Balance of Fluid and Electrolyte

• Fluid and electrolyte balance is a dynamic process

that crucial for life and homeostasis.

• Nursing role is to help prevent and treat any fluid

and electrolyte or acid base balance disturbances.

• Homeostasis: It is the state of equilibrium in the

internal environment of the body, naturally
maintained by keeping the composition and volume
of body fluids within narrow limits of normal.

Compartments
• Intracellular fluid ( inside the cells ) (ICF)
• Extracellular fluid ( outside vessels ) (ECF)
– Intravascular (plasma)
– Interstitial
–
• Transcellular Fluid ( fluid in some organs- such as the brain )

Intracellular Fluid (ICF)

• Fluid located within cells
• 42% of body weight
• Most prevalent cation ( pos ion ) is potassium (K+) - must be controlled or it would cause heart
issues)

• Most prevalent anion (neg ion ) is phosphate (PO -)

4

Extracellular Fluid (ECF ) :

Fluid spaces between cells (interstitial fluid) Transcellular Fluid
and the plasma space
• Most prevalent anion is chloride (Cl-) • Small but important fluid compartment
• Most prevalent cation is sodium - • Approximately 1L
soduim attracts other fluid such as water
• Includes fluid in
(Na+) – Cerebrospinal fluid
• Expands and contracts – Gastrointestinal (GI) tract - lubrication
• 2/3 of ECF in interstitium – Pleural spaces - lungs , heart
– Synovial spaces - fluid in joints
• Intravascular (IV) – Peritoneal fluid spaces - peri - around the
– Within vascular space abdomen
– Measured with blood tests
– 1/3 of ECF
 Fluid Shifts
• Plasma to interstitial fluid shift can results in edema
– Elevation of hydrostatic pressure - fluid moving from area of high pressure to area of low pressure
– Decrease in plasma oncotic ( osmotic ) pressure-which is caused by protein in plasma ( albumin)
– Elevation of interstitial oncotic pressure ‫ زيادة السوائل‬-
oncotic ( osmotic ) pressure - protect the fluid in its place but decreasing it will go out from its place to
interstational ‫ فقد السوائل‬-
hydrostatic pressure - arteries give fluid to capillaries - ‫قوات الضخ‬

• Interstitial fluid ( edema ) to plasma

– Fluid drawn into plasma space whenever there is increase in plasma osmotic or oncotic pressure ( pull
water )
– Wearing of compression stockings or hose is a therapeutic action on this effect - clothing helps
forcing the proteins and blood vessels to pul the fluid .

Fluid Movement Between Extracellular and Intracellular

Water deficit (decreased ECF) is associated with symptoms that result from cell shrinkage as water is pulled into
vascular system
• Water excess (increased ECF) develops from gain or retention of excess water

Fluids loss and gain mechanisms

• Loss:

– Kidney: urine output (1 ml/kg/hr).

• Gain
– Skin: sensible (sweating) and
– Dietary intake of fluid and food or insensible losses (evaporation)- by
enteral feeding talking , breathing , moving .

– Parenteral fluids - IV fluids – Lungs: insensible losses

(evaporation)

– GI tract

Daily
fluid Gain and Loss
 Laboratory Tests for
Evaluating Fluid status

1- Osmolality (mOsm/kg): measures the solute

concentration per kilogram in blood and urine*.

➢ Serum osmolality: primarily reflects the

concentration of sodium - blood
(280-300mOsm/kg).

➢ Urine osmolality: determined by urea,

creatinine and uric acid (200-800mOsm/
kg)
2- Osmolarity: describes the concentration of solution
(mOsm/L).
SUMMARY :
Osmolality - concentration to weight -
concentration due to kg
Osmolarity - concentration of solution due to
liter

3- Urine specific gravity ( concentration of the urine ): measure the kidney’s ability to excrete or
conserve water. (1.010-1.025).
•Less reliable indicator of concentration than urine osmolality.
•SG varies inversely with urine volume?? - SG is high then urine volume or concentration is low and vise
versa

Urine
SG is Urine volum
SG is
High volume e is
low
is low hight

4- BUN: end product of the metabolism of protein (muscle and dietary intake). Normal BUN is 10-20 mg/
dl.(3.6-702mmol/L).
•High BUN:
- GI bleeding = because of releasing the protein
- dehydration - because of protein concentrated
- fever and sepsis because of loosing water and protein concentrated .

