surgical nurse

1. Fluid and Electrolytes:
Balance an d Disturbance
By dr. Abdiasis Omar Mohamed
MBBS

2. Introduction
• Fluid and electrolyte balance is a dynamic process
that is crucial for life and homeostasis.

4. Electrolytes
• Electrolytes in body fluids are active chemicals
(cations that carry positive charges and anions that
carry negative charges).
• The major cations in body fluid are sodium,
potassium, calcium, magnesium, and hydrogen ions.
• The major anions are chloride, bicarbonate,
phosphate, sulfate, and proteinate ions.

5. Regulation of Body
Fluid Compartments

6. • 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

7. • Diffusion is the natural tendency of a substance to
move from an area of higher concentration to one of
lower concentration.
• 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.

8. Systemic Routes of Gains and Losses
• Kidney
• Skin
• Lungs
• gastrointestinal

9. Laboratory Tests for Evaluating Fluid
Status
• Osmolality measures the solute concentration per
kilogram in blood and urine.
• Serum osmolality primarily reflects the concentration
of sodium, although blood urea nitrogen (BUN) and
glucose also play a major role in determining serum
osmolality.
• Urine osmolality is determined by urea, creatinine,
and uric acid.

10. • In healthy adults, serum osmolality is 280 to 300
mOsm/kg, and normal urine osmolality is 200 to 800
mOsm/kg.
• Serum osmolality may be measured directly through
laboratory tests or estimated at the bedside by
doubling the serum sodium level or by using the
following formula: Na*2 =glucose + BUN
18 3

11. Homeostatic Mechanisms

13. Fluid volume disturbances
1. 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.

14. • Causes
• Vomiting
• Diarrhea
• Lack of water intake
• Hemorrhage
• Sweating
• Diabetes insipedus

15. • Clinical manifestations
• acute weight loss;
• decreased skin turgor;
• oligouria; concentrated urine;
• orthostatic hypotension due to volume depletion;
• a weak, rapid heart rate;
• flattened neck veins;

16. • Increased temperature, thirst.
• decreased or delayed capillary refill.
• decreased central venous pressure.
• cool, clammy, pale skin related to peripheral
vasoconstriction.
• Anorexia, nausea.
• Lassitude,muscle weakness; and cramps

17. • Assessment and Diagnostic Findings
• Elevated BUN and creatinine ( 20:1)
• Potassium and sodium levels can be reduced
(hypokalemia, hyponatremia) or elevated
(hyperkalemia, hypernatremia).
• Hypokalemia occurs with GI and renal losses.
• Hyperkalemia occurs with adrenal insufficiency.
• Hyponatremia occurs with increased thirst and
ADH release.
• Hypernatremia results from increased insensible
losses and diabetes insipidus.

18. • Medical Management
1. Oral rehydration
2. Iv fluids
3. Diet therapy

19. • Nursing management
• monitors and measures fluid at least every 8 hours,
and sometimes hourly.
• Monitor daily body weight
• Monitor vital signs
• Observe weak, rapid pulse and orthostatic
hypotension
• Urine concentration is monitored by measuring the
urine specific gravity.
• Asses degree of oral and mucus membrane moisture

20. • Preventing Hypovolemia
• To prevent FVD, the nurse identifies patients at risk
and takes measures to minimize fluid losses. For
example, if the patient has diarrhea, measures should
be implemented to control diarrhea and replacement
fluids administered.
• This includes administering antidiarrheal medications
and small volumes of oral fluids at frequent intervals.

21. 2. 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.
• Because there is isotonic retention of body
substances, the serum sodium concentration remains
essentially normal.

22. • Causes
• heart failure
• renal failure
• cirrhosis of the liver.
• Iv therapy
• Excess sodium ingestion

23. • Clinical manifestations
• 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.

24. • Medical Management
1. Pharmacologic Therapy
• Diuretics; thiazides and loop diuretics
• Thiazides : hydrochlothiazide
• Loop diuretics: furasemide and torsemide
• Potassium supplement
2. Dialysis
3. Nutritional therapy

25. • Nursing Management
• identify excessive fluid retention
• The patient is weighed daily, and rapid weight gain is
noted. An acute weight gain of 2.2 lb (1 kg) is
equivalent to a gain of approximately 1 L of fluid.
• Breath sounds are assessed at regular intervals in at-
risk patients.
• The nurse monitors the degree of edema in the most
dependent parts of the body, such as the feet and
ankles in ambulatory patients and the sacral region in
patients confined to bed.

26. • Preventing Hypervolemia
• most patients require sodium-restricted diets in some
form, and adherence to the prescribed diet is
encouraged.
• Regular rest periods may be beneficial, because bed
rest favors diuresis of edema fluid.
• Sodium and water restriction

27. Electrolyte imbalance
1. Sodium Imbalances
• 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.

28. • hyponatremia
• it results from loss of sodium containing fluids (or)
hypo-osmolality with a shift of water into the cells
• Causes
• diarrhea, vomiting, Ng suction
• Diuritics, adrenal insufficiency, a wasting renal
diseases, Burns, wound drainage

29. • Clinical Manifestations
• Poor skin turgor, dry mucosa, headache, decreased
saliva production, orthostatic fall in blood pressure,
nausea, vomiting, and abdominal cramping occur.
• altered mental status, status epilepticus, and coma.

