Fluid and Electrolytes

10/08/15

Compartments

Intracellular fluid (ICF)

Extracellular fluid (ECF)
Intravascular (plasma)
Interstitial (between cells; lymph)

Transcellular

See Figure 16-2 in Lewis 6th ed.

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Intracellular Fluid (ICF)

Fluid

located within cells

42% of body weight; 2/3 of body
water
Potassium (K+): most prevalent
intracellular cation
Phosphate (PO4-): most prevalent
intracellular anion
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Extracellular Fluid (ECF)

Interstitial (between cells; lymph)

(Cl-):

most prevalent anion

(Na+):most prevalent cation
2/3 of ECF is in interstitial
Intravascular

(IV)

Within

vascular space
Measured with blood tests
1/3 of ECF is intravascular
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Transcellular

Small but important fluid

compartment
Approximately 1 Litre
Includes
CSF
GI

tract
Pleural space
Synovial spaces
Peritoneal space
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Mechanisms Controlling Fluid and

Electrolyte Movement

Diffusion

Facilitated diffusion

molecules move from high to low concentration

involves carrier molecules

Active transport
movement against concentration gradient
requires energy
E.g.: keeping Na out and K in the cells (requires ATP)

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Mechanisms Controlling Fluid and

Electrolyte Movement

Osmosis

Hydrostatic pressure

H2O movement between compartments separated by

membrane from area of high to low solute concentration
Membrane is permeable to water, not solutes

Force within fluid compartment

Oncotic pressure= colloid osmotic pressure

Osmotic pressure exerted by colloids [e.g., protein] n

solution; pulls fluid into vascular space
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Fluid Shifts: Plasma to interstitial space

Results in edema
Due to:

Elevated venous hydrostatic pressure

Decreased plasma oncotic pressure

e.g., low plasma protein r/t malnutrition

Elevated interstitial oncotic pressure

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e.g., CHF, varicose veins

plasma proteins accumulated in

interstitium, pulling water - e.g., burns

Fluid Movement Between Extracellular and

Intracellular

Excess water in ECF

Cells

are more concentrated. Thus:

Water moves into cells Cells swell

Water deficit in ECF : water is pulled

from cells Cells shrink

Both of above cause neurological

symptoms

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Fluid Spacing

First spacing

Second spacing

Abnormal accumulation of interstitial fluid

(e.g., edema associated with varicose veins,
pulmonary edema)

Third spacing

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Normal distribution of fluid in ICF and ECF

Fluid accumulation in part of body where it is

not easily exchanged with rest of ECF (e.g.,
edema due to burns, ascites [in peritoneal
space)

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Regulation of Water Balance

Hypothalamic regulation (controls pituitary)

Pituitary regulation (ADH)
Adrenal cortical regulation (aldosterone
enhances Na and H20 retention)

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Renal regulation
Cardiac regulation
Gastrointestinal regulation (fluid intake)
Insensible water loss
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Insensible Water Loss

Invisible vaporization from lungs and

skin

Approximately 900 ml per day is lost

No electrolytes are lost with

insensible water loss

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Excessive sweating is not an insensible

loss. Diaphoresis leads to loss of water
and electrolytes.

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Sodium

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Plays major role in maintaining ECF

concentration (osmolality) and volume

Main cation in ECF; primary

determinant of osmolality (a measure of
solute concentration)

Important in generation and

transmission of nerve impulses

Important in acid-base balance

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Hypernatremia

Hypernatremia due to

Hypernatremia results in

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Water loss or
Sodium gain

Hyperosmolality water shifts out of

cells cellular dehydration

Primary protection against

hypernatremia is thirst
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Hypernatremia

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Manifestations include thirst,

lethargy, agitation, seizures, and
coma

Hypernatremia secondary to water

deficiency often due to impaired
LOC or inability to get fluids

Also due to deficiency in ADH

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Hypernatremia

Management includes:

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Treating the underlying cause

