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Linda Akuamoah-Sarfo, MSN, C-NE, RN

Fluid and Electrolyte Balances


Definition: Electrolytes are positively or negatively charged particles that readily dissolve in water. The predominant positively charged electrolytes in the body are (also referred to as cations) sodium, potassium, c calcium, and magnesium, while negatively charged electrolytes (also called anions) include chloride, phosphates, and bicarbonate Fluid, electrolyte, and acid-base balances, within the body, are necessary to maintain health and functioning of all systems. These balances are maintained by the intake and output of water and electrolytes and their distribution in the body. Imbalances can alter respiration, metabolism, and the functioning of the CNS

Regulation of Body Fluids


The fluid intake-is regulated primarily through the

thirst mechanism. The thirst control is located within the hypothalamus in the brain. Water is also acquired from food intake such as fruits, vegetables, and meat The fluid out put- it occurs through kidneys and gastrointestinal tract. Water loss from skin can be sensible or insensible loss. Lungs also produce an insensible water loss by expiring approximately 400 ml of H2O per day

Description
Salts are chemical compounds composed of atoms that

carry electrical charges. Dissolved in water, the components in a salt exist as ions. Collectively, these ions are called electrolytes. Electrolytes are dissolved in different compartments of body water including: the serum portion of the blood, inside the cells (intracellular), and out-side the cells (extracellular). The concentration of these electrolytes varies considerably from one area to the other. However, there is a narrow concentration limit of these electrolytes that the body must maintain within each of these compartments. The body transfers electrolytes intracellular and extracellular as required to maintain electrolyte balance. Electrolyte concentrations of extracellular fluid can be measured in a blood sample.

Function
The kidney filters electrolytes in blood and maintains

a balance by excreting the proper amount in the urine. An electrolyte's concentration in a solution of dissolved salts can be measured as the amount in milli equivalents (mEq) per volume of solution (i.e. per liter). Electrolytes have many functions and roles in the body. The concentration of electrolytes must be maintained within a narrow range within the blood, otherwise deleterious physiological effects may occur.

Sodium Regulations
Sodium ions are involved in maintaining water

balance, transmitting nerve impulses, and contracting muscles. Sodium is found in extracellular fluid Sodium is a positively charged ion The normal concentration of Sodium is 135-145 mg/liter Sources of Sodium can be found in salt Sodium is regulated by salt intake, aldosterone, and urine out put

Sodium Balance
Sodium balance The largest portion of the body's sodium reserves is in

the extracellular fluid, which includes the blood plasma. The kidneys function to control the sodium excreted in the urine; thus the level of sodium in the body is relatively constant on a daily basis. An upset between intake of sodium (through dietary consumption) and output (in urine and sweat) creates an imbalance, affecting the total amount of sodium in the body. Variations in the total amount of sodium are related to the volume of water found in the blood.

Sodium Imbalances
A decrease in the overall amount of sodium does not

necessarily cause the concentration of blood sodium to fall, but may decrease blood volume. Low blood volume, such as occurs with hemorrhage, signals the kidneys to conserve both water and sodium through stimulation of aldosteone. This helps to return blood volume toward normal, by increasing the amount of extracellular fluid. With an excess of sodium in the body, blood volume may rise. This increase in blood volume initiates an accumulation of extracellular fluid, often in the feet, ankles, and lower legs, resulting in a condition known as edema.

Edema
Edema means swelling caused by fluid in your body's

tissues. It usually occurs in the feet, ankles and legs, but it can involve your entire body. Causes of edema include

Eating too much salt Sunburn Heart failure Kidney disease Liver problems from cirrhosis Pregnancy Problems with lymph nodes, especially after mastectomy Some medicines Standing or walking a lot when the weather is warm

Edema
Edema is an abnormal accumulation of fluid beneath

the skin or in one or more cavities of the body that produces swelling. Generally, the amount of interstitial fluid is determined by the balance of fluid homeostasis, and increased secretion of fluid into the interstitial or impaired removal of this fluid may cause edema.

