Stressors Affecting

Fluid & Electrolyte

Balance
NUR 101
FALL 2008
LECTURE # 15 & #16
K. Burger, MSEd, MSN, RN,
CNE

Body Fluids

Water= most important nutrient for life.

Water= primary body fluid.
Adult weight is 55-60% water.
Loss of 10% body fluid = 8% weight loss SERIOUS
Loss of 20% body fluid = 15% weight loss FATAL
Fluid gained each day should = fluid lost each day
(2 -3L/day average)
What is the minimum output per hour necessary to
maintain renal function?
30ml/hr

Functions of Body Fluid

Medium for transport

Needed for cellular metabolism
Solvent for electrolytes and other
constituents
Helps maintain body temperature
Helps digestion and elimination
Acts as a lubricant

Mechanisms of
Fluid Gain and Loss

Gain
Fluid intake 1500ml
Food intake 1000ml
Oxidation of
nutrients
300ml
(10ml of H20
Kcal)

per

100

Loss
Sensible
Can be seen.
Urine
1500ml
Sweat
100ml
Insensible
Not visible.
Skin (evaporation) 500ml
Lungs
400ml
Feces
200ml

Regulation of Fluids

Hypothalmus thirst receptors (osmoreceptors)

continuosly monitor serum osmolarity
(concentration). If it rises, thirst mechanism is
triggered.
+Vasopressin (AKA ADH ) increasing H20 reabsorption
Pituitary regulation- posterior pituitary
releases ADH (antidiuretic hormone) in response
to increasing serum osmolarity. Causes renal
tubules to retain H20.
Thirst is a late sign of water deficit

Regulation of Fluids
(continued )

Renal regulation- Nephron receptors

sense decreased pressure (low
osmolarity) and kidney secretes RENIN.
Renin Angiotensin I Angiotensin II

Angiotensin II causes Na and H20

retention by kidneys AND..
Stimulates Adrenal Cortex to secrete
Aldosterone which causes kidneys to
excrete K and retain Na and H20.

Consider This.

The Geriatric Client

-normal physiological aging results in
decreased thirst mechanism
decreased # of sweat glands
decreased renal function
-there also may be decreased mobility
and/or cognitive function which impacts
their ability to get adequate fluid intake.

Variations in Body
Fluids

Elderly: Have lower % of total body

fluid than younger adults
Women: Have lower % total body
fluid than men
WHY DO YOU THINK THIS IS ?????

Muscle tissue has more H20 content THAN adipose

tissue

Fluid Compartments
Intracellular
fluid (ICF)
Fluid inside
the cell
Most (2/3) of
the bodys
H20 is in the
ICF.

Extracellular Fluid
(ECF)
Fluid outside the cell.
1/3 of bodys H20
More prone to loss
3 types:
Interstitial- fluid
around/between cells
Intravascular- (plasma)
fluid in blood vessels
Transcellular CSF,
Synovial fluid etc

Consider this.

Age variations exist in regards to

H20 content of fluid compartments
Infants =
60% of H20 is found in ECF
40% of H20 is found in ICF
What might this mean in regards to
Reverse of adults!
fluid loss for an infant?
Infant MORE PRONE to
fluid LOSS!

Fluid Balance
Dynamic process
Balance between body fluids
and electrolytes
Attraction between ions
(electrolytes) and water (fluids)
causes fluids to move across
membranes and leave their
compartments.

Solvent (H20)
Movement

Cell membranes are semipermeable

allowing water to pass through

Osmosis- major way fluids

transported Water shifts from low
solute concentration to high solute
concentration to reach homeostasis
(balance).

Osmolarity

Concentration of particles in solution

The greater the concentration (Osmolarity) of a
solution, the greater the pulling force (Osmotic
pressure)
Normal serum (blood) osmolarity = 280-295
mOSM/kg

A solution that has HIGH osmolarity is one that

is > serum osmolarity = HYPERTONIC solution
A solution that has LOW osmolarity is one that
is < serum osmolarity = HYPOTONIC solution
A solution that has equal osmolarity as serum
= ISOTONIC solution

Hypertonic Fluids
Hypertonic fluids have a higher
concentration of particles (high
osmolality) than ICF
This higher osmotic
pressure shifts fluid from the
cells into the ECF
Therefore Cells placed in a
hypertonic solution will shrink

Hypertonic Fluids

Used to temporarily treat hypovolemia

Used to expand vascular volume
Fosters normal BP and good urinary output
(often used post operatively)
Monitor for hypervolemia !
Not used for renal or cardiac disease.
THINK Why not? Pulmonary
Edema
D5% 0.45% NS
D5% NS
D5% LR

