Fluid and electrolytes

Imbalances Part – I

SOHAIB ALI SHAH

Acknowledgment: MARWAN KHAN

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 Objectives
 At the end of this lecture the students will acquainted to;
 Body fluid distribution, regulation of fluids in body compartments
 Discuss the types of fluid i.e. Hypotonic , hypertonic & isotonic
 Explain the fluid volume deficit , S/S , diagnosis & intervention .
 Discuss fluid volume excess , S/S, diagnosis & intervention
 Discuss about the following disorders;
 Hyponatremia & Hypernatremia and its management
 Hypokalemia & Hyperkalemia and its management
 Hypocalcemia & Hypercalcemia and its management
 Hypomagnesemia & Hypermagnesemia and its management.
 Hypophosphatemia & hyperphosphatemia .

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 Why We Need to Drink Water
 All chemical reactions occur in liquid medium
 It is crucial in regulating chemical and bioelectrical
distributions within the cells.
 Transports substances such as hormones and nutrients
 O2 transport from lungs to body cells.
 CO2 transport in the opposite direction.
 Dilutes toxic substances and waste products and transports them
to the kidneys and liver.
 Distributes heat around the body

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 Where does all this water go…..
 Water constitutes an average 50 – 70 % of the total body
weight;
Young males – 60% of total body weight
Older males – 52%
Young females – 50% of total body weight
Older females – 47%
 Variation of + 15% in both groups is normal
 Obese have 25 to 30% less body water than lean people.
 Infants 75 – 80%
• Gradual physiological loss of body water

• 65% at one year of age

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Components of body
fluid

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 Functional components of the body
fluid
The water of the body is divided in to 2 functional components (TBW – 60% into 3

Intracellular fluid – 40%of Extracellular fluid – 20% of

the body Weight the body weight

Extra vascular & interstitial Intra vascular 5%

fluid 15%of BW of BW

Rapidly equilibrating/functional Slowly equilibrating /non-functional

component 13 – 14% of BW Component 1 – 2 % BW

1. Connective tissue water

2. Transcellular fluid e.g. CSF, Joint fluid

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Total Body weight Total Body weight
(Female) (Male)

45% 40%
Solids Solids

2/3 Intracellular
Fluid (ICF)
55% 60%
Fluids Fluids

1/3 Extracellular 80% Interstitial

Fluid (ECF)
20% Plasma

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 Composition of body fluids
 Water is the universal solvent
 Solutes

 Electrolytes - inorganic salts, all acids and bases, and some

proteins.
 Non – electrolytes – most non electrolytes are organic

molecules- glucose, lipids, creatinine and urea

 Electrolytes have greater osmotic power than non electrolytes

 Water moves according to osmotic gradients

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 Extracellular (ECF)
1/3 of body fluid
Comprised of 3 major components
Intravascular:
Plasma

Interstitial:
Fluid in and around tissues spaces
Transcellular:
Passing from one cell to another, through adjacent cell
membranes. (total body water contained within epithelial lined
spaces, is about 2.5% of the total body water)  fluid within
epithelium-lined spaces. It includes cerebrospinal fluid (CSF),
gastrointestinal fluids, urine in the bladder, aqueous humor, and
joint fluid
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 Cont…
 Extracellular
 Nutrients for cell functioning
 Na

 Ca

 Cl

 Glucose

 Fatty acids

 Amino Acids

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 Cont…
 Intravascular Component
 Plasma
 Fluid portion of blood

 Made of:
 Water

 Plasma Proteins

 Small amount of other substances

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 Cont…
 Interstitial component
 Made up of fluid between cells
 Surrounds cells

 Transport medium for nutrients, gases, waste products

and other substances between blood and body cells

 Back-up fluid reservoir

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 Cont…
 Transcellular component
 Located in joints, connective tissue, bones, body cavities, CSF,
and other tissues.

 Potential to increase significantly in abnormal conditions.

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Principles of body water distribution
 Body control systems regulate ingestion and excretion:
Constant total body water
Constant total body osmolarity

 Homeostatic mechanisms respond to changes in ECF

 Osmolarity is identical in all body fluid compartments
(steady state condition)

 Body water will redistribute itself as necessary to

accomplish this

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Homeostasis

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 Cont…
 Homeostasis means the constancy of the internal environment
by the coordinated activities of all the systems of the body.

