Fluids and Electrolytes

Atlantic Cape Community College

Karen Zaniewski MSN RN
Myra Caplan MSN RN
Class Outcomes

escri!e t"e distri!ution and composition o#

!ody #luids and mec"anisms !y w"ic" !ody
#luids are regulated$

E%amine t"e &aria!les t"at a##ect #luid and

electrolyte !alance$

'nterpret la!oratory studies associated wit"

#luid and electrolyte !alance$

escri!e t"e ma(or #luid and electrolyte

!alance disorders$
Class Outcomes

E&aluate nursing inter&entions to meet

t"e needs o# patients wit" an alteration
in #luid and electrolyte !alance$

i##erentiate !etween common

distur!ances in #luids and electrolytes$

escri!e "ow to measure and record

intake and output$
)ody Fluids

*ater is t"e primary !ody #luid wit"

adult !ody weig"t ++,-./ water$

aily #luid intake s"ould e0ual daily

#luid output.

What is the minimum urine output

per hour necessary to maintain renal
function?
Functions o# Fluids

Cellular meta!olism

Sol&ent #or electrolytes and ot"er

su!stances

)ody temperature maintenance

Aid wit" digestion and elimination

1u!rication
Normal Fluid 2ains and
1osses
GAINS
Fluid intake 3+..ml
Food intake 3...ml
Nutrient o%idation 4..ml
Losses
Sensi!le5 urine 63+..78 Sweat 63..7
'nsensi!le5 Skin 6+..79 1ungs 6:..79 Feces
6;..7$

Regulatory Mec"anisms
3$<osterior <ituitary5 releases A= 6antidiuretic
"ormone7 in response to increased serum
Osmolality$ A= causes renal rea!sorption o#
water$
Normal Serum Osmolality is 280-295
mosm/kg
and
reflects the concentration of solutes in the blood.
he greater the osmol the greater the !ulling
force "osmotic !ressure#
2. =ypot"almus5 >"irst mec"anism is triggered in
response to increased serum osmolality$
Regulatory Mec"anisms

4$ Renal Regulation5 Receptors in t"e

nep"ron sense decreased serum osmolality
and kidney secretes Renin.
$enin con%erts angiotensinogen to
angiotensin &. hen angiotensin ' is
con%erted to angiotensin && by a con%erting
en(yme.
)ngiotensin && causes %asoconstriction sodium
"Na# and *ater retention by the kidneys )N+
the secretion of )ldosterone from the adrenal
corte, *hich causes the kidneys to e,crete
!otassium "-# and retain N) and *ater.
Regulation

)rain Natriuretic <eptide 6)N<7

Released #rom !rain and rig"t atrium$
Causes decrease in Na
'ncreased wit" C=F
?uestions

*"y does a decrease in !lood &olume cause

an increase in Antidiuretic "ormone@

*"at is t"e end result o# t"e Renin,

Angiotensin mec"anism@

*"at would a medication t"at stimulates t"e

Renin mec"anism do@

An angiotensin !locking agent !locks t"e

renin mec"anism$ *"at would t"e result !e
and w"at would !e t"e concern o# t"e nurse@
Fluids istri!ution

)ody Fluid Compartments5

'ntracellular 6'CF7 #luid inside t"e cell 6;A4 !ody water7
E%tracellular 6ECF75 #luid outside t"e cell 63A4 !ody
water7
'nterstitial5 #luid !etween cells
'ntra&ascular5 li0uid component o# !lood
>ranscellular5 Cere!rospinal 6CSF79 pleural etc$

Speci#ic <opulations

Elderly "a&e a lower percent o# !ody #luid

t"an younger adults$

*omen "a&e a lower percent !ody #luid t"en

men$
*"y@@@@@@@

'n#ants "a&e more e%tracellular #luid t"an

intracellular #luid$ /ost of the fluid in an adult
is intracellular. his makes infants more
!rone to *hat0
Mo&ement o# Fluids