Signs and Symptoms of Edema


Swelling in dependent areas: hands, feet, ankles,

sacrum, abdomen (ascites) Anasarca-generalized edema Periorbital edema-swelling around the eyes Nursing Assessment
Pitting Edema 1-4

Treatment of Edema
Diuretic/diuresis-the process of moving fluids out of

the body Fluid Restriction Daily Weight

Sodium Imbalances
The body maintains extracellular fluid sodium

concentration homeostasis through the thirst mechanism and regulation of kidney water excretion by antidiuretic hormone (ADH). When sodium concentrationas opposed to too much total sodiumis too high, thirst prompts water intake and, at the same time, the ADH signals to the kidneys to conserve water, by increasing water absorption by the organs and passing less water into the excretory system.

Common Disorders
The electrolytes involved in disorders of salt balance

are most often sodium, potassium, calcium, phosphate, and magnesium. The concentration of blood chloride is usually similar to the blood sodium concentration, while bicarbonate is related to acidbase balance. The factors which regulate acid-base balance are called buffers. A buffer is a substance that can absorb or release hydrogen ions to correct an acidbase imbalance. Several types of imbalances may be caused. These are dehydration, edema, ascites, and osmoloar imbalances in the case of Diabetes Insipidus.

Hyponatremia
The most common electrolyte disorder is hyponatremia, it occurs in almost 1% of all patients hospital admissions. Hyponatremia is a condition characterized by low sodium in the blood, below 135 mEq per liter of blood. In hyponatremia, the sodium concentration has been over diluted by an excess of water or a loss of sodium in the body. Hyponatremia may result from intravenous administration of water to hospitalized patients or can also occur with small amounts of water consumption in those who have impaired kidney function and several other conditions such as liver cirrhosis, heart failure, underactive adrenal glands as with Addison's disease, and various antidiuretic hormone disorders. Over 50% of hospitalized patients with AIDS have been reported to suffer from hyponatremia. Lethargy and confusion are typically the first signs of hyponatremia. Muscle twitching and seizures may occur as hyponatremia progresses with risk of stupor, coma, and death in the most severe cases. Due to the effects on the central nervous system, mortality risk is considerably greater in acute hyponatremia than in chronic hyponatremia. Other factors that reduce survival are the presence of debilitating illnesses such as alcoholism, hepatic cirrhosis, heart failure, or malignancy.

Hyponatremia
Causes Kidney Disease Adrenal Insufficiency Gastrointestinal losses Increased swelling Metabolic Acidosis Signs and Symptoms Apprehension Anxiety Personality Changes Nausea, Vomiting, and Diarrhea

Causes of Hyponatremia

Burns Congestive Heart Failure Diarrhea Diuretic medications, which increase urine output Kidney diseases Liver cirrhosis Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Sweating Vomiting

Treatment of Hyponatremia
The cause of hyponatremia must be diagnosed and

treated. In some cases, cancer may cause the condition, and radiation, chemotherapy, or surgery to remove the tumor may correct the sodium imbalance. Other treatments depend on the specific type of hyponatremia. Treatments may include:
Fluids through a vein (IV)
Medication to relieve symptoms Water restriction

Hypernatremia
Hypernatremia is a condition characterized by a high concentration of sodium in the blood, above 145 mEq per liter of blood. There is too little water compared to the amount of sodium in the blood, often resulting from a low intake of water. Profuse sweating, vomiting, fever, diarrhea, or abnormal kidney function may result in hypernatremia. With age, there is a decreased thirst sensation; therefore, hypernatremia is more common in the elderly. Aging reduces the kidney's ability to concentrate urine; therefore, taking diuretics may further exacerbate hypernatremia. Hypernatremia is very serious, particularly in the elderly. Almost half of individuals hospitalized for this condition will die, although it is often secondary to other illnesses.

Hypernatremia
Causes Ingestion of Large amounts of concentrated salinesolution Excessive administration of IV Hypertonic saline solution Excess Aldosterone Secretions Signs and Symptoms Thirst, dry, flushed skin, dry tongue and mucous membranes, fever, agitation, restlessness, oliguria

Hypernatremia
Major causes of high sodium levels include: limited water access, particularly when combined with any other cause excess water loss due to profuse sweating, vomiting, fever, diarrhea disorders of other electrolytes head trauma or neurosurgery involving the pituitary gland use of drugs including : lithium, diuretics diabetes insipidus sickle cell disease

Hypernatremia
As with hyponatremia, the major symptoms of

hypernatremia result from brain dysfunction. Severe hypernatremia can lead to confusion, muscle twitching, seizures, coma, and death. The effects on central nervous system hyperosmolality and the seriousness of the under-lying illness lead to greater mortality in acute hypernatremia compared to chronic hypernatremia.

