Course Description

• This program is
designed to enrich
knowledge and
understanding of the
learners on concept of
fluid volume and
electrolyte status.
Objectives:

1. To discuss problems and treatments

commonly associated with fluids and
electrolytes imbalances.
2. To explain the need for corrective and
replacement therapy in body fluids
and electrolytes disturbances.
Course Content:

- Dynamics of fluids and electrolytes

- Fluid and electrolytes replacement
therapy
- Symptoms resulting from
electrolyte imbalances and Nursing
Interventions/ corrective measures.
BODY SYSTEMS: In F &E
Regulation
1. RENAL SYSTEM
- Controls output
- regulates fluid &
electrolyte
- adjusts acid-base
balance
BODY SYSTEMS: In F &E
Regulation
2. CARDIOVASCULAR
- in order for the
kidneys to reabsorb &
secrete properly, heart
& blood vessels must
be capable of pumping
adequately to distribute
water & nutrients to all
organs & tissues & to
remove waste products
3. LYMPHATIC
 serves as an adjunct to the cardiovascular
system by removing excess interstitial fluid in
the form of lymph.

 Helps maintain fluid balance in the body by

collecting excess fluid & particulate matter from
tissues & depositing them in the bloodstream.

 It helps in the body against infection by

supplying disease-fighting cells called
lymphocytes.
4. NERVOUS
 baroreceptors (pressure-sensitive nerve
endings) in blood vessels respond to
changes in volume in ECF.

 The brain sends electrical signals

through your nerve cells to
communicate with cells throughout the
body, this signal is called nerve impulse
which are generated by changes to the
electrical charge of the nerve cell
membrane.

this changes occurs due to the movement

of the electrolyte Na across the nerve cell
membrane.
5. ENDOCRINE

 Hormones are secreted by the glands of the

endocrine system, traveling through the
bloodstream to various organs and tissues in
the body. The hormones then tell these organs
and tissues what to do or how to function.

 Some examples of bodily functions that are

controlled by the endocrine system include:

Metabolism growth and dev’t.

sexual fxn & repro heart rate
blood pressure appetite
sleeping & waking cycles body temperature
• Parathyroid. Also located in the front of your neck, the parathyroid
gland produces parathyroid hormone that is important for maintaining
control of calcium levels in your bones and blood.

• Adrenal. One adrenal gland can be found on top of each kidney. These
glands produces:
> adrenaline hormones that are important for regulating functions
such as blood pressure, heart rate, and stress response.
> aldosterone, a hormone that controls the body’s salt and water
balance.
6. LUNGS
 regulates exchange of O2 &
CO2 which eventually
controls acid-base balance &
fluid balance thru H2O
evaporation
7. GIT
 absorbs nutrients & H2O &
serves as reservoir for H2O
8. INTEGUMENTARY
 body water is lost thru skin
in
the form of perspiration.
Functions of Water in the Body
 Facilitating digestion and promoting elimination
 Acting as a solvent for electrolytes and non-
electrolytes
 Acting as a tissue lubricant and cushion
 Regulates body temperature – Water is required
to help your body stay cool via perspiration.
When your internal body temperature increases
your body will sweat to allow you to cool down.
 Functions of Water in the Body

Transporting nutrients to cells and

wastes from cells

Transporting hormones, enzymes,

blood platelets, and red and white
blood cells

Facilitating cellular metabolism and

proper cellular chemical functioning
Normal Composition in Average Man

•When a person loses more than 10% of his

total body fluids,he can DIE!!!
BODY FLUID
COMPARTMENTS
Description:
1. Fluid in each of the body
compartments contains
electrolytes

2. Each compartment has a

particular composition of
electrolytes w/c differs from
that of other compartment

3. To function normally, body

cells must have F & E in the
right compartment in the
right amount
BODY FLUID
COMPARTMENTS
4. Whenever an electrolyte
moves out of a cell another
electrolyte moves in to take
its place

5. The numbers of cations &

anions must be the same for
homeostasis

6. Compartments are separated

by semi-permeable
membrane
Constituents
1. Body fluids consists of water
& dissolved substances

2. It provides transportation of
nutrients to the cells &
carries waste products from
the cells

3. The largest single fluid

constituent of the body is
water
Constituents
4. Some substances such as
glucose, urea & creatinine do
not dissociate in a solution

5. Other substances do
dissociate like NaCl where it
dissociates in 2 elements.
Main Compartments:
1. Intracellular Fluid (ICF)
Compartment

- 2/3 of total body water

- consists mainly of K,
Ph, Mg
Main Compartments:

2. Extracellular Fluid (ECF)

Compartment

- 1/3 of total body water

- Consists mainly of Na, Ca,
Cl, HCO3

2 Subcompartment of ECF
space:

a. Interstitial Fluid – fluid in

between cells & vascular
space
b. Intravascular – fluid
within the blood vessels
Main Compartments:

3. Transcellular Fluid –
CSF, synovial, GIT fluid
Factors which can affect the amount
of TBW:
1. Obesity
- Obese person has a
lower percentage of
body water than a
lean person because
fat tissue contains
little water
2. Gender
- Males body weight is
60%water, female
body weight is 50%
water due to the
fat:muscle ratio
Factors which can affect the
amount of TBW:
3. Age
- Process of normal
aging causes a 
in lean body mass
& an  proportion
of body fat
  thirst sensors
for elderly
- Infants have
higher total body
water
Normal Fluid Intake Amount:
1. Water in Food
- 1,300
ml
2. Water as Liquid
- 1,000 ml
3. Water from
Oxidation - 300
ml

2,600 ml
* Oxidation
(Metabolism)
 Water Loss
ROUTES OF WATER LOSS
-SENSIBLE -INSENSIBLE
Urine Lungs
Feces Sweat
Normal Fluid Output Amount:
Insensible:
1. Skin - 600 ml
2. Lungs - 300 ml

Sensible:
3. Feces - 200 ml
4. Kidneys - 1,500 ml
2,600 ml
Test Questions:

1. Based on the fluid & electrolyte concepts, which

of the ff. clients is at highest risk for developing
fluid volume deficit?

A. A 76 y.o. client who has NGT attached to low

suction following colon cancer surgery
B. A thin 55 y.o. client who smokes & takes
glucocorticoids for chronic lung disease
C. A 1 y.o. child being treated in the clinic for a
runny nose & ear infection
D. a 30 y.o. client jogging in 50-degree weather
ANSWER:

A. A 76 y.o. client who has NGT

attached to low suction following.
colon cancer surgery
 Colon absorbs majority of fluids
present in our body. Low suction,
prevents absorption, thereby, can
possibly lead to dehydration.
Test Question:

2. Which of the ff. statements should not be

included in an education program for the elderly
about prevention of dehydration during hot
weather?

