Share with other. Study purpose only. # Nursing An electrolyte imbalance occurs when you have too much or not enough of certain minerals in your body.

1. DATTA MEGHE INSTITUTE OF MEDICAL SCIENCES (DU)
Smt. Radhikabai Meghe Memorial College of Nursing
Sawangi (M) Wardha
TEACHING LEARNING
MODULE
On
FLUID AND ELECTROLYTE BALANCE
Submitted by: Submitted to:
Mr. Abhijit P Bhoyar Mrs. Archana Mourya
M Sc. (N) Ist yr HOD & Professor
Child health nursing. Child health nursing
Submitted on:

2. INTRODUCTION
Infants and young children are at greater risk than adults for disturbance in
fluid and electrolyte balance due to difference in body position, higher
metabolic rate, and immaturity for physiologic regulation systems.
Etiologies of fluid loss: diarrhea, vomiting, hemorrhage, ostomy drainage,
burn…
Diarrhea is the most common etiology for fluid loss in children, and it
followed by vomiting, and 9% of all hospitalization for children under age of
5 years.
KEY ITEMS
Acidosis: abnormal accumulation of acid or loss of bases from the body
pH value: ≤ 7.35
Alkalosis: abnormal accumulation of bicarbonate or loss of acid in the body
pH value: ≥ 7.45
ECF: extracellular fluid found outside the cell, comprising approximately
one third of the bodies fluid in older children and about half of the fluids in
the infants.
ICF: intracellular fluid found within the cells, comprising approximately
two thirds of the body’s fluid in older children and about half of the fluid in
the infants
ECF

3. Interstitial fluid: fluid surrounding the cell, including lymph fluid.
Intravascular fluid: fluid contained with the blood vessel (e.g,
plasma).
Transcellular space: cerebral fluid, pericardial, pleural, synovial,
sweat, digestive secretions
Isotonic dehydration: state in which the solute concentration is practically
identical to that of body fluids: Na between 135 and 145 meq/L.
Hypotonic (hyponatremic) dehydration: state in which the solute
concentration is below that of normal body fluids: Na < 135 meq/L
Hypertonic (hypernatremic) dehydration: state in which the solute
concentration is above that of normal body fluids: Na > 145 meq/L.
Oliguria: diminished amount of urine output (< 1-2 ml/kg /hour).
Anuria: near absence of urine output in observation (< 0.5 ml/kg/hour
Diffusion: the process by which solutes move from an area of higher
concentration to one of lower concentration; does not require expenditure of
energy
Hydrostatic pressure: the pressure created by the weight of fluid against
the wall that contains it. In the body, hydrostatic pressure in blood vessels
results from the weight of fluid itself and the force resulting from cardiac
contraction.
Osmolality: the number of osmoles (the standard unit of osmotic pressure)
per kilogram of solution. Expressed as mOsm/kg. Used more often in
clinical practice than the term osmolarity to evaluate serum and urine. In

4. addition to urea and glucose, sodium contributes the largest number of
particles to osmolality.
Osmolarity: the number of osmoles, the standard unit of osmotic pressure
per liter of solution. It is expressed as milliosmoles per liter (mOsm/L);
describes the concentration of solutes or dissolved particles.
Osmosis: the process by which fluid moves across a semipermeable
membrane from an area of low solute concentration to an area of high solute
concentration; the process continues until the solute concentrations are equal
on both sides of the membrane.
Tonicity: the measurement of the osmotic pressure of a solution; another
term for osmolality.
BODY FLUID DISTRIBUTION
The body contains 2 major fluid compartments: the intracellular fluid (ICF) and the
extracellular fluid (ECF). The ICF comprises of two thirds of the total body water
(TBW), while the ECF accounts for the remaining third. The ECF is further
divided into the interstitial fluid (75%) and plasma (25%). The TBW comprises
approximately 70% of body weight in infants, 65% in children, and 60% in adults.
Infants' and children’s higher body water content, along with their higher
metabolic rates and increased body surface area to mass index, contribute to their
higher turnover of fluids and solute. Therefore, infants and children require
proportionally greater volumes of water than adults to maintain their fluid
equilibrium and are more susceptible to volume depletion. Significant fluid losses
may occur rapidly, leading to depletion of the intravascular volume.
IMBALANCE OF FLUID AND ELECTROLYTES -CONTENTS