Dehydration
Dehydration means your body does not have as much water

and fluids as it should. Dehydration can be caused by losing too much fluid, not drinking enough water or fluids, or both. Vomiting and diarrhea are common causes. Infants and children are more susceptible to dehydration than adults because of their smaller body weights and higher turnover of water and electrolytes. The elderly and those with illnesses are also at higher risk. Dehydration is classified as mild, moderate, or severe based on how much of the body's fluid is lost or not replenished. When severe, dehydration is a life-threatening emergency.

Types of Dehydration
Hypotonic or hyponatremic primarily a loss of

electrolytes, particularly sodium Hypertonic or hypernatremic primarily a loss of water Isotonic or isonatremic equal loss of water and electrolytes

Causes of Dehydration
Diarrhea
Vomiting Fever

Increased urination
Excessive sweating Burns Inadequate intake of water during hot weather or

exercise

Signs and Symptoms of Dehydration


Mild to moderate dehydration is likely to cause: Dry, sticky mouth Sleepiness or tiredness children are likely to be less active than usual Thirst Decreased urine output fewer than six wet diapers a day for infants and eight hours or more without urination for older children and teens Few or no tears when crying Muscle weakness Headache Dizziness or lightheadedness

Treatment of Dehydration
The only effective treatment for dehydration is to

replace lost fluids and lost electrolytes. The best approach to dehydration treatment depends on your age, the severity of your dehydration and its cause. Oral rehydration solution (ORS) Fluid replacement through intravenous therapy Treating the cause of dehydration

Nursing Considerations
Assess vital signs, noting peripheral pulses.
Monitor blood pressure and invasive hemodynamic

parameters. Strictly monitor intake and output. Observe the physical properties of the urine. Correctly infuse the right amount of IVF. Encourage small, frequent feedings. Provide frequent, oral care. Administer medications as prescribe.

Calcium Balances
The body's calcium reserves are predominately stored in bones,

although the blood and cells also contain calcium. Calcium is necessary for proper functioning in many areas of the body including nerve conduction, muscle contraction, and enzyme functions. Like other electrolytes, the body controls calcium levels both in blood and cells. Calcium from the diet is absorbed in the gastrointestinal tract while the excess is excreted in the urine. A minimum of 500-1000 mg of calcium is required daily in order to maintain a normal calcium concentration. Normally, the body transfers calcium to the blood from the bones to maintain calcium homeostasis. If calcium intake falls short of the requirement, too much calcium will be mobilized from the bones, weakening the bones and contributing to osteoporosis.

Calcium
Parathyroid hormone and calcitonin regulate the amount

of calcium in the blood. There are four parathyroid glands located in the neck that increase secretion of parathyroid hormone when the calcium concentration falls too low. Consequently, the gastrointestinal tract is stimulated to absorb more calcium from the blood, release a greater amount of calcium from the bones, and to excrete less in the urine. At the same time, parathyroid hormone induces the kidneys to activate vitamin D which increases uptake of calcium from the gastrointestinal tract. Calcitonin is a hormone produced by the parathyroid, thyroid, and thymus glands. It acts to lower the calcium concentration in blood by enhancing uptake of calcium into the bones.

Hypocalcaemia
A low calcium blood level is referred to as hypocalcemia.

Calcium is measured in extracellular fluid in two forms: total calcium concentration and ionized calcium concentration. About 50% of the total calcium concentration in the plasma exists in ionized form, which is the form that has biological activity at cell membranes. The remainder is either bound to the plasma proteins (about 40%) or complexed in the non-ionized form (about 10%) with anions such as phosphate. In hypocalcemia the total calcium concentration falls below 8.0 mEq/l in the extracellular fluid. Hypocalcemia can result from a number of problems. The most common reason is an inability to mobilize calcium from the bones or a chronic loss of calcium in the urine.

