Fluids and Electrolytes

Introduction

 Good health is maintained by a balance of

fluids, electrolytes , and acids within the
body.
Homeostasis – the physiological balance of
fluids, electrolytes and acid
 Factors affecting homeostasis include:
Illness
Daily living
Excessive temperature
Vigorous exercise
About Fluids
 The body’s fluid exists in two major
compartments
Intracellular fluid (ICF) – within the cell. About
2/3 of total water in the body.
Extracellular fluid (ECF) – outside the cell.
Makes up about 20-40% of all body fluid
 Interstitial fluid between the cell but outside the blood
vessel
 Intravascular fluid – in the blood (plasma)
 Transcellular – CSF, pleural,peritoneal and synovial
fluid
More About Fluids

 Approx. 40-75% of body weight is made

up of water.
 The amount of water varies according age
and gender e.g. up to 90% of body weight
is water in fetus
 Total body fluid in the average adult male
is about 40-45 liters. Approx. 2/3 is
intracellular, 1/3 is extracellular
Functions of Body Fluid

 Maintain blood volume

 Medium for chemical functions
 Cushions and lubricates
 Regulation of body temperature
 Excretion of waste products
 Transportation of nutrients, electrolytes,
and oxygen to cells
Fluid & Electrolyte Movement
 Fluid and electrolytes are in constant
motion within the body to maintain
homeostasis.
 Fluid shift from one compartment to
another is through selective permeability.
 Electrolyte and other solute movement is
accomplished by:
Osmosis
Diffusion
Filtration
Active Transport
Osmosis

 Movement of water across cell

membranes, from the less concentrated
solution to the more concentrated solution.
 Water moves toward the higher
concentration of solute e.g sunbather
perspires
Osmosis Cont’d
 Solutes – substances that dissolve in liquid e.g.
sugar and water.
 Solutes consist of two components
 Crystalloids – salt dissolves into solution
 Colloids – large molecules e.g protein that do not
dissolve readily
 The concentration of solutes within the body
fluid is known as osmolality.
 Osmotic pressure represents the force that pulls
water across a semi permeable membrane.
Diffusion

 Movement of solutes across cell

membranes, from the high concentrated
solution to the less concentrated solution.
Filtration

 Filtration is a process whereby fluid and

solutes move together across a membrane
from one compartment to another.e.g. BP
 Movement is from an area of high
pressure to low pressure.
 Filtration Pressure is the force that causes
the movement of the fluids and solutes
Active Transport

 Substances can move across cell

membranes from a less concentrated
solution to a more concentrated one by
active transport.
 Metabolic energy (ATP) is required as the
process is not passive.
Active Transport
Fluid & Regulation

 Fluids are regulated by

Intake
Output – Total loss 2500 ml/day
Hormonal controls
Fluid Intake Regulation

 Regulated primarily through the thirst

mechanism. The control center is located
in the hypothalamus.
The hypothalamus is stimulated by increased
plasma osmolarity and decreased blood
volume.
 Water is also acquired through food (fruits,
vegetables) intake and the oxidation of
food during digestion.
Fluid Output Regulation
 Occurs through four major organs of water loss:
 Kidneys –
 Urine. 1400-1500 mL/24 hr or 30cc/hr
 Insensible /sensible loss (visible)
 Lungs 350-400 mL/day
 Skin 350-400 mL/day
 Sweat – 100 mL/day
 Gastrointestinal tract
 Feces. About 100-200 mL/day. May increase with
vomiting/diarrhea.
 About 500 mL of fluid is lost through metabolic
waste. Called obligatory loss
Fluid Sources and Losses
Homeostatic Mechanisms

 Homeostasis is maintained through

function of the following;
Kidneys
Endocrine glands
Cardiovascular system
Lungs
GI system
Kidneys

 The primary regulators of fluid and

electrolyte balance.
 The kidneys play a significant role in acid
base regulation also.
Endocrine Glands

 Major hormones affecting fluid and

electrolyte balance are:
Antidiuretic hormone (ADH)
Renin-Angiotensin-Aldesterone System
(Aldosterone)
Atrial Natriuretic factor (peptide secreted by
atrial tissue to regulate BP)
 These hormones maintain and monitor
vascular volume.
Endocrine Glands
 Antidiuretic Hormone
(ADH) osmoreceptors

