Fluid and Elect One

Fluid and
Electrolytes
Asri Kacung
School Of Nursing
Muhammadiyah University Of Surabaya
Copyright 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Homeostasis
State of equilibrium in body
Naturally maintained by adaptive
responses
Body fluids and electrolytes are
maintained within narrow limits
Why nurses need to understand

fluid and electrolytes?
Important
to anticipate the potential

for alterations in fluid and electrolyte
balance associated with certain
disorders and medical therapies, to
recognize the signs and symptoms of
imbalances, and to intervene with
the appropriate action.
Enhanced understanding and

management of fluids and
Composition of body fluids
electrolytes
Fluid
compartments/Extracellular fluid
osmolality
Factors that affect movement of water
and solutes
Regulation of vascular volume
Facilitated by clinical condition
understanding, nursing assessment,
lab analysis

(water content of body)
60%
of body weight in adult

45% to 55% in older adults
70% to 80% in infants
Varies with gender, body mass, and age
Changes in Water Content with

Age
Fig. 17-1

In
addition to water, the body contains

solutes; substances the separate in
solution and conduct electrical current.
Concentration of solutes in
solution=osmolality or osmolarity.
May by electrolytes or non-electrolytes:
Cations(+), Na, K
Anions (-), CL, HCO-3 (bicarbonate), PO
Non-electrolytes (glucose, urea,
creatinine, bilirubin)
Fluid Compartments
Intracellular
fluid (ICF): Located within
cells
42% of body weight
Extracellular fluid (ECF)-found outside
cell
Intravascular (plasma)
Interstitial
lymph
Transcellular
30% of body weight
Fluid Compartments of the

Body
Fig. 17-2
Transcellular Fluid
Part
of ECF
Small but important/Approximately 1
Includes fluid in
Cerebrospinal fluid
Pericardial fluid
Pleural spaces
Synovial spaces
Intraocular fluid
Digestive secretions
Factors that affect Fluid and

Electrolyte Movement
Membranes
Osmosis
Diffusion
Facilitated diffusion
Active transport
Hydrostatic pressure
Oncotic pressure
Membrane physiology
Transport process
Osmosis
Diffusion
Active
transport
filtration
Osmosis
Movement
of water between two

compartments by a membrane
permeable to water but not to solute
Moves from low solute to high solute
concentration
Requires
no energy
Terms associated with

osmosis
Osmotic
Pressure: amount of pressure required to

stop osmotic flow of water. Determined by
concentration of solutes in solution
Oncotic pressure: pressure exerted by colloids
(proteins, such as albumin)
Osmotic diuresis: increased urine output (caused
by substances such as mannitol, glucose or
contrast medium)
Osmotic movement of fluids

Cells
affected by osmolality of the

fluid that surrounds them.
Isotonic-fluid with same osmolality as cell
interior
Hypotonic (hypoosmolar)-solutes are less

concentrated than cells.
hypertonic (hyperosmolar)-solutes more

concentrated than cells.
Diffusion
Random
movement of particles in
all directions from an area of high
concentration to low
concentration.
Active transport
Relies
on availability of carrier
substances, utilizes energy (ATP),
to transport solutes in and out of
cells.
Na, K, hydrogen, glucose, aminoacids,
Filtration
Movement
of water and solutes

from area of high hydrostatic
pressure to area of low
hydrostatic pressure that is
created by weight of fluid.
Kidney is example; (filters
180L/day plasma)
Hydrostatic Pressure
Force
within a fluid compartment

Major force that pushes water out of
vascular system at capillary level
Fluid Movement in
Capillaries
Amount
and direction of movement

determined by
Capillary hydrostatic pressure

Plasma oncotic pressure
Interstitial hydrostatic pressure
Interstitial oncotic pressure
Fluid Exchange Between

Capillary and Tissue
Fig. 17-8
Fluid Shifts
Plasma
to interstitial fluid shift

results in edema
Elevation of hydrostatic pressure

Decrease in plasma oncotic pressure
Elevation of interstitial oncotic pressure
Fluid Shifts (Contd)

Interstitial
fluid to plasma
Fluid drawn into plasma space with

increase in plasma osmotic or oncotic
pressure
Compression stockings decrease
peripheral edema
Fluid Movement between

ECF and ICF
Water
deficit (increased ECF)
Associated with symptoms that result

from cell shrinkage as water is pulled
into vascular system
Fluid Movement between