A. “Observe your urine & immediately drink more

fluid if it starts getting darker.”
B. “Keep a variety of fluids in your home & drink
them frequently throughout the day”
C. “Popsicles, gelatin provide fluid intake as well as
liquids you drink”
D. “Use your thirst as a guide to the amount of fluid
you should be drinking
ANSWER:

D. “Use your thirst as a guide to

the amount of fluid you should
be drinking
 As we age, our sensors
diminishes in function, which
includes our thirst sensors
Functions of Electrolytes:
1. Promote
neuromuscular
Irritability
2. Maintain body
fluid volume &
osmolality
3. Distribute body
water between
fluid
compartments
4. Regulate Acid-
base balance
What are the hormones that
maintain F & E?
1. ADH (Anti
Diuretic
Hormone)
2. Aldosterone
3. Thyroid hormones
4. Parathyroid
hormones
 HOW ADH WORKS
Hypothalamus senses low blood volume &
Serum Osmolality signals the
PITUITARY GLAND

PITUITARY GLAND secretes ADH into the

bloodstream

ADH cause the kidneys to retain water

Water retention boosts blood volume and

decreases serum osmolality
 RENIN-ANGIOTENSIN-ALDOSTERONE SYTEM

Decreased Blood flow to the glomerulus releases

Water retention boosts blood volume and decreases serum
osmolality

Renin (produced by juxtaglomerular cells)

travels to the liver & converts Angiotensinogen to

Angiotensin I

Travels to the Lungs to be converted to

Angiotensin II  Cause Peripheral Vasoconstriction

Travels to the Adrenal glands to stimulate

Release of Aldosterone
 ALDOSTERONE

Release of
ALDOSTERONE

Aldosterone causes kidney to

retain
Sodium And Water
Sodium & water retention leads to
increase in fluid volume and sodium levels
Mechanisms involved in
Fluid Movement:
1. Diffusion https://www.youtube.co
m/watch?v=ufCiGz75DA
k-
2. Osmosis active transport video

3. Filtration https://www.youtube.co
4. Active transport m/watch?v=g432MNsG
W7w-
diffusion, osmosis, filtration
video
Mechanisms involved in Fluid
Movement:

Fluid movement is possible because of a specialized

semi-permeable membrane that encloses each
fluid compartment.

What is Phosphorylation?

 Process of attaching a phosphate group to a

protein, sugar, or other compound
https://www.youtube.com/watch?v=xweYA-IJTqs
video:
What determines ECF Movement b/w
intravenous & interstitial compartments?

1. Plasma Albumin • Osmotic pressure – pressure

concentration exerted by the protein
albumin, that creates the pull
Colloid osmotic on fluids
pressure • Hydrostatic pressure – is the
2. Capillary pressure exerted by fluids
Hydrostatic blood along the walls of the blood
pressure vessels
3. Capillary • Permeability – is the capacity
of a molecule/ subtantance to
Permeability pass thru the capillary
membranes
• Capillary hydrostatic pressure (filtration
pressure) forces fluid out of the blood
capillaries. Hydrostatic pressure results
from the heart forcing blood through the
narrow arterial part of capillaries. The fluid
contains oxygen and nutrients that move
into the surrounding tissue where they are
less concentrated
Regulation of Body Fluid
Compartments
• Tonicity is the ability •
Osmolality reflects the
of solutes to cause concentration of fluid that
osmotic driving affects the movement of
forces water between fluid
compartments by
• Filtration is the
osmosis
movement of water
and solutes from an • Osmotic pressure is the
amount of hydrostatic
area of high
pressure needed to stop
hydrostatic pressure
the flow of water by
to an area of low
osmosis
hydrostatic pressure
What Causes F&E Imbalance?
1. Deficiency of F&E
a. Insufficient dietary &
Fluid intake
b. Increase excretion or loss
c. Compartmental shifts of
F&E
d.  F&E needs resulting
from conditions such as
severe Infection & other

hypermetabolic states
What Causes F&E Imbalance?
.2. Excess of F&E
a. intake is greater
than excretion
b.  excretion, due
to kidney disease or
other impaired
homeostatic
mechanisms
 Fluid Volume Deficit
• Involves either volume or
distribution of water or electrolytes

• Hypovolemia — deficiency in
amount of water and electrolytes in
ECF with near normal
water/electrolyte proportions

• Dehydration — decreased volume

of water and electrolyte change

• Third-space fluid shift —

distributional shift of body fluids
into potential body spaces
Fluid Volume Excess
• Hypervolemia — excessive
retention of water and sodium
in ECF

• Overhydration — above
normal amounts of water in
extracellular spaces

• Edema — excessive ECF

accumulates in tissue spaces

• Interstitial-to-plasma shift —
movement of fluid from space
surrounding cells to blood
TYPES OF H2O & Solute
IMBALANCES
1. Osmolality Imbalances
A. Hyper-osmolar
Imbalance
-  in H20 relative to
solutes or an  in solute
relative to H20 w/c leads
to the shrinking of the
cells

Major Causes of H20 deficits:

a.  water intake due to:

- Dysphagia
- Impaired thirst
- Coma or confusion
- Unavailability of H20
- Severe debility
TYPES OF H2O & Solute
IMBALANCES
b.  water output due to:

- Diarrhea
- DM
- Diabetic ketoacidosis
- Diabetes Insipidus
- Diaphoresis
- Tracheobronchitis

Major Causes of ECF Solute

Excess:
• Excessive Protein intake
• Excessive infusions of
Hypertonic sol.
Causes of Increased
Causes of Increased
Water Loss
Water Gain
• Fever • Increased sodium intake
• Diarrhea • Increased sodium
• Diaphoresis retention
• Vomiting • Excessive intake of water
• Gastric suctioning • Excess secretion of ADH
• Tachypnea
Test Question:

3. The nurse is told that a client who

suffered stroke has also developed
Diabetes Insipidus. The nurse concludes
this client is now at risk for:
A. severe fluid volume deficit due to excess
urine output
B. severe fluid volume excess due to
inadequate urine output
C. hyperglycemia due to poor insulin
production
D. hypoglycemia due to excess insulin
production
ANSWER:

A. severe fluid volume deficit due

to excess urine output
 DI is a disease where there is
absence of ADH causing an
output of more than 4L per day
Assessment of Patient w/ Hyper-
osmolar Imbalance:
- Dryness of skin & Mucous
membrane
- Skin turgor, poor
- Thirst
- Sodium,  (>145mEq/L)
- Hemoglobin 
- Apprehension &
restlessness; coma
- Renal shutdown in severe
dehydration
(hypernatremia +
hypovolemia)
- Eyeballs soft & sunken
- Febrile
- Urine, Concentrated
Nursing Diagnosis for Hyper-osmolar
Imbalances:

- Potential for injury

related to  level of
consciousness 2o to
shrinking of cells in the
CNS
- Potential alteration in
urinary elimination
patterns due to  UO
- Potential impairment of
skin integrity due to
dehydration
Nursing Interventions for Hyper-
osmolar Imbalances:
- Preserve skin & mucous
membrane integrity
- Eliminate the cause of
imbalance
- Replace the water
- Monitor serum Sodium &
Hgb values
- Vital signs must be
monitored
- IVF replacement
complications must be
assessed & prevented
- Dehydration must be
assessed for & prevent
further complications
B. Hypo-osmolar Imbalance (Water
intoxication)

  in water relative
to solutes or  in
solutes relative to
water w/c causes
swollen cells
B. Hypo-osmolar Imbalance (Water
intoxication)
Major Causes of H20 Excess:
a. Water Excess:
- Intake excessive
- Inability to excrete
water excess due to
renal disease or brain
injury or disease
- Iatrogenic problems
(administration of
hypotonic solutions &
multiple tap water
enemas)
B. Hypo-osmolar Imbalance (Water
intoxication)
b. Solute deficit due to:
- Sodium intake is poor
- iatrogenic problems
(Diuretic, low Na diet,
replacement of H20 & Na
losses w/ water only)
B. Hypo-osmolar Imbalance (Water
intoxication)
Assessment of Patient w/
Hypo-osmolar imbalance:
- Hyperirritability
- Polyuria/oliguria
- Convulsions, twitching, coma
- Absence of thirst
- Mental disturbances
- Disorientation
- ICP 
- Sodium  135mEq/L
- Hemoglobin 
Nursing Diagnosis for Hypo-osmolar
Imbalances:

