2. Characteristics of Body Fluids
Fluid = Water that contains dissolved or suspended
substances such as glucose, mineral salts, and proteins.
Fluid amount = Volume.
Fluid concentration = Osmolality.
Fluid composition (electrolyte concentration)
Degree of acidity = pH
3. Scientific Knowledge Base : Location and
Movement of Water and Electrolytes
Intracellular Fluid (ICF)
= Fluids within cells
⬤ ~2/3 of total body water
Extracellular Fluid (ECF) =
Fluid outside of cells
⬤ ~1/3 of total body water
⬤ Three divisions:
– Interstitial (between cells)
– Intravascular (blood plasma)
– Transcellular (CSF, pleural,
peritoneal & synovial fluids)
5. IV Solutions:
HYPERTONIC SOLUTION – a
solution with an osmolality
higher than that of serum. Ex.
3% or 5% sodium chloride
The cell shrink
HYPOTONIC SOLUTION - a
solution with an osmolality
lower than that of serum. Ex.
0.45% NaCl and 0.3% Nacl
The cell expand
6. ■ ISOTONIC SOLUTION – a
solution with the same
osmolality as serum and
other body fluids. Ex. PLR and
0.9 NaCl
IV Solutions:
7. Starling’s Law of the Capillary
■ Fluids leave (filtration) or enter (re-absorption) the capillaries
depending on how the pressure in the capillary and interstitial
spaces relate to one another
■ Volume re-absorbed is similar to volume filtered: “A net
equilibrium”
■ Regulates relative volumes of blood & interstitial fluid
9. Assessment and Fluid Balance
■ Health History/Causes of Deficits and Excesses
■ Diagnostic and Laboratory Data.
■ Physical Examination
■ Daily Weight, Vital Signs, Intake and Output,
Thirst, Skin, Buccal (Oral) Cavity, Eyes, Jugular
and Hand Veins, Neuromuscular System.
11. Diagnostic and Laboratory Data
■ Hemoglobin and Hematocrit Indices.
■ Urine pH.
■ Serum Albumin.
■ Osmolality (a measurement of the total concentration of
dissolved particles per kilogram of water).
■ Serum Osmolality.
■ Urine Osmolality.
13. ECF Volume deficit
Hypovolemia: Sign and Symptoms
Cardiovascular Changes
⚫ Mild to moderate
⚫ ↑ HR (due to SNS)
⚫ Peripheral pulses are weak, difficult to
find
⚫ Change in position may cause ↑ HR or
↓ BP
⚫ Dizziness and light-headedness
⚫ Severe fluid volume
⚫ ↓ BP in lying position
⚫ Pulse: weak, thready
⚫ Flattened neck veins
Respiratory Changes
⚫ ↑ respiratory rate
13
14. ECF Volume deficit
Hypovolemia: Sign and Symptoms
Renal Changes
⚫ UO below 500 mL/day
Neurologic changes
⚫ Alteration in Mental Status
⚫ Restlessness
⚫ Drowsiness
⚫ Lethargy
⚫ Confusion (more common in the
elderly; may be first indicator of
fluid balance problem)
⚫ Seizures, coma
14
15. ECF Volume deficit
Hypovolemia: Sign and Symptoms
⚫ Skin turgor is diminished
⚫ Skin may be warm and dry with mild deficit
⚫ Skin may be cool and moist with severe deficit
⚫ Skin may appear dry and wrinkled
⚫ Oral mucous membranes will be dry, sticky, pastelike coating
and the tongue may be furrowed
⚫ Patient C/O thirst
⚫ Eyes: soft, sunken
⚫ Lab data:
⚫ ↑ H & H; BUN;
15
16. Nursing Care Plan
Therapeutic Interventions
⚫ Restore fluid and electrolyte balance
⚫ IVs and blood products as ordered; small, frequent drinks by mouth
⚫ Daily weights to monitor progress of fluid replacement
⚫ Loss or gain of 2.2 lbs is equal to 1 L of fluid
⚫ I & O, hourly outputs
⚫ Two most important assessments: HR & Output
⚫ Avoid hypertonic solutions
⚫ Promote comfort
⚫ Frequent skin care
⚫ Position: change q hr to relieve pressure
⚫ meds as ordered: antiemetics, antidiarrheal
16
17. Nursing Care Plan
Therapeutic Interventions
⚫ Prevent physical injury
⚫ Risk for falls due to orthostatic hypotension, dysrhythmia, muscle weakness, gait
stability and level of alertness.
