Fluid and electrolyte balance

Jerash University
Faculty of Nursing

Ibrahim R. Ayasreh
1
RN, MSN
 Amount and Composition of Body Fluids
 Approximately 60% of the weight of a typical adult consists of
fluid (water and electrolytes).

 Factors that influence the amount of body fluid are:

- Age: younger people have a higher percentage of body fluid
than older people
- Gender: men have proportionately more body fluid than
women.
- Body fat: People who are obese have less fluid than those
who are thin.
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 Amount and Composition of Body Fluids
 Body fluid is located in two fluid compartments:
- Intracellular space (fluid in the cells): Two thirds.
- Extracellular space (fluid outside the cells): one third.

 The ECF compartment is further divided into:

- Intravascular.
- Interstitial.
- Transcellular: cerebrospinal, pericardial, synovial, intraocular,
and pleural fluids; sweat; and digestive secretions.

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 Amount and Composition of Body Fluids
 Electrolytes in body fluids are active chemicals:
- Cations that carry positive charges.
- Anions that carry negative charges.

 Electrolyte concentration in the body is expressed in terms of

milliequivalents (mEq) per liter, a measure of chemical activity.

 Milliequivalent is defined as being equivalent to the

electrochemical activity of 1 mg of hydrogen.

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 Regulation of Body Fluid Compartments
 Osmosis:
- Fluid shifts through the membrane from the region of low
solute concentration to the region of high solute
concentration across a membrane that is impermeable to
dissolved substances.

- Tonicity is the ability of all the solutes to cause an osmotic

driving force that promotes water movement from one
compartment to another.

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 Regulation of Body Fluid Compartments
 Osmotic pressure is the amount of hydrostatic pressure needed to
stop the flow of water by osmosis.

 Oncotic pressure is the osmotic pressure exerted by proteins (eg,

albumin).

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 Regulation of Body Fluid Compartments
 Diffusion:
- Is the natural tendency of a substance to move from an area of
higher concentration to one of lower concentration.
- Examples of diffusion are the exchange of oxygen and carbon
dioxide between the pulmonary capillaries and alveoli.

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 Regulation of Body Fluid Compartments

 Filtration:
- Hydrostatic pressure in the capillaries tends to filter fluid out
of the intravascular compartment into the interstitial fluid.
- Movement of water and solutes occurs from an area of high
hydrostatic pressure to an area of low hydrostatic pressure.
- The kidneys filter approximately 180 L of plasma per day.

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 Regulation of Body Fluid Compartments
 Sodium–Potassium Pump:
- Sodium tends to enter the cell by diffusion. This tendency is offset by the
sodium–potassium pump that is maintained by the cell membrane and
actively moves sodium from the cell into the ECF.

- Active transport implies that energy must be expended for the movement
to occur against a concentration gradient.

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 Systemic Routes of Gains and Losses

 Kidneys:
- The usual daily urine volume in the adult is 1 to 2 L. A general rule is that
the output is approximately (1 mL/kg/h) in all age groups.
 Skin:
- Sensible perspiration refers to visible water and electrolyte
loss through the skin (sweating). Actual sweat losses can vary from 0 to
1000 mL or more every hour.
- Continuous water loss by evaporation (approximately 600 mL/day)
occurs through the skin as insensible perspiration.

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 Systemic Routes of Gains and Losses

 Lungs:
- The lungs normally eliminate water vapor (insensible loss) at a rate of
approximately 300 mL every day. The loss is much greater with increased
respiratory rate or depth, or in a dry climate.

 Gastrointestinal tract:
- The usual loss through the GI tract is 100 to 200 mL daily, even though
approximately 8 L of fluid circulates through the GI system every 24
hours.

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 Systemic Routes of Gains and Losses

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 Laboratory Tests for Evaluating Fluid Status

 Osmolality:
- It is the concentration of fluid that affects the movement of water between fluid
compartments by osmosis.
- Osmolality measures the solute concentration per kilogram in blood and urine.
- It is also a measure of a solution’s ability to create osmotic pressure.
- Serum osmolality primarily reflects the concentration of sodium.
- Urine osmolality is determined by urea, creatinine, and uric acid.
- Osmolality is reported as milliosmoles per kilogram of water (mOsm/kg).
- In healthy adults, serum osmolality is 280 to 300 mOsm/kg, and normal urine
osmolality is 200 to 800 mOsm/kg.

