Fluid and electrolyte balance is a dynamic process that is crucial for

life and homeostasis.

Fluid occupies almost 60% of the weight of an adult.
Body fluid is located in two fluid compartments: the intracellular
space and the extracellular space.
Electrolytes in body fluids are active chemicals or cations that
carry positive charges and anions that carry negative charges.
The major cations in the body fluid are sodium, potassium,
calcium, magnesium, and hydrogen ions.
The major anions are chloride, bicarbonate, sulfate, and proteinate
ions.
Homeostasis
Homeostasis is the dynamic process in which the body maintains
balance by constantly adjusting to internal and external stimuli.
Negative and Positive Feedback
Feedback is the relaying of information about a given condition
to the appropriate organ or system.
Negative feedback. Negative feedback occurs when the
body reverses an original stimulus for the body to regain
physiologic balance.
Positive feedback. Positive feedback enhances or intensifies the
original stimulus.
Examples. Blood pressure control and maintenance of normal
body temperature are examples of negative feedback while blood 
clotting after an injury and a woman in labor are examples of
positive feedback.
Systems Involved in Feedback
The major systems involved in feedback are the nervous and
endocrine systems.
Nervous system. The nervous system regulates homeostasis by
sensing system deviations and sending nerve impulses to
appropriate organs.
Endocrine system. The endocrine system uses the release and
action of hormones to maintain homeostasis.
Body Fluids
Fluids make up a large portion of the body, which is approximately
50%-60% of the total body weight.

Location of Fluids
Main compartments. Body fluids are divided between two main
compartments: the intracellular fluid and the extracellular fluid
compartments.

Intracellular fluid. Intracellular fluid functions as a stabilizing

agent for the parts of the cell, helps maintain cell shape, and assists
with transport of nutrients across the cell membrane, in and out of
the cell.

Extracellular fluid. Extracellular fluid mostly appears as

interstitial tissue fluid and intravascular fluid.
Fluid Regulation Mechanisms
The thirst center. The thirst center in the hypothalamus
 stimulates or inhibits the desire for a person to drink.
Antidiuretic hormone. ADH regulates the amount of water
the kidney tubules absorb and is released in response to low
blood volume or in response to an increase in concentration of
sodium and other solutes in the intravascular fluids.
The RAA system. The RAA system controls fluid volume, in
which when the blood volume decreases, blood flow to the
renal juxtaglomerular apparatus is reduced, thereby activating
the RAA system.
Atrial natriuretic peptide. The heart also plays a role in
correcting overload imbalances, by releasing ANP from the
right atrium.
Normal Intake and Output
Daily intake. An adult human at rest takes appropriately 2,500
ml of fluid daily.
Levels of intake. Approximate levels of intake include fluids 1,
200 ml, foods 1, 000 ml, and metabolic products 30 ml.
Daily output. Daily output should approximately equal in
intake.
Normal output. Normal output occurs as urine, breathing,
perspiration, feces, and in minimal amounts of vaginal
secretions.
Overhydration and Edema
Overhydration. Overhydration is an excess of water in the body.
Edema. Edema is the excess accumulation of fluid in interstitial
tissue spaces, also called third-space fluid.
Cause of edema. Edema is caused by a disruption of the filtration
and osmotic forces of the body’s circulating fluids.
Treatment of edema. Diuretics are commonly given for systemic
edema.
Dehydration
Dehydration. Dehydration is a deficiency of body water or
excessive loss of water.
External causes. External causes of dehydration include prolonged
sun exposure and excessive exercise, as well as diarrhea, vomiting,
and burns.
Treatment of dehydration. Supplemental fluids and electrolytes are
often administered.
Electrolytes
An electrolyte is a substance that will disassociate into ions when
dissolved in water.
Origins. Electrolytes are found in the form of inorganic salts, acids,
and bases.
Active chemicals. Electrolyte concentrations are measured according
to their chemical activity and expressed as milliequivalents.
Ions. Each chemical element has an electrical charge, either positive or
negative.
Intracellular electrolytes. Important intracellular electrolytes are
potassium, magnesium, sulfate, and phosphate, and the most dominant
cation iss potassium while the most dominant anion is phosphate.
Extracellular electrolytes. Important extracellular electrolytes include
sodium, chlorine, calcium, and bicarbonate, and the most essential
cation is sodium while chlorine is the most important anion.
Fluid and Electrolyte Transport
Total electrolyte concentration affects the body’s fluid balance.
The body cells. Nutrients and oxygen should enter body cells
while waste products should exit the body.
The cell membrane. The cell membrane separates the
intracellular environment from the extracellular environment.
Permeability. The ability of a membrane to allow molecules to
pass through is known as permeability.
Permeability of Membranes
Freely permeable membranes. These membranes allow almost any
food or waste substance to pass through.
Selectively permeable. The cell membrane is selectively permeable,
meaning that each cell’s membrane allows only certain specific
substances to pass through.
Passive Transport
Passive transport. Passive transport mechanisms include diffusion,
osmosis, and filtration.
Diffusion. Diffusion, or the process of “being widely spread”, is the
random movement of molecules from an area of higher concentration
to an area of lower concentration.
Osmosis. Osmosis is the diffusion of a pure solvent, such as water,
across a semipermeable membrane in response to a concentration
gradient in situations where the molecules of a higher concentration
are non diffusible.
Filtration. Filtration is the transport of water and dissolved
materials concentration already exists in the cell.
Active Transport
Mechanisms. Active transport mechanisms require specific
enzymes and an energy expenditure in the form of adenosine
triphosphate (ATP).
Processes. Active transport processes can move solutes “uphill”,
against the normal rules of concentration and pressure.
Fluid and Electrolyte Balance