⚫ Frequent mouth care
⚫ Dry mucous membrane due to dehydration
⚫ Monitor IV flow rate
⚫ Observe for circulatory overload (↑ pulse, ↑ HR)
⚫ Pulmonary edema (SOB)
⚫ Monitor vital signs
⚫ BP should be rising, ↑ LOC: more alert
17
19. ECF Volume excess
Hypervolemia: Signs and symptoms
Cardiovascular Changes
⚫ ↑ Pulse: full and bounding
⚫ Full peripheral pulses
⚫ Distended neck veins
⚫ ↑ BP
Other Changes
-Urine; polyuria, nocturia
-Lab data
↓ Hematocrit, BUN
Respiratory Changes
⚫ ↑ respiratory rate
⚫ Shallow respirations
⚫ ↑ dyspnea with exertion or in the supine
position
⚫ Pulmonary congestion and
pulmonary edema
⚫ SOB
⚫ Irritative cough
⚫ Moist crackles
⚫ Froty sputum
19
20. ECF Volume excess
Hypervolemia: Signs and symptoms
Neurologic changes
⚫ Altered LOC
⚫ Visual disturbances
⚫ Skeletal muscle weakness
⚫ Paresthesias
⚫ Cerebral edema
⚫ Headache
⚫ Confusion
⚫ Lethargy
⚫ Diminished reflexes
⚫ Seizures, coma
⚫ Skin
⚫ Edematous may feel cool
⚫ Skin may feel taut and hard
⚫ Edema-eyelids, facial, dependent
(sacrum), pitting, peripheral extremities
⚫ GI Changes
⚫ Increased motility
⚫ Enlarged liver
20
21. Nursing Care Plan
Therapeutic Interventions
⚫ Maintain oxygen to all cells
⚫ Position: sim-Fowler’s or Fowler’s to facilitate improved gas exchange.
⚫ Vital signs; q 4 hrs and PRN
⚫ Tachycardia
⚫ ↑ BP (overload) and ↓ BP (fluid deficit)
⚫ Fluid restriction: I & O
⚫ Promote excretion of excess fluid
⚫ Meds as ordered: diuretics
⚫ Monitor electrolytes, esp. Mg and K
21
22. Nursing Care Plan
Therapeutic Interventions
⚫ Obtain/maintain fluid balance
⚫ Wt gain is the best indicator of fluid retention and overload
⚫ Weight daily; 2.2 lbs = 1 Liter (1000 ml)
⚫ Measure: all edematous parts, abdominal girth,
⚫ I & O: fluid restriction
⚫ Limit fluids by mouth, IVs per doctors orders
⚫ Strict monitoring of IV fluids
⚫ Prevent tissue injury
⚫ Skin and mouth care as needed
⚫ Evaluate feet for edema and discoloration when client is OOB
⚫ Observe suture line on surgical clients (Potential for evisceration due to excess fluid
retention)
22
27. Functions of Sodium
► Regulates osmolality
► ICF: 14 mmol/L & ECF: 135-145 mmol/L
► Helps maintain blood pressure by balancing the volume of water
in the body
► Works with other electrolytes to promote nerves, muscles and
other body tissues to work properly.
27
28. Hypernatremia
Water loss: Causes
⚫ Inadequate water intake
⚫ Unconscious or cognitively impaired individuals
⚫ NPO status
⚫ Excessive water loss
⚫ ↑ insensible water loss
⚫ High fever
⚫ Diuretic therapy
⚫ Watery diarrhea
⚫ Disease states
⚫ Uncontrolled diabetes mellitus
Water loss: Signs and Symptoms
► Restlessness, agitation, twitching,
confusion
► Seizures*, Coma
► Intense thirst
► Dry, swollen tongue
► Sticky mucous membranes
► Weight loss
► Weakness, lethargy
► Postural hypotension
28
29. Hypernatremia
Na gain: Causes
⚫ Na intake
⚫ IV fluids: hypertonic NaCl, excessive
isotonic NaCl
⚫ Hypertonic tube feeding with out water
supplement
⚫ Use of Na containing drugs
⚫ corticosteroids
⚫ Diseases
⚫ Renal failure
Na gain: Signs and Symptoms
► Restlessness, agitation, twitching
► Seizures, Coma
► Intense thirst
► Flushed skin
► Weight gain
► Peripheral and pulmonary edema
► ↑ BP
29
30. Hyponatremia
► Dilutional Hyponatremia
Causes (↑ ECF Volume)
► Use of hypotonic irrigation
solution
► Tap water enemas
► Excessive water gain
► Excessive hypotonic IV fluid
⚫ Dilutional Hyponatremia (↑ ECF Volume)
Signs and Symptoms
⚫ Headache, apathy, confusion
⚫ Nausea, vomiting, anorexia
⚫ Lethargy
⚫ Weakness
⚫ Muscle spasms, seizures, coma
⚫ Diarrhea, Abdominal cramps
⚫ Weight gain
⚫ ↑ BP
30
31. Hyponatremia
Na Loss: Causes
► GI
► Vomiting
► Diarrhea
► NG suctioning
► NPO Status
► Kidney
► Diuretic
Na Loss: Signs and Symptoms
⚫ Irritability, apprehension,
confusion
⚫ Dizziness
⚫ Personality changes
⚫ Tremors, seizures, coma
⚫ Dry mucous membranes
⚫ Postural hypotension
⚫ Tachycardia, thread pulse
⚫ Cold & clammy skin
31
32. Functions of Potassium
► Maintains fluid balance in the cells
► Contributes to intracellular osmotic pressure
► Direct effect on excitability of nerves and muscles
► Skeletal, cardiac, and smooth muscle contraction
► Regulates glucose use and storage
32
33. Hyperkalemia Causes
► Most cases of hyperkalemia occur in hospitalized
patients and in those undergoing medical treatment.