- Potential for injury due to

mental confusion,
disorientation & convulsions
- Alteration in thought
processes due to cerebral
edema & dysfunction
- Alteration in comfort due to
twitching & hyperirritability
- Alteration in comfort due to
fluid restriction
 Nursing Interventions for Hypo-osmolar
Imbalances:
- Avoid administering excessive Tap
water enemas
- Administer hypotonic IV solutions
judiciously
- Restrict fluid intake for people w/
ADH secretion
- Obtain daily weight
- Replace losses of both Na & H20
w/ isotonic IV & oral liquids
containing both electrolytes of H20
- Irrigate NGT w/ NS rather than
plain H20
- Perform neurologic checks
including: LOC, VS, reflexes &
papillary responses q hour
- Monitor IVF & I & O hourly
- Provide safety measures for
behavioral changes such as
confusion or disorientation
 TYPES OF H2O & Na IMBALANCES

2. ECF Volume Imbalances (saline, isotonic)

> Isotonic solution is one that has the same osmolarity, or solute
concentration, as another solution.

A. Hypervolemia (circulatory overload/overhydration)

- Na, Cl & water are gained together causing an expansion of the ECF.
An excess of fluids in the vascular system
• Isotonic expansion of ECF caused by abnormal retention of water and
sodium
• Fluid moves out of ECF into cells and cells swell
 Causes
• Cardiovascular – Heart failure
• Urinary – Renal failure
• Hepatic – Liver failure, cirrhosis
• Other – Cancer, thrombus, Peripheral Vascular
Disease (PVD), drug therapy (i.e.,
corticosteriods), high sodium intake, protein
malnutrition
• Compromised regulation of fluid movement &
excretion (those w/ Cardiac problems)
• Excessive ingestion of fluids or food containing
Na w/c brings in water
• ADH & Aldosterone , w/c causes H2O retention

77
Assessment of Patient w/ Hypervolemia:

- Weight gain
- Ascites & or edema
- Distended neck veins
- Orthopnea/ Dyspnea/ Crackles
- Cardiac manifestations (chest pain, dysrrhythmias)
- Mental status changes

Nursing Diagnosis for patient’s w/ Hypervolemia:

• Actual fluid volume excess due to significant  in water &

Na resulting in a circulatory overload
• Ineffective breathing pattern related to  bronchial
secretions & pulmonary edema
• Anxiety related to development of pulmonary edema 2 o to
circulatory overload
Diagnostics
• VS
– High CVP/PAWP
(8-12mmHg)
– ↑ cardiac output
• Lab data
– ↓ Hct (dilutional)
– Low serum osmolality
– Low specific gravity
– ↓ BUN (dilutional)
84
Diagnostics

• Radiography
– Pulmonary vascular congestion
– Pleural effusion
– Pericardial effusion
– Ascites

86
 Interventions
• Sodium restriction (foods/water high in
sodium) (1G/day ≈ 1 can tomato soup)
• Fluid restriction, if necessary
• Closely monitor IVF
• If dyspnea or orthopnea > Semi-Fowler’s
• Strict I & O, lung sounds, daily weight,
degree of edema, reposition q 2 hr
• Promote rest and diuresis (diuretics)

90
 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
91
Medical Interventions:
• Restriction of Na & Fluids
• Promoting urine output – diuretics
Nursing Interventions for patiens w/
Hypervolemia:
• Administering diuretics keeping in mind the
possible complications that accompany diuretic
therapy
• Na restriction – diet modification, referral to a
dietician
• Weigh daily
• Strict IV monitoring (IV infusion pump)
• Record accurately I & O
• Measure postural BP
• Electrolyte monitoring
Test Question:

George, 88 y.o. is suffereing from congestive heart

failure. He was admitted to the hospital w/ a
diagnosis of ECF volume excess. He was
frightened, slightly confused, & dyspneic on
exertion

4. During the assessment process, the nurse

expects to identify the following except:

A. A full pulse
B.  CVP
C. Edema
D. neck vein distention
ANSWER:

B.  CVP
 Central venous pressure must
be elevated as a result of the
excess fluid volume
Test Question:

5. An accurate manifestation of
extracellular volume excess is:

A. Altered serum osmolality

B. Hyponatremia
C.  hematocrit when volume
excess develops quickly
D. Rapid weight gain
ANSWER:

D. Rapid weight gain

 Fluid of 1L = 1Kg, an
abnormal  would
immediately be noted
objectively through the
weight
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 preceptor in
hypothalamus)
• ICF hypotonic with decreased osmotic
pressure -> posterior pituitary secretes
more ADH
• Decreased ECF volume -> adrenal glands
secrete Aldosterone

97
A. Hypovolemia
- Na, Cl & water are lost together
causing a  in the size of the ECF

Causes of Hypovolemia
1. Lack of fluid intake due to:
- cognitive impairment
- physical impairment
- impaired thirst mechanism
2. Excess fluid losses due to:
- unmonitored use of potent diuretics
- severe vomiting
- diaphoresis
- GIT suction
- Fistula (fistula is an abnormal connection of two body cavities or a
.)
body cavity and the skin - blood loss
- Hyperthyroidism - diarrhea
- DI - fever
- Hyperglycemia - ileostomy
- Burns -
hyperventilation
 ADH
Assessment of Patient w/ Hypovolemia:
- Flat/ collapsed neck veins
- Postural BP drop
- Oliguria/ anuria
- Shock
- No thirst unless severe
  Hct & CHON concentration
- Normal to decreased serum Na
Signs and Symptoms
• Acute weight loss
• Decreased skin turgor
• Concentrated urine
• Weak, rapid pulse ( blood volume)
• Capillary filling time elongated ( O2
carrying capacity)
• Increased pulse
• Sensations of thirst, weakness,
dizziness, muscle cramps
• A fluid weight loss of 20% is
catastrophic or fatal
100
• defined as "the excessive loss of water
and electrolytes from the body“
• Dehydration can be caused by losing too
much fluid, not drinking enough water or
fluids, or both.
• Infants and children are more susceptible
to dehydration than adults because of
their smaller body weights and higher
turnover of water and electrolytes.
• So are the elderly and those with illnesses
• dehydration occurs when losses are not replaced adequately
and a deficit of water and electrolytes develop.
• These may occur in Vomiting or diarrhea
• Presence of an acute illness where there is loss of appetite
and vomiting:
 Pneumonia
 DHF
 Other Acute Ilnesses
• Excessive urine output, such as with uncontrolled diabetes
or diuretic use
• Excessive sweating (sports)
• Burns
 Significant Points!!!