 Renin-Angiotensin-
Aldosterone

 Atrial Natriuretic
Factor
Introduction to Electrolytes

 Electrolytes are charged ions that conduct

electricity.
 They are present in all fluids and fluid
compartments.
 Generally measured in milliequivalents per
liter of water (mEq/L)
 They are provided through dietary intake
and excreted in urine.
Function of Electrolytes

 Promote neuromuscular reaction

 Maintain body fluid volume and osmolality
 Distribute body fluid between
compartments
 Regulate acid base balance - buffers
 Facilitate enzyme reactions e.g. pepsin
release in the stomach & HCL acid
About Electrolytes

 Ions that carry positive charge are called

cations
 Ions that carry negative charge are called
anions
More About Electrolytes
 Cations
 Na +
 K+
 Ca ++
 MG++
 Anions
 Cl –
 HCO3-
 PO4-
Electrolyte Cation Regulation

 Na+ - Regulated by the kidneys through

renal tubular reabsorption
 K+ - Also regulated through the kidneys
 Ca++ - Regulated through the action of the
parathyroid and thyroid glands
 Mg++ - Regulated indirectly through renal
excretion and some actions of the
parathyroid
Electrolyte Anion Regulation

 Cl- regulated by the kidneys

 HCO3- Also regulated by the kidneys

 PO4- regulated by the parathyroid

hormone
Sodium (Na+)
 Main cation found in the
extracellular or intravascular
fluid.
 Normal concentration of sodium
is 135-145 mEq/L
 Main function is to control and
regulate water balance in the
body.
 Found in foods such as bacon,
ham, processed cheese and
table salt.
Functions of Sodium
 Neuromuscular – transmission and conduction
of nerve impulses.
 Body fluids – largely responsible for osmolarity
of vascular fluids.
 Cellular – Na pump action. Enzyme activity.
 Acid-base – assists in the regulation of acid-
base balance. Combines readily with CL and
HCO3 to promote acid-base balance.
Sources of Sodium

 Bacon
 Ham
 Cheese
 Table salt
 Sea food
 Canned soups and vegetables
 Causes of Hyponatremia
 Vomiting
 Sweating, fever, muscular exercise
 Diarrhea
 Tap-water enema
 Burns
 Surgery
 Gastric suction
 SIADH: Excessive release of ADH resulting in
water retention and dilutional hyponatremia
(Syndrome of inappropriate antidiuretic hormone)
Nursing Process

 Assessment – subjective & objective data

Abdominal cramps
Muscle twitching, tremors and weakness
Altered LOC – e.g. lethargy, confusion
Headache
Nausea
Convulsions
Nursing Process

 Nursing Diagnosis
Altered electrolyte imbalance
Altered tissue perfusion
Fluid volume deficit - hypovolemia
Nursing Process
 Nursing Interventions
 When serum level below 110 mEq/L give hypertonic
saline solution e.g. 3% or 5% salt solution infusion.
 Rapid infusion of concentrated salt solution
result in pulmonary edema.
 Monitor vital signs esp. BP & pulse
 Observe for orthostatic hypotension, tachycardia
 Monitor I & O
 Daily weight
 Assess skin turgor for signs of dehydration
 Monitor serum Na levels closely
Causes of Hypernatremia

 Water intake excess or decrease

 Adrenal cortex dysfunction
Diabetes insipidus
 Excessive sodium intake
Nursing Process for Hypernatremia

 Assessment
S – skin flushed
A – agitation
L – low grade fever
T – thirst
Nursing Process

