Ms.

Pratheeba S,
I Year M.Sc Nursing
 INTRODUCTION
Fluids contains

Minerals (inorganic substances) are dissolved

within and form ions called electrolytes.

Fluid compartments.
•50-60% of body weight in adult body.

•Water content varies with gender and age.

 DEFINITION
Fluid:

A substance, as a liquid or gas, that is capable of

flowing and that changes its shape at a steady rate when
acted upon by a force tending to change its shape.
 FLUID COMPARTMENT
• Intracellular space

• Extracellular space
 Intravascular fluid
(within blood vessels
containing plasma)
 Interstitial fluid (space
between cells)
 Transcellular fluid
(specialized cavities)
 DEFINITION
Homeostasis:

Maintenance of a constant internal

equilibrium in a biologic system that
involves positive and negative feedback
mechanisms.
 DEFINITION

Electrolytes:

Electrolytes are charged particles (ions) that are

dissolved in body fluids.
ELECTROLYTES
 Regulation of Acid-Base Balance

The Lungs
The Kidneys
LUNGS KIDNEYS
 BUFFER SYSTEM

H2O+CO2 H2CO3 H+ + HCO3-

Extracellular Buffers:

Bicarbonate and ammonia

Intracellular Buffers:

Proteins and phosphate

 Fluid & Electrolyte Imbalance

The basic type of fluid imbalances are

Isotonic and

Osmolar.
 Hypovolemia
(Fluid Volume Deficit)
Mild – 2% of body weight loss

Moderate – 5% of body weight loss

Severe – 8% or more of body weight loss

 Fluid Volume Deficit
Occurs when loss of ECF volume exceeds intake of fluid
Causes:
 Loss of Plasma
 Loss of Blood
 Excessive Perspiration
 Fever
 Decreased Oral Intake
 Use of Diuretics
 Clinical manifestations

• Restlessness, Drowsiness, Lethargy, Confusion

• Thirst, Dry Mouth, Cracked Lips

• Sunken, Soft Eyeball

• ↓Skin Turgor, ↓ Capillary Refill, ↓ CVP

 Clinical manifestations

• ↓ Urine Output, Concentrated Urine

• ↑ Respiratory Rate

• Weakness, Dizziness, Weight Loss

• Seizure, Coma
 DIAGNOSTIC FINDINGS
• ↑ Blood urea nitrogen

• ↑ Hematocrit

• ↑ Urine specific gravity

 MANAGEMENT
• Intravenous fluid- Isotonic (Ringer Lactate) first line of treatment

• Hypotonic (Sodium chloride) when rapid volume replacement is

needed
• Oral rehydration
 MANAGEMENT

• Blood

• Intake and output

• Weight

• Vital signs

• Skin assessment and care

 Hypervolemia
(FLUID VOLUME EXCESS)
Causes
•Excess isotonic and hypotonic IV fluid
•Heart failure
•Renal failure
•Primary polydipsia
•SIADH
•Long term use of corticosteroid
•Cushing syndrome
 CLINICAL MANIFESTATION
• Headache, confusion, lethargy

• Peripheral oedema

• Jugular vein distension

• Polyuria
( with normal renal function)
 CLINICAL MANIFESTATION
• Bounding pulse, ↑ BP, ↑ CVP

• Dypsnea, crackles (rales), pulmonary oedema

• Muscle spasm, weight gain

• Seizure, coma
 DIAGNOSTIC FINDINGS
• ↓ Blood Urea Nitrogen, ↓ Hematocrit

• ↓ Serum Osmolality and ↓ Sodium level

• Chest X-ray – Pulmonary Congestion

 MANAGEMENT
• Prevention- restriction of sodium intake and fluid restriction

• Diuretics

• Congestive Heart Failure- Angiotensin Converting Enzyme

(ACE) Inhibitor, Digitalis and Low Dose Beta- Blocker
• Dialysis

• Intake and Output, Daily Weight, Rest and Positioning

 NURSING DIAGNOSIS
Hypovolemia
•Deficient fluid volume related to excessive ECF losses or
decrease fluid intake.
•Decrease cardiac output related to excessive ECF losses or
decrease fluid intake.
•Potential complication: hypovolemia shock.
 NURSING DIAGNOSIS
Hypervolemia
•Excess fluid volume related to increase water and /or sodium
retention
•Impaired gas exchange related to water retention leading to
pulmonary oedema
•Risk for impaired skin integrity related to oedema

