Chapter 13 Unit 1 Fluid and Electrolytes

C H A P TER 13
FLU ID A N D ELEC TR O LY TES : B A LA N C E

A N D D IS TU R B A N C E
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Fluid and Electrolyte Balance

Necessary for life, homeostasis
Nursing role: help prevent, treat
fluid, electrolyte disturbances
Fluid
Approximately 60% of typical adult is fluid
Varies with age, body size, gender
Intracellular fluid
Extracellular fluid
Intravascular
Interstitial
Transcellular
Third spacing: loss of ECF into space that
does not contribute to equilibrium

Electrolytes
Active chemicals that carry positive
(cations), negative (anions) electrical

charges
Major cations: sodium, potassium,
calcium, magnesium, hydrogen ions

Major anions: chloride, bicarbonate,
phosphate, sulfate, and proteinate ions
Electrolyte concentrations differ in
fluid compartments
Regulation ofFluid
Movement of fluid through capillary
walls depends on
Hydrostatic pressure: exerted on walls of
blood vessels
Osmotic pressure: exerted by protein in
plasma
Direction of fluid movement depends
on differences of hydrostatic,
osmotic pressure
Regulation ofFluid
Osmosis: area of low solute concentration to
area of high solute concentration

Diffusion: solutes move from area of higher
concentration to one of lower concentration
Filtration: movement of water, solutes
occurs from area of high hydrostatic
pressure to area of low hydrostatic pressure
Active transport: physiologic pump that
moves fluid from area of lower
concentration of one of higher concentration
Active Transport
Physiologic pump that moves fluid
from area of lower concentration to

one of higher concentration
Movement against concentration
gradient
Sodium-potassium pump: maintains
higher concentration of extracellular
sodium, intracellular potassium
Requires adenosine (ATP) for energy
Q uestion
Tell whether the following statement
is true or false:
Osmosis is the movement of a
substance from an area of higher
concentration to one of lower
concentration.
Answ er
False.
Rationale: Diffusion is the movement of a
substance from an area of higher

concentration to one of lower
concentration. The concentration of
dissolved substances draws fluid in that
direction. Osmosis is the movement of
fluid, through a semipermeable membrane,
from an area of low solute concentration to
an area of high solute concentration until
the solutions are of equal concentration.
Routes ofG ains and Losses

Gain
Dietary intake of fluid, food or enteral
feeding
Parenteral fluids
Routes ofG ains and Losses (contd)

Loss
Kidney: urine output
Skin loss: sensible, insensible losses
Lungs
GI tract
Other
Q uestion
What is the average daily urinary
output in an adult?
0.5 L
1.0 L
1.5 L
2.5 L
Answ er
C. 1.5 L
Rationale: Vital to the regulation of
fluid and electrolyte balance, the

kidneys normal filter 170 L of plasma
every day in the adult, while
excreting only 1.5 L of urine.
G erontologic Considerations
Reduced homeostatic mechanisms:
cardiac, renal, respiratory function

Decreased body fluid percentage
Medication use
Presence of concomitant conditions
Fluid Volum e Im balances

Fluid volume deficit (FVD):
hypovolemia
Fluid volume excess (FVE):
hypervolemia
Fluid Volum e D efi

cit
Loss of extracellular fluid exceeds
intake ratio of water

Electrolytes lost in same proportion as
they exist in normal body fluids
Dehydration: loss of water along with
increased serum sodium level

May occur in combination with other
imbalances
Fluid Volum e D efi

cit (contd)
Dehydration
Causes: fluid loss from vomiting,
diarrhea, GI suctioning, sweating,

decreased intake, inability to gain access
to fluid
Risk factors: diabetes insipidus, adrenal
insufficiency, osmotic diuresis,
hemorrhage, coma, third space shifts
Fluid Volum e D efi

cit (contd)
Manifestations: rapid weight loss,
decreased skin turgor, oliguria,

concentrated urine, postural
hypotension, rapid weak pulse,
increased temperature, cool clammy
skin due to vasoconstriction,
lassitude, thirst, nausea, muscle
weakness, cramps
Laboratory data: elevated BUN in
relation to serum creatinine,
Fluid Volum e D efi

