Fluid and Electrolyte Balance

What?
60% of the adult body is fluid
Varies with age, gender, body size/fat
ICF (intracellular fluid)
2/3 of body
Skeletal muscle mass
ECF (Extracellular fluid)
1/3 of body
Intravascular (3-6L)
Plasma
blood volume
Interstitial (11-12L)
Lymph
Fluid surrounding cells
Transcellular (1 l)
Cerebral spinal, pericardial, intraocular,
pleural, digestive secretions, sweat
Third spacing loss of ECF into spaces that do not
contribute to equilibrium
Decreased urine output with adequate fluid
intake
Electrolytes
Major Cations: sodium, potassium, calcium,
magnesium, hydrogen ions
Major anions: chloride, bicarbonate, phosphate,
sulfate, protienate ions
Labs
Osmolality concentration of fluid that effects
movement of H2O between compartments;
measures solute concentration in blood/urine
Serum and urine measured
Urine Specific Gravity varies inversely with
urine volume
BUN varies w/ volume of urine output (etiologies
for / values)

Regulation of Fluid
Movement of fluid through capillary walls:
Hydrostatic pressure: exerted on walls of
blood vessels
Osmotic pressure: exerted by protein in
plasma
Types of Movement
Osmosis: Fluid moves from Low solute
concentration to high solute concentration
Diffusion: Solutes move from high
concentration to low concentration
Filtration: Movement of water, solutes occurs
from high hydrostatic pressure to an area of
low hydrostatic pressure
Active transport: Pump that moves fluid
from area of lower concentration to high
concentration
Move against concentration gradient
Sodium-potassium
pump:
maintains
Systemic
Routes: Gains
and losses
higher
eC NA
and lower IC K
Healthy: 2.500
cc I&O
daily

Requires
ATP
for
energy
Kidney: urine output: 1 ml urine/kg/hour
(1-2L/day)
Skin: sensible loss, perspiration; solutes Na, Cl, K
1,000 ml/hr due to activity/environment
Effect of fever, major burns
Insensible loss, evaporation (500 mL/day)
Lungs: insensible loss (300 mL/day), with
RR/Dry climate
GI Tract: 8L of fluids/day; 100-200 mL of fluid loss
Critical effects of diarrhea, fistulas

Fluid and Electrolyte Balance: Homeostatic

Mechanisms
Kidney
Regulation of:
ECF volume
Electrolyte levels
pH of ECF
Excretion of wastes/toxic substances
Heart, Blood Vessels
Pumping ensures adequate kidney
perfusion
Lung Functions
Fluid removal
Acid-Base balance
Pituitary Functions
Controls release of ADH

Adrenal Functions
Effects of aldosterone
Effects of cortisol
Parathyroid Functions
Parathyroid hormone (PTH)
Calcium and phosphate balance

Vascular
Baroreceptors: affect sympathetic
nervous system
Renin-angiotensin-aldosterone
system
Antidiuretic hormone and thirst
Osmoreceptors
Natriuretic peptides

Fluid Volume Deficits (FVD) - Hypovolemia

What?
FVD 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 alone with
increased serum sodium level

Pathophysiology
Abnormal fluid loss:
Vomiting
Diarrhea
GI suctioning
Sweating
Inadequate intake:
Nausea
Third spacing
Disease states:
Diabetes insipidus
Major burns
Hemorrhage

Diagnostics

BUN
Serum Creatinine
Serum electrolytes
Urine specific gravity

Manifestations
Major fluid & electrolyte imbalances
Rapid weight loss
Decreased skin turgor
Oliguria, concentrated urine
Postural hypotension, rapid weak pulse,
increased temperature
Cool clammy skin (vasoconstriction),
thirst, nausea, muscle weakness, cramps
Geriatrics
Increased sensitivity to:
Fluid volume changes & Electrolyte
changes
Responsive to changes in function with:
Kidney
Cardiac
GI Function
Management
Medical
Provide fluid (oral, plasma vol.
expanders)
Assess renal function (urine output,
tests)
Nursing
I&O, Daily weight, vitals
Monitor: skin & tongue turgor,
mucosa, urine, mental status

