This document provides an overview of fluid, electrolyte, acid and base balance and imbalances. It discusses fluid volume deficits and excesses, including causes, pathophysiology, clinical manifestations, diagnostic evaluation, management, and nursing care. It also covers acid-base imbalances including metabolic acidosis, metabolic alkalosis, respiratory acidosis and respiratory alkalosis. Causes, signs and symptoms, diagnostic tests, treatment and nursing interventions are described for each condition. The purpose is to educate nursing students on fluid, electrolyte and acid-base disturbances.

1. FLUID ,ELECTROLYTES ,ACID AND BASE
BALANCE AND IMBALANCE
ANISA KHADIM
BScN 2ND PROF

2. OBJECTIVES
At the end of the topic , learners will be able to learn:
 Fluid and acid-base disturbances
 Cause of Fluid and acid-base disturbances
 Pathophysiology of Fluid and acid-base disturbance
 Manifestations of Fluid and acid-base disturbances
 Diagnostic evaluation
 Management of Fluid and acid-base disturbances
 Nursing interventions of Fluid and acid-base disturbances

3. FLUID VOLUME DISTURBANCES
 Fluid volume deficit (Hypovolemia)
 Dehydration
 Fluid volume excess (Hypervolemia)

4. FLUID VOLUME DEFICIT
Fluid volume deficit (FVD) occurs when loss of extracellular fluid 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.

5. CAUSES
Causes and etiological factors that can contribute to Hypovolemia are:
 Abnormal losses through the skin, GI tract, or kidneys.
 Decrease in intake of fluid (e.g., inability to intake fluid due to oral trauma)
 Bleeding
 Movement of fluid into third space.
 Diarrhea
 Diuresis
 Abnormal drainage
 Increased metabolic rate (e.g., fever, infection)

6. PATHOPHYSIOLOGY
Due to etiological factors
Decreased ECF
Decreased blood volume
Venous return decrease
Increased cardiac contractility (compensatory mechanism)
Compensation Non compensated
Increased cardiac output Decreased cardiac output
venous return increase Hypovolemia (if not managed)
Hypovolemic shock

7. CLINICAL MANIFESTATIONS
 Acute weight loss Decreased skin turgor
 Oliguria Concentrated urine
 Postural Hypotension A weak, rapid heart rate
 Flattened neck veins Increased temperature
 Decreased central venous pressure Cool, clammy skin
 Increased thirst Anorexia
 Nausea Lassitude (lack of energy)
 Muscle weakness

8. DIAGNOSTIC EVALUATION
• History of patient ( to know the cause )
• Physical assessment findings ( skin turgor , mucous membranes, eyes)
• Complete blood count ( specially Hematocrit )
• Serum electrolytes ( Na, K, Cl)
• Renal function tests ( urea ,creatinine, eGFR)
• Complete urine examination

9. MANAGEMENT
For mild to moderate FVD:
• Oral fluids are encouraged
• Electrolytes are replaced via oral fluids
• Dietary intake (containing sodium ,potassium)
For severe FVD:
• Fluid resuscitation
• Isotonic solution ( 0.9% N/S , Lactated Ringer )
• When patient gets normotensive (hypotonic solution 0.45% N/S)

10. NURSING CARE MANAGEMENT
• Monitor and document vital signs, especially BP and HR
• Assess and oral mucous membranes for signs of dehydration
• Monitor BP for orthostatic changes
• Assess alteration in mentation/sensorium (confusion, agitation, slowed responses)
• Assess color and amount of urine. Report urine output less than 30 ml/hr for two (2)
consecutive hours
• Monitor and document temperature

11. CONTD….
• Monitor fluid status in relation to dietary intake
• Note the presence of nausea, vomiting, and fever
• Auscultate and document heart sounds; note rate, rhythm, or other abnormal
findings
• Auscultate and document heart sounds; note rate, rhythm, or other abnormal
findings
• Ascertain whether the patient has any related heart problem before initiating
parenteral therapy
• Weigh daily with the same scale, and preferably at the same time of day