 Nursing Diagnosis
Fluid volume excess
Altered tissue perfusion
Altered skin integrity
Nursing Process
 Nursing Interventions
Salt free solution of D5W to return serum level
to normal. Followed by D51/2 NS to prevent
hyponatremia and cerebral edema
Restrict salt intake.
Monitor V/S.
Measuring Intake and Output.
Monitoring daily weight.
Inspect skin for edema, breakdown, infection
Monitor serum Na levels
 Medications Affecting Na Balance
 Hyponatremia  Hypernatremia
 Diuretics  Corticosteriods
 Lithium  Cortisone
 Morphine  Prednisone
 Ibuprofin  sodium phosphate
 Clonidine  amphotericin B
 Nicotine  Lactulose.
Potassium (K+)
 Present in all body fluid.
 Found mostly in intracellular fluid.
 Is classified as a major cation.
 Normal level is 3.5 – 5 mEq/L
 Plays major role in metabolic cell
functions.
 Directly affects how well body cells,
nerves and muscle function.
 Aid contraction of skeletal & cardiac
muscle.
Functions of Potassium
 NEUROMUSCULAR – transmission and
conduction of nerve impulses; contraction
of skeletal and smooth muscles.
 CARDIAC – nerve conduction and
contraction of the myocardium.
 CELLULAR – Enzyme action for cellular
energy production; deposits of glycogen in
liver cells; regulates osmolality of
intracellular fluids
Sources of Potassium

 Fruits e.g. orange, apricot, bananas,

cantaloupe
 Chocolate
 Dried fruits
 Nuts & seeds
 Meat
 Vegetables e.g. potato, mushroom, carrot
& tomatoes
Hypokalemia

 Normal K+ = 3.5 to 5.0 mEq/L

 Mild hypokalemia = 3.0 – 3.5 mEq/L,
usually well tolerated except in dig toxicity
or hepatic disease
 Moderate hypokalemia = 2.5 – 3.0 mEq/L
 Severe = <2.5 mEq/L
Nursing Process of Hypokalemia
 Assessment
 S – skeletal muscle weakness
 U – wave EKG changes (characteristic U wave)
 C – constipation & ileus
 T – toxic effect of digoxin
 I – irregular weak pulses
 O – orthostatic hypotension
 N - numbness
Nursing Process

 Nursing Diagnosis
Electrolyte imbalance
Decreased cardiac output
Causes of Potassium Deficit
 Vomiting  Trauma
 Diarrhea  Exercise
 Gastric suction  Starvation
 Laxative abuse  Wasting disease
 Dehydration
 Anorexia &
starvation
 Metabolic alkalosis
Nursing Process
 Nursing Interventions
Give potassium chloride IV followed by PO
maintenance e.g. slow –K, K-lyte
Monitor serum potassium levels
Monitor vital signs
Keep resuscitation bag at bedside
Observe for danger signs of hypokalemia such
as arrthymias, cardiac arrest, digoxin toxicity,
muscle paralysis, paralytic ileus & respiratory
arrest.
Educate patients regarding use of salt
substitutes
WARNING

 Potassium is never
given IV push, except
at the FLORIDA
STATE PRISON !
 EXTREME caution
when giving K+ IV
solutions
Nursing Process of Hyperkalemia

 Assessment
Abdominal cramping
Diarrhea
Nausea
EKG changes – tall tented T wave
Hypotension
Irritability
Muscle weakness in the lower extremities
Paresthesia (numbness) or tingling
Nursing Process

 Nursing Diagnosis
Altered tissue perfusion
Electrolyte imbalance
Decreased cardiac output
Altered bowel elimination
Altered skin integrity
Nursing Process

 Nursing Interventions for Mild

Hyperkalemia
Give loop diuretics
Dietary restriction of potassium
Stop medications that affect K levels e.g.
NSAID
Nursing Process

 Nursing Interventions for Moderate –

Severe Hyperkalemia
If client in renal failure hemodialysis may be
required
Administer Kayexalate
 For EMERGENCIES!!
Give 10% Ca Gluconate
Na bicarbonate
10 u regular insulin IV
Nursing Process