Hypotonic IV fluids if oral fluids cannot be
ingested
Administering diuretics (promotes
excretion of sodium)

Serum sodium levels must be reduced

gradually to avoid cerebral edema

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Hyponatremia

Due to:

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loss of Na-containing fluids, or

water excess (dilutional hyponatremia)

Hyponatremia hypoosmolality water

moves into cells

Clinical manifestations include confusion,

nausea, vomiting, seizures, and coma

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Hyponatremia

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If caused by water excess, fluid

restriction is needed

If severe symptoms (seizures)

occur, small amount of intravenous
hypertonic saline solution (3%
NaCl) is given

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Hyponatremia

If associated with abnormal fluid

loss (diarrhea, polyuria, etc.):
fluid

replacement with Nacontaining solution (eg. Normal

saline [0.9% NaCl])

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Potassium

Potassium major ICF cation

Potassium is necessary for

Transmission

and conduction of nerve

impulses
Normal cardiac rhythms
Skeletal muscle contraction
Acid-base balance

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Potassium

Critical to action membrane potential

Sources

of potassium
Fruits and vegetables (bananas and
oranges)
Salt substitutes
Potassium medications (PO, IV)
Stored blood

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Hyperkalemia

Causes
Increased retention
Renal failure
Potassium sparing diuretics
Increased intake
Mobilization from ICF
Tissue destruction
Acidosis

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Hyperkalemia

Clinical Manifestations
Skeletal

muscles weak or paralyzed

Ventricular

fibrillation or cardiac

Abdominal

cramping or diarrhea

standstill

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Nursing Management of
Hyperkalemia

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Eliminate oral and parenteral K

intake
Increase elimination of K (diuretics,
dialysis, Kayexalate)
Force K from ECF to ICF with IV
insulin (or sodium bicarbonate if
hyperkalemia is due to acidosis)

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Hypokalemia

Causes
Increased loss
Certain

diuretics
GI losses
Associated with Mg deficiency
Movement into cells

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Hypokalemia
Clinical Manifestations

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Potentially lethal ventricular

arrhythmias
Increased digoxin toxicity in those
taking the drug
ECG changes
Skeletal muscle weakness and
paralysis
Muscle cell breakdown
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Hypokalemia
Clinical Manifestations

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Decreased GI motility

Altered airway responsiveness

Impaired regulation of arterial blood flow

Diuresis

Hyperglycemia
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Nursing Management of
Hypokalemia

Replacement PO or IV
Never

push IV
Painful in peripheral veins
Never give with anuric renal failure

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Teach prevention methods (e.g.

diet)
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Electrolyte Disorders Summary

Signs and Symptoms

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Electrolyte

Excess

Deficit

Sodium (Na)

Hypernatremia
Thirst
CNS deterioration
Increased interstitial fluid

Hyponatremia
CNS deterioration

Potassium (K)

Hyperkalemia
Ventricular fibrillation
ECG changes
CNS changes

Hypokalemia
Bradycardia
ECG changes
CNS changes

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Electrolyte Disorders
Signs and Symptoms
Electrolyte

Excess

Deficit

Calcium (Ca)

Hypernatremia
Thirst
CNS deterioration
Increased interstitial fluid

Hypocalcemia
Tetany
Chvosteks, Trousseaus
Muscle twitching
CNS changes
EKG changes

Magnesium (Mg)

Hypermagnesemia
Loss of deep tendon reflexes
(DTRs)
Depression of CNS
Depression of
neuromuscular function

Hypomagnesemia
Hyperactive deep tendon
reflexes
CNS changes
EKG changes

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Protein Imbalances

Plasma proteins(especially albumin)

are important determinants of
plasma volume

Hyperproteinemia is rare
Occurs

with dehydration-induced
hemoconcentration

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Hypoproteinemia

Caused by
Anorexia
Malnutrition
Starvation
Fad

dieting
Poorly balanced vegetarian diets

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Hypoproteinemia

Poor absorption d/t GI malabsorptive

diseases

Inflammation protein can shift out of

intravascular space

Hemorrhage

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Hypoproteinemia:
Clinical Manifestations