ECF and ICF (Contd)
Water
excess (decreased ECF)
Develops from gain or retention of

excess water
Fluid Spacing
First
spacing
Normal distribution of fluid in ICF and

ECF
Second
spacing
Abnormal accumulation of interstitial

fluid (edema)
Fluid Spacing (Contd)

Third
spacing
Fluid accumulation in part of body where

it is not easily exchanged with ECF; fluid
trapped and unavailable for functional
use (ascites)
3rd spacing, fluid shift from

intravascular to interstitial space;
edema
Regulation of Water Balance

Hypothalamic
regulation
Pituitary regulation
Adrenal cortical regulation
Renal regulation
Cardiac regulation
Gastrointestinal regulation
Insensible water loss
Normal fluid balance

Intake: fluids, food, oxidation=~2500ml
Output: skin and lungs (insensible loss)-900ml, feces
100ml, urine-1500ml=~2500ml/day
Hypothalamic Regulation
Osmoreceptors
in hypothalamus
sense fluid deficit or increase
Stimulates thirst and antidiuretic
hormone (ADH) release
Result in increased free water and
decreased plasma osmolarity
Pituitary Regulation
Under
control of hypothalamus,
posterior pituitary releases ADH
Stress, nausea, nicotine, and
morphine also stimulate ADH release
Adrenal Cortical Regulation

Releases
hormones to regulate water

and electrolytes
Glucocorticoids
Cortisol
Mineralocorticoids
Aldosterone
Factors Affecting Aldosterone

Secretion
Fig. 17-9
Renal Regulation
Primary
organs for regulating fluid

and electrolyte balance
Adjusting urine volume
Selective reabsorption of water and

electrolytes
Renal tubules are sites of action of ADH and
aldosterone
Effects of Stress on F&E

Balance
Fig. 17-10
Cardiac Regulation
Natriuretic
peptides are antagonists

to the RAAS
Produced by cardiomyocytes in response

to increased atrial pressure
Suppress secretion of aldosterone, renin,
and ADH to decrease blood volume and
pressure
Gastrointestinal Regulation
Oral
intake accounts for most water

Small amounts of water are
eliminated by gastrointestinal tract in
feces
Diarrhea and vomiting can lead to
significant fluid and electrolyte loss
Insensible Water Loss

Invisible
vaporization from lungs and

skin to regulate body temperature
Approximately 600 to 900 ml/day
is lost
No electrolytes are lost
Gerontologic Considerations
Structural
changes in kidneys
decrease ability to conserve water
Hormonal changes lead to decrease
in ADH and ANP
Loss of subcutaneous tissue leads to
increased loss of moisture
Gerontologic Considerations
(Contd)
Reduced
thirst mechanism results in

decreased fluid intake
Nurse must assess for these changes
and implement treatment
accordingly
Fluid and Electrolyte

Imbalances
Common
illness
in most patients with
Directly caused by illness or disease

(burns or heart failure)
Result of therapeutic measures
(IV fluid replacement or diuretics)
Extracellular Fluid Volume

Imbalances
ECF
volume deficit (hypovolemia)
Abnormal loss of normal body fluids

(diarrhea, fistula drainage, hemorrhage),
inadequate intake , or plasma-tointerstitial fluid shift
Treatment: replace water and
electrolytes with balanced IV solutions
Extracellular Fluid Volume

Imbalances (Contd)
Fluid
volume excess (hypervolemia)
Excessive intake of fluids, abnormal

retention of fluids (CHF), or interstitial-toplasma fluid shift
Treatment: remove fluid without
changing electrolyte composition or
osmolality of ECF
Nursing Management
Nursing Diagnoses
Hypovolemia
Deficient fluid volume

Decreased cardiac output
Potential complication: hypovolemic
shock
Nursing Management
Nursing Implementation
Neurologic function
(Contd)
LOC
PERLA
Voluntary movement of extremities
Muscle strength
Reflexes
Nursing Management
Nursing Diagnoses (Contd)
Hypervolemia
Excess fluid volume

Ineffective airway clearance
Risk for impaired skin integrity
Disturbed body image
Potential complications: pulmonary
edema, ascites
Nursing Management
Nursing Implementation
I&O
Monitor
cardiovascular changes
Assess respiratory status and
monitor changes
Daily weights
Skin assessment
Electrolytes
Substances
whose molecules
dissociate into ions (charged
particles) when placed into water
Cations: positively charged (Na, K, Ca2,

