Fluid electrolyte balance

1. FLUID ELECTROLYTE BALANCE
BY
ISHAQ ARSHAD

2. INTRODUCTION
• Fluid and electrolyte balance is a dynamic process
that is crucial for life
• It plays an important role in homeostasis.
• Imbalance may result from many factors, and it is
associated with the illness
• Approximately 60% of a typical adult’s weight
consists of fluid (water and electrolytes).
• Factors that influence the amount of body fluid are
age, gender, and body fat.

3. Third-space shift
• Third-space shifts occur in ascites, burns,
peritonitis, bowel obstruction, and massive
bleeding into a joint or body cavity.It causes
imbalance.
• HR increase
• BP drop
• sweating
• CVP decrease
• Weight increase.

4. COMPOSITION OF BODY FLUID
TOTAL BODY FLUID 60% OF BODY wt
Intracellular fluids Extracellular fluids
Interstitial Trancellular intravacular
fluid fluid fluid
15 % of body wt eg. Csf,pleural eg.Plasma

5. AMOUNT AND COMPOSITION OF
BODY FLUIDS
Intracellular fluid (ICF)
• Within the cells
• Comprises 2/3 of body’s water
Extracellular fluid (ECF)
• Outside the cell
• Comprises 1/3 of body’s water

6. ELECTROLYTE
• Electrolyte in body fluids are active chemicals
Cations : Positive charge
Anions : Negative charge
CATIONS:
Sodium, Potassium, Magnesium and
Hydrogen ions
ANIONS:
Chloride, Bicarbonate,Phosphate,Sulfate

7. REGULATION OF FLUID
• Movement of fluid through capillary walls depends
on
Hydrostatic pressure: exerted on walls of blood vessels
Oncotic pressure: exerted by protein in plasma
• Direction of fluid movement depends on differences
of hydrostatic,
osmotic pressure

8. REGULATION OF FLUID
• Osmosis is the movement of solvent particles across a semipermeable
membrane from a dilute solution into a concentrated solution.
• Diffusion is the movement of particles from an area of higher
concentration to lower concentration. The overall effect is to equalize
concentration throughout the medium.
• Tonicity is the ability of all the solutes to cause an osmotic driving force
that promotes water movement from one compartment to another.
• hydrostatic pressure the pressure exerted by the fluid on the walls of the
blood vessel.
• Filtration: Hydrostatic pressure in the capillaries tends to filter fluid out of
the vascular compartment into the interstitial fluid. Filtration allows the
kidneys to filter 180 L of plasma per day.
• Osmotic diuresis occurs when the urine output increases due to the
excretion of substances such as glucose, mannitol, or contrast agents in
the urine.

9. REGULATION OF BODY
FLUID COMPARTMENTS
Passive Transport
OSMOSIS
• Fluid shifts through the membrane from the region
of low solute concentration to the region of high
solute concentration until the solution are of equal
concentration

10. DIFFUSION
A substance to move from an area of higher
concentration to one of the lower concentration

11. REGULATION OF BODY
FLUID COMPARTMENTS
Active Transport
Sodium-Potassium Pump
• Movement of sodium and potassium against the
concentration gradient with expenditure of energy
• Sodium –Extracellular cation
• Potassium- intracellular cation

12. OSMOLALITY
Osmotic pressure
• Is the pressure needed to prevent osmosis through a
semipermeable membrane
• Occurs between a solution and a pure solvent
• Is propotional to the osmlality of the solution
Isotonic (iso-osmolar) solution:
• Have the same osmotic pressure as blood
Examples
• Normale saline
• Lactated ringer’s solution
• 5% dextorse water

13. OSMOLALITY
• Hypotonic (hypo-osmolar) solution:
Lower osmotic pressure then blood
• Examples
• ½ normal saline (1/2 NS or 0.45% nacl)
• Hypertonic (hyperosmolar)solutions.
Higher osmotic pressure then blood.
Examples
5% dextrose in normal saline(D5NS)
5% dextrose in ringer lactated solutions