 Common Nursing Interventions

Monitor vital signs especially EKG changes
Monitor I & O.
Frequent accucheck monitoring if patient on
insulin
Monitor Na & K levels closely
Calcium
 Over 99% of the body’s calcium is
concentrated in the skeletal system
 Calcium exerts a sedative action on nerve
cells and has a major role in the
transmission of nerve impulses
 Helps regulate muscle contraction &
relaxation, including the heartbeat
 Also involved in blood clotting & hormone
secretion
 Normal serum level 8.9 – 10.1 mg/dl
 Normal ionized level 4.4-5.3 mg/dl
Functions of Calcium
 Neuromuscular – normal nerve and
muscle activity.
 Cardiac – contraction of hearth muscle
(myocardium).
 Cellular and blood – maintenance of
normal cellular permeability.
 Bones and teeth – formations of bone and
teeth, calcium and phosphorus make bone
and teeth strong and durable.
Hypocalcemia

 Defined as a total serum calcium level of

less than 8.9 mg/dL and an ionized
calcium concentration of less than 4.4
mg/dL
 Hypoalbuminemia is a common cause of a
reduced total serum calcium concentration
Causes of Hypocalcemia

 Inadequate dietary intake of calcium.

 Poor calcium absorption
Especially in postmenopausal women lacking
estrogen.
 Reduced activity or inactivity.
Inactivity causes a loss of calcium from the
bone and osteoporosis
Serum levels may be normal but bone stores
of the mineral are depleted.
Signs of Hypocalcemia

 Spasm of skeletal muscle, causing cramps

and tetany.
 Convulsions.
 Chvostek’s sign.
 Trousseau’s sign.
 Arrhtymias such as heart block,VF,
torsade de pointes.
Drugs Associated with Hypocalcemia

 Aluminum Containing Antacids

 Anticonvulsants
 Beta-Adrenergic Blockers
 Caffeine
 Corticosteroids
 Heparin
 Loop Diuretics
 Others
Indicators of Hypocalcemia
 Anxiety  Positive Chvostek’s or
 Confusion Trousseau signs
 Decreased cardiac output  Prolonged ST segment
 Lengthened St segment
 Arrhythmias
 Lengthened QT interval
 Fractures
 Tetany
 Irritability
 Tremors
 Muscle cramps
 Twitching
 Paresthesia of the face,
fingers, or toes
Chvostek’s Sign
 Unilateral contraction
of facial and eyelid
muscles. It is elicited
by irritating the facial
nerve by percussing
the face in front of the
ear
Trousseau’s Sign
 Positive Trousseau’s
sign: Ischemia-
induced carpal
spasm. It is elicited by
applying a BP cuff to
the upper arm and
inflating it past the
systolic BP for 2-3
minutes
Treatment of Hypocalcemia
 Correction of the imbalance as quickly and as
safely.
 Immediate correction by:
 I.V. calcium gluconate or I.V. calcium chloride
 Magnesium replacement
 Vitamin D supplements – to facilitate GI absorption of
calcium
 Diet adjusted to allow for an adequate intake of calcium,
V-D, and protein.
 Aluminum Hydroxide antacids – to binds with excess
phosphorus
Nursing Process

 Assess pt. from post-op parathyroid or

thyroid surgery or has received massive
blood transfusions.
 Breast-feeding mother needs to be
assessed for adequate Vit-D intake and
exposure to sunlight.
 Neck surgery.
Nursing Process
 Monitor V/S frequently
 Respiratory status
 Watch for stridor, dyspnea, and crowing
 Monitor pertinent lab test results, albumin
and electrolytes (mag)
 Take precautions for seizures
 Reorient confused pat
 Document all care given
Hypercalcemia

 Occurs when serum calcium level rises

above 10.1 mg/dl.
 Ionized serum calcium level rises above
5.3 mg/dl.
 Rate of calcium entry into extracellular
fluid exceeds the rate of calcium excretion
by the kidney.
.
Causes of Hypercalcemia

 Hyperparathyroidism and cancer are the

two major causes of hypercalcemia.
 Increased absorption of calcium in the GI
tract
 Hyperthyroidism
 Hypophosphatemia and acidosis
 Vitamin A overdose [bone Ca resorption (osteoclast)]
 Lithum or Thiazide diuretics
Signs and Symptoms
 Abdominal pain and  Extreme thirst
constipation  Hypertension
 Anorexia  Lethargy
 Behavorial changes,  Muscle weakness
including confusion  Nausea
 Bone pain  Polyuria
 Charactesistic of ECG
 Vomiting
changes
Nursing Process