•Potential complication: pulmonary oedema, ascites

 ELECTROLYTES

.
 ELECTROLYTES FUNCTION

• Maintain homeostasis by maintaining balance of

fluids between ECF and ICF

• Carry impulses for regulation of myocardial,

neurological and muscle function

• Maintain pH level (oxygen delivery, acid base

balance)
NORMAL VALUE OF
ELECTROLYTE
 NORMAL VALUE OF
ELECTROLYTE
ELECTROLYTES NORMAL VALUE
Sodium (Na +) 135 -145 mEq/L

Potassium (K +) 3.5 - 5 mEq/L

Calcium (Ca 2+) 8.5 - 10.5 mg/dl

Magnesium (Mg 2+) 1.8 – 2.7 mg/dl

Chloride (Cl -) 96 – 108 mEq/L

Phosphate (PO42+) 2.5 – 4.5 mEq/ L

 SODIUM
Most abundant cation in ECF- 90%

FUNCTION
•Maintain balance of extracellular fluid

•Transmission of nerve impulses

•Neuro-muscular and myocardial impulse transmission

 Hyponatremia (<135mEq/L)
Causes:
Vomiting

Diarrhoea

Sweating

Renal diseases
Medication – oxytocin & certain tranquilizer

Hyperglycemia

Heart failure
 Signs & Symptoms
Poor skin turgor

Orthostatic hypotension

Rapid thready pulse

Na+ level < 115mEq/L
o↑ ICP,
oLethargy
oConfusion
oMuscle Twitching
oFocal Weakness
oHemiparesis
oPapilledema
oSeizure
 MANAGEMENT
• Sodium replacement

 Hypertonic saline solution with loop diuretic will increase

serum Na while encouraging loss of excess fluid
 Serum Na must not be increased > 12mEq/L in 24 hours
to avoid neurologic damage due to osmotic demyelination

Water restriction by 800ml in 24hrs

 NURSING INTERVENTION
• Assess for clinical manifestation

• Accurate measures of intake and output

• Weight monitoring

• GI manifestation should be noted

• Watch for CNS changes

• Serum Na monitoring

• Encourage food and fluid high in Na

 Hypernatremia (>145mEq/L)
Causes
Excessive sodium intake
Inadequate water intake
Excessive water loss
Disease states – Diabetis Insipidus
- Hyperaldosteronism
- Cushing Syndrome
 Signs & Symptoms

Restlessness, Agitation
Seizure, Coma
Intense Thirst
Dry Swollen Tongue
Postural Hypotension
Rapid Pulse
Weight Loss
 MANAGEMENT
• Gradual lowering of serum level by
– hypotonic solution (0.45% NaCl) or
– isotonic non-saline solution (5% dextrose)

• Sodium is reduced at a rate of no faster than 0.5 to 1

mEq/L to allow time for readjustment through
diffusion across fluid compartment.
 NURSING INTERVENTION
• Careful monitoring of fluid loss and gain

• Medication history

• Note changes in behaviour

• Note patient’s thirst or elevated body

temperature and evaluate it in relation to other
clinical signs
 Potassium
• Major ICF cation with 98%

Function
 Regulates intracellular osmolality and promotes cellular
growth
 Requires for glycogen to be deposited in muscle and
liver cells
 Maintain acid base balance
 CAUSES AND EFFECTS OF HYPOKALEMIA
< 3.5 mEq/L
Decreased Intake Increased Loss Shift of Potassium
into Cells

HYPOKALEMIA
GI Tract CNS Muscles CV System Kidneys
Anorexia Lethargy, Weakness, Decrease in ↓Capacity to
Diminished Flaccid standing BP, concentrate
N&V deep-tendon paralysis, Dysrhythmias, waste, water
reflexes, Weakness of ECG changes, loss, thirst,
Abdominal Confusion, respiratory Myocardial kidney
distention Mental muscles, damage, damage
depression Respiratory Cardiac arrest
arrest
 MANAGEMENT

• Diet and supplement

• IV replacement therapy- Potassium Chloride

 NURSING INTERVENTION
• The safest way to administer K is orally.

• When K is given IV, the rate of flow must be monitored closely

and should be diluted.
• Should not exceed 20 mEq/hr

• Cardiac monitoring is useful

• Potassium sparing diuretics -spironolactone

 CAUSES AND EFFECTS OF HYPERKALEMIA
>5 mEq/L
Excess Intake Decreased Loss Shift of Potassium
out of the Cells
Dietary intake,
Potassium-sparing diuretics;
Extensive injuries,
Excess parenteral Renal failure; Adrenal
crushing injuries,
administration insufficiency
metabolic acidosis

HYPERKALEMIA

GI Tract CNS Muscles CV System Kidneys

N&V Numbness, Early: irritability Conduction Oliguria
paresthesias disturbance, leading to
Late: weakness
Diarrhea ventricular anuria
leading to flaccid
fibrillation,
paralysis
Cardiac Arrest
 MANAGEMENT