fluid and electrolyte balance is vital for proper functioning of all

body systems.
Osmolarity. This is the property of particles in a solution to
dissociate into ions.
Electroneutrality. This is the balance of positive and negative
charges.
Acid-Base Balance
Acid-base balance is another important aspect of homeostasis.
Acid, Bases, and Salts
Acid. An acid is one type of compound that contains the hydrogen
ion.
Base. A base or alkali is a compound that contains the hydroxyl ion.
Salt. A salt is a combination of a base and an acid and is created
when the positive ions of a base replace the positive hydrogen ions
of an acid.
Important salts. The body contains several important salts like
sodium chloride, potassium chloride, calcium chloride, calcium
carbonate, calcium phosphate, and sodium phosphate.
Potential of Hydrogen
pH. The symbol of pH refers to the potential or power of hydrogen
ion concentration within the solution.
Low pH. If the pH number is lower than 7, the solution is an acid.
High pH. If the pH is greater than 7, a solution is basic or
alkaline.
Neutral pH. If the pH is 7, then the solution is neutral.
Changes. A change in the pH of a solution by one pH unit means a
tenfold change in hydrogen concentration.
Buffers
Buffers. A buffer is a chemical system set up to resist changes,
particularly in hydrogen ion levels.
Bicarbonate buffer system. Sodium bicarbonate and carbonic acid
are the body’s major chemical buffers.
Carbon dioxide. The major compound controlled by the lungs is
CO2, and the respiratory system can very rapidly compensate for too
much acid and too little acid by increasing or decreasing the
respiratory rate, thereby altering the level of CO2.
Bicarbonate. Bicarbonate ions are basic components in the body,
and the kidneys are key in regulating the amount of bicarbonate in
the body.
Measurement of arterial blood gas. The pH level and amounts of
specific gases in the blood indicate if there is more acid or base and
their associated values.
Respiratory acidosis. Respiratory acidosis occurs when breathing is
inadequate and PaCO2 builds up.
Respiratory alkalosis. Respiratory alkalosis occurs as a result of
hyperventilation or excess aspirin intake.
Metabolic acidosis. In metabolic acidosis, metabolism is impaired,
causing a decrease in bicarbonates and a buildup of lactic acid.
Metabolic alkalosis. Metabolic alkalosis occurs when bicarbonate
ion concentration increases, causing an elevation in blood pH.
Classification
There are different fluid volume disturbances that may affect an
individual.
Fluid volume deficit or hypovolemia occurs when loss of ECF
volume exceeds the intake of fluid.
Fluid volume excess or hypervolemia refers to an isotonic volume
expansion of the ECF caused by the abnormal retention of water
and sodium in approximately the same proportions in which they
normally exist in the ECF.
Disturbances in electrolyte balances are common in clinical practice
and must be corrected.
Hyponatremia refers to a serum sodium level that is less than 135
mEq/L
Hypernatremia is a serum sodium level higher than 145 mEq/L.
Hypokalemia usually indicates a deficit in total potassium stores.
Hyperkalemia refers to a potassium level greater than 5.0 mEq/L.
Hypocalcemia are serum levels below 8.6 mg/dl.
Hypercalcemia is calcium level greater than 10.2 mg/dl.
Hypomagnesemia refers to a below-normal serum magnesium
concentration.
Hypermagnesemia are serum levels over 2.3 mg/dl.
Hypophosphatemia is indicated by a value below 2.5 mg/dl.
Hyperphosphatemia is a serum phosphorus level that exceeds 4.5
mg/dl in adults.
Pathophysiology
Nurses need an understanding of the pathophysiology of fluid and
electrolyte balance to anticipate, identify, and respond to possible
imbalances.
Concentrations. Electrolyte concentrations vary from those in the ICF
to those in the ECF.
Sodium. Sodium ions outnumber any other cations in the ECF;
therefore it is essential in the fluid regulation of the body.
Potassium. The ECF has a low concentration of potassium and can
tolerate only small changes in its concentrations.
Maintenance. The body expends a great deal of energy in maintaining
the sodium and potassium concentrations through cell membrane pumps
that exchange sodium and potassium ions.
Osmosis. When two different solutions are separated by a membrane
that is impermeable to the dissolved substances, fluid shifts from the
region of low solute concentration to the high solute concentration until
the solutions are of equal concentrations.
Diffusion. Diffusion is the natural tendency of a substance to move in
Causes
Causes of fluid and electrolyte imbalances are discussed below in
general.
Fluid retention. Retention of sodium is associated with fluid
retention.
Loss of sodium. Excessive loss of sodium is associated with
decreased volume of body fluid.
Trauma. Trauma causes release of intracellular potassium which is
extremely dangerous.
Loss of body fluids. FVD results from loss of body fluids and
occurs more rapidly when coupled with decreased fluid intake.
Fluid overload. Fluid volume excess may be related to a simple
fluid overload or diminished function of the homeostatic
mechanisms responsible for regulating fluid balance.
Low or high electrolyte intake. Diets low or excessive in
electrolytes could also cause electrolyte imbalances.
Medications. There are certain medications that could lead to
electrolyte imbalances when taken against the physician’s orders.
Clinical Manifestations
Signs and symptoms that occur in fluid and electrolyte
imbalances are discussed below.
Fluid volume deficit. Clinical signs and symptoms include acute
weight loss, decreased skin turgor, oliguria, concentrated urine,
orthostatic hypotension, a weak, rapid heart rate, flattened neck
veins, increased temperature, thirst, decreased or delayed
capillary refill, cool, clammy skin, muscle weakness, and cramps.
Fluid volume excess. Clinical manifestations for FVE include
edema, distended neck veins, and crackles.
Hyponatremia. Signs and symptoms include anorexia, nausea
 and vomiting, headache, lethargy, dizziness, confusion, muscle
cramps and weakness, muscular twitching, seizures, dry skin, and
edema.
Hypernatremia. The signs and symptoms are thirst, elevated
body temperature, hallucinations, lethargy, restlessness,
pulmonary edema, twitching, increased BP and pulse.
Hypokalemia. Clinical manifestations are fatigue, anorexia, muscle
weakness, polyuria, decreased bowel motility, paresthesia, ileus,
abdominal distention, and hypoactive reflexes
Hyperkalemia. Signs and symptoms include muscle weakness,
tachycardia, paresthesia, dysrhythmias, intestinal colic, cramps,
abdominal distention, and anxiety.
Hypocalcemia. The signs and symptoms are numbness, tingling of
fingers, toes, and circumoral region, positive Trousseau’s sign and
Chvostek’s sign, seizures, hyperactive deep tendon reflexes,
irritability, and bronchospasm.
Hypercalcemia. The signs and symptoms include muscle weakness, 
constipation, anorexia, nausea and vomiting, dehydration, hypoactive
deep tendon reflexes lethargy, calcium stones, flank pain, pathologic
fractures, and deep bone pain.
Hypomagnesemia. Clinical manifestations include neuromuscular
irritability, positive Trousseau’s and Chvostek’s sign, insomnia, mood
changes, anorexia, vomiting, and increased deep tendon reflexes.
Hypermagnesemia. Signs and symptoms are flushing, hypotension,
muscle weakness, drowsiness, hypoactive reflexes, depressed
respirations, and diaphoresis.
Hypophosphatemia. Signs and symptoms include paresthesias,
muscle weakness, bone pain and tenderness, chest pain, confusion,
seizures, tissue hypoxia, and nystagmus.
Hyperphosphatemia. Clinical manifestations are tetany,
tachycardia, anorexia, nausea and vomiting, muscle weakness, and
hyperactive reflexes.
Complications
Complications
Fluid and electrolyte imbalances could result in complications if not
treated promptly.
Dehydration. Fluid volume deficit could result in dehydration of the
body tissues.
Cardiac overload. Fluid volume excess could result in cardiac
overload if left untreated.
SIADH. Water is retained abnormally in SIADH.
Cardiac arrest. Too much potassium administered could lead to
cardiac arrest.
Assessment and Diagnostic Findings
The following are laboratory studies useful in diagnosing fluid and
electrolyte imbalance

BUN. BUN may be decreased in FVE due to plasma dilution.

Hematocrit. Hematocrit levels in FVD are greater than normal
because there is a decreased plasma volume.
Physical examination. Physical exam is necessary to observe the
signs and symptoms of the imbalances.
Serum electrolyte levels. Measurement of electrolyte levels should
be performed to check for presence of an imbalance.
ECG. ECG changes can also contribute to the diagnosis of fluid
and electrolyte imbalance.
ABG analysis. ABG analysis may reveal acid-base imbalances.
Medical Management
Treatment of fluid and volume imbalances needs accuracy to avoid
consequences that can result in complications.
Isotonic electrolyte solutions. These solutions are used to treat the
hypotensive patient with FVD because they expand plasma volume.
Accurate I&O. Accurate and frequent assessments of I&O should be
performed when therapy should be slowed or increased to prevent
volume deficit or overload.
Dialysis. Hemodialysis or peritoneal dialysis is performed to remove
nitrogenous wastes and control potassium and acid-base balance, and
to remove sodium and fluid.
Nutritional therapy. Treatment of fluid and electrolyte imbalances
should involve restrictions or enforcement of the concerned
electrolyte.
Pharmacologic therapy
AVP receptor agonists. These are new pharmacologic agents that
treat hyponatremia by stimulating free water excretion.
Diuretics. To decrease fluid volume in FVE, diuretics are
administered.
IV calcium gluconate. If serum potassium levels are dangerously
elevated, it may be necessary to administer IV calcium gluconate.
Calcitonin. Calcitonin can be used to lower the serum calcium level
and is particularly useful for patients with heart disease or 
heart failure who cannot tolerate large sodium loads.
Nursing Management
Nurses may use effective teaching and communication skills to help
prevent and treat various fluid and electrolyte disturbances.
Nursing Assessment
Close monitoring should be done for patients with fluid and
electrolyte imbalances.
I&O. the nurse should monitor for fluid I&O at least every 8 hours,
or even hourly.
Daily weight. Assess the patient’s weight daily to measure any gains
or losses.
Vital signs. Vital signs should be closely monitored.
Physical exam. Physical exam is needed to reinforce other data
about a fluid or electrolyte imbalance.
Diagnosis
The following diagnoses are found in patients with fluid and
electrolyte imbalances.
Excess fluid volume related to excess fluid intake and sodium
intake.
Deficient fluid volume related to active fluid loss or failure of
regulatory mechanisms.
Imbalanced nutrition: less than body requirements related to
inability to ingest food or absorb nutrients.
Imbalanced nutrition: more than body requirements related
to excessive intake.
Diarrhea related to adverse effects of medications or
malabsorption.
Nursing Care Planning & Goals
Main Article: 
10 Fluid And Electrolyte Imbalances Nursing Care Plans
Planning and goals for fluid and electrolyte imbalances include:
Maintenance of fluid volume at a functional level.
Display of normal laboratory values.
Demonstration appropriate changes in lifestyle and behaviors
including eating patterns and food quantity/quality.
Reestablishment and maintenance of normal pattern and GI
functioning.
Nursing Interventions
There are specific nursing interventions for fluid and electrolyte
imbalances that can aid in alleviating the patient’s condition.
Monitor turgor. Skin and tongue turgor are indicators of the fluid
status of the patient.
Urine concentration. Obtain urine sample of the patient to check
for urine concentration.
Oral and parenteral fluids. Administer oral or parenteral fluids as
indicated to correct the deficit.
Oral rehydration solutions. These solutions provide fluid, glucose,
and electrolytes in concentrations that are easily absorbed.
Central nervous system changes. The nurse must be alert for
central nervous system changes such as lethargy, seizures,
confusion, and muscle twitching.
Diet. The nurse must encourage intake of electrolytes that are
deficient or restrict intake if the electrolyte levels are excessive.
Evaluation
Evaluation of the care plan can check the
effectiveness of the treatments. The interventions are
deemed effective if the client has:
Maintained fluid volume at a functional level.
Displayed normal laboratory results.
Demonstrated appropriate changes in lifestyle and
behaviors including eating patterns and food
quantity/quality.
Reestablished and maintained normal pattern and GI
functioning.
Discharge and Home Care Guidelines
After hospitalization, treatment and maintenance of
the condition must continue at home.
Diet. A diet rich in all the nutrients and electrolytes
that a person needs should be enforced.
Fluid intake. Fluid intake must take shape according
to the recommendations of the physician.
Follow-up. A week after discharge, the patient must
return for a follow-up checkup for evaluation of
electrolyte and fluid status.
Medications. Compliance to prescribed medications
should be strict to avoid recurrence of the condition.
Documentation Guidelines
Data should be documented for future medical and
legal references. The nurse must document:
Individual findings, including factors affecting ability to
manage body fluids and degree of deficit.
I&O, fluid balance, changes in weight, urine specific
gravity, and vital signs.
Results of diagnostic testing and laboratory studies.
Plan of care.
Client’s responses to treatment, teaching, and actions
performed.
Attainment or progress toward desired outcome.
Modifications to plan of care.