cit (contd)
Medical management: provide fluids
to meet body needs

Oral fluids
IV solutions
Fluid Volum e D efi

cit -N ursing M anagem ent
I&O, VS
Monitor for symptoms: skin and
tongue turgor, mucosa, UO, mental

status
Measures to minimize fluid loss
Oral care
Administration of oral fluids
Administration of parenteral fluids
Q uestion
What is a major indicator of
extracellular FVD?
Full and bounding pulse
Drop in postural blood pressure
Elevated temperature
Pitting edema of lower extremities
Answ er
B. Drop in postural blood pressure
Rationale: FVD signs and symptoms include acute
weight loss; decreased skin turgor; oliguria;

concentrated urine; orthostatic hypotension due to
volume depletion; a weak, rapid heart rate;
flattened neck veins; increased temperature; thirst;
decreased or delayed capillary refill; decreased
central venous pressure; cool, clammy, pale skin
related to peripheral vasoconstriction; anorexia;
nausea; lassitude; muscle weakness; and cramps.
Clinical manifestations of FVE result from expansion
of the ECF and include edema, distended neck
veins, and crackles (abnormal lung sounds).
Fluid Volum e Excess

Due to fluid overload or diminished homeostatic
mechanisms
Risk factors: heart failure, renal failure, cirrhosis of liver
Contributing factors: excessive dietary sodium or
sodium-containing IV solutions
Manifestations: edema, distended neck veins, abnormal
lung sounds (crackles), tachycardia, increased BP, pulse
pressure and CVP, increased weight, increased UO,
shortness of breath and wheezing
Medical management: directed at cause, restriction of
fluids and sodium, administration of diuretics
Fluid Volum e Excess -N ursing M anagem ent
I&O and daily weights; assess lung sounds,
edema, other symptoms; monitor responses to

medications- diuretics
Promote adherence to fluid restrictions, patient
teaching related to sodium and fluid restrictions
Monitor, avoid sources of excessive sodium,
including medications
Promote rest
Semi-Fowlers position for orthopnea
Skin care, positioning/turning
Electrolyte Im balances
Sodium: hyponatremia,
hypernatremia
Potassium: hypokalemia,
hyperkalemia
Calcium: hypocalcemia,
hypercalcemia
Magnesium: hypomagnesemia,
hypermagnesemia
Phosphorus: hypophosphatemia,
hyperphosphatemia
H yponatrem ia
Serum sodium less than 135 mEq/L
Causes: adrenal insufficiency, water intoxication, SIADH
or losses by vomiting, diarrhea, sweating, diuretics

Manifestations: poor skin turgor, dry mucosa, headache,
decreased salivation, decreased BP, nausea, abdominal
cramping, neurologic changes
Medical management: water restriction, sodium
replacement
Nursing management: assessment and prevention,
dietary sodium and fluid intake, identify and monitor atrisk patients, effects of medications (diuretics, lithium)
H ypernatrem ia
Serum sodium greater than 145mEq/L

Causes: excess water loss, excess sodium
administration, diabetes insipidus, heat stroke,

hypertonic IV solutions
Manifestations: thirst; elevated temperature; dry,
swollen tongue; sticky mucosa; neurologic
symptoms; restlessness; weakness
Note: thirst may be impaired in elderly or the ill
Medical management: hypotonic electrolyte
solution or D5W
Nursing management: assessment and
prevention, assess for OTC sources of sodium,
offer and encourage fluids to meet patient needs,
provide sufficient water with tube feedings
H ypokalem ia
Below-normal serum potassium (<3.5 mEq/L), may
occur with normal potassium levels with alkalosis

due to shift of serum potassium into cells
Causes: GI losses, medications, alterations of acidbase balance, hyperaldosterism, poor dietary intake
Manifestations: fatigue, anorexia, nausea, vomiting,
dysrhythmias, muscle weakness and cramps,
paresthesias, glucose intolerance, decreased
muscle strength, DTRs
Medical management: increased dietary potassium,
potassium replacement, IV for severe deficit
Nursing management: assessment, severe
hypokalemia is life-threatening, monitor ECG and
ABGs, dietary potassium, nursing care related to IV
potassium administration
H yperkalem ia
Serum potassium greater than 5.0 mEq/L
Causes: usually treatment related, impaired renal
function, hypoaldosteronism, tissue trauma, acidosis