5. Two major compartment: ECF,ICF
ECF
1) Interstitial spaces (surrounding the cells, such as lymph fluid)
2) Intravascular fluid (fluid within blood or plasma)
3) Transcellular space (cerebral fluid, pericardial, pleural, synovial,
sweat, digestive secretions
CHANGING OF ECF AND ICF DURING FLUID LOSS
ECF is lost first when fluid loss occurs (illness, fever, trauma).
ICF is more difficult to dehydrate
CHANGE OF BODY FLUID DISTRIBUTION
ECF distribution: birth: 80%, 2 years: 30%, adult: 20%
Maturity in terms of body space distribution is usually reached around age 3
years
BODY FLUID DISTRIBUTION
Compartment: fluid, solutes
Water: children (75%), adult (60%)
---The volume of total body fluid decrease with increasing age.
---An inverse relationship between total body water and fat.
Solute: sodium (Na), potassium (K), chloride (CL), and calcium (Ca)
---Major components in ECF: Na

6. ---Major components in ICF: K
BODY FLUID DISTRIBUTION
Body fluid: water + solutes
Water:primary constitutent of fluid
Children (75%)
TABLE:-THE FLUID REQUIREMENT PER KG OF BODY WEIGHT AT
DIFFERENT AGES.
AGE GROUP FLUID REQUIREMENT
Newborn 80 – 100 ml per kg body weight
0-1 year 100-150 ml per kg body weight
1-2 years 100-125 ml per kg body weight
2-10 years 75-100 ml per kg body weight
11-18 years 50-75 ml per kg body weight

7. FUNCTIONS OF ELECTROLYTES

8. TABLE 1 • APPROXIMATE MAJOR ELECTROLYTE CONTENT IN
BODY FLUID
ELECTROLYTES MEQ/L
Extracellular Fluid (Plasma)
Cations
Sodium (Na)
Potassium (K)
Calcium (Ca++)
Magnesium (Mg++)
Total cations
Anions
Chloride (Cl−)
Bicarbonate (HCO3−)
Phosphate (HPO4−−)
Sulfate (SO4−−)
Organic acids
Proteinate
Total anions
Intracellular Fluid
Cations
Potassium (K+)
Magnesium (Mg++)
Sodium (Na+)
Total cations
Anions
142
5
5
2
154
103
26
2
1
5
17
154
150
40
10
200

9. Phosphates and sulfates
Bicarbonate (HCO3−)
Proteinate
Total anions
150
10
40
200
REGULATION OF BODY FLUID COMPARTMENTS
OSMOSIS AND OSMOLALITY
When two different solutions are separated by a membrane that is impermeable to
the dissolved substances, fluid shifts through the membrane from the region of low
solute concentration to the region of high solute concentration until the solutions
are of equal concentration; this diffusion of water caused by a fluid concentration
gradient is known as osmosis . The magnitude of this force depends on the number
of particles dissolved in the solutions, not on their weights. The number of
dissolved particles contained in a unit of fluid determines the osmolality of a
solution, which influences the movement of fluid between the fluid compartments.
Tonicity is the ability of all the solutes to cause an osmotic driving force that
promotes water movement from one compartment to another (Porth, 2002). The
control of tonicity determines the normal state of cellular hydration and cell size.
Sodium, mannitol, glucose, and sorbitol are effective osmoles (capable of affecting
water movement).
Three other terms are associated with osmosis: osmotic pressure, oncotic pressure,
and osmotic diuresis.
• Osmotic pressure is the amount of hydrostatic pressure needed to stop the flow
of water by osmosis. It is primarily determined by the concentration of solutes.
• Oncotic pressure is the osmotic pressure exerted by proteins (eg, albumin).