Mg2)
Anions: negatively charged (HCO3, CL,
PO4 3)
Measurement; International standard is millimoles per
liter (mmol/L), U.S. uses milliequivalent (mEq)
Ions combine mEq for mEq
Electrolyte Composition
ICF
Prevalent cation is K+
Prevalent anion is PO43
ECF
Prevalent cation is Na+

Prevalent anion is Cl
Sodium
Serum levels; 135-145mEq/L
Responsible for water balance and
determination of plasma osmolality
Cation+,plays a major role in
ECF volume and concentration

(movement of Cl- closely associated with Na+)
Imbalances can exist in different volume
states: euvolemia (normal volume), hypovolemia (low
volume), hypervolemia (increased volume)
Na+ (continued)
Generation and transmission of nerve
impulses
Acidbase balance (combining HCO3 and CL to
alter pH)
Impacted by hormonal control (aldosterone,

ADH)
Dietary level: current recommendation 500mg2300mg/day, Western diet; 4000-6000mg/day!!! Primary
source; table salt (NaCL)
Differential Assessment of
ECF Volume
Fig. 17-12
Potassium
Major
cation of ICF
Serum level: 3.5-5.0mEq/L
Necessary for
Transmission and conduction of nerve

and muscle impulses
Control via sodium-potassium pump
(contained within cell membrane of all cells/utilizes ATP)
Inverse relationship between Na+ and K+reabsorption in
the kidney; factors that cause Na+ retention cause K+
loss in the urine.
K+ (continued)
Kidneys
eliminate 90% of K+,
thus
if renal function impaired, toxic levels may be

retained.
Dietary
level:
40-60mEq/day, Western diet

inclusive of K+ salt substitutes may contain K+
Maintenance
of cardiac
rhythms/function
Acidbase balance
Calcium (Ca2+)
Function: transmission of nerve impulses,
muscle/myocardial contraction, blood clotting,

formation of teeth and bones
Balance
controlled by PTH, calcitonin,

vitamin D
Obtained from diet, daily need: 1-1.5G/d
More
than 99% combined with

phosphorus and concentrated in
skeletal system
Inverse relationship with phosphorus
Serum Level:8.5-10.5 mg/dl
Tests for Hypocalcemia
Fig. 17-15
Phosphate/phosphorus
(PO4-/P+)
Serum
Level: 2.5-4.5mg/dL
Primary anion in ICF
Essential to function of muscle, red
blood cells, nervous system and
Ca+levels
Deposited with calcium for bone and
tooth structure, Ca+ and P+ exist in a reciprocal
balance
Required
for release of O2 from

hemoglobin
PO4- (continued)
Involved
in acidbase buffering
system (phosphate buffer), ATP production,
and cellular uptake of glucose
90% excreted by Kidneys; requires
adequate renal functioning
Dietary level; intake via balanced
diet, daily need: 800-1600mg/dl
Magnesium
2nd
most abundant cation in ICF

Serum level: 1.4-2.1 mEq/L
Daily need: 300-350mg (average Western
diet contains 170-720mg/day)
Coenzyme
in metabolism of protein,
carbohydrate and Ca+ absorption
and utilization (Factors that regulate calcium
balance appear to influence magnesium balance)
Mg+
(continued)
Acts
directly on myoneural junction

to transmit electrical impulses (relaxes
lung muscles that open airways)
Important
for normal cardiac
function
Powers Na+/K+ pump
Plays essential role in secretion and
action of insulin (impacts BG)
Chloride
Major
ECF anion
Serum level: 95-108 mEq/L
Function; circulates with Na+ and
H2O to help maintain cellular
integrity, fluid balance and
osmotic pressure
Affects acid/base balance (enzyme
activator, serves as buffer in exchange of O2
and CO2 in RBCs)
CL- (continued)
In
conjunction with Ca+, Mg+, helps

maintain nerve transmission/muscle
function
Vital role in production of HCL
Obtained primarily from foods
(processed) and table salt, daily need:
~750mg.
90% excreted by kidney
IV Fluids
Purposes
1. Maintenance
When oral intake is not adequate
2. Replacement
When losses have occurred
IV Fluids (Contd)
Hypotonic
More water than electrolytes