 Assessment
Assess serum calcium level above 10.1 mg/dl.
Ionized calcium level above 5.3 mg/dl.
Digoxin toxicity.
X-ray revealing pathologic fractures.
Characteristics ECG changes.
Treatment of Hypercalcemia
 Hypercalcemia produces  Hydrating patient to
no symptoms encourage diuresis (NS)
 Treatment may consist  Lasix and ethacrynic acid
only of managing the to promote calcium
underlying cause excretion.
 Dietary intake of calcium  Hemodialysis or
may be reduced peritoneal dialysis
 Medications or infusions
containing calcium must
be stopped.
Nursing Process

 Interventions
Monitor vital signs and assess pt. frequently.
Watch pt for arrhythmias.
Assess neurologic and neuromuscular function
and report any changes.
Monitor pt’s fluid intake and output.
Monitor serum electrolyte levels, especially
calcium.
Magnesium
 Normal level is 1.5-2.5 mEq/L
 Body’s 4th most abundant cation, 50-60%
located in bone
 Balance depends on normal intake & renal
excretion
 Found plentifully in green vegetables,
grains, nuts, and seafood
 Absorbed primarily in the small intestine
 Kidneys are the primary route of excretion
Functions of Magnesium
 Helps in the production and utilization of
adenosine triphosphate (ATP) for energy.
 Promotes enzyme reaction within the cell during
carbohydrate metabolism.
 Used in protein synthesis.
 Causes vasodilation thus helping normal
cardiovascular functioning.
 Helps in the transport of Na and K ions across
the cell.
 Regulates muscle contractions thus affecting
cardiac and skeletal contractility.
 Influences Ca levels through its effect on the
parathyroid hormone.
Sources of Magnesium
 Chocolate
 Dry beans & peas
 Leafy green
vegetables
 Meats
 Nuts & whole grains
 Seafood
Hypomagnesemia

 < 1.5 mEq/L

 Common clinical problem, 10% of all
hospitalized patients affected.
 Symptoms occur when levels fall below 1
mEq/L
Causes of Hypomagnesemia

 Common Causes include:

inadequate intake of magnesium
increased GI losses
increased renal losses
poor absorption by the GI tract
Alcohol abuse
Signs and Symptoms

 Neuromuscular
muscle tremors - Trousseau’s sign
muscle twitching - Chvostek’s sign
tetany
hyperactive deep tendon reflexes (DTRs)
paresthesias
breathing difficulties
Signs and Symptoms Continued

 Cardiovascular
increased sensitivity to digitalis
hypertension
arrhythmias (PVCs, A-fib, PAT, heart block)
increased sensitivity to ischemic heart disease
arrhythmias
coronary artery spasm
Signs and Symptoms Continued

 EKG Changes
prolonged QT and PR intervals
widened QRS complex
depressed ST segment
 Metabolic
hypocalcemia
hypokalemia
hypophosphatemia
insulin resistance
Signs and Symptoms Continued

 CNS
Depression
Agitation
Confusion/altered LOC
Psychosis- hallucinations, delusions
Insomnia
Seizures
Vertigo
Ataxia
Signs and Symptoms Continued

 GI Disturbances
Anorexia
Dysphagia
Nausea & vomiting
Positive Chovostek’s or Trousseau’s signs
Nursing Process of Hypomagnesemia

 Assessment
Assess client’s mental status, report changes
Assess neuromuscular status (3 T’s – tremors,
tetany, twitching, DTRs)
Check for dysphagia before giving meals
assess for other magnesium deficit risk factors
assess digitalized patients, predisposed to
digitalis toxicity
Nursing Process

 Nursing Diagnosis
Impaired swallowing
Acute confusion
Nursing Process
 Interventions
Monitor vital signs and respiratory status
Watch rhythm strip closely for arrhythmias
Implement seizure precautions
Monitor airway due to laryngeal stridor
Environmental safety r/t mental confusion
Monitor for s/s of digoxin toxicity
Monitor serum electrolyte levels. Notify MD of
low K or Ca levels
Monitor I & O carefully
Reorient client prn
Hypermagnesemia