10. • Osmotic diuresis occurs when the urine output increases due to the excretion of
substances such as glucose, mannitol, or contrast agents in the urine.
DIFFUSION Diffusion is the natural tendency of a substance to move from an
area of higher concentration to one of lower concentration (see Fig. 1B). It occurs
through the random movement of ions and molecules. Examples of diffusion are
the exchange of oxygen and carbon dioxide between the pulmonary capillaries and
alveoli and the tendency of sodium to move from the ECF compartment, where the
sodium concentration is high, to the ICF, where its concentration is low.

11. FILTRATION Hydrostatic pressure in the capillaries tends to filter fluid out of
the vascular 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. Filtration allows the kidneys to filter 180 L of plasma per day. Another
example of filtration is the passage of water and electrolytes from the arterial
capillary bed to the interstitial fluid; in this instance, the hydrostatic pressure is
furnished by the pumping action of the heart.

12. FLUID VOLUME DISTURBANCES
WATER DEPLETION
Mechanism and situation Manifestation Management and
nursing care
Failure to absorb and
reabsorb water
Complete and sudden
cessation of intake and
prolonged diminished intake
Neglect of intake by self or
caregiver- confused
psychotic, unconscious or
helpless
Loss from gastrointestinal
tract- vomiting, diarrhea,
nasogastric suction, fistula
Disturb body fluid
chemistry; inappropriate
ADH secretion
Excessive renal excretion, ,
glycosuria (diabetes)
Loss through skin or lungs;
excessive perspiration or
evaporation, febrile state,
General symptoms
dependent to some extent on
proportion of electrolytes lot
with water
Thirst
Variable temperature-
increased infection
Dry skin and mucus
membrane
Poor skin integrity
Poor perfusion (decreased
pulse, slow capillary refilled
time)
Weight loss
Fatigue
Diminished urinary output
Irritability and lethargy
Tachycardia
Tachypnea
Altered level of
Provide
replacement of
fluid losses
commensurate with
volume depletion
Provide
maintenance fluid
and electrolyte
Determine the
correct cause of
water depletion
Measure intake and
output
Monitor vital signs
Monitor urine
specific gravity

13. hyperventilation, increased
ambient temperature,
increased activity (basal
metabolic rate BMR)
Impaired skin integrity-
transudate from injuries
hemorrhage.
Iatrogenic: overzealous use
of diuretics, improper peri-
operative fluid replacement,
use of radiant warmer or
phototherapy.
consciousness, disorientation
Laboratory findings;
High urine specific gravity
Increased hematocrete
Variable serum electrolyte
Variable urine output
Increased blood urea
nitrogen
Increased serum osmolarity
WATER EXCESS
Water intake in excess of out
put
- Excessive oral intake
- Hypotonic fluid
overload
- Plain water enemas
Failure to excrete water in
presence of normal intake
- Kidney disease
- Congestive heart
failure
- Malnutrition
Edema:
- generalized
- pulmonary (moist rales
or crackle)
- intacutaneous (noted
especially in the loose
aeriolar tissue)
elevated serum pressure
hepatomegaly
slow, bonding pulse
Weight gain
Lethargy
Increased spinal fluid
Limit fluid intake
Administered
diuretics
Monitor vital signs
Determine and treat
cause of water
excess
Analyzed laboratory
findings

14. pressure
Central nervous system
manifestations (seizures,
coma)
Laboratory findings
- low urine specific
gravity
- decreased serum
electrolyte
- decreased hematocrit
- variable urine volume
SODIUM DEPLETION (HYPONETRAMIA)
• Prolonged low sodium
diet
• Deceased sodium
intake
• Fever
• Excess sweating
• Increased water intake
without electrolyte
• Tachypnea
• Cystic fibrosis
• Burns and wounds
• Vomitind, diarrhea,
nosogastric suction,
fistulas
Associated with water loss:
- dehydration, weakness,
dizziness, nausea,
cramps, apprehensions
- mild -apathy,
weakness, nausea,
weak pulse
- moderate- decreased
blood pressure,
lethargy
laboratory findings:
- sodium
concentration˂130mEq
/L
• Determine
and treat
cause
• Administered
iv fluids with
appropriate
saline
concentration

