FLUID AND

ELECTROLYTE
IMBALANCES
Prepared by:
REMEROSE C. RAGASA, RN
Anatomy & Physiology

Fluid & Electrolyte Movement

 Filtration
 Diffusion
 Osmosis
Fluid Functions
 Regulate body temperature
 Transport nutrients and gases throughout the body
 Carry cellular waste products to excretion sites

Electrolytes
Electrolytes are a major component of body fluids that play
important roles in maintaining chemical balance. There are six
major electrolytes: Sodium, Potassium, Calcium, Chloride,
Phosphorus, and Magnesium.
 Nursing Interventions

I&O.  Daily weight. Vital signs.

Monitor turgor. Urine concentration
Monitor Cardiac, Respiratory, Neuromuscular, Renal, and GI
status.
Diet.
Oral and parenteral fluids.
 IV SOLUTIONS

 Isotonic - Isotonic IV solutions that have the same

concentration of solutes as blood plasma.
 Hypotonic -  Hypotonic solutions have lesser
concentration of solutes than plasma.
 Hypertonic - Hypertonic solutions have greater
concentration of solutes than plasma
Fluid Volume Deficit (Hypovolemia)
When water and electrolytes are lost in the same proportion so
that the ratio of serum electrolytes to water remains the same.

Causes of Hypovolemia
Absolute hypovolemia
-Massive bleeding from injury or surgery
-Excessive fluid loss from vomiting, diarrhea, urine, sweating
Relative hypovolemia
-Massive vasodilation from septic shock
-Internal bleeding, third-spacing of fluid (severe burns, fracture of
long bones)
Signs/Symptoms
- Acute weight loss, decreased skin turgor
- Oliguria, concentrated urine
- Weak, rapid heart rate, flattened neck vein
- Increased temperature, thirst
- Cold, clammy, pale skin
- Hypotension,
- Muscle weakeness
Treatment goals: fluid resuscitation, correct underlying cause
that is leading to the fluid loss
Nursing Intervention
 If bleeding, hold firm, direct pressure.
 Place in modified Trendelenburg position (feet at 45’ and head
flat)
 Obtain IV access (at least two IV sites that are large…many
patients with severe hypovolemic shock especially ones who
are not responding to fluid treatment will have a central line
 Collect labs: hgb, hct (blood level), lactate level (status of cell’s
metabolism), blood gases (acidosis), electrolytes, bun, and
creatinine
Fluids for Hypovolemic Shock
Crystalloids: Normal Saline or Lactated Ringer’s
**Remember the 3:1 rule for crystalloid solutions: For every 1 mL
of approximate blood loss, 3 mL of crystalloid solution is given.**
**If giving large amount of fluids, need to WARM them. If not
warmed, it can lead to hypothermia & will alter clotting
enzymes**
Colloids: Albumin, Hetastarch
Blood and Blood Products: Packed Red Blood Cells, Platelets or Fresh
Frozen Plasma (FFP)
**Monitor for transfusion reaction with these products**
Fluid Volume Excess (Hypervolemia)
Isotonic expansion of the ECF caused by abnormal retention of
water and sodium in which they normally exist in the ECF.
Because there is isotonic retention of body substances, the serum
Na+ concentration remains substantially normal.

Causes of Hypervolemia
- Congestive Heart Failure
- Early renal failure
- Excessive IV therapy
- Excessive sodium ingestion
- Corticosteroid
- Liver disease
Signs/Symptoms
Tachypnea ,Dyspnea, Crackles, Rapid or bounding pulse,
Hypertension (unless in heart failure), Jugular vein distention,
Acute weight gain, Edema
Nursing Intervention
 Limit sodium intake as prescribed
 Take diuretics as prescribed.
 Administer IV fluids through an infusion pump, if possible.
 Place the patient in a semi-Fowler’s or high-Fowler’s position.
 Aid with repositioning every 2 hours if the patient is not
mobile.
 Use antiembolic stockings, as ordered
 Sodium (Na)
Normal range: 135-145 mEq/L
- Helps regulate water inside and outside of the cell. 
-  Play a role in muscle, nerves, and organ function.