• Dehydration – one of most common

disturbances in infants and children

• Additional S/S
–Sunken eyeballs
–Depressed fontanels
–Significant wt loss
106
 Significant Points!!!

• Older Adult
–Vein filling better indicator than
skin turgor
–Have additional health problems
–Take various medications
–May ↓ intake to prevent
incontinence
107
• Since diarrhea and vomiting are the
most common causes of dehydration in
children, the volume of fluid loss may
vary from 5 ml/kg (normal) to 200
ml/kg
• Concentration of electrolytes lost also
varies
• NaCl and K are the most common
electrolytes lost through stools
• In order to diagnose the type of
dehydration, you need to know the History
and you must do a thorough physical
examination
• We classify type of dehydration depending
on the amount of water and electrolytes lost
• These are reflected by the signs and
symptoms the child will present
• Dehydration is classified as no
dehydration, some dehydration, or
severe dehydration based on how
much of the body's fluid is lost or not
replenished.
• When severe, dehydration is a
life-threatening emergency
 Assesment of Dehydration
• Graded according to the signs and symptoms
that reflect the amount of fluid lost.
• There are usually no signs or symptoms in
the early stages
• As dehydration increases, signs and
symptoms develop. Initially, thirst,
restlessness, irritability, decreased skin
turgor, sunken eyes and sunken fontanelles.
• As more losses occur, these
• effects become more pronounced.
Signs of hypovolemic shock
(SEQUELAE)

1. diminished sensorium (lethargy)

2. Lack of urine output
3. Cool moist extremities
4. A rapid and feeble pulse
5. Decreased BP
6. Peripheral cyanosis
7. DEATH.
 Look
*Lethargic or
at :condition* Well , alert *restless,irritable
unconscious;floppy
Eyes Normal sunken
very sunken & dry
Tears Present absent
absent
Mouth and Moist dry
very dry
tongue Drinks *thirsty,drinks
*drinks poorly or not
Thirst normally,not eagerly
able to drink *
Thirsty

Goes back *goes back

Feel skin pinch *Goes back very slowly
quickly slowly*

If the patient has

If the patient has 2 or
The patient has 2 or more signs,
more signs, including at
Decide no sign of including at least
least 1 *sign* , there is
dehydration 1 *signs*, there is
Severe Dehydration
Some Dehydration
Labs

• Increased HCT
• Increased BUN out of proportion to Cr
• High serum osmolality
• Increased urine osmolality
• Increased specific gravity
• Decreased urine volume, dark color

116
• Hematocrit: The proportion of the blood that
consists of packed red blood cells. The hematocrit
is expressed as a percentage by volume.
The normal ranges for the hematocrit are:
Newborns: 55-68%
One (1) week of age: 47-65%
One (1) month of age: 37-49%
Three (3) months of age: 30-36%
One (1) year of age: 29-41%
Ten (10) years of age: 36-40%
Adult males: 42-54%
Adult women: 38-46%
117
Interventions:
• Major goal is to prevent or correct
abnormal fluid volume status before ARF
occurs
• Encourage fluids
• IV fluids
– Isotonic solutions (0.9% NS or LR) until
BP back to normal, then hypotonic
(0.45% NS)
• Monitor I & O, urine specific gravity, daily
weights
118
Nursing Diagnoses for Patient w/
Hypovolemia:

• Potential of injury due to postural

hypotension related to hypovolemia
• Actual fluid volume deficit due to large
losses of Na & water resulting from
diarrhea & vomiting
• Alteration in urinary elimination patterns
due to  plasma volume w/ resulting  in
blood flow to kidney
• Alteration in cardiac output due to
inadequate blood volume
Medical Management for Patient w/
Hypovolemia:
• Oral rehydration
• IV rehydration
- is calculated on the basis of the client’s
wt & the presence of any other co-
morbidities such as cardiac, renal, liver or
pulmonary disorders
- Isotonic ECFVD = treated w/ isotonic
solutions
- Hypertonic ECFVD = treated w/
hypotonic solutions
- Hypotonic ECFVD = treated w/
hypertonic solutions
• Monitoring for complications of fluid
restoration
Nursing Interventions Patient w/
Hypovolemia:
• Assess VS q 1-4 hours
• Assess peripheral vein filling, it should
have venous refill in 3-5 seconds
• Monitor I&O, daily weights
• Monitor plasma Na, BUN, glucose & hct
levels
• Determine history of chronic illness to
help eliminate possible causes
• Assess oral cavity, check for dryness of
mucous membrane & tongue (oral care)
• Check for skin turgor – forearm &
sternum
• Restore oral fluid intake
• Monitor skin turgor
• Monitor VS and mental status
• Evaluation
– Normal skin turgor, increased
UOP with normal specific gravity,
normal VS, clear sensorium, good
oral intake of fluids, labs

122
123
Test Question:

Phoemela, 30 y.o.has been admitted to the burn

treatment center w/ full-thickness burns over
30% of her upper body. Her diagnosis is
consistent w/ extracellular volume deficit.

6. The major indicator of extracellular volume

deficit can be identified by assessing for:

A. A full bounding pulse

B. A drop in postural BP
C. An  temperature
D. Pitting edema of the lower extremities
ANSWER:

B. A drop in postural BP
Test Question:

7. Nursing intervention for Phoemela includes all

of the following, except:

A. Monitor Urine output to assess kidney perfusion

B. Place the patient on trendelenburg to maximize
cerebral blood flow
C. Position the patient flat on bed w/ legs elevated
to maintain adequate circulating volume
D. Teaching leg exercises to promote venous
return & prevent postural hypotension when the
patient stands
ANSWER:
7. Nursing intervention for Phoemela includes all
of the following, except:

B. Place the patient on trendelenburg to

maximize cerebral blood flow
 Trendelenburg causes undue pressure to the
upper body where the burn is mostly located.
Elevation of legs is more appropriate to
maintain circulating volume
Electrolytes
Electrolyte
is a substance that dissociates in water into charged particles called ions.

 Positively charged ions are called cations. Negatively charged ions are
called anions.

Simply, an electrolyte is a substance that can conduct an electric current

when melted or dissolved in water.

All inorganic acids, base, salts electrolytes

Fluids have an overall neutral charge due to the balances between

electrolytes.