Fluid Volume Excess (FVE) - Hypervolemia

What?
Isotonic expansion of ECF
Abnormal retention of water and sodium
consistent with normal proportions
Serum sodium levels remain normal
Pathophysiology
Due to fluid overload or diminished
homeostatic mechanisms
Risk factors: heart failure, renal failure,
liver cirrhosis
Contributing factors: excessive dietary
sodium or sodium containing IV solutions

Manifestations

Edema
Distended neck veins
Abnormal lung sounds (crackles),
tachycardia, increased blood pressure,
pulse pressure, CVP
Increased weight, increased urine output
Shortness of breath and wheezing
Management
Medical
Directed at cause
Restrictions of fluid and sodium
Administration of diuretics
Nursing
I&O, Daily weights; assess lung
sounds, edema, etc
Monitor response to meds
Promote adherence to fluid
rerstrictions
Teaching r/t sodium and fluid
limits
Monitor:
Avoid sources of excessive
sodium, including meds
Semi-fowlers position for
orthopnea
Skin care, positioning/trauma

Electrolyte Imbalances - Sodium

Hyponatremia

What?
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
Management

Medical
Water restriction
Sodium replacement
Nursing
Assessment and Prevention
Dietary sodium and fluid intake
Identify and monitor at-risk patients
Effects of meds (diuretics, lithium)

Hypernatremia

What?
Serum sodium greater than 145 mEq/L
Causes: Excess water loss, excess
sodium administration, diabetes
insipidus, heat stroke, hypertonic IV
solutions Manifestations
Thirst (may be impaired in elderly and
ill)
Elevated temperature, dry/swollen
tongue
Sticky mucosa
Neurologic symptoms
Restlessness,
weakness
Management
Medical
Hypotonic electrolyte solution or
D5W
Nursing
Assessment and prevention
Assess for OTC sources of sodium
Offer and encourage fluids
Provide sufficient fluids with tube
feedings

Electrolyte Imbalances - Potassium

Hypokalemia

What?
Serum potassoi, less than 3.5 mEq/L
Causes: GI losses, medications,
alterations of acid-base balance,
hyperaldosteronism, poor diet intake
Manifestations
Fatigue, anorexia, nausea, vomiting
Dysrhythmias, muscle weakness/cramps,
paresthesias
Glucose intolerance, decreased muscle
strength
DTRs
Management
Medical
Increased dietary potassium
Potassium replacement
IV for severe deficit
Nursing
Assessment
Severe deficit is life threatening
Monitor ECG and ABG
Dietary potassium
IV potassium administration

Hyperkalemia

What?
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
Management
Medical
Monitor ECG
Limitation of dietary potassium
Cation-exchange resin (Kayexalate)
IV sodium bicarbonate
IV calcium gluconate
Regular insulin and hypertonic dextrose
IV
B-2 agonists
DIalysis
Nursing
Assess potassium levels
Mix Ivs containing K+ well
Monitor Med effects
Dietary potassium restrictions/ diet
teaching
Hemolysis of blood or drawing above IV
may cause false lab results
Salt substitutes, meds containing

Electrolyte Imbalances - Calcium

Hypocalcemia

What?
Serum calcium less than 8.6 mg/dL
(consider albumin)
Causes: Hypoparathyroidism,
malabsorption, pancreatitis, alkalosis,
massive transfusion of citrated blood,
Manifestations
renal failure,
medications
Tetany, circumoral numbness,
paresthesias
Hyperactive DTRs, Trouseaus sign,
Chovsteks sign
Seizures, respiratory symptoms (dyspnea
& laryngospasm)
Management
Abnormal clotting, anxiety
Medical
IV of calcium gluconate
Calcium and vitamin D supplements
Diet
Nursing
Assessment
Severe cases are life threatening
Weight-bearing exercises to decrease
bone calcium loss
Teaching related to diet and
medications
IV Calcium administration