Causes of Hypernatremia
Water loss, inadequate water intake, excessive sodium intake,
Diabetes Insipidus, certain diuretics, corticosteroid use,
antihypertensive drug

Signs/Symptoms
Thirst, Dry sticky mucous membranes, Restlessness,
Disorientation, Muscle weakness and irritability, ↑ BP
Nursing Intervention
 Restrict sodium intake! Know foods high in salt such as bacon,
canned & processed food, cheese, lunch meat, and table salt.
 Keep patient safe because they will be confused.
 Doctor may order to give isotonic or hypotonic solutions such
as 0.45% NS (which is hypotonic and most commonly used).
Give hypotonic fluids slowly because brain tissue is at risk due
for cerebral edema.
Causes of Hyponatremia
Inadequate sodium intake, Excessive water gain, heart and renal
failure, cirrhosis, laxatives, nasogastric suctioning, Medications
such as antidiabetics, diuretics

Signs/Symptoms
Confusion, Orthostatic hypotension, Nausea, Vomiting Weight
gain, Edema, Muscle spasms, Seizure
Nursing Intervention
Hypovolemic Hyponatremia: give IV sodium chloride infusion to
restore sodium and fluids (3% Saline hypertonic solution….harsh
on the veins).
Hypervolemic Hyponatremia: Restrict fluid intake and in some
cases administer diuretics. If the patient has renal impairment
they may need dialysis.
Caused by SIADH problems: fluid restriction or treated with
Declomycin which is part of the tetracycline family (don’t give
with food especially dairy or antacids).
Increase oral sodium intake and some physicians may prescribe
sodium tablets. Food rich in sodium include: bacon, canned
food, cheese, lunch meat, processed food, table salt.
 Potassium ( K)
Normal Level 3.5 - 5 mEq/L
- Regulates cell excitability & nerve impulse conduction
- Permeates cell membranes
- Regulates muscle contraction & myocardial responsiveness
Causes of Hyperkalemia
High potassium intake, Renal impairment, Adrenal Insufficiency
with Addison’s Disease, Drugs (potassium-sparing drugs:
spironolactone, Triamterene, ACE inhibitors,
Signs/Symptoms
Muscle weakness, Urine production little, Respiratory failure,
Decreased cardiac contractility (weak pulse, low blood pressure),
EKG changes: Tall peaked t waves, prolonged PR interval
Nursing Intervention
 Stop IV potassium if running and hold any PO potassium
supplements
 Initiate potassium restricted diet and remember foods that are
high in potassium such as Potatoes, Pork, Oranges, Tomatoes,
Avocados, Strawberries, Spinach.
 Prepare patient for ready for dialysis. Most patient are renal
patients who get dialysis regularly.
 Kayexalate is sometimes ordered and given PO or via enema.
 Doctor may order potassium wasting drugs like Lasix.
 Administer a hypertonic solution of glucose and regular insulin
Causes of Hypokalemia
Drugs (laxatives, diuretics), Inadequate consumption of Potassium
(NPO), Too much water intake, Heavy Fluid Loss (NG suction,
vomiting, diarrhea), Cushing Syndrome

Signs/Symptoms
Shallow respirations,
Confusion, Flaccid paralysis, Decrease deep tendon reflexes,
Decreased bowel sounds, Low BP, Cardiac Dysrthymias (ST
depression), Polyuria

Nursing Intervention
Watch other electrolytes like Magnesium (hard to get K+ to
increase if Mag is low), glucose, sodium, and calcium 
Administer oral potassium Supplements with doctor’s order
(give with food can cause GI upset)
NEVER EVER GIVE POTASSIUM via IV push or IM or SC routes
IV Potassiun has to be given slow. Patients given more than 10-
20 meq/hr should be on a cardiac monitor.
Don’t give LASIX, (waste more Potassium) or Digoxin (cause
digoxin toxicity) if Potassium level low. Notify MD for further
orders.
Instruct patient to eat Potassium rich foods.
Have emergency equipment available for cardiopulmonary
resuscitation and cardiac defibrillation.
 Calcium Normal
Level 4.5 – 5.5 mEq/L
- Found in cell membranes it helps cells adhere to one another
and maintain their shape
- Acts as an enzyme activator within cells
- Aids in coagulation
Causes of Hypercalcemia
Hyperparathyroidism, Increased intake of calcium, Glucocorticoids
usage Hyperthyroidism, Addison’s Disease, Lithium usage
Signs/Symptoms
Weakness of muscles, EKG changes shortened QT interval, Absent
reflexes, Disorientated, Abdominal distention from constipation,
Kidney Stone formation, Pathologic fractures
Nursing Intervention
 Keep patient hydrated (decrease chance of renal stone
formation)
 Encourage ambulation
 Keep patient safe from falls or injury
 Administer calcium reabsorption inhibitors: Calcitonin
 Decrease calcium rich foods and intake of calcium-preserving
drugs like thiazides, Vitamin D supplements
 Severe cases of Hypercalcemia, prepare patient for dialysis
Causes of Hypocalcemia
Hypoparathyroidism, ↓intake of calcium, Celiac’s & Crohn’s
Disease, Acute Pancreatitis, ↓ Vitamin D levels, Chronic kidney
issues, ↑phosphorus levels in the blood
Signs/Symptoms
Confusion, Reflexes hyperactive
Arrhythmias (prolonged QT interval),Muscle spasms in calves or
feet, tetany, Seizures
Positive Trousseau’s and Chvostek’s sign 