In intracellular fluid, K+ and HPO42- are the predominant electrolytes

In extracellular fluid, Na+ and Cl- predominate.
 Importance of electrolytes
-Maintain voltages across cell membranes
-Carry electrical impulses to other cells
-Found in blood or the human body in the form of
acids, bases or salts (Sodium, calcium, potasium,
chlorine, magnesium, bicarbonate)
-Conduct an electric current that transports
energy thoughout the body
 Effects of Electrolytes

The loss of electrolytes in the body can lead to

an unbalance of fluids in the body and the pH,
and a damage of the electric potential between
the nerve cells that transmit the nerve signals
(Encarta)
 Major Electrolytes/Chief Function
Sodium — controls and regulates volume of body
fluids
Potassium — chief regulator of cellular enzyme
activity and water content
Calcium — nerve impulse, blood clotting, muscle
contraction, B12 absorption
Magnesium — metabolism of carbohydrates and
proteins, vital actions involving enzymes
Chloride — maintains osmotic pressure in blood,
produces hydrochloric acid
Bicarbonate — body’s primary buffer system
Phosphate — involved in important chemical reactions
in body, cell division and hereditary traits
ELECTROLYTE IMBALANCES:
1.) Sodium Imbalances
A. Hyponatremia
- serum Na level  135 mEq/L
- Na imbalances are usually associated w/
fluid imbalances
Etiology:
- Treatments with diuretics
- Restricted Na intake
- Loss from GI or billiary drainage & draining
fistula
  aldosterone secretion (Addison’s dse.)
- “Trapping “ of Na & water
- Edema, ascites, burns or small bowel
obstruction
- Diaphoresis – warm climate, exercise, fever, salt-wasting
nephritis

- Freshwater drowning

- SIADH (Syndrome of Inappropriate Antidiuretic Hormone

Secretion) - is a condition in which your body makes too much
antidiuretic hormone (ADH).

Assessment of HYPONATREMIA:

1. Cardiovascular
-  PR, normal BP
- hypovolemic – thready, weak, rapid pulse; hypotension; flat
neck veins, low or normal CVP
- hypervolemic – rapid, bounding pulse, BP & CVP normal or 

2. Respiratory
- shallow, ineffective respiratory movements as a late
manifestation related to skeletal muscle weakness
- signs of pulmonary edema: moist rales, rapid
3. Neuromuscular
- generalized skeletal muscle weakness that
is worse in the extremities
- diminished DTR (deep tendon reflexes)
4. Cerebral function
- headache, personality changes
5. GI
-  motility & hyperactive bowel sounds,
nausea, abdominal cramping, diarrhea
6. Renal
-  specific gravity
-  UO
Collaborative management of HYPONATREMIA:
• Treatment of shock:
> 0.9 NaCl/ IV
> plasma expanders for patients w/ hypovolemia
• Replace other electrolytes depleted (K, Ca, HCO3)
• Salt in diet (soy sauce, cured pork, cottage cheese,
butter, whole-wheat bread, ketchup, canned foods)
• Safety measures ( use of side rails, supervision during
ambulation)
• If client is taking lithium, monitor lithium level because
hyponatremia can cause  lithium excretion & result
in toxicity
• For patients accompanied by hypervolemia, osmotic
diuretics are given to promote excretion
• Monitor general status
B. Hypernatremia
 Na & Water  edema; excess Na in relation
to water in ECF  hypernatremia;
 serum Na > 145mEq/L

Etiology:
- More H20 than Na is lost from the body
(hyperventilation, diarrhea, fever, infection)
- High Na intake/ salt tablets
- Cushing’s syndrome (Cushing syndrome occurs when
your body has too much of the hormone cortisol over
time. This can result from taking oral corticosteroid
medication. Or your body might produce too much
cortisol), renal failure, corticosteroids
- Rapid infusion of saline IV
- Water deprivation
Assessment of HYPERNATREMIA:
1. Cardiovascular
-  myocardial contractility & diminished CO
- HR & BP respond to vascular volume
2. Respiratory
- pulmonary edema if hypervolemia is present
3. Neuromuscular
- Early = spontaneous muscle twitches,
irregular muscle contractions
- Late = skeletal muscle weakness; DTR  or
absent
4. CNS
- altered cerebral function most comon
manifestation
- normovolemia or hypovolemia; agitation,
confusion, seizure
- hypervolemia; lethargy, stupor, coma
5. Renal
-  urine specific gravity
-  UO
6. Integumentary
- dry, flaky skin
- presence or absence of edema, depnding on
fluid volume changes
Collaborative management of HYPERNATREMIA:
• Monitor I & O & general physical status
• Restrict Na in diet as ordered
• Monitor behavior changes
  oral fluids or D5W IV
• Diuretics
• Dialysis – for ultrafiltration if Na levels are dangerously
high
• If there is fluid loss, IVF of D5W
ELECTROLYTE IMBALANCES:
2.) Potassium Imbalances
- serum K level 3.5-5.3 mEq/L
- excitability of nerves & muscles
- ICF osmotic pressure
- maintains acid-base balance & normal
kidney function
- During anabolism or glycogenesis, K
enters the cell
- during catabolism (trauma,
dehydration, starvation), K leaves the
cells
 A. Hypokalemia
- serum K level  3.5 mEq/L
Etiology:
- GI losses (diarrhea,vomiting, starvation)
- Alkalosis
- Hyperaldosteronism
- Potassium losing diuretics (Diuril)
- Meds like: corticosteroids, Na penicillin,
amphotericin B
- Patients w/ persistent insulin hypersecretion
since insulin promotes entry of K into skeletal
muscle & hepatic cells w/c is often the case in
clients receiving high CHO parenteral fluids
- Magnesium depletion
 Assessment for Hypokalemia:
1. Cardiovascular
- thready, weak pulse, variable HR
- peripheral pulses difficult to palpate
- orthostatic hypotension
- ECG changes: ST depression, flat or inverted T
wave, prominent U wave, heart block