•Low BUN:
•low-protein diet - starvation , liver disease because of not getting enough protein

5- Creatinine: end product of muscle metabolism. Best indicator of renal function than BUN. Why?
•Normal serum creatinine (0.7-1.4 mg/dl) (62-124 mmol/L).
•Increase when renal function decrease
 6- Hematocrit: measure the volume percentage of RBCs in whole blood ( fluid) (42%-52% male)(35%-47%
female). If RBC is increased in volume the its because the fluid is decreased
•What are the conditions that ↑ and ↓ Hct level??
•Bleeding , fluid defecent, dehydration , enema , fever

7- Urine sodium: change with Na intake and change in the fluid status. (75-200mmol/24hrs)
- high indicate hypernatremia , low indicate hyponatremia -

•Used to assess volume status and useful in the diagnosis of hyponatremia - low sodium and renal failure.
•As Na+ intake ↑body tees to drink water , resulting in excretion ↑ - going to urinate .
•As circulatory volume ↓ , Na+ conserved meaning - no excretion

Fluid Volume Disturbances :

• Fluid Volume deficit ( FVD ) : Hypovolemia

• FVD: Loss of extracellular fluid exceeds decrease intake ratio of water, and electrolytes are lost in
the same proportion as they exist in normal body fluids. So when urination loss of electrolyte will
occur ( loss of electrolyte is more decreasing and losing than the lose of water and electrolyte in the
body ).

• Dehydration refers to loss of water alone with increased serum sodium level that is kept in body.

• FVD , May occur in combination with other imbalances or diseases.

• Causes: fluid loss from vomiting

• diarrhea
• GI suctioning
• sweating
• decreased intake of fluid, and inability to gain access to fluid

• Risk factors:
• diabetes Insipidus - lier diabetes causes by hormone ( antidiuretic will effect urination if hormone
decreased , urination is more and if hormone is increased , urination is less )
• adrenal insufficiency - release aldosterone hormone protect sodium and fluid so , ( low aldosterone
causing low NA (sodium ) and fluid )
• osmotic diuresis - low fluid meaning fluid is going out )
• hemorrhage
• coma - because there is no nutrient intake
• and third space shifts - interstitial space -caused by surgeries and kidney disease
Manifestations ( signs and symptoms ):

• Rapid weight loss.

• Decreased skin turgor .

• Oliguria - abnormal urine and concentrated urine.

• Postural hypotension, rapid and weak pulse. - so pulse in high or rapid heart rate but weak pulse

• Increased temperature, cool and clammy skin due to vasoconstriction.

• Thirst.

• Nausea , decreased in electrolyte

• Muscle weakness, and cramps.

Laboratory data:
• Elevated BUN in relation to serum creatinine.
• Increased hematocrit, and possible serum electrolyte changes.

• Physical exam
– Assess skin dryness, mucous membrane, conjunctiva.
– Assess the vital signs.
– Assess mental status: confusion and lethargy - because of the electrolyte
– Neuromuscular assessment of muscle tone and strength, movement, coordination, and
tremors.
– Assess I &O chart.

Medical Management:
• Reverse the cause when possible by :
- Provide oral fluids
- Administer IV Fluid, Blood transfusion.
- Drug Therapy: (Depends on cause: antiemetic - anti-vometing , anti diarrhea).