Hypercalcemia

What?
Serum calcium greater than 10.2 mg/dL
Causes: Malignancy, and
hyperparathyroidism, bone loss related
to immobility
Manifestations
Muscle weakness, incoordination,
anorexia
Constipation, nausea, vomiting
Abdominal and bone pain
Polyuria, thirst
ECG changes, dysrhythmias
Management
Medical
Treat cause
Fluids
Furosemide, phosphates, calcitonin,
biphosphonates
Nursing
Assessment
Crisis has a high mortality
Ambulate patient
3-4 l fluids per day
Provide fluids with sodium unless CI
Fiber for constipation
Ensure safety

Electrolyte Imbalances - Magnesium

Hypomagnesemia

What?
Serum magnesium less than 1.3 mg/dL
(consider albumin)
Causes: Alcoholism, GI losses, enteral or
parenteral feeding deficit in magnesium,
medications, rapid administration of
citrated blood, contributing causes in:
DKA, sepsis,Manifestations
burns, hypothermia
Neuromuscular irritability, muscle
weakness, tremors
Athetoid movements, ECG changes and
dysrhythmias
Alterations inManagement
mood and LOC
Medical
Diet
Oral magnesium
Magnesium sulfate IV
Nursing
Assessment
Teaching: diet, meds, alcohol
IV magnesium sulfate administration
Often accompanies hypocalcemia
(monitor and treat)
Dysphagia common (assess pt
abilities)

Hypermagnesemia

What?
Serum Magnesium greater than 2.3
mg/dL
Causes: Renal failure, DKA, excess Mg
administration
Manifestations
Flushing, low BP, nausea, vomiting,
hypoactive reflexes
Drowsiness, muscle weakness, resp
depression
ECG changes, hemodialysis
Management
Medical
IV calcium gluconate, loop diuretics
IV NS or LR
Hemodialysis
Nursing
Assessment
Do not administer meds with
magnesium
Patient teaching regarding OTC
meds with Mg

Electrolyte Imbalances - Phosphorus

Hypophosphatemia

What?
Serum phosphorus less than 2.5 mg/dL
Causes: Alcoholism, refeeding of
patients after starvation, pain, heat
stroke, resp alkalosis, hyperventilation,
DKA, hepatic encephalopathy, major
burns, hyperparathyroidism, low
magnesium, low potassium, diarrhea, low
vitamin D, use
of diuretics or antacids
Manifestations
Neurologic symptoms, Confusion
Muscle weakness, tissue hypoxia,
muscle/bone pain
Increased susceptibility to infection

Hyperphosphatemia

Management

Management

Medical
Oral or IV replacement
Nursing
Assessment
Encourage foods high in phosphorus
Gradually introduce calories for
malnourished pts receiving
parenteral nutrition

What?
Serum phosphorus greater than 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
Treat underlying disorder
Vitamin D preparations
Ca binding antacids
Phosphate-binding gels or antacids
Loop diuretics, NS IV, dialysis
Nursing
Assessment
Avoid high phosphorus foods
Diet teaching (phosphate
containing substances)
Signs of hypocalcemia

Electrolyte Imbalances - Chloride

Hypochloremia

What?
Serum chloride less than 97 mEq/L
Causes: Addisons disease, reduced
chloride intake, GI loss, DKA, 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
Dysrhthmias, seizures, coma

Hyperchloremia

Management

Management

Medical
Replace chloride IV NS or 0.45% NS
Nursing
Assessment
Avoid free water
Encourage high-chloride foods
Patient teaching related to highchloride foods

What?
Serum Chloride greater than 107 mEq/L
Causes: Excess sodium chloride
infusions with water loss, head injury,
hypernatremia, dehydration, severe
diarrhea, respiratory alkalosis,
metabolic Manifestations
acidosis
Tachypnea, lethargy, weakness
Rapid/deep respirations
Hypertensions, cognitive changes
Normal serum anion gap

Medical
Restore electrolyte and fluid
balance, LR, sodium bicarbonate,
diuretics
Nursing
Assessment
Patient teaching related to diet and
hydration