2. Respiratory
- shallow, ineffective respirations that result from
profound muscle weakness of the skeletal
muscles of respiration
-  breath sounds
3. Neuromuscular
- anxiety, lethargy, confusion, coma
- skeletal muscle weakness, leg cramps,
eventual flaccid paralysis (weakness or
paralysis and reduced muscle tone)
- loss of tactile discrimination
- Deep Tendon Reflex: hyporeflexia
4. GI
-  motility, hypoactive to absent bowel
sounds
- N & V, constipation, abdominal distention
- paralytic ileus
5. Renal
-  UO & specific gravity
Management for Hypokalemia:
• Potassium rich food – banana, driet fruits (raisins,
prunes), orange, raw carrots, raw tomato, baked
potata, melon, watermelon, spinach
• K supplement per slow IV drip only (KCl) which may
cause N & V they should not be taken on an empty
stomach, discontinue if N & V, abdominal distention
persists
• K sparing diuretics (spironolactone)
• Monitor electrolyte values regularly
• Liquid K has an unpleasant taste & should be taken w/
juice or other liquid
• Attach patient to cardiac monitor specially when on K
drip & assess IV site regularly
• Raise siderails for safety due to muscle weakness
B. Hyperkalemia
- serum K level  5.3 mEq/L
Etiology:
- Commonly due to iatrogenic (induced) causes like excess K
replacement during hypokalemia treatment
- Pseudohyperkalemia due to tight tourniquet around an
excercising extremity while drawing a blood sample & hemolysis
of the sample before analysis, Marked leukocytosis, Drawing
blood above potassium infusion site (Pseudohyperkalemia is a
condition in which the serum potassium levels are raised
compared to the normal plasma potassium level. This means the
calculated value of potassium is higher, but the actual value of
potassium is within the normal range. Pseudohyperkalemia is also
known as spurious hyperkalemia, factitious hyperkalemia)
  renal excretion of K
- Hypoaldosteronism
- Meds like: KCl, heparin, ACE inhibitors, captopril, NSAID, K
sparing diuretics
- Administration of aged blood
 Assessment for Hyperkalemia:
1. Cardiovascular
- irregular heart rate, slow, weak HR
- BP
- ECG changes: tall T wave, widened QRS
complex, prolonged PR interval, flattened
or absent P waves, heart blocks
- dysrhythmias
2. Respiratory
- shallow, ineffective respirations that
result from profound muscle weakness of
the skeletal muscles of respiration
3. Neuromuscular
Early – muscle twitches, cramps,
paresthesias
Late – profound weakness, ascending
flaccid paralysis in the arms & legs &
respiratory muscles become affected
when serum K level is in lethal level
4. GI
- GI motility, hyperactive bowel sounds
- diarrhea
Management for Hyperkalemia:
• Avoid K rich foods (bananas)
• 10% glucose w/ regular insulin
• Polysterene sulfonate
• Dialysis & blood ultrafiltration if K levels are
dangerously high
• Ca gluconate/IV (antagonize effects of K)
• Prepare to administer Na Polystyrene Sulfonate
(Kayexalate), a cation exhange resin that
promotes GI Na absorption & K excretion
• Promote bedrest
• Discontinue K pump
• Prepare to administer K-excreting
diuretics if renal function is ok (diuril)
• If BT is required in these patients, the
client must receive fresh blood, K is
increased in old stored blood due to
cellular breakdown
• Teach client to avoid use of salt
substitutes or other K containing
substance
ELECTROLYTE IMBALANCES:
3.) Calcium Imbalances
- Total serum Ca level 8.6-10 mg/dl
- Ionized form level 4.5-5.5 mEq/L
- There are 2 types:
> Ionized
> bound to plasma CHONS
-Free ionized Ca is needed for:
> blood coagulation
> smooth skeletal & cardiac muscle
fxn
> nerve function
> bone & teeth formation
-Vitamin D & PTH must be present for Ca to
be absorbed from GIT
3.) Calcium Imbalances
A. Hypocalcemia
- serum Ca level  8.6mg/dl
Etiology:
1. Inhibition of Ca absorption from GIT
- inadequate oral intake of Ca
- lactose intolerant
- malabsorption syndromes such as Crohn’s (chronic
inflammation of the digestive tract that leads to
abdominal pain, severe diarrhea, fatigue, weight loss
and malnutrition)
- inadequate intake of Vit D
2.  Ca excretion
- renal failure, polyuric phase
- diarrhea
- steatorrhea (e excretion of abnormal quantities of fat
with the faeces owing to reduced absorption of fat by
the intestine).
- wound drainage (ileostomy, colostomy)
3. Conditions that  ionized Ca
- hyperprotenemia
- alkalosis
- medications like Ca chelators or binders
- acute pancreatitis
- hyperphosphatemia
- immobility
- removal or destruction of parathyroid gland

Assessment for HYPOCALCEMIA:

1. Cardiovascular
-  HR & myocardial contractility
- hypotention
- diminished peripheral pulses
- ECG changes: prolonged ST & QT interval
2. Respiratory
- not directly affected however failure or arrest can result
from  respiratory movement
3. Neuromuscular
- irritable skeletal muscles, twitches, cramps, tetany,
seizures
- painful muscle spasms in the calf or foot during periods of
inactivity
- paresthesias followed by numbeness that may affect the
lips, nose & ears in addition to the limbs
- (+) trousseau’s & Chvostek’s signs
- hyperactive DTR
- anxiety, irritability, psychosis
4. GI
-  GI motility, hyperactive bowel sounds
- abdominal cramping, diarrhea
Management for HYPOCALCEMIA:
• Monitor breathing (laryngeal stridor)
• Ca gluconate
• High Ca diet (milk, yogurt, tofu, green
beans, cheese, broccoli, carrots)
• Oral Ca salts
• Vit D, PTH supplement
• Phosphate binder (AlOH)
• Safety precautions for possible seizure
• Move client, carefully & monitor for
signs of fracture
• When administering IV Ca, warm
injection to body temp before
administration & administer slowly
 B. Hypercalcemia
- serum Ca level  10mg/dl
Etiology:
1.  Ca absorption ( oral intake of Ca &
Vit D)
2.  Ca Excretion (renal failure; use of
thiazide diuretics)
3.  bone resorption of Ca
(hyperparathyroidsm, malignancy, use
of glucocorticoids)
4. Hemoconcentration (dehydration)
Assessment for HYPERCALCEMIA:
1. Cardiovascular
-  HR in early phase, brady & cardiac arrest in
late phase
 BP
- bounding, full peripheral pulse
- clot formation in vessels or organs in which
blood flow is slow or blocked
2. Respiratory – ineffective respi movement as a
result of profound skeletal muscle weakness
3. Neuromuscular
- profound muscle weakness
-  or absent DTR
- disorientation, lethargy, coma
4. Renal -  UO leading to dehydration, formation
of renal calculi
5. GIT -  motility, hypoactive BS, anorexia,
constipation
Management for HYPERCALCEMIA:
• Place client on cardiac monitor
• Discontinue Ca infusion/ medication
• Discontinue thiazide diuretic & replace w.
others that enhance Ca excretion
• Administer NS to help restore Ca level
• Administer Phosphorous, calcitonin,
biphosphates (etidronate) &
prostaglandin synthesis inhibitors
(aspirin & NSAID) to inhibit Ca resorption
from bone
• Prepare the client for possible dialysis
• Move client carefully & monitor for signs
of flacture
• Instruct client to avoid (milk, yogurt,
tofu, green beans, spinach, cheese,
broccoli)
 Magnesium

• Normal 1.3 to 2.3 mEq/L

• Ensures K and Na transport across cell
membrane
• Important in CHO and protein metabolism
• Plays significant role in nerve cell
conduction
• Important in transmitting CNS messages
and maintaining neuromuscular activity
 Magnesium
• Causes vasodilatation
• Decreases peripheral vascular resistance
• Has sedative effect on neuromuscular
junction
• Balance - closely related to K and Ca
balance
• Intracellular compartment electrolyte
• Hypomagnesemia - < 1.3 mEq/L
• Hypermagnesemia - > 2.3 mEq/L
 Hypomagnesemia

• Causes
– Decreased intake or decreased absorption or
excessive loss through urinary or bowel
elimination
– Acute pancreatitis, starvation, malabsorption
syndrome, chronic alcoholism, burns, prolonged
hyperalimentation without adequate Mg
– Hypoparathyroidism with hypocalcemia
– Diuretic therapy
 Signs/Symptoms

• Tremors, tetany, ↑ reflexes, paresthesias

of feet and legs, convulsions
• Positive Babinski, Chvostek and Trousseau
signs
• Personality changes with agitation,
depression or confusion, hallucinations
• ECG changes (PVC’S, V-tach and V-fib)
 Treatment

• Mild
– Diet – Best sources are unprocessed cereal
grains, nuts, legumes, green leafy vegetables,
dairy products, dried fruits, meat, fish
– Magnesium salts
• More severe
– MgSO4 IM (gluteal area)
– MgSO4 IV slowly
Treatment

• Monitor Mg q 12 hr
• Monitor VS, knee reflexes (DTR)
• Precautions for seizures/confusion
• Check swallow reflex
 Hypermagnesemia
• Most common cause is renal failure,
especially if taking large amounts of Mg-
containing antacids or cathartics; DKA
with severe water loss
• Signs and symptoms
– Hypotension, drowsiness, diminished or
absent DTRs,
– respiratory depression, coma, cardiac arrest
ECG – Bradycardia, CHB, cardiac arrest, tall T
waves
 Treatment