Medical Management:
•Isotonic - balance electrolyte solutions (lactated Ringer’s, 0.9%sodium chloride) are used for hypotensive
pt with low FVD.
•Hypotonic solutions (concentration of electrolyte is low then the fluid is high )(0.45% sodium chloride) are
used when pt becomes normotensive, to provide both electrolytes and water for renal excretion of waste
product.
•Hypertonic solutions ( concentration of electrolyte is high then the fluid)

Hypotonic :
Isotonic : Hypertonic :
- half normal
- ringer lactate - ringer lactate
saline 0.45 %
- Normal saline 0.9 % - Half normal saline 0.9%
Nursing Management:
• Measuring I & O
• Daily body weight - in morning
• Evaluate tongue turgor (more than one longitudinal groove and tongue is smaller because of fluid
loss)
• Measuring urine specific gravity (normal 1.015- 1.025), Urine SG will increase in relation to the
kidney’s attempt to conserve water.

Fluid Volume Excess ( fluid overload ):

• FVE : refers to an expansion of the ECF caused by abnormal retention of water and sodium.

• This may be related to fluid overload or diminished homeostatic mechanisms.

Causes:
• Excessive dietary sodium or sodium-containing IV solutions
• Heart failure - edema and Renal failure -result in accumulation of fluid
• Primary polydipsia - excess thirst
• Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
• Long term use of corticosteroids - cortisol conserve of sodium and water

Manifestations:

➢Edema; distended neck veins;

➢Abnormal lung sounds (crackles); shortness of breath; and wheezing

➢ Tachycardia with bounding pulse; increased BP, pulse pressure, and CVP-
central venous pressure

➢ Increased weight; increased UOP

➢Possible seizures and coma

Medical management:
•Corner stone is directed at the cause, restriction of fluids and sodium, and the administration of
diuretics.
•Drug therapy – osmotic diuretics first, then the loop diuretic such as Lasix
•Monitor responses to medications such as diuretics.
•Dialysis
•Nutritional therapy
 Nursing Management:
➢Weights daily, I&O, serum electrolytes, EKG, and albumin level
➢Assessment of cardiopulmonary, renal, mental, lung sounds, edema & skin.
➢V/S every 4 hours and PRN; I&O each shift and PRN, Check IV fluids hourly.
➢Use semi-Fowler’s position for orthopnea
➢Monitor responses to medications- diuretics
➢Promote adherence to fluid restrictions, patient teaching related to sodium and fluid restrictions
➢Skin care, positioning/turning - patient very prone to skin breakdown and infections - prevent
ulcer by turning patient every 2hr
➢Teaching patients about edema ( be ware whether localized like RA, generalized-anasarca, or
ascites)

Isotonic Solution Hypotonic solution Hypertonic solution

• Normal Saline (NaCl.9%), • Half- Strength Saline (NaCl • Normal saline or R/L contain
), with osmolality of 5% dextrose
Dextrose water (D5W), R/L. 0.45%
154mOsm/L. • (D 5%NaCl0.9%) - hypertonic

• (D 5%NaCl0.45%) hypotonic ,
• higher concentration of
dextrose (D50%W), (DW
10%) are hypertonic.
• Fluids have the total • Purpose of use: replace • These solutions draw water
cellular fluid, provide free from the ICF to the ECF and
osmolality of the ECF, and
water for excretion of body cause cells to shrink.
do not cause cell to swell or wastes.
shrink.
• Isotonic fluid expand ECF • Used to treat • Rapid or excessive
hypernatremia & other admiration may cause EC
volume, i.e, 1L fluid expand
hyperosmolar - con of volume excess and
ECF by1L, and plasma by electrolyte higher then
fluid - conditions. circulatory overload.
0.25L because it is a
crystalloid fluid and diffuses
quickly into ECF.
• Excessive infusion ( too
quickly or too large
amount) can lead to
intravascular depletion,↓
BP, cellular edema and
death.
 Nursing management of the patient receiving Intravenous Therapy
1- Preparing to administer Intravenous Therapy.
2- Choosing an intravenous site.
➢ Condition of the vein.
➢ Type of fluid and medications to be infused
➢ Duration of therapy
➢ Patient age and size
➢ Whether pt is right or left handed.