Osmosis: >"e mo&ement o# water #rom an

area o# low solute concentration to an area
o# "ig" solute concentration$

>"e greater t"e concentration 6Osmolality7

o# a solution t"e greater t"e pulling #orce
6Osmotic pressure7$
=ypertonic Fluids

=ypertonic5 "a&e a "ig"er osmolality t"an 'CF$

=ig"er osmotic pressure pulls t"e #luid #rom t"e
cells 6cells s"rink7

Bsed to treat hy!o%olemia1 it e,!ands %ascular

%olume and therefore increases blood !ressure
"23# and 4rine out!ut "4.O.#5ontraindicated *ith
5ongesti%e heart failure "567#. 86900000

:,am!les;

+5< 0.=5NSS +5<>$

+5<NSS
=ypotonic Fluids

=ypotonic #luids "a&e less concentration o# particles

6low osmolality7 t"an 'CF$ 1ow osmotic pressure
s"i#ts t"e #luid into t"e cells$ >"e cells swell$

>reats cellular de"ydration

Contraindicated wit" increased intercranial pressure

6'C<7$

Esamples5 .$:+ NSS .$44NSS

'sotonic Fluids

'sotonic #luids "a&e t"e same osmolality as

t"e 'CF$

Osmotic pressure is t"e same inside and

outside t"e cell$

No cellular c"anges9 and e%pands t"e 'CF

and ECF &olume$ O#ten used #or e%cessi&e
&omiting and diarr"ea$

E%amples5 .$C NSS9 +*9 RingerDs 1actate$

Al!umin

Al!umin is a serum protein t"at "as w"at is

called colloid osmotic pressure6or oncotic
pressure7$ Al!umin pulls water #rom t"e
interstitial compartments into t"e
intra&ascular compartment$

<atients wit" low serum al!umin tend to

retain #luids in t"e interstitial layers9 and "a&e
edema? and hy!otension.
?uestion
A patient wit" low al!umin le&els would
pro!a!ly !e prescri!ed w"at type o# #luid@
A1SO
Al!umin !inds wit" many drugs$ '# al!umin le&el
is low t"en more #ree drug is a&aila!le9 "ence
increased risk #or to%icity$
Solute

i##usion is t"e mo&ement o# solute #rom an

area o# "ig" concentration to an area o# low
concentration$

Acti&e >ransport5 mo&ement o# solute #rom a

low concentration to a "ig" concentration$
6re0uires energyAA><7$
Sol&ent and Solute

Filtration5 <assage #rom an area o# "ig"

pressure to an area o# low pressure$
>ermed "ydrostatic pressure$

Arterioles "a&e a "ig"er pressure t"an

'CF9 so #luid9 O; and nutrients mo&e into
cells9 w"ereas &enules "a&e lower
pressure t"an 'CF so #luid CO; and water
mo&e out o# cells$
Nursing iag$5FEE5=yper&olemia

Fluid o&erloadF o&er"ydration

E%cess #luid &ascular space is hy!er%olemia$

E%cess #luid interstital space is edema$

Etiology 6causes7 o# FEE

E%cessi&e intake o# water$

E%cessi&e intake o# Na

'ncreased NaA=;. retention$

Syndrome o# inappropriate A= 6S'A=7

=eart #ailure8 kidney #ailure$

Assessment FEE

Neuro5 Altered 1OC8 muscle twitc"ing$

Cardiac5 'ncreased =R9 increased )<8GE9

!ounding pulse$

Respiratory5 6SO) or dyspnea79 a!normal

lung sounds 6#ine rales79 'ncreased
respiratory rate$

2astrointestinal5 increased motility9

stomac" cramps9 nausea and &omiting$
FEE

Renal5 weig"t gain9 decreased speci#ic gra&ity o#

urine$

'ntegumentary5 Edema

1A)S5 ecreased =H= 6=empglo!in and

=ematocrit7

=g) men 34,3IgA3..mlAwomen 3;,3-gA3..ml

=C>5men :;,+.Awomen :.,:I

ecreased )lood Brea Nitrogen 6)BN7 Normal F

3.,;.mgA3..ml7
Nursing iagnosisA<lanning

Fluid &olume e%cess related to e%cessi&e

water intake as e&idenced !y "eadac"e9
con#usion9 increased )< and "eart rate9
"yponatremia$