 >2.5 mEq/L
 Caused by:
 Impaired magnesium excretion e.g. renal
failure, Addison’s disease, DKA
Excessive magnesium intake e.g. dialysis,
continous infusion of magnesium
Signs & Symptoms of Hypermagnesemia

 Early symptoms @ 3-5 mEq/L

Warm flushed appearance
Mild- moderate hypotension
Nausea & vomiting
Diminished DTRs
Muscle weakness
Bradycardia
EKG changes
Signs & Symptoms of Hypermagnesemia
Cont’d
 Late Symptoms @ 7-12 mEq/L
Loss of DTRs
Respiratory compromise
Heart block
Coma
 Severe Symptoms @ 15-20 mEq/L
Respiratory arrest
Cardiac arrest
Nursing Process for Hypermagnesemia

 Assessment
Assess the patient’s neuromuscular system
including DTRs and muscle strength
Assess EKG tracings for pertinent changes
Nursing Process

 Interventions
Identify high risk patients e.g. elderly, renal pts.
etc.
Monitor vital signs
Monitor labs
Strict I & O
Have calcium gluconate on hand for emergency
Avoid use of all magnesium containing meds.
E.g. maalox, mylanta, MOM
Phosphorus
 Primary anion, or
negatively charged ion
 Found in the intracellular
fluid
 Contained in the body as
phosphate
 Essential element of all
body tissues
 Vital to various body
functions
 Plays a crucial role in cell
membrane integrity,
muscle function,
neurologic function, and
the metabolism of
Carbohydrate, fat, and
protein
 Major buffer of acids and
bases
 Promotes energy transfer
to the cells as ATP
Phosphorus

 Normal serum level is adults range from

2.5 to 4.5 mg/dl (1.8-2.6 mEq/L).
 Total amount of phosphorus is related to
dietary intake, hormonal regulation, kidney
excretion, and transcellular shifts.
 Readily absorbed through the GI tract.
 Most ingested is absorbed through the
jejunum.
Sources of Phosporous
 Cheese
 Dried beans
 Eggs
 Fish
 Dairy products
 Organ meats (offal)
 Poultry
 Whole grain
 Nuts & seeds
Hypophosphatemia
 Occurs when the serum phosphorus level
falls below 2.5 mg/dl (or 1.8 mEq/L).
 Underlying causes:
Shift of phosphorus from extracellular fluid to
intracellular fluid.
A decrease in intestinal absorption of
phosphorus.
An increased loss of phosphorus through the
kidney.
Hyperventilation – respiratory alkalosis.
Nursing Process

 Assessment
Weakness
Paresthesia, irritability, apprehension and
confusion
Hypotension
Low cardiac output
Respiratory failure
Nursing Process

 Treatments
IV’s – potassium phosphate and I.V. sodium
phosphate.
Diet high in phosphorus-rich foods – eggs, nuts,
whole grains, meat, fish, poultry, and milk
products.
Oral supplements of Neutra-Phos.
Nursing Process
 Interventions
Monitor vital signs – can lead to respiratory
failure, low cardiac output, confusion, seizures
or coma.
Assess pt’s level of consciousness and
neurological status.
Monitor for evidence of heart failure related to
myocardial functioning.
Monitor pt for signs of infection.
Monitor pt’s frequently for evidence of
decreasing muscle strength.
Hyperphosphatemia

 >4.5mg/dl
 Caused by:
Increased phosphorous intake
Inability to excrete excess phosphorous d/t
renal failure leads to a shift of phosphorous
from the intracellular fluid to the extracellular
fluid.
Signs & Symptoms of Hyperphosphatemia

 Anorexia
 Chvosteks or trousseau’s sign
 Conjuncivitis
 Visual impairment
 Decreased mental status
 Muscle weakness, cramps
 EKG changes
 Nausea & vomiting
Nursing Process for Hyperphosphatemia

 Assessment
High phosphorous levels combine with calcium
to form calcium phosphate -calcification
Assess for signs of hypocalcemia
Assess for arrhythmias
Assess mental status
Assess for impaired vision
Nursing Process