• Withhold Mg-containing medications

- Mg Hydroxide antacid
• Calcium chloride or gluconate IV for acute
symptoms
• IV hydration and diuretics
• Monitor VS, LOC
• Check patellar reflexes regularly
 Evaluation

• Serum magnesium levels Within Normal

Limits
• Improvement of symptoms
 Phosphorous

• Normal 2.5-4.5 mg/dL

• Intracellular mineral
• Essential to tissue oxygenation, normal CNS
function and movement of glucose into
cells, assists in regulation of Ca and
maintenance of acid-base balance
• Influenced by parathyroid hormone and
has inverse relationship to Calcium
 Hypophosphotemia

• Causes
– Malnutrition
– Hyperparathyroidism
– Certain renal tubular defects
– Metabolic acidosis (esp. DKA)
– Disorders causing hypercalcemia
 Signs/Symptoms

• Impaired cardiac function

• Poor tissue oxygenation
• Muscle fatigue and weakness
• Nausea/Vomitting, anorexia
• Disorientation, seizures, coma
 Treatment

• Closely monitor and correct imbalances

– Adequate amounts of Phos
– Recommended dietary allowance for formula-
fed infants 300 mg Phos/day for 1st 6 mos.
and 500 mg per day for latter ½ of first year
– 1:1 ratio Phos and Ca recommended dietary
allowance. Exception is infants, whose Ca
requirements is 300 mg/day for 1st 6 mos and
500 mg/day for next 6 months
Treatment

• Treatment of moderate to severe

deficiency
– Oral or IV phosphate (do not exceed rate of
10 mEq/h)
– Identify clients at risk for disorder and
monitor
– Prevent infections
– Monitor levels during treatment
 Hyperphosphatemia

• Causes
– Chronic renal failure (most common)
– Hyperthyroidism, hypoparathyroidism
– Severe catabolic states
– Conditions causing hypocalcemia
 Signs/Symptoms

• Muscle cramping and weakness

• ↑ HR
• Diarrhea, abdominal cramping, and
nausea
 Treatment

• Prevention is the goal

• Restrict phosphate-containing foods
• Administer phosphate-binding agents
• Diuretics
• Treat cause
• Treatment may need to focus on
correcting calcium levels
 Evaluation

• Lab values within normal limits

• Improvement of symptoms
 Chloride
• Normal serum chloride 97 - 107 mEq/L
• Intracellularly, chloride level is 4mEq/L
• Major anion in the ECF
• Aldosterone secretion may  chloride
absorption
• CSF formation @ choroid plexus is
dependent on Na & Cl to attract fluid to
form fluid portion of CSF
• It has inverse relationship w/ Bicarbonate
 Hypochloremia
Causes:
GI tube drainage, gastric suctionoing
Gastric surgery
Severe vomiting & diarrhea
Low sodium intake/  Na levels
Metabolic alkalosis
Diuretic therapy
Massive BT
 Hypochloremia
Signs & Symptoms:
Agitation, irritability, tremors
Muscle cramps
Hyperactive DTR, tetany
dysrrhythmias
Slow, shallow respirations
 pH due to  HCO3
 serum Cl & K
 Hypochloremia
Management:
PNSS or 0.45 NaCl IV
Assess type of diuretic, it may be
stopped or changed accordingly
Ammonium chloride – to treat the
accompanying metabolic alkalosis
- caution in giving to patients w/
liver problems as it is metabolized
by liver & lasts for 3 days.
 Hypochloremia
Nursing Management:
Monitor I & O, ABG, electrolyte values
Monitor LOC & muscle strength
Give foods high in chloride:
- tomato, dates, eggs, salty broth,
canned vegetables, processed
meats. Avoid drinking distilled
water
 Hyperchloremia
Causes:
Excessive NaCl infusions, head injury
(Na retention), hypernatremia
Corticosteroid use, dehydration
Severe diarrhea (loss of HCO3)
Metabolic acidosis
Kayexalate, acetazolamide,
ammonium chloride use
hyperparathyroidism
 Hyperchloremia
Signs & Symptoms:
Tachypnea, lethargy, weakness
Deep rapid respiration
Tachycardia, dysrhythmias
Pitting edema, seizures
 serum Cl, K, or Na
 serum HCO3
 Hyperchloremia
Management:
Hypotonic IV
PLR – converts lactate to HCO3 in
the liver results to  HCO3 & corrects
acidosis
IV NaHCO3 to  HCO3
Diuretics
 Hyperchloremia
Nursing Management:
Monitor ABG & I & O
Emphasize on the diet
Maintain adequate hydration
Monitor neurologic & cardiovascular
functioning & report to AP any
abnormalities
Type of Fluid Replacement
1. Hypotonic
> is a solution with a lower concentration of solutes than another
solution

> D5W – no electrolytes; replace deficits of total body water, dextrose

is metabolized on 1st pass thru the liver, leaving a solution of water
but without the hemolytic problems
> used for the intravenous replacement of body fluids contains 0.310
glucose. (D5W is an approximately 5% solution of dextrose [the
medical name for glucose] in water.)

> D545%NS (used to treat hypertonic dehydration, not indicated for

3rd space fluid shift, can be used as maintenance fluid)
2. Isotonic

> An isotonic solution is one with a salt concentration that is

exactly equal to that of blood cells
> Isotonic solutions are IV fluids that have a similar concentration
of dissolved particles as blood. An example of an isotonic IV
solution is 0.9% Normal Saline (0.9% NaCl). Isotonic solutions are
used for patients with fluid volume deficit (also called hypovolemia)
to raise their blood pressure.