<atient will demonstrate #luid !alance !y

e0ual intake and output normal serum
sodium wit"inJJJ
FEE 'nter&entions

iuretics 6'$e$ 1asi%7

Fluid restriction

Sodium restriction

'HO 6intake and output7

aily weig"ts 6 most signi#icant determanent

o# #luid !alance7

Monitor la!s 6C)C7 Complete !lood count

6includes =H=78 )M< 6includes )S9 )BN
Creatinine9 lytes7
Nursing iag5 FE=ypo&olemia

=ypo&olemia is loss o# #luids and lytes$

e"ydration is loss o# #luids$

Dehydration most common abn.in the elderly.

Etiology5 'ncreased output 6'$e$ dia!etes insipitus9

"yperglycemia9 !urns9 "emorr"age9 &omiting9
diarr"ea7

Also t"ird spacing w"ere t"ere is a #luid s"i#t out o#

t"e &ascular space into t"e interstitial space
6malnutrition9 !urns9li&er disease7
FE Assessment

Neuro5 ecreased 1OC9 skeletal muscle weakness$

Cardiac5 decreased perip"eral pulses9)< and

ort"ostatic "ypotension9 'ncreased =R$

Respiratory5 'ncreased rate and dept"$

2'5 >"irst9 decreased !owel sounds

Renal5 decrease output9 increased S2 weig"t loss9

increased Na

'ntegumentary5 ry9 poor turgor9 pitting edema9

sunken eye!alls$
Nursing iagnosisA<lanning

Fluid &olume de#icit related to loss o# 2'

#luidsA&omiting as e&idenced !y dry
mucus mem!ranes9 decreased urinary
output9 t"irst9 and increased "ematocrit$

<atient will "a&e moist mucus

mem!ranes !alanced 'HO9 and normal
"ematocrit 6=C>7 wit"inJJJ$$
FE 'nter&entions

Restore #luid and electrolytes$

Antiemetic9 antidiarr"eal medications

aily weig"tsA'HO

1a!s5 C)C9 CM<

1etDs look at ia!etes 'nsipitus
6'7

impaired a!ility to conser&e water due to a

decrease in A=$

Main causes are neurologic and nep"rogenic$

Same signs and symptoms as de"ydration$

*"y is t"e urine speci#ic gra&ity decreased wit" '@

*ould t"e )BN !e increased or decreased wit" '$

Electrolytes

Solutes #ound in &arious concentrations and

measured in mE0 units$

<ositi&ely c"arged 6cations75

Sodium 6NaK7 34+,3:+ mE0A1 6ECF7
<otassium 6KK7 4$+,+$+ mE0A1 6'CF7
Calcium 6CaKK7 I$+,3.$+ mgA3..ml or :$+,+$+
mE0A1
Magnesium6MgKK75 3$+,;$+ mE0A1