Manifestations: cardiac changes and dysrhythmias,
muscle weakness with potential respiratory
impairment, paresthesias, anxiety, GI manifestations
Medical management: monitor ECG, limitation of
dietary potassium, cation-exchange resin
(Kayexalate), IV sodium bicarbonate , IV calcium
gluconate, regular insulin and hypertonic dextrose
IV, -2 agonists, dialysis
H yperkalem ia (contd)
Nursing management: assessment of serum
potassium levels, mix IVs containing K+ well,

monitor medication affects, dietary potassium
restriction/dietary teaching for patients at risk
Hemolysis of blood specimen or drawing of blood
above IV site may result in false laboratory result
Salt substitutes, medications may contain
potassium
Potassium-sparing diuretics may cause elevation
of potassium
Should not be used in patients with renal dysfunction
Q uestion
Tell whether the following statement
is true or false:
The ECG change that is specific to
hyperkalemia is a peaked T wave.
Answ er
True.
Rationale: The ECG changes that are
specific to hyperkalemia are peaked

T wave; wide, flat P wave; and wide
QRS complex. The ECG changes that
are specific to hypokalemia are
flatted T wave and the appearance of
a U wave.
H ypocalcem ia
Serum level less than 8.5 mg/dL, must be
considered in conjunction with serum albumin

level
Causes: hypoparathyroidism, malabsorption,
pancreatitis, alkalosis, massive transfusion of
citrated blood, renal failure, medications, other
Manifestations: tetany, circumoral numbness,
paresthesias, hyperactive DTRs, Trousseaus
sign, Chovstek's sign, seizures, respiratory
symptoms of dyspnea and laryngospasm,
abnormal clotting, anxiety
H ypocalcem ia (contd)
Medical management: IV of calcium
gluconate, calcium and vitamin D

supplements; diet
Nursing management: assessment,
severe hypocalcemia is lifethreatening, weight-bearing
exercises to decrease bone calcium
loss, patient teaching related to diet
and medications, and nursing care
related to IV calcium administration
Trousseaus Sign
H ypercalcem ia
Serum level above 10.5 mg/dL

Causes: malignancy and hyperparathyroidism, bone
loss related to immobility

Manifestations: muscle weakness, incoordination,
anorexia, constipation, nausea and vomiting,
abdominal and bone pain, polyuria, thirst, ECG
changes, dysrhythmias
Medical management: treat underlying cause, fluids,
furosemide, phosphates, calcitonin, biphosphonates
Nursing management: assessment, hypercalcemic
crisis has high mortality, encourage ambulation,
fluids of 3 to 4 L/d, provide fluids containing sodium
unless contraindicated, fiber for constipation, ensure
safety
H ypom agnesem ia
Serum level less than 1.8 mg/dL, evaluate in
conjunction with serum albumin

Causes: alcoholism, GI losses, enteral or parenteral
feeding deficient in magnesium, medications, rapid
administration of citrated blood; contributing
causes include diabetic ketoacidosis, sepsis, burns,
hypothermia
Manifestations: neuromuscular irritability, muscle
weakness, tremors, athetoid movements, ECG
changes and dysrhythmias, alterations in mood and
level of consciousness
Medical management: diet, oral magnesium,
magnesium sulfate IV
H ypom agnesem ia (contd)

Nursing management: assessment, ensure
safety, patient teaching related to diet,

medications, alcohol use, and nursing care
related to IV magnesium sulfate
Hypomagnesemia often accompanied by
hypocalcemia
Need to monitor, treat potential hypocalcemia
Dysphasia common in magnesium-depleted
patients
Assess ability to swallow with water before
administering food or medications