Hypocalcaemia
Other causes of hypocalcemia include: low blood albumin concentration hypoparathyroidism vitamin D deficiency renal failure magnesium depletion acute pancreatitis hypoproteinemia septic shock hyperphosphatemia drugs such as those used to treat hypercalcemia; anticonvulsants excessive secretion of calcitonin

Hypocalcaemia
An abnormally low blood calcium concentration may

not produce any symptoms. However, over time the lack of calcium in the blood can affect brain function causing neurologic symptoms such as memory loss, depression, confusion, delirium, and hallucinations. Once calcium levels return to normal, these symptoms are reversible. Very severe cases of hypocalcemia can lead to seizures, tetany, and muscle spasms in the throat, affecting breathing. The condition is usually first discovered during routine blood tests because often there are no symptoms evident.

Hypercalcaemia
A high calcium blood level is referred to as

hypercalcemia. The blood calcium concentration rises above 10.5 mg per deciliter of blood. Increased gastrointestinal tract absorption or increased intake of calcium may lead to hypercalcemia. Individuals who consume large amounts of calcium or who take calcium containing antacids can develop hypercalcemia. Absorption of calcium can be increased in the gastrointestinal tract with an overdose of vitamin D. The condition is usually first discovered during routine blood tests because hypercalcemia often doesn't have any symptoms at all

Hypercalcaemia
If symptoms occur, typically the earliest are: constipation loss of appetite nausea and vomiting abdominal pain Large amounts of urine may be produced by the kidneys. Due to

excess urine production, fluid levels in the body decrease and may lead to dehydration. Severe hypercalcemia may induce brain dysfunction symptoms such as weakness, confusion, emotional disturbances, delirium, hallucinations, and coma. Additionally, abnormal heart rhythms and death may follow. In chronic conditions, kidney stones or calcium-containing crystals that can cause permanent damage may form.

Potassium Balance
Potassium plays a major part in cell metabolism and in

nerve and muscle cell function. Most of the body's potassium is located intracellular. Too high or low concentrations of blood potassium can have serious effects such as an abnormal heart rhythm or cardiac arrest. The potassium concentration in the blood is maintained with the assistance of intracellular potassium. Like other electrolytes, potassium balance is regulated through gastrointestinal tract absorption of potassium in food, and by excretion of potassium by the kidneys. Some potassium is lost in the gastrointestinal tract, but most is lost through urine. Some conditions and drugs influence potassium balance intracellular, also affecting blood concentrations.

Potassium
High sources of dietary potassium are: bananas melons tomatoes oranges potatoes and sweet potatoes green leafy vegetables such as spinach, turnip greens, collard greens, kale etc. most peas and beans potassium supplements salt substitutes (potassium chloride)

Hypokalemia
A low potassium blood level is referred to as hypokalemia. It occurs

when the blood potassium concentration falls below 3.5 mEq per liter of blood. Hypokalemia is common in the elderly. Common causes include decreased intake of potassium during acute illness, nausea and vomiting, and treatment with thiazide or loop diuretics. About 20% of patients receiving thiazide diuretics develop hypokalemia, which is dose-dependent but usually mild. Since several foods contain potassium, hypokalemia is not typically due to a low intake. It is usually due to malfunction of the kidneys or abnormal loss through the gastrointestinal tract. People with heart disease have to be especially cautious regarding hypokalemia (particularly when taking digoxin), because they are prone to developing abnormal heart rhythms. Potassium usually can be replaced relatively easily by eating foods rich in potassium or by taking potassium salts (potassium chloride) orally.

Hyperkalemia
A high level of potassium in the blood is referred to as

hyperkalemia. It occurs when the blood potassium concentration rises above 5.5 mEq per liter of blood. Hyperkalemia typically results when the kidneys excrete too little potassium. Some common causes are due to:
drugs which block potassium excretion (angiotensin converting

enzyme [ACE] inhibitors, triamterene, and spironolactone) Addison's disease kidney failure a sudden release of potassium from the cell reservoir in such cases as when a large amount of muscle tissue is destroyed (crush injury) or severe burn injuries, or an overdose on crack cocaine

Hyperkalemia
Signs and symptoms Anxiety, Irritability dysrhythmias Hypotension Weakness

Hyperkalemia
The kidney's ability to excrete potassium is over-whelmed due to

a rapid influx into the blood, resulting in life-threatening hyperkalemia. Generally, hyperkalemia is more dangerous than hypokalemia. A blood potassium concentration above 5.5 mEq/liter starts to affect the electrical conducting system in the heart. If the concentration continues to increase, the heart rhythm becomes irregular which may cause the heart to eventually stop. Mild hyperkalemia often may not produce any symptoms. Symptoms may include an irregular heartbeat that could be experienced as palpitations. Hyperkalemia is typically first diagnosed during a routine blood test or by examining changes in an electrocardiogram. Severe deficiencies may lead to muscular weakness, twitches, and paralysis.