► Those at greatest risk for hyperkalemia are
► Chronically ill patients
► Debilitated patients
► Older adult
33
34. Hyperkalemia Causes
Actual hyperkalemia
► Excess potassium
Intake
► Excessive or rapid
parenteral
administration
Relative hyperkalemia
► Shift of potassium Out of Cells
► Acidosis
► Crushing injury
► Tissue catabolism (fever,
sepsis, burns)
34
40. Hypokalemia
Medical Management
⚫ Administration of KCl supplements
⚫ K may be given orally (K chloride, K gluconate, K citrate) or IV
⚫ KCl should be administered IV at a rate of 10 to 20 mEq/L over an
hour. Rapid infusion could cause cardiac arrest
⚫ IV K solutions irritate veins and cause phlebitis. Check IV site q 2
hrs. Discontinue IV if infiltrate to prevent necrotic and slough of
tissue
40
41. Functions of Calcium
► Helps maintain muscle tone
► Contributes to regulation of blood pressure by
maintaining cardiac contractility
► Necessary for nerve transmission and contraction of
skeletal and cardiac muscle
41
45. Hypocalcemia
Signs and Symptoms
Clinical Manifestations
⚫ Easy fatigability
⚫ Depression, anxiety, confusion
⚫ Numbness and tingling in extremities
and region around mouth
► Hyperreflexia, muscle cramps
► Chvostek’s sign & Trousseau’s sign
► Laryngeal spasm
► Tetany, seizures
Electrocardiogram
Changes
► Ventricular tachycardia
45
46.
47. Functions of Magnesium
► Cofactor in clotting cascade
► Acts directly on myoneural junction, affecting muscular
irritability and contractions
► Maintains strong and healthy bones
47
48. Hypermagnesemia
Causes
⚫ Renal failure
⚫ Diabetes Mellitus
⚫ Clients who ingest large amounts of Mg-containing
antacids such as Tums, Maalox, Mylanta, or laxatives
such as MOM (Milk of Magnesium) are also in ↑ risk for
developing hypermagnesemia
48
49. Hypermagnesemia
Signs and Symptoms
► Bradycardia and hypotension
► Severe hypermagnesemia: cardiac arrest
► Drowsy or lethargic
► Coma
► Deep tendon reflexes are reduced or absent
► Skeletal muscle contractions become progressively
weaker and finally stop
49
50. Hypomagnesaemia
Causes
► Malabsorption disorders
► Inflammatory bowel disease (IBD)
► Bowel resection
► Bariatric population who undergoes gastric bypass surgery
► Alcoholism
► Prolonged diarrhea
► Draining GI fistulas
► Diuretics
50
51. Hypomagnesaemia
Signs and Symptoms
► Confusion
► Hyperactive deep tendon reflexes
► Tremors
► Seizures
► Neuromuscular changes
► Hyperactive deep tendon reflexes
► Numbness and tingling
► Painful muscle contractions
► Monitor for positive Chvostek’s
and Trousseau’s signs
51
53. Acids, Bases, and pH
■ Acids, bases, and Ph are important for life.
■ When blood pH falls below 7.35, acidosis occurs.
■ When blood pH increases about 7.45, alkalosis occurs.
54. Acid-Base Balance
► The body has three main control systems that
regulate acid-base balance to counter acidosis or
alkalosis:
■ Buffer systems.
■ Respiratory Regulation of Acid-Base Balance.
■ Renal Control of Hydrogen Ion
■ Concentration
55. Buffers
■ Substances that attempt to maintain pH range or
H+
ion concentration, in the presence of added
acids or bases.
56. Diagnostic and Laboratory Data
■ The biochemical indicators of acid-base
balance are assessed by measuring the
arterial blood gases (ABGs).
59. Respiratory Acidosis/Alkalosis
Respiratory Acidosis:
► Maintain patent airway
► Improve ventilation
► Monitor for signs of respiratory distress
► Administer O2
► Place in a semi-Fowler’s position
► Encourage and assist the client DBE
Respiratory Alkalosis:
► Maintain a patent airway
► Provide emotional support and
reassurance to the client
► Encourage appropriate breathing
patterns
► Assist with breathing techniques
(breath holding, use of rebreathing
bag)
60. Metabolic Acidosis/Alkalosis
Metabolic Acidosis:
► Determine the cause of the acidosis
► Maintain a patent airway
► Assess LOC for CNS depression
► Monitor electrolyte values
► Maintain intake and output (I&O) and assist with
fluid and electrolyte replacement as prescribed
► Initiate safety precautions for convulsions and
coma
Metabolic Alkalosis:
► Maintain a patent airway
► Monitor vital signs
► Monitor input and output
► Monitor electrolyte values
► Monitor for muscle weakness
