrhea
• Pancreatitis
Causes
• Hyperphosphatemia
• Thyroidectomy
• Medications (calcium binders)
Signs and symptoms
• Muscle cramps
• Tetany
• Convulsions
• Arrhythmias
• Positive Chvostek’s sign
• Positive Trousseau’s sign
Signs and symptoms
• Laryngeal spasm
• Hyperactive DTRs
• Cardiac changes: decreased pulse, prolonged ST
interval, prolonged QT interval, decreased
myocardial contractility
• Calcium regulates depolarization in the cardiac
cells. If calcium is decreased, depolarization is
impaired
Signs and symptoms
• Respiratory arrest
• LOC changes
• Increased gastric activity
Diagnostic tests and treatments
Tests:
• assess the electrolytes
• ECG may be performed
Diagnostic tests and treatments
• dependent on the cause
• IV calcium
• heart monitor
• Vitamin D therapy
• Increase dietary calcium
Complications
• Seizures, laryngospasm, respiratory arrest, and
arrhythmias
Hypercalcemia
• serum calcium level that exceeds 10.5 mg/dL.
Causes
• Decreased DTRs
• Muscle weakness
• Renal calculi
• Pathological fractures
• Central nervous system (CNS) depression:
lethargy, coma, confusion
Causes
• Early cardiac changes: increased P-wave;
decreased ST interval; wide T-wave; increased
BP
• Late cardiac changes: decreased pulse moving to
cardiac arrest
• Respiratory arrest
• Decreased bowel sounds
Signs and Symptoms
• Increased urine output
• Increased clotting times
• Kidney stones
Diagnostic tests and treatments
Tests:
• assess the serum electrolytes.
• ECG
• X-ray
• UTZ
• Urinalysis
Diagnostic tests and treatments
Treatment:
• dependent on the cause
• Normal Saline IV
• Excess calcium: think SEDATED
• IV phosphate
Complication
• Respiratory depression and arrhythmias
Phosphorus imbalances
• Promotes the function of muscle, red blood cells
(RBCs), and the nervous system.
• Assists with carbohydrate, protein, and fat
metabolism.
• Food sources: beef, pork, dried peas/beans,
instant pudding.
Phosphorus imbalances
• Has an inverse relationship with calcium.
• Regulated by the parathyroid hormone.
• Normal phosphorus is 3.0 to 4.5 mg/dL.
• Remember that phosphorus and calcium have an
inverse relationship!
Hypophosphatemia
• serum phosphate that is below 3.0 mg/dL.
Causes
• Hypophosphatemia looks just like
hypercalcemia.
Signs and symptoms
• Hypophosphatemia looks just like
hypercalcemia.
Diagnostic tests and treatments
Tests:
• Serum electrolytes
• X-ray
Diagnostic tests and treatments
Treatment:
• Supplemental Phosphorus
• IV phosphorus is given when phosphorus drips
below 1 mg/dL and when the GI tract is
functioning properly
• Additional treatments depend on the underlying
cause.
Complication
• respiratory depression and arrhythmias
Hyperphosphatemia
• serum phosphate level that is above 4.5 mg/dL.
Causes
• Hyperphosphatemia looks just like
hypocalcemia.
Signs and symptoms
• Hyperphosphatemia looks just like
hypocalcemia.
Diagnostic test and treatments
Tests:
• check electrolyte levels.
• X-ray
Diagnostic test and treatments
Treatment:
• underlying cause must be treated
• Administer of vitamin D preparations such as
calcitrol (rocaltrol)
• Administration of phosphate-binding gels
• Restriction of dietary phosphorus
• Possibly dialysis
Complications
• Seizures, laryngospasm, respiratory arrest, and
arrhythmias
Magnesium imbalances
Present in heart, bone, nerves, and muscle
tissues.
Second most important intracellular ion.
Assists with metabolism of carbohydrates and
proteins.
Helps maintain electrical activity in nerves and
muscle.
Magnesium imbalances
Also acts like a sedative on muscle.
Food sources: vegetables, nuts, fish, whole grains,
peas, beans.
Magnesium levels are controlled by the kidneys
(excreted by kidneys).