15. • Renal disease
• Diabetic kitoacidosis
• Malnutritions
- urine specific gravity is
depend on water deficit
or excess
SODIUM EXCESS (hypernetramia)
• High salt intake-enteral
or IV
• Renal disease
• Fever
• High insensible water
loss
- Increased
temperature
- Increased
humidity
- Hyperventilation
- Diabetic
insepidus
- Hyperglysemia
• Intense thirst
• Dry, sticky mucus
membrane
• Flushed skin
• Temperature possibly
increased
• Hoarseness
• Oliguria
• Nausea and vomiting
• Possible progression to
disorientation,
convulsions, muscle
twitching, nuchal
rigidity, lethargy at
rest, hyperirritability,
when aroused.
• Laboratory findings:
- Serum sodium
concentration≥1
• Determine
and treat
cause
• Administered
fluid as
prescribed
• Measure
intake and
output
• Monitor
laboratory
data
• Monitor
neurologic
status

16. 50mEq/L
- High plasma
volume
- Alkalosis
POTASSIUM DEPLETION(HYPOKALEMIA)
• Starvation
• Clinical condition
associated with poor
food intake
• Malabsorption
• IV fluid without added
potassium
• Gastrointestinal
lossess- diarrhea,
vomiting, fistulas,
nasogastric suction.
• Dieresis
• Administrations of
diuretics,
corticosteroids
• Diuretic phase of
nephritic syndrome
• Healing stage of burn
• Potassium- losing
nephrisis
• Muscle weakness,
cramping, dtiffness,
paralysis, hyporeflesia
• Cardiac arrithmias,
• Tachycardia or
bracardiady
• Ileus
• Apathy
• Fatigue
• Drowsiness
• Irritability
• Laboratory findings:
- Decreased serum
potassium
concentration≤
3.5mEq/L
- Abnormal ECG-
notched or
flattened T
wave, decreased
ST segment,
• Determine
and treat
cause
• Monitor vital
signs,
including
ECG
• Administered
supplemental
potassium
slowly
• Assess for
adequate
renal output
• IV
replacement
therapy
• For oral
therapy, offer
high
potassium

17. • Hyperglycemic dieresis
• IV administration of
insulin
premature
ventricular
contraction.
fluids and
foods
• Evaluate acid
base status
HYPERKALEMIA (POTASSIUM EXCESS)
• Renal disease
• Renal failure
• Adrenal insufficiency
(addisons disease)
• Associated with
metabolic acidosis
• Too rapid
administration of IV
potassium chloride
• Transfusion with old
donor blood
• Severe dehydration
• Crushing injury
• Burns, hemolysis,
dehydration
• Potassium sparing
diuretics
• Increased intake of
potassium (e,g. salt
substitute)
• Muscle weakness,
flacied paralysis
• Twitching
• Hyperreflexia
• Bradycardia
• Ventricular firilation
and cardiac arrest
• Oliguria
• Apnea- respiratory
arrest
• laboratory findings:
- high serum
potassium
concentration
- variable urine
volume
- flat p wave on
ECG, peaked T
wave.
• Determine
and treat
cause
• Monitor vital
signs,
including
ECG
• Administered
exchange
resin, if
prescribed.
• Administered
IV fluids
• Monitor
potassium
levels
• Evaluate acid
base status

