Stressors

Affecting
Fluid
NUR 101&
FALL 2008
Electrolyte
LECTURE
#
15
&
Balance

#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
Sweat
Insensible
Not visible.
Skin (evaporation)
Lungs
Feces
200ml

1500ml
100ml
500ml
400ml

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
of adults!
What might this Reverse
mean in
regards
to fluid loss for
an MORE
infant?
Infant
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.
Pulmonary Edema
THINK Why not?
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
area-thickness 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:

Integumentary:

Decreased CNS activity

(lethargy to coma)

Possible fever

Skeletal muscle weakness

Hyperactive DTR

Dry mouth & skin

Poor turgor (tenting)
Pitting edema
Sunken eyeballs

Renal:

Decreased output
Increased spec grav of
urine
Weight loss
Hypernatremia

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 areahypervolemia
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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EVOLVE

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
Anions
Negatively
charged

Cations
Positively
charged

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

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

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

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
!!
Administer potassium by slow IVR!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

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)

Cl-

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, parathesiafingertips/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