31. • Medical management
1. Sodium Replacement(12 mEq/L in 24 hours)
- For patients who can eat and drink, a normal diet.
- lactated Ringer’s solution or NS
2. Water Restriction
3. Pharmacologic Therapy
- IV conivaptan hydrochloride (Vaprisol)

32. • Hypernatremia
• Hypernatremia is a higher than normal sodium level
exceeding (145meq/L)
• CAUSES
• Gain of sodium in excess of water
• Inadequate water intake
• Increased serum sodium concentration

33. • Clinical Manifestations
• restlessness and weakness in moderate hypernatremia
and by disorientation, delusions, and hallucinations in
severe hypernatremia.

34. • medical management
• Gradual lowering of the sodium level by the
infusion of a hypotonic electrolyte solution 0.3%
sodium chloride
• Diuretics also may be prescribed to treat the sodium
gain

35. • 2. potassium imbalance
• potassium is major ICF cation, with 98% of the
body potassium being intracellular
• potassium is critical for many cellular and
metabolic function.
• the kidneys are the primary route for potassium
loss 90% of daily potassium intake is eliminated
by kidney.
• The normal serum potassium concentration
ranges from 3.5 to 5.0 mEq/L (3.5 to 5 mmol/L),
and even minor variations are significant.

36. • Hyperkalemia
• It may be caused by a massive intake of
potassium
• causes:
• excess potassium intake
• excessive or rapid parenteral administration
potassium containing drugs, shift of potassium out of
cell
• acidosis, crush injury, tissue catabolism(fever)
• failure to eliminate potassium, renal disease, adrenal
insufficiency, ACE inhibitors

38. • Medical management
• Immediate ECG Should be obtained
• Serum potassium level from vein without IV fluid
infusion
• Restriction of dietary potassium, Potassium
containing diuretic
• IV calcium gluconate administration in serum
potassium level are dangerously elevated

39. • Hypokalemia
• Hypokalemia can results from abnormal losses of
potassium from a shift of potassium from ECF to
ICF or rarely from deficient dietary potassium intake
• CAUSES
• Potassium loss
• Shifts of potassium into cells
• Lack of potassium intake

40. • Manifestations of hypokalemia include fatigue,
anorexia, nausea, vomiting, muscle weakness, leg
cramps, decreased bowel motility, paresthesias
(numbness and tingling), and dysrhythmias.

41. • Medical management
• It is treated with oral or IV replacement
• Administer 40 to 80 meq/ day of potassium
• When oral administration of potassium is not feasible
the IV route is indicated
• For patient at risk for hypokalemia diet
containing potassium should be provided

42. • 3. Calcium imbalance
• More tan 99% of the body’s calcium is located in
skeletal system
• It is a major component of bone and teeth, about
1% of skeletal calcium is exchanged with blood
calcium
• Calcium plays a major role in transmitting nerve
impulses and helps to regulate muscle contraction
and relaxation, including cardiac muscle
• The normal total serum calcium level is 8.6 to 10.2
mg/dL (2.2 to 2.6 mmol/L).

43. • Hypocalcemia
• Any condition that causes a decreased in the
production of PTH may result in the development of
hypocalcemia
• Causes
• Multiple blood transfusion
• Chronic renal failure
• Elevated phosphorous
• Chronic alcoholism
• Alkalosis

44. • Medical management
• IV Administration of calcium like calcium
gluconate , calcium chloride , calcium
gluceptate
• Vitamin D therapy be initiated to increase calcium
absorption from GI tract
• Increasing the dietary intake of calcium at least 1,000
to 1,500mg/day

45. • hypercalcemia
• Hypercalcemia [excess of calcium in the plasma] is
dangerous imbalance when severe Hypercalcemia
crisis has a mortality rate as high as 50% if not
treated properly
• causes
• Multiple myeloma
• Prolonged immobilization
• Vit D over dose
• Thiazide diuretics [slight elevation]

46. • Medical management
• Administer fluids to dilute serum calcium and
promote its excretion by the kidney
• IV administration of 0.9% sodium chloride
solution temporarily dilutes the serum calcium
level
• Administering furosemide increases calcium
excretion
• Calcitonin is administered to lower the serum
calcium level

47. Acid base
• The body normally maintains a steady balance
between acid produced during metabolism and bases
that neutralize and promote the excretion of the acid ,
many health problems lead to acid base imbalance in
addition to fluid and electrolyte imbalance
• Patient with diabetes mellitus, chronic obstructive
pulmonary disease and kidney disease frequently
develop acid-base imbalance