Hypotonic Fluids
Hypotonic fluids have less
concentration of particles (low
osmolality) than ICF
This low osmotic pressure
shifts fluid from ECF into cells
Cells placed in a hypotonic
solution will swell

Hypotonic Fluids
Used to dilute plasma
particularly in hypernatremia
Treats cellular dehydration
Do not use for pts with increased
ICP risk or third spacing risk

0.45%NS
0.33%NS

Isotonic Fluid
Isotonic fluids have the same
concentration of particles
(osmolality) as ICF (275-295
mOsm/L)
Osmotic pressure is therefore the
same inside & outside the cells
Cells neither shrink nor swell in an
isotonic solution, they stay the same

Isotonic Fluid
Expands both intracellular and
extracellular volume
Used commonly for: excessive

vomiting,diarrhea

0.9% Normal saline

D5W
Ringers Lactate

Other Osmotic Factors

ALBUMIN ( a serum protein )

Albumin in the serum has osmotic properties
called colloid pressure
Albumin pulls H20 from the interstitial
compartments into the intravascular
compartments (serum). Helps to maintain BP.
Persons with low serum albumin levels tend to
retain fluid in their interstitial layers.
What abnormal assessments might you find in
the client with low serum albumin levels?
Edema,

Hmmm.

What type of IV fluid

(hypotonic isotonic hypertonic)
might be of benefit to this client
with low albumin levels?

Consider this.

When tissue injury occurs, proteins

pathologically leak from the
intravascular space into the
intersititial space.
Termed: Third spacing
EDEMA
This explains __________
as a sign
of the inflammatory process.

Solute Movement Diffusion

Movement of solutes from high

concentration to low concentration
It is a PASSIVE movement DOWN the
concentration gradiant. (requires no energy)
Many body processes use diffusion.
Example: O2 and CO2 exchange
Rate is affected by: concentration
gradiant, permeability-surface areathickness of membranes, and size of
particles.
(Ficks Law)

Solute Movement
other mechanisms

Active transport- requires energy (ATP)

to move from low concentration to high
concentration (uphill)
Example: Na / K pump
May be enhanced by carrier molecules
with binding sites on cell membrane
Example: Glucose
(Insulin promotes the insertion of binding
sites for Glucose on cell membranes).

Filtration

Solvent AND solute movement

Passage from an area of High Pressure to an
area of Low Pressure
Termed: Hydrostatic Pressure
Example:
Arterioles have higher pressure than ICF
Fluid, oxygen and nutrients move into cells
Venules have lower pressure than ICF
Fluid, carbon dioxide and wastes move out of
cells

Fluid volume deficit FVD

(Hypovolemia)

Loss of both H20 and

electrolytes from ECF.

Causes include:
Increased output, Hemorrhage,
vomiting, diarrhea, burns,
OR
Fluid shift out of vascular space
( third spacing ) into interstitial
spaces

Dehydration

Isotonic dehydration = H20 &

electrolyte loss in equal amounts;
diarrhea and vomiting

Hypertonic dehydration = H20 loss

greater than electrolyte loss; excessive
perspiration, diabetes insipidus

Assessment
FVD - Hypovolemia
Cardiovascular:
Diminished peripheral pulses; quality 1+
(thready)
Decreased BP & orthostatic hypotension
Increased HR
Flat neck & hand veins in dependent position
Elevated Hematocrit (Hct)
Gastrointestinal:
Thirst
Decreased motility; diminished bowel sounds,
possible constipation

Assessment
FVD Hypovolemia
(continued)
Neuromuscular:

Decreased CNS activity

(lethargy to coma)

Possible fever

Skeletal muscle weakness

Hyperactive DTR

Renal:

Integumentary:

Decreased output
Increased spec grav of
urine
Weight loss
Hypernatremia

Dry mouth & skin

Poor turgor (tenting)
Pitting edema
Sunken eyeballs

Respiratory:

Increased rate and depth

Nursing Diagnosis - FVD

Deficient Fluid Volume

R/T loss of GI Fluids via vomiting
AEB elevated Hct, dry mucous
membranes, decreased output,
thirst

Planning - FVD

Client will demonstrate fluid

balance aeb moist mucous
membranes, balanced I & O
measurements, Hct WNL, by
.