Nursing Intervention
 Safety (prevent falls because patient is at risk for bone
fractures, seizures precautions, and watch for laryngeal
spasms)
Administer IV calcium as ordered (ex: 10% calcium gluconate)
Give slowly as ordered & watch for cardiac dysrhythmias. Assess
for infiltration or phlebitis.
If phosphorus level is high the doctor may order aluminum
hydroxide antacids to decrease phosphorus level.
Administer oral calcium with Vitamin D supplements (given
after meals or at bedtime with a full glass of water)
 Encourage intake of foods high in calcium: Yogurt, Sardines,
Cheese, Spinach, Collard greens, Tofu, Milk
 Magnesium ( Mg) Normal level
1.5 - 2.5 mEq/L
- Important in the functioning of the heart, nerves, and muscles
- Regulation of parathyroid hormone PTH (which also plays a role
in calcium levels)
- Metabolism of carbs, lipids, and proteins, and BP regulation

Causes of Hypermagnesemia
Magnesium containing antacids and laxatives, Addison’s disease,
Glomerular filtration insufficiency (<30mL/min) renal failure. This
is because the kidneys are keeping too much magnesium
Signs/Symptoms
Lethargy, EKG changes with prolonged PR & QT interval with
widened QRS complex, Tendon reflexes absent/diminished,
Hypotension, Arrhythmias, Respiratory arrest, GI issues (nausea,
vomiting), Impaired breathing (due to skeletal weakness),
Respiratory and Cardiac Arrest

Nursing Intervention
Ensure safety due to lethargic/drowsiness
Prevention:
- Avoid giving Magnesium containing antacids/laxative to
patients with renal failure
- Assess for hypermagnesemia during IV infusions of
magnesium sulfate for hypomagnesemia
 Withhold foods high in magnesium, such as: Avocado, Green
leafy vegetables, Peanut Butter, Potatoes, Pork, Oatmeal, Fish
(canned white tuna/mackerel), Cauliflower, chocolate (dark),
Legumes, Nuts
 Administer diuretics that waste magnesium (if patient is not in
renal failure) such as Loop and Thiazide diuretics
 Patient in renal failure patient prep for dialysis
 IV calcium may be order to reverse side effects of Magnesium
(watch IV for infiltration…prefer central line)
Causes of Hypomagnesemia
Malabsorption issues (Crohn’s, Celiac), Alcohol (alcohol stimulates
the kidneys to excreted Mg), Glycemic issues (DKA), Limited
intake Mg+ (starvation), Other electrolyte issues cause low Mg+
levels,
Loop and thiazide diuretic
Signs/Symptoms
Trouesseau’s /Chvostek’s sign (positive due to hypocalcemia),
Weak respirations, Irritability, Hypertension, Hyperreflexia
Involuntary movements, GI issues (decreased bowel sounds,
nausea), Seizures, ECG changes (moderate: Tall T-waves and
depressed ST segments*** severe: prolonged PR & QT interval
(prolong of QT interval increases patient’s risk for Torsades de
pointes) 
Nursing Intervention
 Administer Magnesium Sulfate IV route. Monitor Mg+ level
closely because patient can become magnesium toxic
(***Watch for depressed or loss of deep tendon reflexes)
 Place patient in seizure precautions
 Oral forms of Magnesium may cause diarrhea which can
increase magnesium loss so watch out for this
 Encourage foods rich in Magnesium: Avocado, Green leafy
vegetables, Peanut Butter, Potatoes, Pork, Oatmeal, Fish
(canned white tuna/mackerel), chocolate (dark), Legumes,
Nuts
 May administer potassium supplements due to hypokalemia
(hard to get magnesium level up if potassium level is down)
 Administering calcium supplements
 Phosphorus (p)
Normal level 2.5 - 4.5 mg/dl
-Promotes energy storage and carbohydrate, protein and fat
metabolism
-Helps build bones and teeth and nerve/muscle function.

