Chapter 14

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
 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 of Fluid
• 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 of Fluid
• 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
 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
 Question

• 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.
 Answer
• 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
 Routes of Gains and
Losses

• Gain
– Dietary intake of fluid, food or enteral
feeding
– Parenteral fluids
 Routes of Gains and
Losses (cont’d)
• Loss
– Kidney: urine output
– Skin loss: sensible, insensible losses
– Lungs
– GI tract
– Other
 Question
• What is the average daily urinary output in an
adult?
• 0.5 L
• 1.0 L
• 1.5 L
• 2.5 L
 Answer

• 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.
 Gerontologic
Considerations
• Reduced homeostatic mechanisms: cardiac,
renal, respiratory function
• Decreased body fluid percentage
• Medication use
• Presence of concomitant conditions
Fluid Volume Imbalances

• Fluid volume deficit (FVD): hypovolemia

• Fluid volume excess (FVE): hypervolemia
 Fluid Volume Deficit
• 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 Volume Deficit
(cont’d)
• 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 Volume Deficit
(cont’d)
• 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, increased hematocrit
 Fluid Volume Deficit
(cont’d)

• Medical management: provide fluids to meet

body needs
– Oral fluids
– IV solutions
 Fluid Volume Deficit -
Nursing Management
• 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
 Question

• What is a major indicator of extracellular FVD?

• Full and bounding pulse
• Drop in postural blood pressure
• Elevated temperature
• Pitting edema of lower extremities
 Answer
• 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
 Fluid Volume 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
 Fluid Volume Excess -
Nursing Management
• 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-Fowler’s position for orthopnea
• Skin care, positioning/turning
 Electrolyte Imbalances
• Sodium: hyponatremia, hypernatremia
• Potassium: hypokalemia, hyperkalemia
• Calcium: hypocalcemia, hypercalcemia
• Magnesium: hypomagnesemia, hypermagnesemia
• Phosphorus: hypophosphatemia,
hyperphosphatemia
• Chloride: hypochloremia, hyperchloremia
 Hyponatremia
• 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
 Hypernatremia
• 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
 Hypokalemia
• 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 acid-base
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
 Hyperkalemia
• 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
 Hyperkalemia (cont’d)
• 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
 Question

• Tell whether the following statement is true or

false:
• The ECG change that is specific to hyperkalemia
is a peaked T wave.
 Answer

• 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.
 Hypocalcemia
• 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, Trousseau’s sign,
 Hypocalcemia (cont’d)
• Medical management: IV of calcium gluconate,
calcium and vitamin D supplements; diet
• Nursing management: assessment, severe
hypocalcemia is life-threatening, weight-bearing
exercises to decrease bone calcium loss, patient
teaching related to diet and medications, and
nursing care related to IV calcium
administration
Trousseau’s Sign
 Hypercalcemia
• 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
 Hypomagnesemia
• 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
 Hypomagnesemia
(cont’d)
• 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
 Hypermagnesemia
• 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
 Hypophosphatemia

• 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
 Hyperphosphatemia

• 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, vitamin-
D preparations, calcium-binding antacids, phosphate-
binding gels or antacids, loop diuretics, NS IV, dialysis
• Nursing management: assessment, avoid high-phosphorus
 Hypochloremia
• Serum level less than 96 mEq/L
• Causes: Addison’s 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
 Hyperchloremia
• 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
 Maintaining 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
 Maintaining Acid-Base
Balance (cont’d)

• Other buffer systems

– ECF: inorganic phosphates, plasma proteins
– ICF: proteins, organic, inorganic phosphates
– Hemoglobin
 Question
• What is the most common buffer system in the
body?
• Plasma protein
• Hemoglobin
• Phosphate
• Bicarbonate-carbonic acid
 Answer

• D. Bicarbonate-carbonic acid
• Rationale: The body’s major extracellular buffer
system is the bicarbonate–carbonic acid buffer
system, which is assessed when arterial blood
gases are measured.
 Metabolic 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
 Metabolic Acidosis
(cont’d)
• 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
 Metabolic 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
 Metabolic Alkalosis
(cont’d)

• 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
 Respiratory Acidosis
(cont’d)

• 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
 Arterial Blood Gases
• pH 7.35 - (7.4) - 7.45
• PaCO2 35 - (40) - 45 mm Hg
• HCO3ˉ 22 - (24) - 26 mEq/L
– Assumed average values for ABG
interpretation
• PaO2 80 to 100 mm Hg
• Oxygen saturation >94%
IV Site Selection
 Complications of IV
Therapy
• Fluid overload
• Air embolism
• Septicemia, other infections
• Infiltration, extravasation
• Phlebitis
• Thrombophlebitis