14. DIFFERENCE BETWEEN OSMOLALITY
AND OSMOLARITY
• Osmolarity and osmolality are frequently confused and
incorrectly interchanged.
• Osmolarity refers to the number of solute particles per 1 L
of solvent, whereas osmolality is the number of solute
particles in 1 kg of solvent.
• For dilute solutions, the difference
between osmolarity and osmolality is insignificant.
Measurements of osmolarity are temperature dependent
because the volume of solvent varies with temperature
(i.e., the volume is larger at higher temperatures). In
contrast, osmolality, which is based on the mass of the
solvent, is temperature independent.

15. SYSTEMIC ROUTES OF GAINS
AND LOSSES
• KIDNEY
Output is approximately 1 mL of urine per kilogram of body
weight per hour (1 mL/kg/h)
• SKIN
Continuous water loss by evaporation (approximately 600
mL/day) occurs through the skin as insensible perspiration
• LUNGS
The lungs normally eliminate water vapor at a rate of
approximately 300 mL every day
• GI TRACTS
The usual loss through the GI tract is 100 to 200 mL daily,

16. HOMEOSTATIC MECHANISMS
• Kidney Functions
Water and electrolyte balance
• Lung Functions
Decrease or increase water loss through lungs
• Pituitary Functions
ADH-water and sodium retention
• Adrenal Functions
Inc. Aldosteron-water and sodium retention

17. HOMEOSTATIC MECHANISMS
• Baroreceptors
• Renain–Angiotensin–Aldosterone System
• Osmoreceptors
• Atrial Natriuretic Peptide
• Decrease secretion of aldosteron and renin

18. FLUID VOLUME IMBALANCES
• Fluid volume deficit (FVD): hypovolemia
• Fluid volume excess (FVE): hypervolemia

19. FLUID VOLUME DISTURBANCES
• Hypovolemia (Fluid volume deficit)
Occurs when loss of ECF volume exceeds the intake
of fluid. It occurs when water and electrolytes are
lost in the same proportion as exist in normal body
fluids,
• Dehydration:
which refers to loss of water alone, with increased
serum sodium levels and other electrolyte
imbalances

20. CAUSES OF FVD
FLUID LOSS
• Hemorrhage
• Frequent urination
• Diarrhea
• vomiting
• Fever excessive,
nasogatric suctiong
• Burns
• Acute intestinal
obstruction
• pancreatitis
REDUCE FLUID INTAKE
• Dysphagea
• Unconscious status
• Lack of fluid
• Reduce ability to sense
taste.

21. DEHYDRATION
CAUSES:
fluid loss from vomiting, diarrhea, GI suctioning,
sweating, decreased intake, inability to gain access to
fluid
RISK FACTORS:
diabetes insipidus, adrenal insufficiency, osmotic
diuresis, hemorrhage, coma, third-space shifts

22. CLINICAL MANIFESTATIONS FVD
• Hypotension
• Tachycardia
• Thirst
• Poor skin turgor
• Dry skin membrane
• Decrease in urinary output
• Flattened neck veins
• If sever, shock
•
Rapid weight loss,
• Oliguria,
• Concentrated urine,
• Postural hypotension,
• Rapid weak pulse,
• Increased temperature,
• Cool clammy skin due to
vasoconstriction,
• Lassitude,
• Nausea,
• Muscle weakness,
• Cramps

23. 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

24. MEDICAL MANAGEMENT OF FVD
• Oral parenteral fluids
• Blood or blood products, if due to hemorrhage
• Anti diarrheal loss, if due to diarrhea
• Antiemetic , if vomiting
• Vasopressors, if patient in hypovolemic shock
• Oral route ..mild loss
• IV route…moderate/severe loss
• Fluid challenge test