Normal magnesium: 1.3 to 2.1 mEq/L.
Magnesium imbalances
Can cause vasodilatation.
The majority of magnesium comes from our
dietary intake.
Hypomagnesemia
• serum magnesium level below 1.3 mEq/L.
Causes
• Diarrhea
• Diuretics
• Decreased intake
• Chronic alcoholism
• Medications
• Decreased magnesium levels increase nerve
impulses. Think: NOT SEDATED.
Signs and symptoms
• Increased neuromuscular irritability
• Seizure
• Hyperactive DTRs
• Laryngeal stridor
Signs and symptoms and why
• Positive Chvostek’s and Trousseau’s signs
• Cardiac changes: arrhythmias; peaked T-waves;
depressed ST segment; ventricular tachycardia;
ventricular fibrillation; irregular heartbeat
• The heart is a smooth muscle. If there is not
enough magnesium to sedate it, impaired nerve
conduction and muscle spasms can occur
Signs and symptoms and why
• Dysphagia
• Decreased GI motility
• Changes in LOC
Quickie tests and treatments
Tests:
• assess the serum electrolytes.
• Urinalysis
• ECG
• New diagnostic tests include nuclear magnetic
resonance spectroscopy and ion-selective
electrode tests
Quickie tests and treatments
Treatment:
• underlying cause must be identified and treated.
• Increased dietary magnesium
• Magnesium salts
• Magnesium sulfate IV
Complications
• Laryngospasm.
• Aspiration due to dysphagia.
• Arrhythmias.
Hypermagnesemia
• serum magnesium level above 2.1 mEq/L.
• Remember magnesium acts like a sedative.
• “THINK SEDATED” with hypermagnesemia.
Causes
• Renal failure
• Increased oral or IV intake
• Antacids
Signs and symptoms and why
• BP decreases
• Facial warmth and flushing
• Drowsiness to comatose state depending on
severity of imbalance
• Decreased DTRs
Signs and symptoms and why
• Generalized weakness
• Decreased respirations to respiratory arrest
depending on severity of imbalance
• Cardiac changes: decreased pulse, prolonged PR,
wide QRS, cardiac arrest
Diagnostic tests and treatments
Tests:
• serum electrolytes
• ECG
Diagnostic tests and treatments
Treatments:
• depends on the primary cause
• Decrease magnesium salt administration
• If in an emergency situation, respiratory support may be
needed
• Hemodialysis with magnesium free dialysate
• Loop diuretics
• 0.45% saline solution and/or IV calcium gluconate to help
balance the magnesium levels.
Complications
• arrest, cardiac arrest, and hypotension.
ACID-BASE BALANCE
AN OVERVIEW OF ACID–BASE IMBALANCES
Respiratory acidosis and alkalosis overview

• carbon dioxide---an acid

• carbon dioxide + water =carbonic acid.
• get rid of carbon dioxide exhaling
Respiratory acidosis and alkalosis overview
Lungs: carbon dioxide.
In an acid–base imbalance such as respiratory
acidosis or alkalosis, the lungs are sick.
compensating organs:kidneys
manipulating the chemicals bicarbonate and
hydrogen to correct the imbalance and bring the
pH back into normal range
Respiratory acidosis and alkalosis overview
This is done by secreting bicarbonate and
excreting hydrogen.
Kidneys: slow but effective
Metabolic acidosis and alkalosis overview
• Kidneys: ORGANS in metabolic acidosis and
metabolic alkalosis
• Bicarbonate and hydrogen are considered the
problem chemicals when the kidneys are sick.
• compensating organs: lungs
• Lungs can blow off or retain Carbon Dioxide
quickly
Respiratory acidosis
• An acid–base imbalance that occurs when the
pH is decreased, partial pressure of carbon
dioxide (PCO2) is increased—greater than 45
mm Hg.
• Carbon dioxide builds up in the blood:
hypoventilate
• Hypercapnia--buildup of carbon dioxide in the
blood to levels greater than 45 mm Hg.