 Interventions
Offer low phosphorous diet
Eliminate phosphorus based laxatives and
enemas
Administer drugs that decrease phosphorous
absorption e.g. aluminum, magnesium, calcium
gel, phosphate binding anatacids
Monitor vital signs
Monitor I & O, serum electrolyte levels
 Chloride
 Most abundant anion in extracellular fluid
 Most commonly found in CSF, bile, and in
gastric and pancreatic juices
 Normal level range between 98 to 108 mEq/L.
 Occurs in conjunction with sodium imbalance
 Inverse relation with bicarbonate
Cl HCO3
 Sources of Chloride

 Fruit
 Vegetables
 Processed meats
 Table salt
 Can vegetables
 Salty foods
 Hypochloremia

 Usually related to excess losses of

chloride ion through the GI tract, kidneys,
or sweating
 Patients are at risk for alkalosis and may
experience muscle twitching, tremors, or
tetany
 Hyperchloremia

 Excess replacement of sodium chloride or

potassium are additional risk factors
 Include acidosis, weakness, and lethargy
with a risk of dysrhythmias and coma
 Bicarbonate ( HCO3)

 Major body buffer involved in acid-base

regulation
 Has inverse relationship to Chloride
 Present in CSF
 Disturbances in Fluid Volume

 Factors affecting the body’s ability to

maintain fluids, electrolyte, and acid-base
balance include:
Illness – e.g. vomiting, diarrhea, NG suctioning
Trauma – e.g. tissue damage from burns
Surgery
Medications- e.g. diuretics, corticosteroids
 Fluid Imbalances

 Isotonic
Water and electrolytes are lost or gained in
equal proportions.
Osmolality of body fluid remains constant.
 Osmolar imbalances
Loss or gain of only water
Osmolality of serum is altered.
 Categories of Fluid Imbalances

 Isotonic loss of water and electrolytes

Fluid volume deficit
 Isotonic gain of water and electrolytes
Fluid volume excess
 Hyperosmolar loss of only water
Dehydration
 Hypo-osmolar gain of only water
Overhydration
 Laboratory Tests

 Serum Electrolytes
 Comple Blood Count (CBC)
 Osmolality
 Urine pH & SG
 ABGs
 Fluid Volume Deficit (FVD)
 Body loses both water and electrolytes
from the ECF in similar proportions.
 Fluid initially lost from the intravascular
compartment and is referred to as
hypovolemia.
 Causes include:
 Abnormal losses through the skin, GI tract,or kidney
 Decrease intake of fluid
 Bleeding
 Movement of fluid into a third space
 Third Space Syndrome
 Fluid shifts from the vascular space into an area
where it is not readily accessible as extracellular
fluid.
 Unavailability for usage causes an isotonic fluid
volume deficit.
 Fluid may be stored:
 in the bowel
 in the intestitual space as edema
 in inflamed tissue
 in potential spaces such as the peritoneal or pleural cavities.
 Assessment for manifestation of fluid volume
excess or hypervolemia is vital
 Risk Factors of Isotonic FVD
 Loss of water and  Insufficient intake due
electrolytes from: to:
 Vomiting  Anorexia
 Diarrhea  Nausea
 Excessive sweating  Inability to access fluids
 Polyuria  Impaired swallowing
 Fever  Confusion
 Nasogastric suction  Depression
 Abdominal drainage or
wound losses
 Clinical Manifestations of FVD
 C/O weakness and thirst  Weak, rapid pulse
 Weight loss  Decreased B/P
 2% loss= mild FVD
 Postural hypotension
 Flat neck veins: decreased
 5% loss= moderate
capillary refill
 8% loss= severe
 Decreased CVP
 Fluid intake less than  Decreased urine output
output (<30 ml/h)
 Decreased tissue turgor  Increased specific gravity (>
1.030)
 Dry mucous membrane,
 Increased hematocrit
sunken eyeballs
 Increased blood urea
 Subnormal temperature nitrogen (BUN)
 Nursing Interventions
 Assess for clinical  Provide frequent mouth
manifestations of FVD. care
 Monitor weight and v/s  Implement measures to
 Assess skin turgor prevent skin breakdown
 Assess breath sounds  Provide for safety, eg,
 Monitor fluid intake and provide assistance for a
output client rising from bed
 Monitor lab findings
 Administer oral and
intravenous fluids as
indicated
 Fluid Volume Excess (FVE)
 Retention of both water and sodium in equal
proportion to normal ECF. Otherwise referred to
as hypervolemia.
Serum sodium concentration remains normal
 Secondary to an increase in the total body
sodium content.
 Causes include:
Excessive intake of sodium chloride
Administering sodium-containing infusions too
rapidly
Disease processes that alter regulatory
mechanisms: CHF, HF, RF, Cirrhosis of the liver,
Cushing’s Syndrome
Risk Factors of Isotonic FVE