25. Nursing Management
• monitors and measures fluid intake and
output at least every 8 hours.
• Vital signs, postural hypotension
• Skin and tongue turgor
• Low CVP(central venous pressure)
• PREVENTING FVD
• CORRECTING FVD

26. FLUID VOLUME DEFICIT—NURSING
MANAGEMENT
• Monitor for symptoms: skin and tongue turgor,
mucosa, urine output, mental status
• Measures to minimize fluid loss
• Oral care
• Administration of oral fluids
• Administration of parenteral fluids

27. FLUID VOLUME EXCESS
• 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.

28. CAUSES OF FVE
• Risk factors: heart failure, renal failure, cirrhosis of
liver
• Contributing factors: excessive dietary sodium or
sodium-containing IV solutions
Fluid volume excess:
• Hypervolemia
• Edema
• Third spacing

29. CLINICAL MANIFESTATIONS OF FVE
• Edema, distended neck veins, abnormal lung sounds
(crackles),
• tachycardia, increased blood pressure, pulse
pressure and CVP,
• increased weight, increased urine output, shortness
of breath and
• wheezing

30. MEDICAL MANAGEMENT:
• Directed at cause
• Pharmacologic Therapy:
 Diuretics : Loop, Thiazide, may cause
electrolyte imbalance especially potassium
imbalance, then potassium sparing diuretics may
be given.
• Dialysis
• Nutritional Therapy
• Restrictions of sodium and fluids

31. Fluid Volume Excess—Nursing
Management
• I&O and daily weights; An acute weight gain of 2.2 lb
(1 kg) is equivalent to a gain of approximately 1 L of
fluid.
• assess lung sounds
• Edema
• Monitor responses to medications—diuretics
• Promote adherence to fluid restrictions, patient
teaching related to sodium and fluid restrictions

32. • Promote rest
• Semi-Fowler’s position for orthopnea
• Skin care, positioning/turning
• Monitor, avoid sources of excessive sodium,
including medications

33. Stages of pitting edema
1. Severe generalized edema is called anasarca.

34. Electrolytes
• Electrolytes in body fluids are active chemicals
(cations, which carry positive charges, and
anions, which carry negative charges).
• The major cations :Na, K, Ca, Mg,H.
• The major anions: Cl, HCO3, Ph, S, proteinate .
• ECF:Na,Cl
• ICF:K,phosphates and sulphates
• Milliequivalent is defined as being equivalent to
the electrochemical activity of 1 mg of hydrogen.
“Unit of chemical activity”

35. Electrolyte imbalance

36. ELECTROLYT IMBALNCE
• Sodium: hyponatremia, hypernatremia
• Potassium: hypokalemia, hyperkalemia
• Calcium: hypocalcemia, hypercalcemia
•Magnesium: hypomagnesemia, hypermagnesemia
• Phosphorus: hypophosphatemia,
hyperphosphatemia
• Chloride: hypochloremia, hyperchloremia

37. SODIUM IMBALANC
• Sodium is the most abundant electrolyte in the ECF;
its concentration ranges from 135 to 145 mEq/L (135
to 145 mmol/L) and it is the primary determinant of
ECF volume and osmolality.
• The average intake of sodium is 4 to 5 g/day

38. HYPONATREMIA
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 blood
pressure, nausea, abdominal cramping, neurologic
changes

39. CONTI…
• Medical management:
water restriction, sodium replacement
• Nursing management:
assessment and prevention, dietary sodium and
fluid intake, identify and monitor at-risk patients,
effects of medications (diuretics, lithium)

40. HYPERNATREMIA
Serum sodium greater than 145 mEq/L
• Causes: excess water loss, excess sodium
administration, diabetes insipidus, heat stroke,
hypertonic IV solutions
• Manifestations: thirst; elevated temperature; dry,
swollen tongue; sticky mucosa; neurologic
symptoms; restlessness; weakness