Patients at risk should be identified

Impaired renal function to avoid OTC (NSAIDS), Salt

Food that are high in potassium to be avoided

Medications:

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 Calcium

• Most abundant electrolyte in the body- 99% in bones

Function:
 CAUSES AND EFFECTS OF HYPOCALCEMIA
< 8.5 mg/dl
Inadequate Decrease in GI Tract
Decreased Excess Loss Intake and Bone Absorption
Ionized Ca
↑Magnesium
Kidney Disease Dietary Deficit
Large
↑Calcitonin
transfusion
with citrated ↓Vitamin D
blood ↓Parathyroid Hormone

HYPOCALCEMIA

Bones CNS Muscles Cardiovascular

Muscle spasm System
Osteoporosis Tingling
leading to Dysrhythmias
Fractures ↓ convulsions ↓
↓
Tetany
Cardiac arrest
Trousseau’s sign – carpal spasms
Chvostek’s sign – cheek twitching
 MANAGEMENT

 IV/PO Calcium Carbonate or Calcium Gluconate

 Encourage increased dietary intake of Calcium

 With vitamin D supplement to increase calcium absorption

 Monitor neurlogical status

 Establish seizure precautions

 HYPERCALCEMIA: Causes and Effects
> 10.5 mg/dL
Loss from bones Excess Intake Increase in factors
Causing Mobilization
Immobilization,
↑ Calcium diet (esp. milk) from bone
Carcinoma with bone
metastases, Multiple Antacids containing ↑PTH, ↑ Vitamin D,
myeloma calcium steroid therapy

HYPERCALCEMIA

Kidneys CNS Bones Muscles CV System

Stones ↓Deep-tendon Bone pain Muscle fatigue, Depressed

reflexes hypotonia activity
↓ ↓
↓ ↓ ↓
Kidney Osteoporosis
Damage Lethargy ↓ GI motility Dysrhythmias
↓
↓ ↓
Fractures
Coma Cardiac Arrest
 MANAGEMENT
• Mild hypercalcemia: hydration and education about avoiding
foods high in calcium or medications that promote calcium
elevation
• Severe hypercalcemia: medical emergency: continuous cardiac
monitoring, hydration, IV furosemide, Calcitonin and/or
plicamycin (mithramycin), reduces bone reabsorption
 MAGNESIUM
Second most abundant intracellular cation
50- 60% in bones
Function:
 HYPOMAGNESEMIA: < 1.8 mEq/L

• Usually coexists with hypokalemia and less often with hypocalcemia

Decreased Intake Impaired absorption from GI Tract Excessive

Excretion
Prolonged Malabsorption syndrome, Alcohol
malnutrition, Withdrawal Syndrome, Hypercalcemia, ↑Aldosterone,
Starvation Diarrhea Conditions
causing large
loss of urine
HYPOMAGNESEMIA

Muscles
Mental Changes CNS CV System
Cramps,
Agitation, Convulsions, Spasticity, Tachycardia,
Depression, Paresthesias, Tetany, Hypotension,
Confusion Tremor, Ataxia chvostek’s sign, Dysrhythmias
trousseou’s
HYPOKALEMIA sign
 MANAGEMENT
• Treatment of the underlying cause is the first
consideration in hypomagnesemia

• Severe: parenteral magnesium(MgSO4) replacement is

indicated

• IV therapy: continuous cardiac monitoring

• Safety measures for patients with mental status changes

 HYPERMAGNESEMIA >2.7 mg/dl
• Seldom develops in the presence of normal renal
function/ failure

• May occur as a result of Mg replacement/ antacid

• May occur when MgSO4 is administered to prevent

seizures resulting from eclampsia

• Careful monitoring is imperative

 PATHOPHYSIOLOGY

Renal failure, Excessive IV infusion of

magnesium, Decreased GI elimination

Accummulation of Mg in the body

Mg Level Rises

Altered Electrical Conduction

Slowed heart
Diminishing of reflexes, drowsiness, lethargy rate and AV
Block
Severe Respiratory Depression
Peripheral
vasodilation
RESPIRATORY ARREST may occur

Hypotension, flushing, and

increased skin warmth
 MANAGEMENT
• Prevention
• Precaution in chronic kidney disease
• Discontinue parenteral and oral magnesium
• Inj Calcium chloride and calcium gluconate
• Loop diuretics, NaCl or Ringer lactate
• Dialysis
• If cardiorespiratory collapse is imminent, the patient may
require temporary pacemaker and ventilator support
 ACID-BASE BALANCE

ABG
CONCLUSION
JOURNAL
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