Causes
• respiratory acidosis: “breathing”
• Decreased alveolar ventilation: carbon dioxide
retention
• Anytime poor gas exchange exists, CO2 builds up
in the blood Respiratory acidosis
Causes
• Respiratory arrest
• Some drugs (narcotics, sedatives hypnotics,
anesthesia, ecstasy)
• Sleep apnea
• Excessive alcohol
• Surgical incisions (especially abdominal), broken
ribs
Causes
• Collapsed lung (pneumothorax, hemothorax)
• Weak respiratory muscles (myasthenia gravis,
Guillain–Barré syndrome)
• Airway obstruction (poor cough mechanism,
laryngeal spasm)
• Brain trauma (specifically medulla)
• High-flow O2 in chronic lung disease
• Severe respiratory distress syndrome
Signs and symptoms
• Vary depending on the initial cause:
• Neurological changes: headache, confusion,
blurred vision, lethargy coma, decreased deep
tendon reflexes (DTRs)
• Papilledema
• Hyperkalemia
• Decreased muscle tone; decreased DTRs
• Acute respiratory acidosis causes hyperkalemia.
With chronic respiratory acidosis, the K+ may
be normal as the kidneys have time to readjust
and get the K+ back into the normal range.
Signs and symptoms
• Vary depending on the initial cause:
• Neurological changes: headache, confusion,
blurred vision, lethargy coma, decreased deep
tendon reflexes (DTRs)
• Papilledema
• Hyperkalemia
• Decreased muscle tone; decreased DTRs
Signs and symptoms
• Hypotension
• Restlessness; tachycardia
• Arrhythmias
• Cardiac arrest
• Acidic urine
• Warm skin
Diagnostic tests and treatments
• Treat the cause.
• Airway clearance: possible intubation.
• Administer drugs to open up the airways and
thin out secretions so they can be coughed up.
• Increase fluids to liquefy secretions so they can
be coughed up more easily.
• Oxygen therapy.
Diagnostic tests and treatments
• Respiratory therapy: breathing treatments.
• Elevate head of bed (HOB) for lung expansion.
• Monitor ABGs.
• Monitor for electrolyte imbalances.
• Monitor pulse oximetry.
• Administration of Pulmocare: a tube feeding
sometimes used to decrease CO2 retention.
Diagnostic tests and treatments
MORE ON OXYGEN THERAPY
• low-dose oxygen-- chronic lung conditions
• high dose oxygen– acute lung conditions
What do the ABGs look like?
• pH
• Less than 7.35
• PaCO2
• Greater than 45 mm Hg
• PaO2
• Less than 80 mm Hg
• HCO3
• Normal until kidney compensation starts; then will
start to rise above 26 mEq/L
What can harm my client?
Respiratory arrest.
Arrhythmias: leading to cardiac arrest and shock.
Severe decrease in LOC.
Recap of respiratory acidosis
• The name “respiratory” tips you off to the fact that a
lung problem exists
• Since it is a lung problem, the problem chemical is the
acid carbon dioxide
• Acidosis from a lung problem is due to irregular
breathing. Perhaps the client is hypoventilating—
breathing only 2 to 4 times a minute, causing
retention of carbon dioxide (CO2).
Recap of respiratory acidosis
• Maybe the client has stopped breathing
altogether—possibly not exhaling carbon dioxide
(CO2) at all The client retains all of this carbon
dioxide (CO2), which causes a buildup of acid in
the body
• This buildup of acid causes the pH to decrease.
Respiratory alkalosis
• an acid–base imbalance where the PCO2 is less
than 35 mm Hg and the pH is greater than 7.45.
• Decrease PaCO2 in the blood: excessive
exhalation—hyperventilation.
• When the lungs are impaired, the kidneys
compensate with their own chemicals—
bicarbonate and H+.
• The kidneys will retain H+ because this is acid.
Respiratory alkalosis
• The kidneys will excrete bicarbonate because
this is base/alkalotic.
• This excretion of the base will help raise acid
levels and restore the body to a normal pH.
• Respiratory alkalosis means that the client has
lost excessive CO2 (acid), thus making the client
alkalotic.
• Hypocapnia: occurs when the CO2 is low
Causes
• Hysteria; anxiety • Sepsis
• High mechanical • High altitudes
ventilator setting • Anemia
• Aspirin overdose • Hypoxia
• Pain (having a baby) • Labor and delivery
• Fever measures!