3- Selecting vein puncture devices:

➢Cannulas
➢Needles intravenous delivery systems
➢Peripherally inserted central catheter
(PICC) line
4- Teaching the patient.
5- Preparing the IV site.
6- Promoting Venipuncture
7- Maintain therapy.
8- Factors affecting the flow.
➢ Height of liquid column.
➢ Diameter of the tubing
➢ Length of the tubing
➢ Viscosity of the liquid.
9- Monitoring flow
10- Discontinuing an infusion.
Managing complications.
A) Managing Systemic Complications:
➢Fluid overload.
➢Air embolism
➢Infections.
B) Managing Local Complications:
➢ Infiltration ( fluid not entering the vein , going out to the tissue - The leakage of blood,
lymph, or other fluid, such as an anticancer drug, from a blood vessel or tube into the
tissue around it.) and extravasation
➢ Phlebitis: is an inflammation of a vein.
➢ Thrombophlebitis: phlebitis associated with the formation of blood clots.
➢ Hematoma.
➢ Clotting and Obstruction.

Electrolytes
• Are substances whose molecules split into ions when place in water.
• Major cations: Major anions:
▪ Sodium (Na+) Chloride (Cl-)
▪ Potassium (K+) Bicarbonate (HCO -)
3
▪ Calcium (Ca++) Phosphate (PO 3-)
4
▪ Magnesium (Mg++)
▪ Hydrogen ions (H+)

• Electrolyte concentrations differ in the fluid compartments.

• Normal Concentration of potassium is from 3 -5
 Electrolyte Imbalances
Sodium: hyponatremia and hypernatremia
Potassium: hypokalemia and hyperkalemia
Calcium: hypocalcemia and hypercalcemia
Magnesium: hypomagnesemia and hypermagnesemia
Phosphorus: hypophosphatemia and hyperphosphatemia
Chloride: hypochloremia, hyperchloremia

Sodium : hyponatremia and hypernatremia

• Imbalances typically associated with parallel changes in osmolality

• Plays a major role in
– ECF volume and concentration
– Generation and transmission of nerve impulses
– Acid-base balance

Hypernatremia : giving fluid Hyponatremia : do not want fluid

• Elevated serum sodium occurring with water loss • Results from loss of sodium-containing fluids or
or sodium gain from water excess
• • Clinical manifestations include confusion,
nausea, vomiting, seizures, and coma - cell will
• Causes hyperosmolality leading to cellular swell and burst
dehydration - shift fluid interstitial to vessels
• If caused by water excess, fluid restriction is
• needed
• Primary protection is thirst from hypothalamus • If severe symptoms (seizures) occur, small
amount of intravenous hypertonic saline solution
( more fluid give) - (3% NaCl) is given
• If associated with abnormal fluid loss, fluid
replacement with sodium-containing solution is
needed
• Manifestations include: Medical management
- thirst Water restriction.
- lethargy - weakness - Sodium replacement (by mouth, NGT, or
parenteral route (isotonic : 0.9% sodium
- agitation - moving alot chloride, or RL).
- seizures and coma - cell shrinking - In SIADH -( high fluid means less sodium result
in causing hyponatremia ): HTN* saline in
• If secondary to water deficiency, it often results combination with diuretic frusemide, if we can
of impaired LOC ( loss of water and high sodium not restrict water, lithium, or Declomycin
level effect level of consciousness . ( antibiotic )that antagonizes the effect of ADH
• Can be produced by clinical states such as - Assessment, prevention, & monitoring of dietary
central or nephrogenic sodium and fluid intake

• diabetes insipidus - no antidiuretic result in more

urine and causes hypernatremia - Identification and monitoring of at-risk patients
and the effects of medications (diuretics and
lithium)
• Hyponatremia can be dangerous for persons
taking Lithium

Factors causing hyponatremia :