18. CALCIUM DEPLETION (HYPOCALCEMIA)
• Inadequate dietary
calcium
• Vitamin d deficiency
• Rapid transit through
GI tract
• Advanced renal
insufficiency
• Administration of
diuretics
• Hypoparathyroidism
• Alkalosis
• Calcium trapped in
diseased tissue
• Increased serum
protein
• Exchange transfusion
with citrated blood
• Inadequate blood
administration diseased
status
• Neuromuscular
irritability
• Tingling of nose. Ears,
fingertips, toes
• Tetany
• Laryngopasm
• Generalized
convulsions
• May be changes in
clotting
• Positive chvostek and
trousseau signs
• Hypotension
• Cardiac arrest
• Laboratory findings
- Decreased serum
calcium level in
the blood
- Prolonged QT
intervals
• Determine
and treat
cause
• Administered
calcium
supplements
as prescribed;
administered
slowly.
• Monitor IV
site ; calcium
may cause
vascular
irritations
• Monitor
serum
calcium level
• Monitor
serum
potassium
level
CALCIUM EXCESS (HYPERCALCEMIA)
• Acidosis
• Prolonged
• Constipation
• Weakness, fatigue
• Determine
and treat

19. immobilization
• Condition associated
with increased bone
catabolism
• Hypoproteinemia
• Kidney disease
• Hypervitaminosis D
• Hyperparathyroidism
• Hyperthyroidism
• Excessive IV or oral
administration
• Nausea , vomiting
• Anorexia, dry mouth
• Muscle hypotonicity
• Bradycardia, cardiac
arrest
• Increased calcium
concentration in the
urine, causing
formation of kidney
stone
• Increased serum
calcium level in the
blood.
cause
• Monitor
serum
calcium level
ACID AND BASE PROBLEM
The most common acid-base derangement that occurs with volume depletion,
especially in infants, is metabolic acidosis. Mechanisms include bicarbonate loss in
stool, ketone production from starvation, and lactic acid production from decreased
tissue perfusion in hypovolemia. Decreased renal perfusion also causes decreased
glomerular filtration rate, which, in turn, leads to decreased hydrogen (H+
) ion
excretion. These factors can combine to produce a metabolic acidosis.
In most patients, acidosis is mild and easily corrected with volume restoration;
increased renal perfusion permits excretion of excess H+
ions in the urine.
Administration of glucose-containing fluids further decreases ketone production.
Etiology

20. The mechanisms of dehydration may be broadly divided into 3 categories:
(1) decreased intake due to diseases such as stomatitis,
(2) increased output from diarrhea or osmotic diuresis from uncontrolled diabetes
mellitus, and
(3) increased insensible losses such as with fever.
Pediatric dehydration is frequently the result of increased output from
gastroenteritis, characterized by vomiting and diarrhea.
However, vomiting and diarrhea may be caused by other processes as summarized
below.
CNS causes of vomiting include the following:
→ Infections
→ Increased intracranial pressure
→ Psychogenic vomiting is not seen in infants and is rare in children
GI causes of vomiting include the following:
→ Gastroenteritis
→ Obstruction
→ Hepatitis
→ Liver failure
→ Appendicitis
→ Peritonitis
→ Intussusception
→ Volvulus
→ Pyloric stenosis

21. → Drug toxicity (ingestion, overdose, drug effects)
Endocrine causes of vomiting include the following:
→ Diabetic ketoacidosis (DKA
→ Congenital adrenal hypoplasia
→ Addisonian crisis
Renal causes of vomiting include the following:
→ Infection
→ Pyelonephritis
→ Renal failure
→ Renal tubular acidosis
GI causes of diarrhea include the following:
→ Gastroenteritis
→ Malabsorption (eg, milk intolerance, excessive fruit juice)
→ Intussusception
→ Irritable bowel syndrome
→ Inflammatory bowel disease
→ Short gut syndrome
Endocrine causes of diarrhea include the following:
→ Thyrotoxicosis
→ Congenital adrenal hypoplasia

22. → Addisonian crisis
→ Diabetic enteropathy
Volume depletion from increased output not caused by vomiting or diarrhea may
be divided into renal or extrarenal causes. Renal causes of volume depletion
include the following:
• Use of diuretics
• Renal tubular acidosis
• Renal failure (eg, renal trauma, urinary tract obstruction, salt-wasting nephritis)
• Diabetes insipidus, hypothyroidism, and adrenal insufficiency
Extrarenal causes of volume depletion include the following:
• Third-space extravasation of intravascular fluid (eg, pancreatitis, peritonitis,
sepsis, heart failure)
• Hemorrhage
Other causes of volume depletion as mentioned above include poor oral intake and
insensible losses from fever, sweating, burns, or pulmonary processes.
Overview
Dehydration is a common complication of illness observed in pediatric patients
presenting to the emergency department (ED). Early recognition and early
intervention are important to reduce risk of progression to hypovolemic shock and
end-organ failure.
In most cases, volume depletion in children is caused by fluid losses from vomiting
or diarrhea. On physical examination, combinations of findings can be used to
determine the degree of dehydration. Laboratory studies are of limited utility in