Signs and symptoms
• Hyperventilation
• Light-headedness, dizziness fainting
• Rapid pulse
• Hypokalemia
• Arrhythmias
• Hypocapnia stimulates the autonomic nervous
system, which cause anxiety, changes in
respiration, tingling, and sweating.
• Calcium acts like a sedative. Hypocapnia
decreases serum calcium so the muscles may get
tight. This can lead to tetany and seizures!
Why do you breathe into the brown bag when
you are hyperventilating?
Quickie tests and treatments
• Treat the cause.
• Monitor vital signs, especially respirations.
• Monitor electrolytes.
• Administer antianxiety medications as ordered.
Quickie tests and treatments
• Place on mechanical ventilator to control
respiratory rate in severe cases.
• Monitor ABGs.
• Calm the client.
• Have client breathe into paper bag or rebreather
mask to encourage CO2 retention.
What do the ABGs look like?
• pH
• Greater than 7.45 (alkalosis makes pH go up)
• PaCO2
• Less than 35 mm Hg (because it is being exhaled)
• PaO2
• Greater than 100 mm Hg
• HCO3
• Normal until kidney compensation starts; then will be
less than 22 mEq/L
Complications
• Life-threatening arrhythmias.
• Seizures.
Recap of respiratory alkalosis
• The name “respiratory” tips you off to the fact that a
lung problem exists
• Since it is a lung problem, the problem chemical is the
acid carbon dioxide (CO2)
• Excessive exhalation causes PCO2 to decrease in the
blood. Acid is lost.
• When the lungs are impaired, the kidneys compensate
with their own chemicals—bicarbonate and H+. The
kidneys will retain H+ because this is acid.
Recap of respiratory alkalosis
• We want to keep acid since the body is losing acid
from the excessive exhalation.
• The kidneys will excrete bicarbonate—a base—in
order to create a more acidic environment and return
the pH to normal
• Respiratory alkalosis means that the client has lost
excessive CO2 (acid), thus making the client alkalotic
Metabolic acidosis
• An acid–base imbalance where the pH is less
than 7.35 and the bicarbonate level is less than
22 mEq/L.
• Acid (H+ ions) builds up in the body, or too
much bicarbonate has been lost from the body.
Metabolic acidosis
• The less bicarb you have in the body, the more
acid you will be.
• Kidneys: Metabolic disorders
• Bicarbonate and H+
• The decrease in the alkaline substances (bases)
causes a build up of acids in the body, causing
acidosis.
• Lungs: compensate in just a few minutes
Causes
• Diabetic ketoacidosis, malnutrition, starvation
• Lactic acidosis
• Shock
• Kidney illness
Causes
• Gastrointestinal (GI) illness: diarrhea
• Drugs: Diamox, Aldactone
• Aspirin overdose
Signs and symptoms
• if renal failure is the initial cause, you will see
signs and symptoms related to renal failure;
• if diabetic, ketoacidosis is the initial cause
Signs and symptoms
• Hyperkalemia
• Arrhythmias
• Increased respiratory rate
• Headache, decreased LOC, coma
Signs and symptoms
• Muscle twitching and burning, oral numbness,
weakness, flaccid paralysis (severe hyperkalemia)
• Weakness, flaccid paralysis, tingling and numbness in
the arms and legs
• A Kussmaul’s respiration is an increase in rate and
depth of respiration.
• When Kussmaul’s respirations are present, CO2 is
being blown off in increased amounts.
Diagnostic tests and treatments
• Monitor ABGs.
• Treat the cause.
• Monitor and manage hyperkalemia.
• Monitor and manage arrhythmias.
• Monitor and manage hypercalcemia.
Diagnostic tests and treatments
• Administer sodium bicarbonate IV to decrease
acidity of blood.
• Monitor LOC closely.
• Administer lactated Ringers (LR) given IV to
increase base level.
• Institute seizure precautions (brain doesn’t like it
when the pH is messed up).
What do the ABGs look like?
• pH
• Less than 7.35
• PaCO2
• Will decrease to less than 35 mm Hg as it is blown off
• PaO2
• Normal
• HCO3
• Less than 22 mEq/L
• Sodium bicarbonate:
• should be used only as a quick, temporary fix for
increased acid levels and should be given
according to specific ABG values rather than
generously as we used to do in the past during
code situations.
Complications
• Life-threatening arrhythmias.
• Cardiac arrest.
Recap of metabolic acidosis
• The problem is with the kidneys, not the lungs.
• Bicarbonate (base) and H+ (acid) are associated
with the kidneys.
• Metabolic acidosis can be caused by loss of
bicarbonate through diarrhea, and renal
insufficiency.
Recap of metabolic acidosis
• The decrease in the alkaline substances (bases)
causes a buildup of acids in the body. It can also
be caused by diseases that increase acid levels
(OFA)
• The lungs compensate increasing respiratory
rate and depth to blow off CO2 and increase pH.
This is called a Kussmaul’s respiration.
• Metabolic alkalosis is the most common acid–
base imbalance.
• It accounts for 50% of all acid–base
disturbances.
Metabolic alkalosis
• an acid–base imbalance where the pH is greater
than 7.45 and the bicarbonate level is greater
than 26 mEq/L.
• There is an excess of base in the body and a loss
of acid.
• Basically, pH is increased and bicarbonate is
increased.
Metabolic alkalosis
• Metabolic: kidneys, which involve bicarbonate
and H+.
• The lungs compensate by retaining CO2 by
means of hypoventilation.
• This compensates for the alkalosis and helps the
pH go down into normal range.
Causes
• Vomiting; bulimia; nasogastric (NG) tube
suctioning
• Excess antacid ingestion
• Blood transfusions
• Sodium bicarbonate
• Thiazide and loop diuretics
Causes
• Baking soda
• Hypokalemia
• Activation of renin–angiotensin system
• Steroids
• Dialysis
• Licorice
The two most common causes of metabolic
alkalosis are:
• loss of stomach acid and
• diuretics.
Signs and symptoms
• Arrhythmias, flattened T-wave
• Decreased respirations, hypoventilation
• Hypokalemia
• Tightening of muscles, tetany, LOC changes,
seizures, tingling in fingers and toes
• LOC changes
• Hepatic encephalopathy
What do the ABGs look like?
• pH
• Greater than 7.45
• PaCO2
• Normal; increases with compensation
• PaO2
• Remains the same
• HCO3
• − Greater than 26 mEq/L
Diagnostic tests and treatments
• Treating the cause of the acid–base imbalance
(antiemetics for vomiting, etc.).
• Monitoring ABGs for further complications.
• Treating arrhythmias.
• Stopping client bicarbonate intake.
• Monitoring potassium levels and correcting
hypokalemia.
Diagnostic tests and treatments
• Monitoring respirations and LOC.
• Assessing for hypotension.
• Treating dehydration if present.
• Assessing DTRs.
• Administering ammonium chloride IV in severe cases
to increase acidity (increases H+).
• Administering acetazolamide (Diamox) to increase
excretion of bicarbonate through the kidneys.
Complications
Metabolic alkalosis can cause the following life-
threatening illnesses:
• Arrhythmias.
• Cardiac arrest.
• Seizures.
Recap of metabolic alkalosis
• The problem is with the kidneys, not the lungs
• Bicarbonate (base) and H+ (acid) are associated
with the kidneys
Recap of metabolic alkalosis
• Metabolic alkalosis can be caused by increased
bicarbonate through diuretic therapy, prolonged
nasogastric suctioning, and excessive vomiting,
resulting in ↑ pH levels
• The lungs compensate by retaining CO2 by
means of hypoventilation. This compensates for
the alkalosis
SUMMARY
• The respiratory and renal systems can be both
the cause and “cure” for pH imbalances.
• Remember that the lungs control carbon dioxide
levels and the kidneys control bicarbonate levels.
• By monitoring your client’s carbon dioxide,
bicarbonate, and pH levels you can successfully
prevent and treat any acid–base imbalances.
SUMMARY
• Acidosis:
• Think hyperkalemia and hypercalcemia.
• Alkalosis:
• Think hypokalemia and hypocalcemia.
END