> 0.9%NaCl(154mEq/L of NaCl)- ECF deficits in patients w/ low

serum Na.
- not used for routine administration of IV fluids because it contains
more Na than ECF
> Lactated Ringer’s – ECF deficits such as fluid loss w/ burns &
bleeding & dehydration.
- lactate is equivalent to bicarbonate & can be used to treat many
forms of acidosis
3. Hypertonic
> Hypertonic solutions have a higher concentration of
dissolved particles than blood
> D5LR (ECF deficits such as fluid loss w/ burns & bleeding &
dehydration from loss of bile or diarrhea)
> D5NS ( ECF deficits in patients w/ low serum levels of NaCl,
before & after infusion of blood products
> D53%NaCl (highly hypertonic solution used only in critical
situations to treat hyponatremia, must be administered slowly &
cautiously
COLLOID SOLUTION
Dextran 40/70, Albumin, Mannitol, Hetastarch
Used as volume/plasma expander for intravascular part of ECF,
affects clotting by coating platelets & decreasing ability to clot
Isotonic Infusions:
Examples
 5% dextrose in water (D5W)
 Lactated Ringer’s
 Ringer’s
 Normal Saline (0.9% NaCl)
 5% Albumin
 Normosol
Isotonic: Nursing
Considerations
 Closely monitor the patient for signs of
fluid overload, especially if he has
hypertension or heart failure
 Because isotonic solutions expand the
intravascular compartment
Don’t give lactated Ringer’s solution if the
patient’s blood pH exceeds 7.5
 Because the liver converts lactate to
bicarbonate
Avoid giving D5W to a patient at risk for
increased ICP because it acts like a
hypotonic
 D5W is actually isotonic only in the
container, but after administration,
dextrose is quickly metabolized, leaving
only water- a hypotonic fluid
Hypotonic: Examples
 Half- normal saline
 0.33% sodium Chloride
 Dextrose
Hypotonic: Nursing
Considerations
 Administer cautiously
 Hypotonic solutions cause a fluid
shift from blood vessels into cells
 The shift could cause cardiovascular
collapse from intravascular fluid
depletion and increased ICP
 Don’t give a patient at risk for increased
ICP from stroke, head trauma, or
neurosurgery.
 Don’t give to the ff patient with:
 Burns
 Trauma
 Malnutrition (low serum protein levels)
Hypertonic
Examples
 Dextrose 5% in half-normal saline
 Dextrose 5% in normal saline
 Dextrose 5% in Lactated Ringer’s Solution
 3% NaCl
 25% Albumin
 7.5% NaCl
Hypertonic:
Nursing Considerations
 Administer through IV pump and closely
monitor for circulatory overload.
 Hyper solutions expand the intravascular
compartment
 Don’t give to a patient with cellular
dehydration
 E.g Diabetic ketoacidosis
 Hyper pull fluid from the intracellular
compartment
Hypertonic:
Nursing Considerations
 Don’t give to a patient with impaired heart or
kidney function
 Patient can’t handle the extra fluid
DIURETICS

• Osmotic diuretic - Mannitol

• Thiazide diuretic - Diuril
• K-sparing diuretic – Aldactone
• Loop diuretic - Lasix
 ACID-BASE BALANCE
 Normal pH = 7.35-7.45
 pH means “The Power of Hydrogen”
 ACID = hydrogen donor
weak acid – Carbonic acid (releases only some
H)
 BASE = hydrogen acceptor/ proton acceptor
base – Sodium bicarbonate (accepts H)
 ABG represents Hydrogen ion concentration in
the ECF
3 Physiologic Buffering System:
1. Chemical Buffering system
A. Bicarbonate-carbonic acid- major ECF buffer
B. Phosphate system - active in kidneys
C. Protein system – active in plasma cells
D. Hemoglobin System – part of the protein
system
2. Respiratory System – excretion of acid by
the lungs
3. Renal System - excretion of acid or
regeneration of base by the kidneys

CLINICAL CONDITIONS:
1. Respiratory Acidosis
2. Respiratory Alkalosis
3. Metabolic Acidosis
4. Metabolic Alkalosis

SUMMARY OF NORMAL ABG:

pH = 7.35 - 7.45
PCO2 = 35 – 45 mmHg
HCO3 = 22 – 26 mEq/L
PO2 = 80 – 100 mmHg
pH = 7.35 - 7.45 Alkalosis Acidosis
PaCO2 = 35 – 45 mmHg Acidosis Alkalosis
HCO3 = 22 – 26 mEq/L Acidosis Alkalosis

pH= 7.25 pH = 7.41

PaCo2 = 60 PaCO2 = 26
HCo3 = 26 HCO3 = 17

pH= 7.23 pH = 7.37

PaCO2 = 60 PaCO2=33
HCO3=28 HCO3=17

pH=7.55
PaCO2=45
HCO3 = 30
ABG Procedure
A. Respiratory Alkalosis:
 State of relative excess of base in body
fluids from increased respiratory
elimination of CO2
Risk Factors:
- Caused by alveolar hyperventilation in
which excess CO2 is eliminated
Kinds:
1. Transient – 2o to anxiety attack
2. Mild Chronic – common affected people
are in residence in high altitudes &
pregnancy
Manifestations:
- ABG pH, PCO2, Normal or HCO3
- Paresthesias, ligheadednes, confusion
- Chest pain secondary to coronary
artery spasm
- N & V, diarrhea
Management:
Treatment is more of symptomatic
B. Respiratory Acidosis
- State of relative excess of acid in body
fluids resulting from retention or excessive
CO2 production
- Results from hypoventilation
- COPD, inadequate mechanical ventillation
- Guillain-Barre syndrome
- CNS lesions
  CHO in TPN may contribute to  PCO2
levels
Manifestations:
- Hypotension, cardiac dysrhythmias,
tremors, seizures, lethargy, stupor,
coma

Management:
- Identify the cause
- Administer Na HCO3 or lactate
containing IV since lactate will oxidize
to carbonic acid, allowing the Na to
react w/ H2CO3 to foram NaHCO3
C. Metabolic Alkalosis
- Developed by loss of acids (vomiting or
gain of base w/ NaHCO3 meds) OR loss of
fluids containing more Cl than HCO3 (w/
over use of loop diuretics)
- Also developed by massive transfusion of
blood
Manifestations:
- ABG: pH & HCO3 while PCO2 rises to
compensate
- Adaptive hypoventilation may be
experienced
- Irritability, disorientation, tetany,
convulsions, shallow respirations
Management:
- Treatment of underlying disorder
- Administration of Acetazolamide
(Diamox) – diuretic that inhibits
carbonic acid
- Administration of Ammonium
Chloride or Arginine
monohydrochloride (exogenous acid)
D. Metabolic Acidosis
- Is a state of relative acid excess or base deficit
in body fluids resulting from a gain of fixed acids
or a loss of bicarbonate
- It could be high anion gap (heavy load of non
volatile acid as in ketoacidosis)
- It could be Non-anion gap (as in abnormal loss
of NaHCO3 like in enteric drainage in ileostomy)

Manifestations:
- ABG: pH & HCO3 while PCO2  to
compensate
- Signs similar to respiratory acidosis except
compensatory hyperventilation occurs
Management for Metabolic Acidosis:
- Treatment of underlying disorder
- NaHCO3 (watch out for fluid
overload, hyperosmolar imbalance &
alkalosis)
- Protect client from potential injury
due to disorientation
- Ensure accuracy in ABG specimen
collection to avoid any error in result
Test Question:
Eddie, 63 y.o. was admitted to the hospital
w/ a diagnosis of DM. On admission, the
nurse observed rapid respiration,
confusion & signs of dehydration.

Eddie’s ABG are pH=7.27, HCO3=20mEq/L,

PaCO2=33 mmHg,.
A. Metabolic Acidosis partially compensated
B. Metabolic Alkalosis uncompensated
C. Respiratory Acidosis partially
compensated
D. Respiratory Alkalosis fully compensated
ANSWER:

Eddie’s ABG are pH=7.27,

HCO3=20mEq/L, PCO2=33 mmHg,
PaO2 33mmHg.

A. Metabolic Acidosis partially

compensated
Test Question:

The nurse should anticipate that the

physician will attempt to reverse
this acid-base imbalance by
prescribing an intravenous
administration of

A. Potassium chloride
B. Potassium iodide
C. Sodium bicarbonate
D. Sodium chloride
ANSWER:

The nurse should anticipate that the

physician will attempt to reverse
this acid-base imbalance by
prescribing an intravenous
administration of

C. Sodium bicarbonate
 Na Bicarbonate is a base that will
buffer the metabolic acidosis
BURN