Causes of Hyperphosphatemia
Renal disease, Hypoparathyroidism or hyperthyroidism, Excessive
vitamin D intake, Muscle necrosis, Excessive phosphate intake,
Signs/Symptoms
Confusion, Hyperactive reflexes, Anorexia, Muscle spasms in
calves or feet, Seizures, Positive Trousseau’s Signs, Chvostek,
Pruritus
Nursing Intervention
 Avoid using phosphate medication such as laxatives and enema
 Restrict foods high is phosphate such as: poultry, fish, dairy,
nuts, sodas, oatmeal
 Prepare patient for dialysis if patient in renal failure
 Administer phosphate-binding drugs (PhosLo) which works on
the GI system and causes phosphorus to be excreted through
the stool.***(Give with a meals or right after eating meal)
Causes of Hypophosphatemia
Pulmonary issues such as respiratory alkalosis, Hyperglycemia,
Alcoholism, Thermal Burns, Electrolyte imbalances:
hypercalcemia, hypomagnesemia, hypokalemia also cause
phosphate levels to decrease, Refeeding Syndrome

Signs/Symptoms
Extreme weakness, Ecchymosis from decreased platelets , Neuro
status changes (irritability, confusion, seizures), Breathing
problems due to muscle weakness, Osteomalacia (softening of
the bones), fractures and decreased bone density
 Nursing Intervention
 Ensure patient safety due to risk of bone fractures
 Encourage foods high is phosphate but low in calcium: **Foods
high in phosphate are fish, organ meats, nuts, pork, beef,
chicken, whole grains
 If phosphate levels less than 1mg/dL, the doctor may order IV
phosphorous which affects calcium levels
causing hypocalcemia.***Also, assess renal status
(BUN/creatintine normal) before administering phosphorous
because if the kidneys are failing the patient won’t be able to
clear phosphate.
Burn
It is damage to the skin’s integrity from some type of energy
source, such as: Heat (thermal), Electrical, Chemical, Cold,
Radiation, Friction

Burn Severity Depends on:

- Depth of damage to the skin
- Percentage of the total surface of the skin affected
- Patient’s age
- Medical history
- Where the burn is located
- Did the patient experience an inhalation injury?
Degrees of Burns
Rule of Nines for Burns in an Adult
It’s a calculation used to calculate the total body
surface area burned for burns partial-thickness or greater.
Nursing Intervention
Phases of Burn Management:
Emergent: (lasts 24-48 hours)
Focus: Treat airway and breathing, Ensure proper circulation
 Assess Airway, Breathing, Circulation
 Observe for signs of inhalation injury: blistering of lips
or buccal mucosa; singed nostrils; burns of face, neck, or
chest; increasing hoarseness; or soot or respiratory secretions
 Provide humidified oxygen, institute aggressive pulmonary
care measures: turning, coughing, deep breathing,
 Report signs of hypoxia to physician immediately; prepare
to assist with intubation and escharotomies
 Maintain IV lines and regular fluids at appropriate rates.
Parkland’s Burn Formula:….
Volume of Fluid needed (LR) = 4 mL x percentage of BSA x

patient weight kilograms

How to give the fluids: 1/2 during the first 8 hours and then
other 1/2 over the next 16 hours to equal 24 hours
 Monitor vital signs and urinary output (hourly)
 Circumferential burns are Dangerous! Watch out for
compartment syndrome.
 Monitoring and Managing Potential Complications
- Acute tubular necrosis (monitor the urine for hemoglobin
and
myoglobin if the patient has full-thickness or severe electrical
burns)
 - Paralytic ileus
- Curling’s ulcer (watch for reports of stomach pain (gnawing),
vomiting, blood in stool)
 Keep patient NPO until bowel sounds are present
 Provide warm environment: use heat shield, space
blanket, heat lights
Acute : (starts 48-72 hours until wound heals)
Focus: preventing infection, alleviating pain, ensuring proper
nutrition, wound care
 Use a pain scale to assess pain level
 Administer IV opioid analgesics as prescribed. Always select
the option with IV route and PRE-MEDICATE before dressing
changes or debridement procedures.
 Protective isolation: wear hair cover, shoe cover, gown, gloves,
mask
 Strict hand hygiene
 Practice clean technique for wound care procedures and
aseptic technique for any invasive procedures.
 Positioning care with burns: NO pillows for the ear or neck
(decreases blood flow and can lead to wound contractures)
 NEVER allow two burn areas to touch due to webbing that can
occur.
 Elevate extremities and extend them to help prevent edema
and prevent contractures.
 Open dressing/Closed Dressing
 Nutrition
 Initiate oral fluids slowly when bowel sounds resume
 Collaborate with dietitian to plan a protein and calorie-
rich diet 
Rehabilitative
Focus: psychosocial, ADLs, PT, OT, cosmetic correction
Technically, this stage begins with closure of the burn and ends
when the client has reached the optimal level of functioning. In
actuality, it begins the day the client enters the hospital and can
continue for a lifetime