H yperm agnesem ia
Serum level more than 2.7 mg/dL

Causes: renal failure, diabetic ketoacidosis, excessive
administration of magnesium
Manifestations: flushing, lowered BP, nausea, vomiting,
hypoactive reflexes, drowsiness, muscle weakness,
depressed respirations, ECG changes, dysrhythmias
Medical management: IV calcium gluconate, loop
diuretics, IV NS of RL, hemodialysis
Nursing management: assessment, do not administer
medications containing magnesium, patient teaching
regarding magnesium containing OTC medications
H ypophosphatem ia
Serum level below 2.5 mg/DL
Causes: alcoholism, refeeding of patients after starvation,
pain, heat stroke, respiratory alkalosis, hyperventilation,

diabetic ketoacidosis, hepatic encephalopathy, major burns,
hyperparathyroidism, low magnesium, low potassium,
diarrhea, vitamin D deficiency, use of diuretic and antacids
Manifestations: neurologic symptoms, confusion, muscle
weakness, tissue hypoxia, muscle and bone pain, increased

susceptibility to infection
Medical management: oral or IV phosphorus replacement
Nursing management: assessment, encourage foods high in
phosphorus, gradually introduce calories for malnourished

patients receiving parenteral nutrition
H yperphosphatem ia
Serum level above 4.5 mg/DL
Causes: renal failure, excess phosphorus, excess vitamin
D, acidosis, hypoparathyroidism, chemotherapy

Manifestations: few symptoms; soft-tissue calcifications,
symptoms occur due to associated hypocalcemia
Medical management: treat underlying disorder, vitaminD preparations, calcium-binding antacids, phosphatebinding gels or antacids, loop diuretics, NS IV, dialysis
Nursing management: assessment, avoid highphosphorus foods; patient teaching related to diet,
phosphate-containing substances, signs of hypocalcemia
H ypochlorem ia
Serum level less than 96 mEq/L

Causes: Addisons disease, reduced chloride intake,
GI loss, diabetic ketoacidosis, excessive sweating,

fever, burns, medications, metabolic alkalosis
Loss of chloride occurs with loss of other
electrolytes, potassium, sodium
Manifestations: agitation, irritability, weakness,
hyperexcitability of muscles, dysrhythmias,
seizures, coma
Medical management: replace chloride-IV NS or
0.45% NS
Nursing management: assessment, avoid free
water, encourage high-chloride foods, patient
teaching related to high-chloride foods
H yperchlorem ia
Serum level more than 108 mEq/L

Causes: excess sodium chloride infusions with water
loss, head injury, hypernatremia, dehydration, severe

diarrhea, respiratory alkalosis, metabolic acidosis,
hyperparathyroidism, medications
Manifestations: tachypnea, lethargy, weakness, rapid,
deep respirations, hypertension, cognitive changes
Normal serum anion gap
Medical management: restore electrolyte and fluid
balance, LR, sodium bicarbonate, diuretics
Nursing management: assessment, patient teaching
related to diet and hydration
M aintaining Acid-Base Balance

Normal plasma pH 7-35-7.45:
hydrogen ion concentration

Major extracellular fluid buffer
system;
bicarbonate-carbonic acid buffer
system
Kidneys regulate bicarbonate in ECF
Lungs under control of medulla
regulate CO2, carbonic acid in ECF
M aintaining Acid-Base Balance

(contd)
Other buffer systems
ECF: inorganic phosphates, plasma
proteins
ICF: proteins, organic, inorganic
phosphates
Hemoglobin
Q uestion
What is the most common buffer
system in the body?