Electrolytes

Anions 6,7

C"loride 6C1,7 C+,3.+ mE0A1

<"osp"ate 6<o:,7 ;$+,:$+ mgAdl

)icar!onate 6=CO4, 7;4,4.mE0A1

Electrolytes5 Sodium 34+,
3:+mE0A1

Ma(or e%tracellular cation 634+,3:+7

Regulates &olume o# !ody #luids

Needed #or ner&e impulse and muscle

#i!er transmission$

Renal and endocrine regulation$

=yponatremia LLL NA

M 34+ mE0A1

Results #rom e%cess water loss or loss o#

NaK

S%5 con#usion9 "eadac"e9 a!dominal

cramps9 N$ E9 pitting edema o&er sternum$

R%5 iet9 'E t"erapy9 Fluid restrictions

=ypernatremia

N 3:+ mE0A1

NaK gained in e%cess o# =;. or water lost

in e%cess o# NaK

Fluid s"i#ts #rom cells to ECF

S%5 con#usion9 t"irst9 #lus"ed skin9 dry

mucus mem!ranes9 oliguria9 increased
temperature and "eart rate$

R%5 'E t"erapy9 diet

<otassium 4$+,+$+mE0A1 'CF

Cellular meta!olism

>ransmission o# ner&e impulses in ner&es9

"eart9 and skeletal muscles$

Acid !ase !alance

Regulated !y diet9 renal e%cretion9 and any

condition t"at increases output decreases
potassium$ 6in&erse relations"ip to sodium7$
=ypokalemia

1ess t"an 4$+ mE0A1

Results #rom decreased intake9 loss &ia 2'ARenal

and potassium depleting drugs suc" as diuretics$

S%5 muscle weakness9 leg cramps9 decreased 2'

motility9 cardiac arr"yt"mias

R%5 diet5 6oranges9 peac"es9 kiwi9 prunes9 melons9

!ananas9 raisons9 apricots9 #igs9 dates9 !rocelli9
potatoes9 !eansO7

Oral <otassium

'E <otassium 6NEEER 'E <BS=7

=yperkalemia

N+$+

Etiologye%cessi&e intake9 trauma9 !urns9 renal failure.

MOS> COMMON REASON FOR 'A1PS'SO

S%5 Con#usion9 muscle weakness9 cardiac arrhythmias?

N9E99 parest"esias o# "ands and #eet$

R%5 >emporary5 sodium !icar!onate9 glucose and

insulin$

Kaye%alate9 dialysis

K restriction Monitor cardiac status$

Calcium5 I$+$, 3.$+mgA3.. ml8
:$+,+$+mE0A1

Most #ound in !ones and teet"$

Needed #or !lood clotting9 ner&e impulse

transmission9 )3; a!sorption9 myocardial
contractility$

'n&erse relations"ip wit" <"osp"orous

Needs Eitamin #or a!sorption

=ypocalcemia5 MI$+mgAM :$4mE0A1

Etiology5 loop diuretics9 parat"yroid disorders9 renal

#ailure$

S%5 num!ness and tingling9 tetany9 #ractures9 pro!lems

wit" !lood clotting9 K >rousseau and C"o&ekDs signs$

>rousseau5 'n#late )< cu## to ;.mm a!o&e systolic and

note carpal spasms$

C"o&sek5>ap #acial ner&e ;cm #rom earlo! K F

twitc"ing$

R%5 Amp"ogel6!inds p"osp"ate78 calcium9 seiQure

precautions9 diet 6green lea#y9 dairy7$
=ypercalcemia5 N
3.$+mgA3..ml or N +$4mE0A1

Etiology5 "yperparat"yroidism9 some

cancers9 prolonged immo!iliQation$

S%5 muscle weakness9 decreased re#le%es9

renal calculi9 #atigue9 sedation9 slurred
speec" cardiac c"anges9 constipation$

R%5 <arat"yroidectomy 6as needed79

steroids9 mit"romycin9 calcitonin$
'ntake and Output

Measurement o# #luid in and out$

<atients w"o need 'HO F 'E t"erapy9 Fluid restriction9

!lood administration9 cardio&asular disorders9 critically
ill$

'ntake 'ncludes5

Oral li0uids 6includes Gello9 ice cream9 popcicles9

!rot"7

'EDs

'E<)

>u!e FeedingsA>u!e Flus"es

)lood and !lood products

Fluids and Electrolytes Group Exercise

3$ Floyd Fluid is in t"e "ospital wit" Congesti&e =eart Failure$ =is p"ysician initially ordered
Furosemide 61asi%7 I. mg 'E )'$ Now t"at "e is going "ome9 t"e order was c"anged to
Furosemide :. mg po )'$ =e is also on igo%in .$;+ mg daily and nitro,dur patc" )'$ *"at
#luid and electrolyte im!alances would you assess #or and w"at nursing inter&entions would
you initiate@ 61asi% is a diuretic8 digo%in increases cardiac contractility and nitro,dur is a &aso,
dilator7
9ou *ould assess for hy!okalemia due to diuretics. )ssess for *eakness? malaise? fatigue? :5@
changes. /onitor !otassium le%el. each !t about !otassium containing foods at discharge as
*ell as side effects of the medications.