Magnesium Balance
Magnesium influences the function of many enzymes.

Dietary intake is essential to maintain normal levels. The body's magnesium stores are predominately found in bone with little appearing in the blood. Excess is excreted in the urine or stool.

Hypomagnesemia
A low level of magnesium in the blood is known as hypomagnesaemia. The level of magnesium in the blood decreases below 1.6 mEq per liter of blood. Metabolic and nutritional disorders are usually the culprit of hypomagnesaemia, most often when intake of magnesium is decreased during starvation or intestinal malabsorption compounded with greater kidney excretion. Symptoms of hypomagnesaemia may include: loss of appetite nausea and vomiting sleepiness weakness personality changes muscle spasms tremors When hypomagnesaemia occurs along with hypocalcemia, the magnesium must be replaced before successful treatment of the calcium disorder.

Hypermagnesemia
HYPERMAGNESEMIA. A high level of magnesium in

the blood is referred to as hypermagnesemia. The blood magnesium concentration rises above 2.1 mEq per liter of blood. Hypermagnesemia is quite rare unless people with kidney failure are given magnesium salts or consume magnesium-containing drugs such as antacids. Weakness, low blood pressure, and impaired breathing can result and the heart may stop if the concentration increases above 12 to 15 mEq per liter.

Phosphate
Phosphate regulation Phosphorus occurs in the body almost solely in the form of

phosphate, which is composed of one phosphorus and four oxygen atoms. Phosphate is found mostly in bones, although a significant amount is found intracellular. It plays a role in energy metabolism and acid-base regulation, and it is used as a building block for DNA. Phosphate is excreted in the urine and stool. Sources of phosphate include: spinach, turnip greens, collard greens, kale, and other green leafy vegetables milk and dairy products nuts chocolate many peas and beans dark-colored soft drinks

Bicarbonate
Bicarbonate is the major chemical buffer within the

body. The bicarbonate ion (HCo3-)is found intracellular and extracellular. Kidneys regulate bicarbonate. Normal arterial bicarbonate levels range between 22-26 mg/L. It is very essential for acid-base balance

Acid Base Balance


Acid-Base balance is a result of a stable concentration

of hydrogen ions in body fluids. The ph is the scale measuring the acidity and alkalinity of a fluid. A ph of 7 is neutral. Below 7 is considered acidic and above 7 is considered alkaline. Normal arterial blood is 7.357.45

Metabolic Acidosis
It results from a rise in Hydrogen-ion concentration in the

extracellular fluid, caused by and increase in Hydrogen ions levels or a decrease in Bicarbonate levels. Signs and Symptoms
Headache, lethargy, confusion, deep respirations, flushed

skin, and tachypnoea

Causes: Starvation DKA Renal Failure Shock Diarrhea

Metabolic Alkalosis
It is marked by heavy loss of acid from the body or

increased levels of Bicarbonate. The most common cause is vomiting. Other causes are hypokalemia, prolonged gastric suctioning, Cushing's syndrome, use of certain drugs like steroids, bicarbonates, and diuretics. Signs and Symptoms
Headache, irritability, lethargy, dysrhythmia, abdominal

cramping, numbness, tingling, muscle cramps, and tetany

Respiratory Acidosis
Is marked by an increase arterial carbon dioxide

concentration, excess carbonic acid and increased hydrogen-ion concentration. Respiratory Acidosis is caused by hypoventilation. Hypoxia occurs CSF becomes acidic

Respiratory Alkalosis
Is marked by a decreased carbon dioxide concentration

and decreased hydrogen-ion concentration. Respiratory Alkalosis results from excessive exhalation or hyperventilation Signs and Symptoms
Headache, irritability, dizziness, tingling sensation of

extremities, tachypnea, and dysrhytmias

Review
Questions
Nursing Process

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