48. • hydrogen ion concentration
• acidity or alkalinity of a solution is determined by its
concentration of hydrogen ions (h+)
• the unit used to describe acid base is ph
• the ph scale ranges from 1-4. a neutral solution
measures 7
• normal blood plasma is slightly alkaline and has a
normal ph range of 7.35-7.45

49. • Acidosis
• it is the condition characterized by an excess of h
ions or loss of base ions/bicarbonate in ECF in which
the ph falls bellow 7.35
• Alkalosis
• it occurs when there is a lack of h ions or again of
based and the ph exceeds 7.45

50. • Acid base regulation
• The body’s metabolic processes constantly produce
acids.
• These acids must be neutralized and excreted
to maintain acid base balance
• Normally the body has three mechanisms by which it
regulates acid-base balance to maintain the arterial ph
7.35 and 7.45

51. • buffer system
• respiratory system
• renal system

52. • the regulatory mechanisms react at different speeds.
• buffer reacts immediately
• the respiratory system responds in minutes and
reaches maximum effectiveness in hours
• the renal response takes 2-3 days to responds
maximally

53. • Alteration in acid base balance
• The acid-base imbalance is produced when the
ratio of 1:20 between acid and base content is
altered
• A primary disease or process may alter one side
of the ratio
• The compensatory process attempts to
maintain the other side of the ratio
• When compensatory mechanism fails, an acid base
imbalance occurs

54. • acid-base imbalances are classified as
• Respiratory imbalance: it affects carbonic acid
concentration
• Metabolic imbalance: it affects the base bicarbonate

55. • Respiratory acidosis
• Respiratory acidosis is a clinical disorder in which
the ph is less than 7.35 and the paco2 is greater than
42mmhg. it may either acute and chronic
• Causes
• Elevated plasma level, elevated carbonic acid, acute
pulmonary edema, Atelectasis and impaired
respiratory muscles

56. Clinical manifestations
• Increased pulse
• Increased respiratory rate
• Increased blood pressure
• Mental cloudiness
• Cerebrovascular vasodilatation
• Increased intracranial pressure
• Papilledema
• Feeling of fullness in head

57. Medical management
• Treatment is directed by improving ventilation
• Pharmacologic agent bronchodilators
antibiotic, anti coagulants
• Pulmonary hygiene measures adequate
hydration mechanical ventilation

58. • Respiratory alkalosis
• Respiratory alkalosis is a clinical condition in which
the arterial ph is greater than 7.45 and the paco2 is
less than 38 mm hg

59. • Etiology
• Respiratory alkalosis is always due to
hyperventilation
• Anxiety
• Hypoxemia
• Chronic hypocapnia
• Decreased serum bicarbonate levels
• Chronic hepatic insufficiency and cerebral
tumors

60. • Clinical manifestations
• Light headedness due to
vasoconstriction
• Decreased cerebral flow
• Numbness tinnitus,
• Loss of consciousness
• Tachycardia
• Ventricular and arterial dysrhythmias

61. • Medical management
• Treatment depends on the underlying cause
respiratory alkalosis
• Anxiety : patient is instructed to breath more slowly
to allow CO2 to accumulate
• Sedative may be required to relieve hyperventilation
in very anxious patients

62. • Metabolic acidosis
• Metabolic acidosis is a clinical disturbance
characterized by a low pH (increased hydrogen ions)
and a low plasma bicarbonate concentration
• It can be produced by a gain of hydrogen ions or a
loss of bicarbonate

63. • Clinical manifestations
• Headache
• Confusion
• Drowsiness
• Increased respiratory rate depth
• Nausea and vomiting
• Decreased blood pressure
• Cold and clammy skin
• Dysrhythmias
• shock

64. • Medical management
• Treatment is directed at correcting the
metabolic defect
• If problem results from excessive intake of chloride,
treatment is aimed at eliminating the source of
chloride
• Bicarbonate is administered if the ph is less than 7.1
• Serum potassium level is monitored closely and
hypokalemia is corrected as acidosis reversed

65. • Metabolic alkalosis
• Metabolic alkalosis is a clinical disturbance
characterized by a high ph (decreased H⁺ ions
concentration) and a high plasma bicarbonate
concentration.
• It can be produced by a gain of bicarbonate or a loss
of H⁺ ions

66. • Etiology
• Vomiting
• gastric suction
• Pyloric stenosis
• Diuretic therapy that promotes excretion of potassium
• Cystic fibrosis
• Chronic ingestion of milkand calcium
carbonate

67. • Clinical manifestations
• Tingling of the fingers and toes
• Dizziness
• Symptoms of hypocalcemia is often the
symptoms of alkalosis
• Ventricular disturbances (ph increase above 7.6)

68. • Medical management
• Sufficient chloride must be supplied for kidney to
absorb sodium with chloride
• Administering sodium chloridefluids
• Histamine-2 receptor antagonists, suchas cimetidin
(tagamet). Reduces the gastric hcl, thereby
decreasing the metabolic alkalosis associated with
gastricsuction
• Input and output should be monitored

69. THANKS