;$ Mrs$ Emanuele is an I3 year old admitted wit" a 4 day "istory o# &omiting and diarr"ea$ S"e
"as only "ad ice c"ips since t"e #irst episode o# &omiting and is now complaining o# malaise9
cramping muscles and a temp o# 3.3$ *"ic" la! #indings would you e%pect to !e a!normal and
w"at inter&entions would you !e e%pecting@

+ehydration A ele%ated 24N? 6B6. )ssess for confusion? *eakness? decreased skin turgor
hy!otension? tachycardia? Needs fluids. /onitor for cause? skin breakdo*n? change in CS?confusion..
/ake sure to monitor for safety.

4$ arlene Malone9 age :;9 comes to t"e E wit" weakness9 #atigue and "eart palpitations$ S"e
"as not seen a "ealt" care pro&ider #or 3. years$ S"e goes into cardiac arrest and is
resuscitated$ =er la! results are5
a$ <otassium 6K7 F R mE0A1
!$ )BN F 3.; mgAd1
c$ Creatinine F + mgAd1
Acute renal #ailure is diagnosed$ *"ic" la! results are a!normal@ *"ic" la! result directly
re#lects "er renal #ailure@ *"at do you t"ink is causing "er "yperkalemia@ *"ic" la! result
is t"e most dangerous@

)ll the lab results are abnormal. hey are all ele%ated. he lab result that most directly
reflects her renal failure is the creatinine /ost likely she *ent into acute renal failure from
the cardiac arrest and the hyperkalemia is from the renal failure because the kidneys
cannot excrete the potassium. he ele%ated !otassium is the most dangerous result
because of the !otential to cause cardiac arrest.
3$ Matc" t"e #ollowing #luid and A or electrolyte disorder wit" its appropriate c"aracteristic$
SSSS 3$ "yperkalemia d$ #re0uent cause o# deat" in patients wit" renal #ailure
SSSES ;$ de"ydration e$ dry skin9 oliguria9 t"irst$ NNde"ydration
SS)SSS4$ "ypokalemia !$ #re0uent complication o# diuretics 6lowK7
SSSSFSS :$ "ypocalcemia #$ tetany8 increased re#le%e
SSCSSS +$ dia!etes insipitus c$ may !e seen a#ter cranial surgery8 'ncrease in urine output
SSSASS -$ t"ird spacing a$ caused !y decreased plasma proteins

;$ etermine t"e #ollowing intake and output in milliliters

Intake Output
T cup o# (ello , 3;.
3 cup o# co##ee , ;:.
; cups o# corn#lakes
>oast
T cup o# milk , 3;.
; cups water , :I.
Brine U :I. ml
*ound drainage 3;. ml
>otal F C-. >otal F -..

*"at #luid and electrolyte a!normalities would you suspect wit" t"e #ollowing clients@ 1ist ; important
assessments #or eac"$

Client Condition Suspected
A!normality
Assessment
An I. year old li&ing alone wit"
diminished appetite and thirst

e"ydration )<9 =R9 con#usion
A :; year old #emale wit" bone cancer


=ypercalcemia =ypotonicity9 kidney stones9 slurred speec"9
decreased re#le%es
A +4 year old #emale wit" renal ailure


=yperkalemia
O&er"ydration
EC2 c"anges9 diarr"ea9 mental c"anges9
parest"esia 6tingling7
A R4 year old male taking large
amounts o# diuretics or heart ailure



=ypokalemia EC2 c"anges9 nausea and &omiting9 weak pulse