The working systems include;

1. Respiratory system
2. Excretory system
3. Digestive system
4. Circulatory system
5. Nervous and endocrine systems
The amount of water we drink is regulated by homeostasis;
1. Output = intake
2. Thirst & satiety
3. Hormonal regulation

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Natriuretic
peptides

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 Causes of Hyper and Hypo
volemia

Hypervolemia Hypovolemia
Excessive infusion of intravenous fluids  Vomiting, diarrhea , fistulae

Retention of water in abnormal conditions  When the patient is febrile; fluid loss
such as cardiac, renal and hepatic failure increases by 12% with every centigrade
rise in temperature

Absorption of water as during  Sequestration of fluid in third

transurethral resection of prostate using space/interstitial space
distilled water

 Hemorrhage

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Serum electrolytes

Management

Treat the cause

Regulation of water and salt
Diuretics or dialysis: to remove excess of water in case of
hypervolemia

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Signs and symptoms of Signs and symptoms of
hypernatremia hyponatremia
o Nausea and vomiting.
o Early symptoms may include a Strong o Headache.
Feeling of o Confusion.
• Thirst, o Loss of energy and fatigue.
• Weakness, o Restlessness and irritability.
• Nausea, o Muscle weakness, spasms or cramps.
• Loss of appetite. o Seizures.
o Coma.
o Severe symptoms include confusion,
muscle twitching, and bleeding in or
around the brain.

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 Etiology and management of
hypernatremia
Hypernatremia Etiology Treatment
Hypervolemic Administration of Diuretics
hypertonic sodium –
containing solution .
Minerolocorticoid excess

Isovolemic Insensible skin and Water replacement

respiratory loss diabetes
insipidus

Hypovolemic Renal losses. Isotonic Na Cl, then

Gastrointestinal losses, hypotonic saline
respiratory losses, profuse
sweating, adrenal
deficiencies

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 Imbalance of composition
 Imbalance of potassium
 Imbalances of chloride
 Imbalances of magnesium

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 Imbalances in levels of potassium
Major cation in intracellular compartments
 Regulates metabolic activities , necessary for glycogen deposits
in liver and skeletal muscle, transmission and conduction of
nerve impulses, normal cardiac conduction and skeletal and
smooth muscle contraction.

 Regulated by dietary intake and renal excretion

 Normal level – 3.5 – 5.5 meq /l
 Body conserves potassium poorly
Increased urine output decreases serum K

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 Impaired gastrointestinal motility

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 Osmoreceptors
 A receptor in the central nervous system (probably the
hypothalamus) that responds to changes in the osmotic pressure
of the blood.

Baroreceptor
 A receptor sensitive to changes in pressure, a sensory nerve
ending especially in the walls of large arteries (such as the
carotid sinus) that is sensitive to changes in blood pressure.

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 Chemoreceptor
 Chemoreceptor detect the levels of carbon dioxide in the blood
by monitoring the concentrations of hydrogen ions in the
blood.

 Central chemoreceptors, located on the ventral surface of medulla

oblongata, detect changes in pH of cerebrospinal fluid.

 Peripheral chemoreceptors act mostly to detect variation of the

oxygen in the arterial blood, in addition to detecting arterial
carbon dioxide and Ph.

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 Regulation of Body Fluid Volume

Hypervolemia excess fluid Hypovolemia Deficient fluid

volume volume

Inhibit Stimulation

ADH release Aldosterone Thirst Thirst ADH release Aldosterone release

Inhibited release Inhibited Stimulated Stimulated Stimulated
Inhibited

Contribute to Contribute to

Increased urination of dilute Decreased urination of

urine concentrated urine

Normal fluid volume restored

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 Regulation of Fluids in
Compartments
 Osmosis
 Movement of water through a selectively permeable membrane from an
area of low solute concentration to a higher concentration until equilibrium
occurs.

 Movement occurs until near equal concentration found

 Passive process

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Fluid and Electrolytes 2

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Regulation of Fluids

Diffusion

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 Osmosis versus Diffusion
 Osmosis
 Low to high

 Water potential

 Diffusion
 High to low

 Movement of particles

 Both can occur at the same time

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 Isotonic Solution
Isotonic: The concentration of solutes in the solution is equal to the
concentration of solutes inside the cell.