41. CONTI..
• Medical management: hypotonic electrolyte
solution or D5W
• Nursing management: assessment and prevention,
assess for OTC sources of sodium, offer and
encourage fluids to meet patient needs, provide
sufficient water with tube feedings

42. HYPOKALEMIA
• Below-normal serum potassium (<3.5 mEq/L), Severe
hypokalemia(K+ less than 2.5 mEq/L) may cause
cardiac arrest
• Causes: GI losses, medications, alterations of acid–
base balance, hyperaldosterism, poor dietary intake
• Manifestations: fatigue, anorexia, nausea, vomiting,
dysrhythmias, muscle weakness and cramps,
paresthesias, glucose intolerance, decreased muscle
strength,ECG changes (inverted T wave) , cardiac
arrhythmias, decreased refelexes

43. CONTI..
• Medical management: increased dietary potassium,
potassium replacement, IV for severe deficit
• Nursing management: assessment, severe
hypokalemia is life-threatening, monitor ECG and
ABGs, dietary potassium, nursing care related to IV
potassium administration (inj KCL)

44. HYPERKALEMIA
Serum potassium greater than 5.0 mEq/L
• Causes: usually treatment related (K+sparing),
impaired renal function, hypoaldosteronism, tissue
trauma, acidosis, intestinal obstruction, diabetes,
Digitalis toxicity
• Manifestations: cardiac changes and dysrhythmias,
muscle weakness with potential respiratory
impairment, paresthesias, anxiety, GI
manifestations(nausea and Vomiting),parasthesias
ECG Changes( hyper T wave)

45. CONTI..
• Medical management:
 monitor ECG,
 limitation of dietary potassium,
 cation-exchange resin (Kayexalate),
 IV sodium bicarbonate,
 IV calcium gluconate,
 regular insulin and hypertonic dextrose IV

46. HYPERKALEMIA (CONT’D)
Nursing Management:
• assessment of serum potassium levels, monitor
medication affects, dietary potassium
restriction/dietary teaching for patients at risk
• Hemolysis of blood specimen or drawing of blood
above IV site may result in false laboratory result
• Salt substitutes, medications may contain potassium
• Potassium-sparing diuretics may cause elevation of
potassium
• Should not be used in patients with renal
dysfunction

47. HYPOCALCEMIA
Serum level less than 8.6 mg/dL,
• Calcium ions are needed for enzyme reactions
including blood clotting, nerve conduction, and muscle
contraction
• CAUSES: hypoparathyroidism, malabsorption,
pancreatitis, alkalosis, massive transfusion of citrated
blood, renal failure, medications, alkalosis, cancer Vit
D deficiency, diarrhea vomiting

48. HYPOCALCEMIA CONTI..
• MANIFESTATIONS:
tetany, circumoral numbness, paresthesias,
hyperactivity, Trousseau’s sign, Chovstek's sign,
seizures, respiratory symptoms of dyspnea and
laryngospasm, abnormal clotting, anxiety, abdominal
cramping, low BP, Decreased Pulse , cardiac
arrhythmias

49. HYPOCALCEMIA (CONT’D)
• MEDICAL MANAGEMENT:
IV of calcium gluconate, calcium and vitamin D
supplements; diet
• NURSING MANAGEMENT:
 assessment, severe hypocalcaemia is life-
threatening, weight-bearing exercises to decrease
bone calcium loss,
 patient teaching related to diet and medications,
and nursing care related to IV calcium administration

50. HYPERCALCEMIA
• Serum level greater than10.2 mg/dL
• Causes: malignancy and hyperparathyroidism, bone
loss related to immobility, inc. intake of Ca, Vit D,
immobility, osteoporosis.
• Manifestations: muscle weakness, incoordination,
anorexia, constipation, nausea and vomiting,
abdominal and bone pain ,polyuria, thirst, ECG
changes, dysrhythmias, renal calculi, fractures