Pure water lyses RBCs
Water moves from ECF to ICF by osmosis

Usually maintenance fluids
Isotonic
Expands only ECF

No net loss or gain from ICF
IV Fluids (Contd)
Hypertonic
Initially expands and raises the

osmolality of ECF
Require frequent monitoring of
Blood pressure
Lung sounds
Serum sodium levels
D5W
Isotonic
Provides 170
Free water
cal/L
Moves into ICF

Increases renal solute excretion
Used
to replace water losses and

treat hyponatremia
Does not provide electrolytes
Normal Saline (NS)

Isotonic
No
calories
Expands IV volume
Preferred fluid for immediate response
Does
not change ICF volume

Compatible with most
medications/blood administration
Lactated Ringers
Isotonic
More
similar to plasma than NS
Has less NaCl

Has K, Ca, PO43, lactate (metabolized to
HCO3)
Expands
ECF
D5 NS
Hypertonic
Common
maintenance fluid
KCl added for maintenance or
replacement
D10W
Hypertonic
Provides
340 kcal/L
Free water
Limit of dextrose concentration may
be infused peripherally
Plasma Expanders
Stay
in vascular space and increase

osmotic pressure
Colloids (protein solutions)
Packed RBCs
Albumin
Plasma
Diuretics
Act
by increasing volume of urine

production in tx of hypertension,
heart failure, and kidney disorders.
Electrolyte depletion common
(hypokalemia)
Nursing interventions
I&O,
loc, nutritional status, monitor liver

and kidney function, observe for
hypersensitivity, monitor hearing and
vision (loop/lasix are ototoxic, thiazide
may impact vision), monitor alcohol and
caffeine (diuretic), safety (oh), monitor
light exposure (photosensitivity), monitor
edema, labs, admin in am.
References
*Copyright@ by S. Buckley, 2012 (all rights
reserved)
Medical-Surgical Nursing
Lewis, Heitkemper, Kirksen, Obrien, Bucher,
Tabers cyclopedic Medical Dictionary
Venes, 19th edition
Pharmacology, A nursing approach
Kee, Hayes, 3rd edition
Fluid and Electrolytes
Innerarity, Stark, 3rd edition
References (continued)
Fluid, Electrolyte, and Acid-base Balance
Heitz, Horne-Mosby, 4th edition
IV Therapy made incredibly Easy!
McCann, Lippincott, 3rd edition
Acute Renal Failure
Hudson, Rn, MSN
Electronic source;
dynamicnursingeducation.com
Fluid & Electrolytes
Chernecky, Macklin, Murphy-ende, Saunders
2002
Fluids, Electrolytes & Acid-Base Balance
Hogan, Wane, Prentice Hall nursing

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Fluid and

Why nurses need to understand

to anticipate the potential

Enhanced understanding and

Composition of body fluids

of body weight in adult

Varies with gender, body mass, and age

Changes in Water Content with

Composition of body fluids

addition to water, the body contains

fluid (ICF): Located within

30% of body weight

Fluid Compartments of the

Factors that affect Fluid and

of water between two

Terms associated with

Pressure: amount of pressure required to

Osmotic movement of fluids

affected by osmolality of the

Hypotonic (hypoosmolar)-solutes are less

hypertonic (hyperosmolar)-solutes more

of water and solutes

within a fluid compartment

and direction of movement

Capillary hydrostatic pressure

Fluid Exchange Between

to interstitial fluid shift

Elevation of hydrostatic pressure

Fluid Shifts (Contd)

Fluid drawn into plasma space with

Fluid Movement between

deficit (increased ECF)

Associated with symptoms that result

Fluid Movement between

excess (decreased ECF)

Develops from gain or retention of

Normal distribution of fluid in ICF and

Abnormal accumulation of interstitial

Fluid Spacing (Contd)

Fluid accumulation in part of body where

3rd spacing, fluid shift from

Regulation of Water Balance

Normal fluid balance

Adrenal Cortical Regulation

hormones to regulate water

Factors Affecting Aldosterone

organs for regulating fluid

Selective reabsorption of water and

Effects of Stress on F&E

peptides are antagonists

Produced by cardiomyocytes in response

intake accounts for most water

Insensible Water Loss

vaporization from lungs and

thirst mechanism results in

Fluid and Electrolyte

in most patients with

Directly caused by illness or disease

Extracellular Fluid Volume

volume deficit (hypovolemia)

Abnormal loss of normal body fluids

Extracellular Fluid Volume

volume excess (hypervolemia)

Excessive intake of fluids, abnormal