Result: Water moves equally in both directions and the cell remains same
size! (Dynamic Equilibrium)

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 Hypotonic Solution
Hypotonic: The solution has a lower concentration of solutes and a
higher concentration of water than inside the cell. (Low solute;
High water)

Result: Water moves from the solution to inside the cell): Cell Swells and bursts
open (cytolysis)!

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 Hypertonic Solution
Hypertonic: The solution has a higher concentration of solutes and a lower
concentration of water than inside the cell. (High solute; Low water)

Shrinks
Result: Water moves from inside the cell into the solution: Cell
shrinks (Plasmolysis)!
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 Regulation of Fluids

 Active Transport
 Allows molecules to move against concentration and osmotic
pressure to areas of higher concentration
 Active process – energy is expended

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 Active Transport
 Na / K pump
 Exchange of Na ions for K ions
 3 Na ions move out of cell
 2 potassium ions move into the cell
 More water pulled into cell when sodium enters
 Water passively follows the sodium
 ECF / ICF balance is maintained

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 Fluid Volume Shifts
 Fluid normally shifts between intracellular and extracellular
compartments to maintain equilibrium between spaces.

 Fluid not lost from body but not available for use in either
compartment – considered third-space fluid shift (“third-
spacing”) are called (transcellular fluid).

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 Causes of Third-Spacing
 Burns
 Peritonitis
 Bowel obstruction
 Massive bleeding into joint or cavity
 Liver or renal failure
 Lowered plasma proteins
 Increased capillary permeability
 Lymphatic blockage

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 Fluid volume deficit
 Hypovolemia
 Abnormally low volume of body fluid in intravascular and/or
interstitial compartments.

 Causes
o Vomiting
o Diarrhea
o Fever
o Excess sweating
o Burns
o Diabetes insipidus
o Uncontrolled diabetes mellitus

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 Fluid volume deficit

 What happens
 Output > Intake -> Water extracted from ECF
 ECF hypertonic (water moves out of cell - cell dehydration) +

osmotic pressure increased (stimulates thirst receptor in

hypothalamus)
 ICF hypotonic with decreased osmotic pressure = posterior

pituitary secretes more ADH

 Decreased ECF volume = adrenal glands secrete Aldosterone

which helps in regulation/ retention of water and sodium.

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 Signs and Symptoms
 Acute weight loss
 Decreased skin turgor
 Oliguria
 Concentrated urine
 Weak, rapid pulse
 Capillary filling time elongated
 Decreased BP
 Increased pulse
 Sensations of thirst, weakness, dizziness, muscle cramps

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 Significant Points
 Dehydration – one of most common disturbances in
infants and children

 Additional S/S
 Sunken eyeballs
 Depressed fontanels
 Significant wt loss

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 Labs
 Increased hct Normal 35% – 45%
25% means that there are 25 milliliters of red blood cells in
100 milliliters of blood.
 Increased BUN
 High serum osmolality
 Increased urine osmolality
 Increased specific gravity
 Decreased urine volume, dark color

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 Labs
 Increased hct Normal 35% – 45%
25% means that there are 25 milliliters of red blood cells in
100 milliliters of blood.
 Increased BUN
 High serum osmolality
 Increased urine osmolality
 Increased specific gravity
 Decreased urine volume, dark color

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 Fluid volume deficit

 What happens
 Output > Intake -> Water extracted from ECF
 ECF hypertonic (water moves out of cell - cell dehydration) +

osmotic pressure increased (stimulates thirst receptor in

hypothalamus)
 ICF hypotonic with decreased osmotic pressure = posterior

pituitary secretes more ADH

 Decreased ECF volume = adrenal glands secrete Aldosterone

which helps in regulation/ retention of water and sodium.

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 Fluid volume deficit

 What happens
 Output > Intake -> Water extracted from ECF
 ECF hypertonic (water moves out of cell - cell dehydration) +

osmotic pressure increased (stimulates thirst receptor in

hypothalamus)
 ICF hypotonic with decreased osmotic pressure = posterior

pituitary secretes more ADH

 Decreased ECF volume = adrenal glands secrete Aldosterone

which helps in regulation/ retention of water and sodium.