Interventions for
FVD - Hypovolemia

Prevent further fluid loss

Oral rehydration therapy
IV therapy
Medications; antiemetics, antidiarrheals
Monitor CV, Resp, Renal, GI status
Monitor electrolytes possible supplement rx
MONITOR WEIGHT and I & O

NCLEX Practice
Intravenous fluids are ordered for your client
who is experiencing diarrhea and vomiting for
the past 2 days. Which IV solution would the
nurse expect to see prescribed?
a.
D5NS
b.
0.45%NS
c.
D51/2NS
d.
RL

Fluid Volume Excess

FVE - Hypervolemia
Fluid overload is an excess of
body fluid - overhydration
Excess fluid volume in the
intravascular area-hypervolemia
Excess fluid volume in interstitial
spaces edema

Fluid Volume Excess

Causes:
Increased Na/H2O retention
Excessive intake of Na (PO or IV)
Excessive intake of H2O ( PO or IV)
(Water intoxication)
Syndrome of inappropriate
antidiuretic hormone (SIADH)
Renal failure, congestive heart failure

Assessment
FVE - Hypervolemia
CV:
Elevated pulse; 4+
bounding, elevated BP,
distended neck & hand
veins, ventricular gallop
(S3)
Hyponatremia
Resp:
Dyspnea, Moist
Crackles,Tachypnea
Integumentary:
Periorbital edema
Pitting or Non-pitting edema

GI:
Increased motility
Stomach cramps
Nausea & Vomiting
Renal:
Weight gain
Decreased spec grav
of urine
Neuromuscular:
Altered LOC,
headache, skeletal
muscle twitching

Nursing Diagnosis - FVE

Fluid volume excess
R/T excessive H20 intake
AEB confusion, headache, muscle
twitching, abdominal cramps,
elevated BP and HR, hyponatremia.

Planning - FVE

Client will demonstrate fluid

balance by balanced I & O
measurements, Serum Na WNL,
etc. by .

Interventions
FVE - Hypervolemia
Restore normal fluid balance,
prevent further overload
Drug therapy; diuretics
Diet therapy; decrease Na & fluids
Monitor intake and output (I & O)
Monitor weights
Monitor electrolytes
Monitor CV, Resp, Renal systems

Clinical Application
You have been assigned to care for an 80y.o.
client admitted with hypernatremia that has
an IV infusing 0.45% NS @ 100ml/hr via
pump and an indwelling urinary catheter. At
11am you assess an output in the urinary
drainage bag of 150ml dk amber urine. You
also notice that the client is SOB while
speaking on the phone to her daughter.
What do you think is happening??
What will you do??

SUMMARY
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Electrolytes

Work with fluids to keep the body healthy

and in balance
They are solutes that are found in
various concentrations and measured in
terms of milliequivalent (mEq) units
Can be negatively charged (anions) or
positively charged (cations)
For homeostasis body needs:
Total body ANIONS = Total body CATIONS

Electrolytes
Cations
Positively charged

Sodium Na+
Potassium K+
Calcium Ca++
Magnesium Mg+
+

Anions
Negatively charged
Chloride Cl Phosphate PO4 Bicarbonate
HCO3

Electrolyte Functions
Regulate water distribution
Muscle contraction
Nerve impulse transmission
Blood clotting
Regulate enzyme reactions (ATP)
Regulate acid-base balance

Sodium Na+
135-145mEq/L
Major Cation
Chief electrolyte of the ECF
Regulates volume of body fluids
Needed for nerve impulse & muscle
fiber transmission (Na/K pump)
Regulated by kidneys/ hormones

Hmmm
Hyper and Hypo Natremia are the most
common electrolyte disturbances. Why do
you think that is?

It is most abundant in the

EXTRACELLULAR FLUID and therefore
more prone to fluctuation.

Hyponatremia
Serum Na+ <135mEq/L
Results from excess of water or loss
of Na+
Water shifts from ECF into cells
S/S: abd cramps, confusion, N/V,
H/A, pitting edema over sternum
Tx: Diet/IV therapy/fluid restrictions

Lets think about

Hyponatremia

What are some medical conditions that may cause a

dilutional hyponatremia?
CHF
Renal Failure
SIADH ( Cancer, pituitary trauma )
Addisons Disease ( hypoaldosteronism & Na loss )
What are some conditions that might cause actual loss
of sodium from the body?
GI losses nasogastric suctioning, vomiting, diarrhea
Certain diuretic therapies
Permanent neurological damage can occur when serum
Na levels fall below 110 mEq/L. Why?
Hypotonic environment swells cells, increasing ICP
brain damage

Hypernatremia

Serum Na+> 145mEq/L

Results from Na+ gained in excess of
H2O OR Water is lost in excess of Na+
Water shifts from cells to ECF
S/S: thirst, dry mucous membranes &
lips, oliguria, increased temp &
pulse,flushed skin,confusion
Tx: IV therapy/diet

Lets think about.