- lithium
- Declomycin
- SIADH
• Management includes Nursing management
– Treat underlying cause , such as coma - Assessment, prevention, & monitoring of dietary
– If oral fluids cannot be ingested, IV sodium and fluid intake
solution of 5% dextrose in water or
hypotonic saline - more or high fluid
– Diuretics - Identification and monitoring of at-risk patients
and the effects of medications (diuretics and
• Serum sodium levels must be reduced gradually lithium)
to avoid cerebral edema - Nursing alert : hypertonic solutions , to be
administered only in intensive care units
Nursing management
- Assessment, prevention, assess for over-the-
counter (OTC) medications* high of sodium.

- Offer and encourage fluids to meet patient

needs, and provide sufficient water with tube
feedings.
LOW SODUIM
 Potassium : Hyperkalemia , Hypokalemia

• Potassium major ICF cation

• Potassium is necessary ( needed ) for :
– Transmission and conduction of nerve impulses
– Maintenance of normal cardiac rhythms
– Skeletal muscle contraction or relaxed if low potassium
– Acid-base balance
3.5 - 5 normal range of potassium
Hyperkalemia Hypokalemia
• Causes • Causes
– Increased retention – Increased
• Renal failure , • Aldosterone
• Potassium sparing diuretics • Loop diuretics
(Amiloride - protect potassuim) • GI losses
– Increased intake - banana , potato • Associated with Mg deficiency
– Mobilization from ICF • Movement into cells
• Tissue destruction - such as
burn , pressing for taking blood NOTE :
• Acidosis - ‫ الحمضيه‬- PH 7.35 -7.45 Aldosterone used to : conserve sodium and fluid
• if PH is less <7.35 result in and excrete potassium
acidosis
• If PH is high >7.45 result in But if !!! :
alkalosis aldosterone Increased results in - excrete
potassium
aldosterone Decrease results in - keeping
potassium
- Loop diuretics used to - excretes fluid and
potassium
❑Clinical Manifestations ❑ Clinical Manifestations
• Skeletal muscles contraction or paralyzed • Potentially lethal ventricular arrhythmias
• Ventricular fibrillation
• Impaired repolarization
• Cardiac depolarization is impaired
• Increased digoxin toxicity in those taking the
• Repolarization occurs more quickly
drug
• Abdominal cramping or diarrhea when moving
• Skeletal muscle weakness and paralysis
• Muscle cell breakdown
– Leads to myoglobin in plasma and
urine

NOTE :
Digoxin - lowers HR
Hypokalemia - cause digoxin toxicity cause lower
HR entering patient to cardiac arrest
 medical management medical management
- Monitor ECG. - Administer potassium chloride ( KCL )
supplements orally or IV slowly or in IV pump.
- Cation exchange resin (Kayexalate orally or by
enema) taking out extra potassium - Increase dietary intake of potassium.( ABC fruit
and vegetables* )
- Stop K+ oral or parenteral intake.
- Monitor lab values.
- Increase elimination of k+ by administer diuretics
(lasix), NOTE :
Apple, Banana, Cantaloupes – Asparagus, Broccoli,
- IV sodium bicarbonate - alkaline( in acidosis) (to Carrots + tomatoes ( in general red soups are rich
force K to ICF)
with Ka content)
- IV calcium gluconate ( preserve myocardium)
- Regular insulin and hypertonic dextrose
IV( intracellular shift)
- last resort: perform dialysis
nursing care interventions nursing care interventions
- Assess serum potassium levels Monitor lab work.
- Monitor medication effects. - Increase dietary intake of potassium.
- Initiate dietary potassium restriction and - Monitoring of electrocardiogram (ECG)
dietary teaching for patients at risk - Arterial blood gases (ABGs). Ex : PH
- Providing nursing care related to IV potassium
administration - phlebitis
NOTE :
Taking acidosis - hyper
Taking alkaline brings potassium normal
 Calcium : Hypercalcemia, Hypocalcemia