23. cases of mild dehydration, but they may be considered under certain conditions and
are recommended in patients with more severe dehydration.
Mild or moderate volume depletion should be treated with oral rehydration when
possible. Intravenous fluid therapy is necessary when oral therapy fails or volume
depletion is severe.
Dehydration
Definition- Fluid loss in excess of fluid intake
Dehydration-Classification
Hypotonic dehydration: Na <135 (130) meq/L
Isotonic dehydration: Na (135-145 meq/L)
Hypertonic dehydration: Na > 145 (150) meq/L
Symptom Degree of Dehydration
Mild (< 3%
body weight lost)
Moderate (3-9%
body weight lost)
Severe (>9% body
weight lost)
Mental status Normal, alert Restless or fatigued,
irritable
Apathetic, lethargic,
unconscious

24. Heart rate Normal Normal to increased Tachycardia or
bradycardia
Quality of
pulse
Normal Normal to decreased Weak, thready,
impalpable
Breathing Normal Normal to increased Tachypnea and
hyperpnea
Eyes Normal Slightly sunken Deeply sunken
Fontanelles Normal Slightly sunken Deeply sunken
Tears Normal Normal to decreased Absent
Mucous
membranes
Moist Dry Parched
Skin turgor Instant recoil Recoil < 2 seconds Recoil >2 seconds
Capillary refill < 2 seconds Prolonged Minimal
Extremities Warm Cool Mottled, cyanotic
NURSING MANAGEMENT
ASSESSMENT
• Identify recurring and present symptoms associated with the child’s fluid
alteration.

25. • Determine how the child’s underlying disease affects daily function.
• Determine child’s medication use.
• Assess the child’s laboratory results.
• Assess the child’s physical examination findings
NURSING DIAGNOSIS
• Decreased cardiac output.
• Acute confusion
• Deficient fluid volume
• Excess fluid volume
• Impaired gas exchange
• Risk for injury
• Deficient knowledge regarding disease management
• Impaired oral mucus membrane
• Impaired skin integrity
• Ineffective tissue perfusion
IMPLEMENTATION
• Enteral Repalcement of Fluids
• Restriction of fluids
• Parenteral replacement of Fluids and Electrolytes

26. • Total Parenteral Nutrition
• Intravenous Therapy (Crystalloids)
• Vascular Access Devices

27. CONCLUSION
Infants and young children are at greater risk than adults for disturbance in
fluid and electrolyte balance due to difference in body position, higher metabolic
rate, and immaturity for physiologic regulation systems. And early detection and
treatment is save the life of the child. and it prevents the further complications of
the child.

28. REFERENCES
Susan Rowen James; Jean Weiler Ashwill; Nursing Care Of Children;
Principle And Practice; 3rd
Edition; Published By ELSEVIER; Page
no.486-503.
Wong’s; Essential Pediatric Nursing; 8th
Edition; Published By
MOSBY ELSEVIER; Page no.814-826.
Datta Parul; Pediatric Nursing ; 2nd
Edition; Published BY JAYPEE
Publication; Page no.220-225.
Black M Joyce,”medical surgical nursing- clinical management for
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Brunner and suddarth’s”text book of medical-surgical nursing” page
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Fundamentals Of Nursing s t a n d a r d s & pr a c t i c e s e c o n d e d
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Kozier & Erbs; Fundamental of Nursing; Concept, Process, and
practice; 8th
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1425-1474.
Principle and practice of nursing; part two; 4th
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