51. HYPERCALCEMIA CONTI..
MEDICAL MANAGEMENT:
treat underlying cause, fluids, furosemide(diuretic),
phosphates, calcitonin, biphosphonates
NURSING MANAGEMENT:
assessment, hypercalcemic crisis has high
• mortality, encourage ambulation, fluids of 3 to 4 L/d,
provide fluids
• containing sodium unless contraindicated, fiber for
constipation,
• ensure safety

52. Hypomagnesemia
• Serum level less than 1.3 mg/dL,
• Magnesium is important in DNA and protein
synthesis, and in many enzyme reactions
CAUSES:
 alcoholism, GI losses, enteral or parenteral feeding
deficient in magnesium, medications, rapid
administration of citrated blood; contributing
 causes include diabetic ketoacidosis, sepsis, burns,
hypothermia, colostomy
 usually is present when hypokalemia and
hypocalcemia occur

53. HYPOMAGNESEMIA (CONT’D)
• MANIFESTATIONS:
neuromuscular irritability, muscle weakness, tremors,
athetoid movements, ECG changes and dysrhythmias,
alterations in mood and level of
consciousness,twitching
• MEDICAL MANAGEMENT:
diet(milk cerials) , oral magnesium, magnesium
sulfate IV slowly

54. HYPOMAGNESEMIA (CONT’D)
• NURSING MANAGEMENT:
 assessment, ensure safety, patient teaching related to
diet, medications, alcohol use, and nursing care related
to IV magnesium sulfate
 Hypomagnesemia often accompanied by
hypocalcemia
 Need to monitor, treat potential hypocalcemia
 Dysphasia common in magnesium-depleted patients
 Assess ability to swallow with water before
administering food or medications

55. HYPERMAGNESEMIA
• Serum level greater than 2.3 mg/dL
• CAUSES:
renal failure, diabetic ketoacidosis, excessive
administration of magnesium ,medications (antacids)
, sea drowning
• MANIFESTATIONS:
flushing, lowered BP, nausea, vomiting, hypoactive
reflexes, drowsiness, muscle weakness, depressed
respirations, ECG changes, dysrhythmias, paralysis

56. HYPERMAGNESEMIA CONTI..
• MEDICAL MANAGEMENT:
IV calcium gluconate, loop diuretics, IV NS of RL,
hemodialysis
• NURSING MANAGEMENT:
assessment, do not administer medications
containing magnesium, patient teaching regarding
magnesium-containing OTC medications (antacids,
laxatives) ,

57. HYPOPHOSPHATEMIA
• Serum level below 2.5 mg/DL
• CAUSES:
alcoholism, refeeding of patients after starvation, pain,
heat stroke, respiratory alkalosis, hyperventilation, diabetic
ketoacidosis, hepatic encephalopathy, major burns,
hyperparathyroidism, low magnesium, low potassium,
diarrhea, vitamin D deficiency, use of diuretic and antacids
• MANIFESTATIONS:
neurologic symptoms, confusion, muscle weakness, tissue
hypoxia, muscle and bone pain, increased susceptibility to
infection ,coma

58. HYPOPHOSPHATEMIA CONTI..
• MEDICAL MANAGEMENT:
oral or IV phosphorus replacement
• NURSING MANAGEMENT:
 assessment, encourage foods high in phosphorus,
gradually introduce calories for malnourished
 patients receiving parenteral nutrition

59. HYPERPHOSPHATEMIA
• Serum level above 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

60. HYPERPHOSPHATEMIA CONTI..
• MEDICAL MANAGEMENT:
treat underlying disorder, vitamin-D preparations,
calcium-binding antacids, phosphate-binding gels or
antacids, loop diuretics, NS IV, dialysis
• NURSING MANAGEMENT:
assessment, avoid high-phosphorus foods; patient
teaching related to diet, phosphate-containing
substances, signs of hypocalcemia