• Obtained from ingested foods

• More than 99% combined with phosphorus and concentrated in skeletal system
• Inverse relationship with phosphorus
• Bones readily available store of calcium
• Calcium blocks sodium transport and stabilizes cell membrane

- Functions include
- transmission of nerve impulses
- myocardial contractions
- blood clotting
- formation of teeth and bone
- muscle contractions

• Only ionized form of calcium is biologically active

• Controlled by
– Parathyroid hormone - low Parathyroid hormone production result in hypocalciuma
and High Parathyroid hormone production result in hypercalciuma
– Calcitonin
– Vitamin D
Hypercalcemia : High serum calcium levels Hypocalcemia : Low serum calcium levels
• Causes include • Causes include
– Hyperparathyroidism – Decreased production of PTH
– Malignancy – Acute pancreatitis
– Vitamin D overdose – Multiple drug transfusions
– Prolonged immobilization - bedridden – Alkalosis - PH
– Decreased intake
calcium get out from bone and goes out
to blood vessels

• Clinical manifestations include ‫التأثيرات‬ Signs # 1 :

– decreased memory • Chvostek’s sign:
– confusion
– disorientation sign refers to a twitch of the facial muscles that
occurs when gently tapping an individual's
– fatigue cheek, in front of the ear.
WHY ? Is this happening : The Chvostek sign is a
clinical finding associated with
hypocalcemia, or low levels of calcium in the
blood.

https://www.youtube.com/watch?v=SFVQFLJbir0
• Management includes Signs # 2 :
– loop diuretic
– hydration with isotonic saline infusion • Trousseau’s sign is carpal spam induced by
inflating BP cuff above the SBP for a few or
– synthetic calcitonin - build calcium to refers to the involuntary contraction of the
bone muscles in the hand and wrist (i.e.,
– mobilization carpopedal spasm) that occurs after the
compression of the upper arm with a blood
pressure cuff.

https://www.youtube.com/watch?v=SBuquydjZDc
• Clinical manifestations include positive
Trousseau’s sign and Chvostek’s sign
• Others include laryngeal stridor, dysphagia,
numbness, and tingling around the mouth or in
the extremities
• Management
– Treat cause
– Oral or IV calcium supplements such as
vitamin D
– Treatment of pain and anxiety to prevent
hyperventilation-induced respiratory
alkalosis - when breathing too much
 Magnisum : hypomagnesemia and hypermagnesemia

Magnesium Imbalances
• Magnesium (Mg++) is the most abundant intracellular cation after Potassium (K+).
• The normal serum magnesium level is 1.3 to 2.3mg/dl (0.62 to 0.95mmol/L).

• It plays a major role in both carbohydrate and protein metabolism.

• Variation in the Mg level affect neuromuscular irritability and contractility - muscle .

• Mg level < 1.3 is Hypomagnesemia, and level > 2.3 is Hypermagnesemia.

Causes: Causes:
Hypermagnesemia: Hypomagnesemia:
•Renal failure •Alcoholism.
•Diabetic ketoacidosis •GI losses.
•Excessive administration of magnesium* •Enteral or parenteral feeding
•Deficient in magnesium.
•Medications
Clinical Manifestations(symptomes ): Clinical Manifestations ( symptoms ):
Hypermagnesemia:
Hypomagnesemia:
•Neuromuscular irritability •Flushing
•Muscle weakness •lowered BP
•Tremors, athetoid movements. •Nausea & vomiting
•ECG changes and dysrhythmias •Hypoactive reflexes
•Alterations in mood and level of consciousness. •Drowsiness,
•Dysphagia is common •Muscle weakness
•Hyperactive reflexes •Depressed respirations
•ECG changes, and dysrhythmias
Medical managements: Medical managements :
Hypomagnesemia: Hypermagnesemia:
•Diet •IV calcium gluconate
•Oral magnesium • loop diuretics
•Magnesium sulfate IV •Hemodialysis