Hypernatremia

What are some medical conditions that may cause elevated

serum Na?
Renal failure
Diabetes Insipidus
Diabetes Mellitus ( hyperglycemic dehydration)
Cushings syndrome (hyperaldosteronism)
What are some other patient populations at risk for
hypernatremia?
Elderly ( decreased thirst mechanism )
Patients receiving:
-tube feedings
-corticosteroid drugs
-certain diuretic therapies
Seizures, coma, death my result if hypernatremia is left
untreated. Why?
Cells loose fluid into the ECF causing irreversible cell
damage.

Critical Thinking
Hypo / Hyper Natremia
For the client experiencing
FVE & hyponatremia d/t
excessive intake of water,
which IV solution would
you
expect the physician to
order?
a.
D5NS
b.
NS
c.
D5W
d.
NS

For the client

experiencing
FVD and hypernatremia
d/t excessive water loss,
which IV solution would
you expect the physician
to order?
a.
D5 NS
b.
D5RL
c.
D5W
d.
NS

Potassium

K+

3.5-5.0 mEq/L
Chief electrolyte of ICF
Major mineral in all cellular fluids
Aids in muscle contraction, nerve &
electrical impulse conduction, regulates
enzyme activity, regulates IC H20
content, assists in acid-base balance
Regulated by kidneys/ hormones
Inversely proportional to Na

Hypokalemia

Serum level < 3.5mEq/L

Results from decreased intake, loss via
GI/Renal & potassium depleting diuretics
Life threatening-all body systems affected
S/S muscle weakness & leg cramps,
decreased GI motility, cardiac arrhythmias
Tx: diet/supplements/IV therapy

Lets think about

Hypokalemia

What are some medical conditions that may cause a

hypokalemia?
Renal Disease / CHF (dilutional)
Metabolic Alkalosis
Cushings Disease ( Na retention leads to K loss )
What are some conditions that might cause actual loss
of potassium from the body?
GI losses nasogastric suctioning, vomiting, diarrhea
Certain diuretic therapies
Inadequate intake ( body cannot conserve K, need PO
intake)
Cardiac arrest may occur when serum K levels fall
below 2.5 mEq/L. Why?
Increased cardiac muscle irritability leads to PACs and

Hyperkalemia
Serum level >5 mEq/L
Results from excessive intake, trauma,
crush injuries, burns, renal failure
S/S muscle weakness, cardiac
changes, N/V, parathesias of
face/fingers/tongue
Tx:diet/meds/IV therapy/ possible
dialysis

Lets think about

Hyperkalemia

What are some medical conditions that may cause

hyperkalemia?
Renal Disease=most common cause
Burns and other major tissue trauma
Metabolic Acidosis
Addisons Disease ( Na loss leads to K retention )
What are some conditions that might cause potassium
levels to rise in the body?
Certain diuretic therapies
Excessive intake ( inappropriate supplements)
Cardiac arrest may occur when serum K levels rise
above mEq/L. Why?
Decreased electrical impulse conduction leads to
bradycardia and eventual asystole.

Critical Thinking
Potassium IV additives
Which of the following interventions will the
nurse undertake when administering
parenteral K additives?
Monitor the IV site for phlebitis
Place on cardiac monitor if > 10 mEq
Assure of adequate mixing of K in solution
Monitor for elevated K levels
Monitor for decreased Na levels
!!
!
R
Administer potassium by slow IV
push
method
E
V
NE

Calcium Ca++

4.5-5.5mEq/L
Most abundant in body but:
99% in teeth and bones
Needed for nerve transmission,
vitamin B12 absorption, muscle
contraction & blood clotting
Inverse relationship with Phosphorus
Vitamin D needed for Ca absorption

Hypocalcemia

Serum Ca < 4.3mEq/L

Results from low intake, loop
diuretics, parathyroid disorders, renal
failure
S/S osteomalacia, EKG changes,
numbness/tingling in fingers, muscle
cramps / tetany, seizures, Chovstek
Sign & Trousseau Sign
Tx: diet/IV therapy

Chovstek

Trousseau

Lets think about

Hypocalcemia

What are some medical conditions that may cause

hypocalcemia?
Hypoparathyroidism (low PTH levels = decreased release
of Ca from bones)
S/P thryoid surgery ( low Calcitonin = decreased release of
Ca from bones) Acute pancreatitis
Crohns Disease
Hyperphosphatemia ( ESRF)
What are some other conditions that might cause low Ca?
GI losses nasogastric suctioning, vomiting, diarrhea
Long term immobilization
Lactose intolerance
If hypocalcemia is prolonged, the body will utilize stored
Ca from bones.
What complication might arise?
Fractures ( late sign )