 Excessive intake of sodium containing IV

fluid
 Excessive intake of sodium in the diet or
sodium containing medications such as
antacids, enemas
 Impaired fluid balance regulation due to
disease such as heart failure, renal failure,
and cirrhosis of the liver.
Clinical Manifestations of FVE
 Weight gain  Tachycardia
 2% gain = mild FVE  Distended neck veins
 5% gain = moderate or slow venous
 8% gain = severe emptying
 Intake of fluid  Moist crackles in the
exceeds output lungs
 Moist mucous  Dyspnea, and/or
membranes shortness of breath
 Bounding pulses  Mental confusion
Nursing Interventions for FVE
 Assess for signs and  Place client in fowlers
symptoms position
 Monitor VS  Administer diuretics
 Monitor weight as ordered
 Assess for edema  Restrict fluid intake as
 Assess breath sounds ordered
 Monitor I & O  Restrict dietary Na
intake
 Monitor lab findings
 Implement measures
to prevent skin
breakdown
 Edema
 Fluid excess both intravascular and interstitial
spaces.
 Dependent edema
 Excess interstitial fluid.
 Apparent in areas where the tissue pressure is low,
such as around the eyes, and in dependent tissues
have an increased water and sodium content.
 Pitting edema
 Edema that leaves small depression or pit after finger
pressure is applied to the swollen area.
 Dehydration
 Also called hyperosmolar imbalance
 Water is lost from the body without
significant loss of electrolytes
Sodium is retained causing the serum osmolality
and serum sodium levels to increase.
Water is drawn into the vascular compartment
from the interstitial space and cells resulting in
cellular dehydration.
 This particular affects the elderly due to
the decrease in their thirst sensation.
Signs & Symptoms of Dehydration

 Dry skin and mucous  Increased heart rate

membranes with d/t lowered BP in
 Poor skin turgor hypovolemia
 Sunken eyeballs  Irritability
 Decreased urinary  Confusion
output  Dizziness &
 Fever weakness
Nursing Interventions for Dehydration
 Monitor VS  Maintain a safe
 Monitor and environment for
administer IV fluids as clients in confusion
ordered  Provide skin and
 May insert foley to mouth care
accurately monitor I &  Educate client re:
O. treatment and cause
 Daily weights of dehydration
 Overhydration
 Also known as hypo-osmolar imbalance or water
intoxication
 Water gain exceeds that of electrolytes resulting
in low serum osmolality and low serum sodium
levels
Water is drawn into the cells causing them to swell.
 Water intoxication occurs when both fluid and
electrolytes are lost but only water is replaced.
Causes include:
SIADH, excessive use of tap water enemas
Electrolytes
Electrolyte Symbol ICF Serum Regulated Function:
OR Concen. by:
ECF
SODIUM

POTASSIUM

CALCIUM

MAGNESIUM

CHLORIDE

BICARBONATE

PHOSPHATE
 Electrolyte Imbalance
Electrolyte Name Assessme Risk S&S Nsg.
nt Factors Int.
SODIUM

SODIUM

CALCIUM

CALCIUM

MAGNESIU
M
MAGNESIU
M
Electrolyte Imbalance
Electrolyte Name Assessm Risk S&S Nursing
ent Factor Interventions
s
CHLORIDE

CHLORIDE

PHOSPAHT
E
PHOSPHAT
E

Potassium

Potassium