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 Laboratory Tests for Evaluating Fluid Status

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 Laboratory Tests for Evaluating Fluid Status

 Osmolarity:
- It is measured in milliosmoles per liter (mOsm/L).
- The calculated value usually is within 10 mOsm of the measured osmolality.

 Urine specific gravity :

- It measures the kidneys’ ability to excrete or conserve water.
- The normal range of urine specific gravity is 1.010 to 1.025
- Normally, the larger the volume of urine, the lower the specific gravity is.
- Factors that increase or decrease urine osmolality are the same as those for
urine specific gravity.

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 Laboratory Tests for Evaluating Fluid Status

 BUN( Blood Urea Nitrogen):

- Is made up of urea, which is an end product of the metabolism of protein
by the liver.
- The normal BUN is 10 to 20 mg/dL (3.6 to 7.2 mmol/L).
- Factors that increase BUN include decreased renal function, GI bleeding,
dehydration, increased protein intake, fever, and sepsis.
- Factors that decrease BUN include end-stage liver disease, a low-protein
diet, starvation, and any condition that results in expanded fluid volume
(eg, pregnancy).

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 Laboratory Tests for Evaluating Fluid Status
 Creatinine:
- It is the end product of muscle metabolism.
- It is a better indicator of renal function than BUN because it does not vary
with protein intake and metabolic state.
- The normal serum creatinine is approximately 0.7 to 1.4 mg/dL

 Hematocrit:
- It measures the volume percentage of red blood cells in whole blood.
- Normally ranges from 42% to 52% (males) and 35% to 47% (females).
- Conditions that increase the hematocrit value are dehydration and
polycythemia, and those that decrease hematocrit are overhydration and
anemia.
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 Homeostatic Mechanisms
 Kidney Functions:
- The kidneys normally filter 180 L of plasma every day in the adult and
excrete 1 to 2 L of urine.
- Major functions of the kidneys in maintaining normal fluid balance include:
* Regulation of ECF volume by selective retention and excretion of body
fluids.
* Regulation of normal electrolyte levels by selective electrolyte retention
and excretion.
* Regulation of pH of the ECF by retention of hydrogen ions.
* Excretion of metabolic wastes and toxic substances.

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 Homeostatic Mechanisms
 Heart and Blood Vessel Functions.
 Lung Functions.
 Pituitary Functions:
- Antidiuretic hormone (ADH), which is released from the posterior
pituitary gland and released as needed to conserve water.
 Adrenal Functions:
- Aldosterone, a mineralocorticoid secreted by the adrenal cortex.
- Increased secretion of aldosterone causes sodium retention (and thus water
retention) and potassium loss.
- Decreased secretion of aldosterone causes sodium and water loss and
potassium retention.
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 Homeostatic Mechanisms
 Renin–Angiotensin–Aldosterone System:

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 Hypovolemia
 Fluid volume deficit (FVD), or hypovolemia, occurs when loss
of ECF volume exceeds the intake of fluid.

 It occurs when water and electrolytes are lost in the same

proportion as they exist in normal body fluids, so that the ratio
of serum electrolytes to water remains the same.

 Dehydration, which refers to loss of water alone, with increased serum

sodium levels.

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 Pathophysiology of Hypovolemia
 Abnormal fluid losses, such as those resulting from vomiting, diarrhea, GI
suctioning, and sweating.

 Decreased intake, as in nausea or lack of access to fluids.

 Third-space fluid shifts, or the movement of fluid from the vascular system
to other body spaces(eg, with edema formation in burns, ascites with liver
dysfunction).

 Additional causes include diabetes insipidus, adrenal insufficiency, osmotic

diuresis, hemorrhage, and coma.
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 Clinical Manifestations of Hypovolemia

 Acute weight loss.  Increased temperature.

 Decreased skin turgor.  Thirst.
 Oliguria ( less than 400 mL/day).  Decreased or delayed capillary
 Concentrated urine. refill.
 Orthostatic hypotension.  Decreased central venous pressure.

 Weak, rapid heart rate.  Cool, clammy, pale skin.