Plasma protein
Hemoglobin
Phosphate
Bicarbonate-carbonic acid
Answ er
D. Bicarbonate-carbonic acid
Rationale: The bodys major
extracellular buffer system is the

bicarbonatecarbonic acid buffer
system, which is assessed when
arterial blood gases are measured.
M etabolic Acidosis
Low pH <7.35
Low bicarbonate <22 mEq/L
Most commonly due to renal failure
Manifestations: headache, confusion, drowsiness,
increased respiratory rate and depth, decreased blood

pressure, decreased cardiac output, dysrhythmias,
shock; if decrease is slow, patient may be
asymptomatic until bicarbonate is 15 mEq/L or less
Correct underlying problem, correct imbalance
Bicarbonate may be administered
M etabolic Acidosis (contd)

With acidosis, hyperkalemia may
occur as potassium shifts out of cell

As acidosis is corrected, potassium
shifts back into cell, potassium levels
decrease
Monitor potassium levels
Serum calcium levels may be low
with chronic metabolic acidosis
Must be corrected before treating
acidosis
M etabolic Alkalosis
High pH >7.45
High bicarbonate >26 mEq/L
Most commonly due to vomiting or
gastric suction
May also be due to medications,
especially long-term diuretic use
Hypokalemia will produce alkalosis

Manifestations: symptoms related to
decreased calcium, respiratory

depression, tachycardia, symptoms
M etabolic Alkalosis (contd)

Correct underlying disorder, supply
chloride to allow excretion of excess

bicarbonate, restore fluid volume
with sodium chloride solutions
Respiratory Acidosis
Low pH <7.35
PaCO2 >42 mm Hg
Always due to respiratory problem
with inadequate excretion of CO2

With chronic respiratory acidosis,
body may compensate, may be
asymptomatic
Symptoms may be suddenly increased
pulse, respiratory rate and BP, mental

changes, feeling of fullness in head
Respiratory Acidosis (contd)

Potential increased intracranial
pressure
Treatment aimed at improving
ventilation
Respiratory Alkalosis
High pH >7.45
PaCO2 <35 mm Hg
Always due to hyperventilation
Manifestations: lightheadedness,
inability to concentrate, numbness

and tingling, sometimes loss of
consciousness
Correct cause of hyperventilation
ArterialBlood G ases
pH 7.35 - (7.4) - 7.45
PaCO2 35 - (40) - 45 mm Hg
HCO3 22 - (24) - 26 mEq/L
Assumed average values for ABG
interpretation
PaO2 80 to 100 mm Hg
Oxygen saturation >94%
Base excess/deficit 2 mEq/L
IV Site Selection
Com plications ofIV Therapy

Fluid overload
Air embolism
Septicemia, other infections
Infiltration, extravasation
Phlebitis
Thrombophlebitis
Hematoma
Clotting, obstruction

Chapter 13 Unit 1 Fluid and Electrolytes

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C H A P TER 13

FLU ID A N D ELEC TR O LY TES : B A LA N C E

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fluid and Electrolyte Balance

fluid, electrolyte disturbances

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Third spacing: loss of ECF into space that

does not contribute to equilibrium

(cations), negative (anions) electrical

calcium, magnesium, hydrogen ions

Electrolyte concentrations differ in

Direction of fluid movement depends

area of high solute concentration

from area of lower concentration to

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

substance from an area of higher

Routes ofG ains and Losses

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Routes ofG ains and Losses (contd)

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

fluid and electrolyte balance, the

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

cardiac, renal, respiratory function

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fluid Volum e Im balances

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fluid Volum e D efi

intake ratio of water

they exist in normal body fluids

Dehydration: loss of water along with

increased serum sodium level

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fluid Volum e D efi

diarrhea, GI suctioning, sweating,

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fluid Volum e D efi

decreased skin turgor, oliguria,

Fluid Volum e D efi

to meet body needs

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Fluid Volum e D efi

tongue turgor, mucosa, UO, mental

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

weight loss; decreased skin turgor; oliguria;

Fluid Volum e Excess

Fluid Volum e Excess -N ursing M anagem ent

I&O and daily weights; assess lung sounds,

edema, other symptoms; monitor responses to

or losses by vomiting, diarrhea, sweating, diuretics

Serum sodium greater than 145mEq/L

administration, diabetes insipidus, heat stroke,

Below-normal serum potassium (<3.5 mEq/L), may

occur with normal potassium levels with alkalosis

function, hypoaldosteronism, tissue trauma, acidosis

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

potassium levels, mix IVs containing K+ well,

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

specific to hyperkalemia are peaked

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins