FLUID IMBALANCE

INTRODUCTION
•Fluid and electrolyte balance is a
dynamic process that is crucial for life.
•Potential and actual disorders of fluid
and electrolyte balance occur in every
setting , with every disorder and with a
variety of changes that affect well people.
•Example: Increased fluid and sodium
loss with strenuous exercises.
AMOUNT AND COMPOSITION
OF BODY FLUIDS
• Approx 60% of a typical adult’s weight
consists of fluid (water and electrolytes).
• Factors influencing amount of body fluid
are :-
Age
Gender
Body fat
Location of body fluids is in two
compartments :

1. The Intracellular space

( fluid in the cells)

2. The Extracellular space

(fluid outside the cells)
 EXTRA INTRA
CELLULAR CELLULAR FLUID
FLUID

TRANS
INTERSTIAL
PLASMA CELLULAR
FLUID
FLUID

CSF
INTRA OCULAR
PLEURAL
SYNOVIAL
DIGESTIVE
INTRACELLULAR FLUID
(ICF)

• The fluid within the cells is ICF.

• Approximately two thirds of body
fluid is in the intracellular fluid (ICF)
compartment and is located primarily
in the skeletal muscle mass.
 EXTRA CELLULAR FLUID
(ECF)
•All bodily fluids outside the cells is ECF.

• The extracellular fluid (ECF)

compartment is further divided into :-
1- The intravascular (Plasma)
2- The interstitial
3- The transcellular fluid spaces
 1.The intravascular space
• The fluid within the blood vessels
contains plasma. Approximately 3
Litres of the average 6 Litres blood
volume is made up of plasma.

• The remaining 3 Litres constitutes of

erythrocytes, leukocytes and
thrombocytes.
 2. The Interstitial space

• The interstitial space contains the

fluid that surrounds the cell and totals
about 11 to 12 Litres in an adult.

•Example: Lymph
 3. The Transcellular Space
• The transcellular space is the smallest
division of the ECF compartment and
contains approximately 1 litre of fluid at
any given time.

• Example: cerebrospinal, pericardial,

synovial, intraocular and pleural fluids;
sweat and digestive secretions.
•Body fluid normally shifts between
the two major compartments or
spaces in an effort to maintain an
equilibrium between the spaces.

•Loss of fluid from the body can

disrupt this equilibrium. Sometimes
fluid is not lost from the body but is
unavailable for use by either ECF or
ICF.
•Loss of ECF into a space that does
not contribute to equilibrium between
the ICF and the ECF is referred to as a
third - space fluid shift, or “third
spacing” for short.

•An early clue is decrease in urine

output. Third space shifts occur in
ascites, burns, peritonitis, bowel
obstruction.
 REGULATION OF BODY FLUIDS
COMPARTMENTS
• OSMOSIS AND
OSMOLALITY
• When two different solutions
are separated by a membrane
that is impermeable to the
diffused substances, fluid
shifts through the membrane
from the region of low solute
concentration to the region of
high solute concentration until
the solutions are of equal
concentration. This process is
called osmosis
OSMOLALITY - The concentration of a
solution expressed as the total number of
solute particles / Kg.

•The number of dissolved particles

contained in a unit of fluid determines the
osmolality of a solution , which
influences the movement of fluid
between the fluid compartments.
 TYPES OF SOLUTIONS

3 Types of Solutions:
• Hypotonic Solution
• Isotonic Solution
• Hypertonic Solution
CONTD..
 HYPOTONIC SOLUTION
(HYPO = the cell is going to BLOW)
a. Cell increases in size

b. WATER enters the cell

c. Solution has MORE

water and the cell has
LESS water
 Hypotonic solutions

•0.45% Saline (1/2 NS)

•0.225% Saline (1/4 NS)
•0.33% saline (1/3 NS)
 ISOTONIC SOLUTION
(in is the same as out)
a. Cell remains the same
size.

b. WATER moves in and

out of the cell equally.

c. Solution and cell have

EQUAL amounts of
water.
 Isotonic fluids
•0.9% Saline
•5% dextrose in water (D5W)**also
used as a hypotonic solution after it is
administered because the body
absorbs the dextrose BUT it is
considered isotonic)
•5% Dextrose in 0.225% saline
(D5W1/4NS)
•Lactated Ringer’s
 HYPERTONIC SOLUTION
• a. Cell shrinks in
size.

• b. WATER leaves the

cell.

• c. Solution has
LESS water and the
cell has MORE
water.
 Hypertonic solutions

•3% Saline
•5% Saline
•10% Dextrose in Water (D10W)
•5% Dextrose in 0.9% Saline
•5% Dextrose in 0.45% saline
•5% Dextrose in Lactated
Ringer’s
 DIFFUSION
• Diffusion is the natural
tendency of a substance to
move from an area of
higher concentration to an
area of lower
concentration. It occurs
through the random
movement of ions and
molecules.
• Examples of diffusion are
the exchange of O2 and
CO2 between the
pulmonary capillaries and
alveoli.
 FILTRATION
• Hydrostatic pressure in the capillaries
tends to filter fluid out of the vascular
compartment into the interstitial fluid.
• Movement of water and solutes occurs
from an area of high hydrostatic
pressure to an area of low hydrostatic
pressure.
• Filtration allows the kidneys to filter
180 Litres of plasma / day.
 SODIUM–POTASSIUM PUMP
• The sodium concentration is greater in the
ECF than in the ICF, and because of this,
sodium tends to enter the cell by diffusion.
• This tendency is offset by the sodium–
potassium pump, which is located in the cell
membrane and actively moves sodium from
the cell into the ECF.
• Conversely, the high intracellular potassium
concentration is maintained by pumping
potassium into the cell.
 ROUTES OF FLUID GAINS
• Water and electrolytes are gained in
various ways.
• A healthy person gains fluids by drinking
and eating.
• In patients with some disorders, fluids may
be provided by the parenteral route or by
means of an enteral feeding tube in the
stomach or intestine.
REGULATION OF WATER INTAKE
Governed by thirst

Decreased blood volume

and increased osmolality

Peripheral volume sensors

Central osmorecetors

Hypothalamus

Thirst felt
ROUTES OF FLUID LOSSES

Kidneys
Skin
Lungs
GI Tract
RAS (Renin Angiotensin System)
FLUID VOLUME
DISTURBANCES
 FLUID VOLUME DEFICIT
(HYPOVOLEMIA)
• Fluid volume deficit (FVD) or Hypovolemia
occurs when loss of extracellular fluid volume
exceeds the intake of fluid.
• It occurs when water and electrolytes are lost in
the same proportion as they exist in normal body
fluid.
• FVD should not be confused with the term
dehydration, which refers to loss of water alone
with increased serum sodium levels.
•FVD may occur alone or in combination with
other imbalances.
 PATHOPHYSIOLOGY
• FVD results from loss of body fluids and
occurs more rapidly when coupled with
decreased fluid intake.
• FVD can develop from inadequate intake
alone if the decreased intake is prolonged.

Causes of FVD include:

 Abnormal fluid losses, such as those
resulting from vomiting, diarrhea, GI
suctioning, and sweating.
Decreased fluid intake, as in nausea or
inability to gain access to fluids.
Additional risk factors include:
• Diabetes insipidus
• Adrenal insufficiency
• Osmotic diuresis
• Hemorrhage
• Coma

 Third-space fluid shifts, or the movement of

fluid from the vascular system to other body
spaces (eg, with edema formation in burns or
ascites with liver dysfunction), also produce FVD.
CLINICAL MANIFESTATIONS
• Weight loss • Increased
temperature
• Decreased skin
turgor • Decreased central
venous pressure
• Oliguria
• Cool, clammy skin
• Concentrated urine
• Thirst
• Postural hypotension
• Anorexia
• A weak, rapid heart
rate • Nausea
• Flattened neck veins • Muscle weakness
ASSESSMENT AND DIAGNOSTIC
FINDINGS

• Health history
• Physical examination
• BUN (Blood urea nitrogen)
• Greater hematocrit level
• Increased urine specific gravity
 MEDICAL MANAGEMENT
• When the deficit is not severe, the oral
route is preferred, provided the patient
can drink.
• When fluid losses are acute or severe
the IV route is required.
• Isotonic electrolyte solutions (eg
lactated Ringer’s or 0.9% sodium
chloride) are frequently used to treat the
hypotensive patient with FVD because
they expand plasma volume.
 NURSING MANAGEMENT
•Monitor and measures fluid intake and
output at least every 8 hours, and
sometimes hourly.
•Monitor daily body weights.
•Closely monitor vital signs.
•Monitor skin and tongue turgor
•Monitor urinary concentration
 FLUID VOLUME EXCESS
(HYPERVOLEMIA)
• Fluid volume excess (FVE) or
Hypervolemia refers to an isotonic
expansion of the ECF.

•This is caused by the abnormal retention

of water and sodium in approximately the
same proportions in which they normally
exist in the ECF.
 PATHOPHYSIOLOGY
FVE may be related to simple fluid
overload or diminished function of the
homeostatic mechanisms responsible for
regulating fluid balance.
Contributing factors include:
• Heart failure
• Renal failure
• Cirrhosis of the liver
• Consumption of excessive amounts of
table or other sodium salts
CLINICAL MANIFESTATIONS
• Edema
• Distended neck veins
• Crackles (abnormal lung sounds)
• Tachycardia
• Increased blood pressure, pulse pressure
• Central venous pressure
• Increased weight
• Increased urine output
• Shortness of breath and wheezing
 ASSESSMENT AND
DIAGNOSTIC FINDINGS
• Decreased BUN and hematocrit levels
because of plasma dilution.

• Chest X-rays may reveal pulmonary

congestion.

• In chronic renal failure, both serum

osmolality and the sodium level are
decreased due to excessive retention of
water
 MEDICAL MANAGEMENT
1. Pharmacologic therapy
• Thiazide diuetics are given in mild to
moderate FVE. Eg chlorothiazide
•Loop diuretics are given in severe FVE.
Eg lasix
2. Hemodialysis
3. Nutritional therapy
• Average daily diet not restricted in Na-
6-15gm of Na
• Low Na diet-250mg of Na
 NURSING MANAGEMENT
• Measures intake and output at regular
intervals to identify excessive fluid retention.

• Weigh the patient daily and note acute weight

gain an acute weight gain of 0.9 Kg represents
a gain of approximately 1 Litres.

• Assess breath sounds at regular intervals in at-

risk patients, particularly when parenteral fluids
are being administered.
•Monitor the degree of edema in the
most dependent parts of the body, such
as the feet and ankles in ambulatory
patients and the sacral region in
bedridden patients.

•The degree of pitting edema is assessed,

and the extent of peripheral edema is
monitored by measuring the
circumference of the extremity with a
tape marked in millimeters.
 ASSIGNMENT

Normal values of serum

electrolyte.
 BIBLIOGRAPHY
1. Abraham, I. L., & Fulmer, T. (1999). Geriatric nursing protocols for best
practice. New York: Springer.
2. Abrams, W. B., Beers, M. H., & Berkow, R. (2000). Merck manual of
geriatrics (3rd ed.). Whitehouse Station, NJ: Merck & Co.
3. Alzheimer’s Disease Education and Referral (ADEAR) Center. (1999).
Progress report on Alzheimer’s Disease. Silver Springs, MD: U.S.
Department of Health and Human Services, Public Health Service,
National Institutes of Health, National Institutes of Aging.
4. Bast, R. C., Kufe, D. W., Pollock, R. E., et al. (Eds.) (2000). Holland &
Frei cancer medicine (5th ed.) Hamilton: B.C. Decker, Inc.
5. Judith Hopper, April Hazard Vallerand, Davis’s Drung Guide for
Nurses, 9th Edition, F.A Davis Company. Philadelphia.
6. Suzanne C Smeltzer, Brend Bare, Brunner and Suddarth’s Textbook of
Medical and Surgical Nursing, 10th Edition, A Wolkers Kluwer
Company, Philadelphia.