Hypercalcemia

Serum Ca > 5.3mEq/L

Results from hyperparathyroidism,
some cancers, prolonged
immobilization
S/S muscle weakness, renal calculi,
fatigue, altered LOC, decreased GI
motility, cardiac changes
Tx: medication/ IV therapy

Lets think about

Hypercalcemia

What are some medical conditions that may cause

hypercalcemia?
Hyperparathyroidism (high PTH levels = increased release
of Ca from bones)
Pagets Disease
Some Cancers Multiple Myleoma
Chronic Alcoholism ( with low serum phosphorus )

What are some other conditions that might cause low Ca?
Excessive intake of Ca OR Vitamin D
Excessive intake of OTC antacids
If hypercalcemia is uncorrected, AV block and cardiac
arrest may occur.

Magnesium Mg2+
1.5-2.5mEq/L
Most located within ICF
Needed for activating enzymes,
electrical activity, metabolism of
carbs/proteins, DNA synthesis
Regulated by intestinal
absorption and kidney

Hypomagnesemia

Serum < 1.5mEq/L

Results from decreased intake, prolonged
NPO status, chronic alcoholism & nasogastric
suctioning
S/S: muscle weakness, cardiac changes,
mental changes, hyperactive reflexes &
other hypocalcemia S/S.
Tx: replacement IV therapy
restore normal Ca levels ( Mg mimics Ca)
seizure precautions

Hypomagnesemia

Common in critically ill patients

Associated with high mortality rates
Increases cardiac irritability and
ventricular dysrhythmias - especially in
patients with recent MI
Maintenance of adequate serum Mg has
been shown to reduce mortality rates post
MI

Hypermagnesemia

Serum>2.5mEq/L
Results from renal failure,
increased intake
S/S: flushing, lethargy, cardiac
changes (decreased HR),decreased
resp, loss of deep tendon reflexes
Tx: restrict intake
diuretic rx

Chloride

Cl-

95-105mEq/L
Most abundant anion in ECF
Combines with Na to form salts
Maintains water balance, acid-base
balance, aids in digestion (hydrochoric acid)
& osmotic pressure (with Na and H20)
Regulated by kidneys
Follows Sodium (Na)

Hypochloremia

Serum level 96mEq/L

Results from prolonged vomiting &
suctioning
S/S metabolic alkalosis, nerve
excitability, muscle cramps,
twitching, hypoventilation,
decreased BP if severe
Tx: diet/IV therapy

Hyperchloremia

Serum level > 106mEq/L

Results from excessive intake or
retention by kidneys metabolic
acidosis
S/S Arrhythmias, decreased cardiac
output, muscle weakness, LOC
changes, Kussmaulss respirations
Tx: restore fluid & electrolyte balance

Phosphate PO4

2.5-4.5mg/dl
Needed for acid-base
balance,neurological & muscle function,
energy transfer ATP & affects
metabolism of carbs/proteins/lipids, B
vitamin synthesis
Found in the bones
Regulated by intake and kidneys
Inversely proportional to Calcium
Therefore some regulation by PTH as well

Hypophosphatemia
Serum level < 1.8mEq/L
Results from decreased intestinal
absorption and increased
excretion
S/S bone & muscle pain, mental
changes, chest pain, resp. failure
Tx: Diet/ IV therapy

Hyperphosphatemia

Serum level> 2.6mEq/L

Results from renal failure, low intake of
calcium
S/S: neuromuscular changes (tetany), EKG
changes, parathesia-fingertips/mouth
Tx: Diet; hypocalcemic interventions
Medications: phosphate binding
The body can tolerate hyperphosphatemia
fairly well BUT the accompanying
hypocalcemia is a larger problem!

Critical Thinking - NCLEX

a.
b.
c.
d.

The nurse is caring for a client with renal

failure whose magnesium level is 3.6
mg/dL. Which of the following signs
would the nurse most likely expect to
note in the client based on this Mg level?
Twitching
Hyperactive reflexes
Irritability
Loss of deep tendon reflexes

Electrolyte homeostasis

This means to maintain

balance to control by
balancing the dietary intake of
electrolytes with the renal
excretion and reabsorption of
electrolytes

Interventions for F/E

balance

Assess patient carefully- note

changes
Monitor I & O (Intake & Output)
Monitor weight changes
Monitor urine
Monitor vs
Monitor lab results and dx test
Maintain proper IV therapy

Summary
Fluid compartments in the body must
balance
Body systems regulate F&E balance
Assessment of body fluid is important
to determine causes of imbalance
Interventions for imbalances are
based on the cause