Edema

Slow healing
Anorexia
Fatigue
Anemia
Muscle loss
Ascites (same reason as edema)

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(b/c insufficient oncotic pressure to hold

water in vascular space)

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Management
High-carbohydrate,

high-protein diet

Dietary

protein supplements
Hypoproteinemia
Enteral

nutrition or total parenteral

nutrition

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Extracellular Fluid Volume

Imbalances

Hypovolemia due to:

loss of normal body fluids (diarrhea,
fistula drainage, hemorrhage)
decreased intake
or plasma-to-interstitial fluid shift

Hypervolemia due to:

excessive intake of fluids
abnormal retention of fluids (CHF)
or interstitial-to-plasma fluid shift

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Extracellular Fluid Volume

Imbalances

Hypovolemia:
Treat

with fluid replacement (NS,

Ringers, blood)

Hypervolemia
Remove

excess fluid (diuretics, dialysis)

Fluid restriction, sodium restriction

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Nursing Diagnoses: Hypervolemia

Excess

fluid volume
Ineffective airway clearance
Risk for impaired skin integrity
Disturbed body image
PC: pulmonary edema, ascites

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Nursing Diagnoses: Hypovolemia

Fluid

volume deficit

Decreased
PC:

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cardiac output

hypovolemic shock

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Nursing Implementation for

Volume Imbalances

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I&O

Cardiovascular status (BP, pulse strength, JVD, HR,

orthostatic hypotension)

Respiratory status (crackles, RR)

Neurological function

Daily weights (1 kg = 1000 ml)

Skin assessment (turgor, edema)

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Nursing Implementation for Volume

Imbalances

Neurologic function
LOC
PERLA
Voluntary

movement of extremities
Muscle strength
Reflexes

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IV Fluids
Purposes
1. Maintenance

2.

Replacement

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When oral intake is not adequate

When losses have occurred

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Solution Types

Hypotonic
Provides

more water than electrolytes

Dilutes ECF, thus water moves from
ECF ICF
Examples: 0.45 NaCl

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Solution Types

Isotonic
Same

osmolality as ECF
Expands only ECF (what goes in ECF
stays in ECF; no shifting to ICF)
Examples: Normal saline (0.9% NaCl),
Lactated Ringers (Ringers Lactate)

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Solution Types

Hypertonic
More

concentrated than ECF

Expands ECF volume
Increased osmolality draws water from
cells into ECF

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D5W

Isotonic
But

becomes hypotonic after dextrose

is metabolized b/c only water remains

A source of calories

A source of free water:

metabolism of glucose)
Moves

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(as above b/c of

into ICF
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D5W

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Prevents ketosis

Supports edema formation do not

use in clients with cerebral edema!

Decreased chance of IV fluid overload

Usually compatible with medications

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Normal Saline (NS; 0.9% NaCl)

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Isotonic

No calories

More NaCl than ECF

(could cause
hypernatremia, hyperchloremia)

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Normal Saline (NS; 0.9% NaCl)

Expands IV volume

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Preferred fluid for immediate response

Risk for fluid overload higher

Does not change ICF Volume

Blood products

Compatible with most medications

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Lactated Ringers

Isotonic

More similar to plasma than NS (b/c has

electrolytes)

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Commonly used postoperatively

Expands ECF, IV

Common replacement fluid

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D5 NS

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Hypertonic (becomes Hypotonic in

body after dextose is absorbed)

Common maintenance fluid

KCl added for maintenance or

replacement

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D5 NS (Hypertonic)

Provides calories
Prevents

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ketosis

Moves into ICF

Usually compatible with medications

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Plasma Expanders (Hypertonic)

Pull fluid from interstitium into

vascular space
Colloids
Packed

RBCs
Albumin
Plasma

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