 Flattened neck veins.  Anorexia, nausea.

 Lassitude
 Muscle weakness; and cramps.

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 Assessment and Diagnostic Findings

 BUN elevated out of proportion to the serum creatinine (ratio

greater than 20:1).
 hematocrit level is greater than normal.
 Urine specific gravity is increased.

 Decreased potassium occurs with GI and renal losses.

 Increased potassium occurs with adrenal insufficiency.
 Decreased sodium occurs with increased thirst and ADH release.
 Increased sodium results from increased insensible losses and diabetes
insipidus
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 Medical Management of Hypovolemia
 If the deficit is not severe, the oral route is preferred, provided the patient
can drink.

 If fluid losses are acute or severe, the IV route is required.

 Isotonic electrolyte solutions (eg, lactated Ringer’s solution, 0.9% sodium

chloride) are frequently used to treat the hypotensive patient with FVD.

 Shock can occur when the volume of fluid lost exceeds 25% of the
intravascular volume, or when fluid loss is rapid.

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 Nursing Management of Hypovolemia

 Monitors and measures fluid I&O at least every 8 hours, and sometimes
hourly.
 Monitor daily body weights.
 Monitor vital signs.
 Monitor skin and tongue turgor.
 Measure the urine specific gravity.
 Preventing hypovolemia.

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 Hypervolemia
 Fluid volume excess (FVE), or hypervolemia, refers to an isotonic
expansion of the ECF caused by the abnormal retention of water and
sodium in approximately the same proportions in which they normally
exist in the ECF.

 It is always secondary to an increase in the total body sodium content,

which, in turn, leads to an increase in total body water.

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 Pathophysiology of Hypervolemia

 Contributing factors can include:

- Heart failure.
- Renal failure.
- Cirrhosis of the liver.
- Consumption of excessive amounts of table or other sodium
salts.
- Excessive administration of sodium-containing fluids.

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 Clinical Manifestations of Hypervolemia

 Edema.
 Distended neck veins.
 Crackles (abnormal lung sounds).
 Tachycardia.
 Increased blood pressure, pulse pressure, and central venous
pressure.
 Increased weight.
 Increased urine output.
 Shortness of breath and wheezing.

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 Assessment and Diagnostic Findings

 BUN and hematocrit levels may be decreased.

 In chronic renal failure, both serum sodium level are decreased due
to excessive retention of water.

 Chest x-ray may reveal pulmonary congestion.

 The urine sodium level is increased if the kidneys are attempting to

excrete excess volume.

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 Medical Management of Hypervolemia

 Pharmacologic therapy.

 Dialysis.

 Nutritional therapy.

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 Pharmacologic Therapy
 Diuretics are prescribed when dietary restriction of sodium alone is insufficient.

 The choice of diuretic is based on the severity of the hypervolemic state, the degree of
impairment of renal function, and the potency of the diuretic.

 Thiazide diuretics such as hydrochlorothiazide or metolazone block sodium reabsorption in the

distal tubule, where only 5% to 10% of filtered sodium is reabsorbed.

 Loop diuretics, such as furosemide (Lasix) can cause a greater loss of both sodium and water
because they block sodium reabsorption in the ascending limb of the loop of Henle, where 20%
to 30% of filtered sodium is normally reabsorbed.

 Generally, thiazide diuretics are prescribed for mild to moderate hypervolemia and loop
diuretics for severe hypervolemia.
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 Pharmacologic Therapy
 Hypokalemia can occur with all diuretics except those that work in the last
distal tubule of the nephrons.
(Potassium supplements can be prescribed to avoid this complication)

 Hyperkalemia can occur with diuretics that work in the last distal tubule
(eg, spironolactone)

 Decreased magnesium levels occur with administration of loop and thiazide

diuretics.

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 Medical Management of Hypervolemia
 Dialysis:
- Hemodialysis or peritoneal dialysis may be used to remove nitrogenous wastes and
control potassium and acid–base balance, and to remove sodium and fluid.

 Nutritional Therapy:
- Dietary restriction of sodium.
- Lemon juice, onions, and garlic are excellent substitute flavorings of seasonings.
- Patients may need to use distilled water if the local water supply is very high in
sodium.

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