61. HYPOCHLOREMIA
• Serum level less than 97 mEq/L
• CAUSES:
 Addison’s disease, reduced chloride intake, GI loss,
diabetic ketoacidosis, excessive sweating, fever,
burns, medications, metabolic alkalosis
 Loss of chloride occurs with loss of other
electrolytes, potassium, sodium

62. HYPOCHLOREMIA CONTI…
• MANIFESTATIONS:
agitation, irritability, weakness, hyperexcitability of
muscles, dysrhythmias, seizures, coma
• MEDICAL MANAGEMENT:
replace chloride-IV NS or 0.45% NS
• NURSING MANAGEMENT:
assessment, avoid free water, encourage high-
chloride foods, patient teaching related to high-
chloride foods

63. HYPERCHLOREMIA
• Serum level more than 107 mEq/L
• CAUSES:
excess sodium chloride infusions with water loss,
head injury, hypernatremia, dehydration, severe
diarrhea, respiratory alkalosis, metabolic acidosis,
hyperparathyroidism, medications
• MANIFESTATIONS:
tachypnea, lethargy, weakness, rapid, deep
respirations, hypertension, cognitive changes Normal
serum anion gap

64. HYPERCHLOREMIA CONTI..
• MEDICAL MANAGEMENT:
restore electrolyte and fluid balance, sodium
bicarbonate, diuretics
• NURSING MANAGEMENT:
assessment, patient teaching related to diet and
hydration

65. Acid base balance
• Plasma pH is an indicator of hydrogen ion (H+)
concentration. Homeostatic mechanisms keep
pH within a normal range (7.35–7.45).
• These mechanisms consist of buffer systems
(bicarbonate-carbonic acid 20:1), the kidneys,
and the lungs.
• The H+ concentration is extremely important:
the greater the concentration, the more acidic
the solution and the lower the pH.

66. ABGS interpretation
• PaO2 (75-100 mmHg)
• pH (7.35-7.45)
• PaCO2 (35-45 mmHg)
• HCO3 (22-26 meq/L)
1. Respiratry acidosis,Alkalosis
2. Metabolic acidosis and alkalosis
3. Mixed disorder
• The only mixed disorder that cannot occur is a
mixed respiratory acidosis and alkalosis.

67. ABGS Abnormalities

68. Parentral Infusion therapy
• To provide water, electrolytes, and nutrients
to meet daily requirements
• To replace water and correct electrolyte
deficits
• To administer medications and blood products
IV solutions contain dextrose or electrolytes
mixed in various proportions with water.
• Note: Pure, electrolyte-free water can never be administered IV because it
rapidly enters red blood cells and causes them to rupture.

69. Types of solutions
• Isotonic NaCl 0.9%,R/L D5W
• Hypotonic0.45%NaCl
• Hypertonic3%,5% NaCl
• Colloid SolutionsDextrose 5%

70. Nursing Management of the Patient
Receiving IV Therapy
• PREPARING TO ADMINISTER IV THERAPY
• CHOOSING AN IV SITE :sites to avoid: veins distal to a previous IV infiltration
or phlebitic area, sclerosed or thrombosed veins, an arm with an arteriovenous shunt or fistula and mastectomy,
or an arm affected by edema, infection, blood clot, or skin breakdown.
• The following are factors to consider when selecting a site for venipuncture: • Condition of
the vein • Type of fluid or medication to be infused • Duration of therapy • Patient’s age and size • Whether the
patient is right- or left-handed • Patient’s medical history and current health status • Skill of the person
performing the venipuncture.
• SELECTING VENIPUNCTURE DEVICES
• TEACHING THE PATIENT
• DISCONTINUING AN INFUSION
• MANAGING SYSTEMIC COMPLICATIONS : circulatory
overload, air embolism, febrile reaction, and infection.
• Local complications of IV therapy include infiltration and extravasation, phlebitis,
thrombophlebitis, hematoma, and clotting of the needle.

71. Thank you