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 Fluid volume deficit

 What happens
 Output > Intake -> Water extracted from ECF
 ECF hypertonic (water moves out of cell - cell dehydration) +

osmotic pressure increased (stimulates thirst receptor in

hypothalamus)
 ICF hypotonic with decreased osmotic pressure = posterior

pituitary secretes more ADH

 Decreased ECF volume = adrenal glands secrete Aldosterone

which helps in regulation/ retention of water and sodium.

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 Interventions
 Major goal prevent or correct abnormal fluid volume status
before ARF occurs

 Encourage fluids

 IV fluids
 Isotonic solutions (0.9% NS or L/R) until BP back to normal,

then hypotonic (0.45% NS)

 Monitor I & O, urine specific gravity, daily weights.

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 Cont…

 Monitor skin turgor

 Monitor vital sign and mental status
 Evaluation
 Normal skin turgor, increased UOP with normal specific

gravity, normal VS, clear sensory stimuli , good oral intake

of fluids, labs WNL.

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 Fluid Volume Excess (FVE)

 Hypervolemia
 Isotonic expansion of ECF caused by abnormal retention of
water and sodium
 Fluid moves out of ECF into cells and cells swell

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 Causes
 Cardiovascular – Heart failure
 Urinary – Renal failure
 Hepatic – Liver failure, cirrhosis
 Other – Cancer, thrombus, PVD, drug therapy (i.e.,
corticosteroids), high sodium intake, protein malnutrition.

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 Signs/Symptoms
 Physical assessment
 Weight gain
 Distended neck veins
 Periorbital edema, pitting edema
 Adventitious lung sounds (mainly crackles)
 Dyspnea
 Mental status changes
 Generalized or dependent edema

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 Signs / Symptoms
 VS
 High CVP/PAWP
 ↑ cardiac output
 Lab data
 ↓ Hct (dilutional)
 Low serum osmolality
 Low specific gravity
 ↓ BUN (dilutional)

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 Signs / Symptoms

 Radiography
 Pulmonary vascular congestion
 Pleural effusion
 Pericardial effusion
 Ascites

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 Interventions
 Sodium restriction (foods/water high in sodium)
 Fluid restriction, if necessary
 Closely monitor IVF
 If dyspnea or orthopnea provide Semi-Fowler’s sitting
 Strict I & O, lung sounds, daily weight, degree of edema, re-
position 2 x hourly
 Promote rest and diuresis.

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 Sources of Water
 Oral liquids: 1300ml/day
 Water in foods: 1000ml/day
 Meats and vegetables: 60-90% water

 Water from oxidation: 300ml/day

 10ml/cal of food metabolized

 Parenteral fluids
 Enteral feedings

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 “ Normal” Water Loss
 Skin:
 Perspiration: 0-1000 ml/day

 Lungs: 300-400 ml/day

 Increases with increased respiratory rate or depth or dry

climate

 GI Tract: 100-200 ml/day

 Kidneys: 1-2 L/day
 Insensible loss: 600 ml/day (evaporation)
1ml/kg of body wt/hr in all ages

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Other Causes of Water Loss
 Fever
 Burns
 Diarrhea
 Vomiting
 N-G Suction
 Fistulas
 Wound drainage

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 IV Fluid Replacement
 IV Fluid to manage fluid volume imbalances
 Isotonic fluids (approximate normal serum plasma)
 Rapid ECF expansion needed
 DW5%, NS, L/R

 Hypotonic fluids
 Treatment of cellular dehydration

 .45% NS, NS, 2.5% dextrose

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 Cont…

 Hypertonic
 Treatment of water intoxication
 D5 ½ NS, DW 10%, 3% NS
 Shifts fluids from ICF & ECF to intravascular
component – expands blood volume
 Now can be removed by kidneys

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 References
 Helen Giannakopoulos, LEE Carrasco. Jason Alabakoff, peter D. Quinn.
Fluid and electrolyte management and blood product usage.

 Fluid, Electrolyte, and Acid-base Balance Heitz, Horne-Mosby, 4th edition

IV Therapy made incredibly Easy!

 McCann, Lippincott, 3rd edition

 Fluid & Electrolytes Chernecky, Macklin, Murphy- ende, Saunders 2002

 Fluids, Electrolytes & Acid-Base Balance Hogan, Wane, Prentice Hall

nursing

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