12. HYPERVOLEMIA
Fluid volume excess (FVE) 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

13. CAUSES
• Compromised regulatory mechanisms
• Decreased cardiac output; chronic or acute heart disease
• Excessive fluid intake
• Excessive sodium intake
• Head injury
• Hormonal disturbances
• Liver disease
• Low protein intake
• Malnutrition
• Renal insufficiency
• Severe stress
• Steroid therapy (increased appetite)

14. CLINICAL MANIFESTATIONS
 Tachycardia
 Increased blood pressure, pulse pressure, and central venous pressure
 Increased weight
 Increased urine output
 Shortness of breath and wheezing
 Edema
 Distended neck vein
 Crackles

15. DIAGNOSTIC EVALUATION
 Physical examination (skin, edema, lung sounds)
 Complete blood count ( specially Hematocrit )
 Serum electrolytes ( Na, K, Cl)
 Serum albumin
 Renal function tests ( urea ,creatinine, eGFR)
 Complete urine examination

16. MANAGEMENT
 Treatment is focused on cause of FVE.
 FVE caused by excessive sodium intake is managed by sodium restricted fluids and
foods
 Diuretic therapy (when not managed by oral restriction of sodium)
 Fluid restriction
 Paracentesis (removal of fluid from abdominal cavity via syringe or catheter)
 If not managed by either of the factors ,dialysis is the option of choice

17. NURSING CARE MANAGEMENT
 Assess for potential causes of excess fluid volume
 Monitor intake and output
 Monitor vital signs
 Monitor lung sounds
 Assess for edema and weight gain
 Palpate pulses
 Monitor lab values
 Enforce fluid restrictions and educate on the importance
 Administer diuretics as ordered
 Provide mouth care
 Assist with procedures such as paracentesis or dialysis
 Reposition and provide skin care.

18. DEHYDRATION
A condition that occurs when the body loses too much water and other fluids that it
needs to work normally
CAUSES
 Not drinking enough fluid to replace what we lose
 Climate change
 Fever

19. CLINICAL MANIFESTATIONS
Some of the early warning signs of dehydration include:
 Feeling thirsty and lightheaded
 Dry mouth
 Tiredness
 Dark colored, strong-smelling urine
 Passing urine less often than usual
A baby may be dehydrated if they:
 Have a sunken soft spot (fontanelle) on their head
 Have few or no tears when they cry
 Have fewer wet nappies
 Drowsy

20. DIAGNOSTIC TESTS
 Skin assessment
 Blood tests
 Urinalysis
Management
 Oral rehydration (mild to moderate)
 I/V fluid resuscitation

21. ACID-BASE IMBALANCES
 Metabolic Acidosis
 Metabolic Alkalosis
 Respiratory Acidosis
 Respiratory Alkalosis

22. Normal Ranges of ABGs
pH = 7.35 to 7.45
pCO2= 35 to 45mmHg
HCO3= 22 to 26 mEq/L
pO2= 93 to 98 mmHg
Na=135 to 145 mEq/L
K=3.5 to 5.5 mEq/L
Ca=8.5 to 10.5 mg/dL
Mg=1.5 to 2.5 mEq/L
Cl=96 to 106 mEq/L

23. METABOLIC ACIDOSIS
Metabolic acidosis is a clinical disturbance characterized by a low pH (increased
H+ concentration) and a low plasma bicarbonate concentration.
Causes:
 Alcohol intake without taking any nutritional diet
 Excessive exercise for long time
 Acid intake
 Low blood sugar
 Diabetes
 Excretion of bicarbonate/chloride via kidney leads to high Anion Gap
(formula to check anion gap is : Anion gap = Na+ - (Cl- + HCO3-)

24. CLINICAL MANIFESTATIONS
 Headache
 Drowsiness
 Increased respiratory rate and depth (hyperventilation)
 Nausea and vomiting
 Decreased blood pressure
 Cold and clammy skin
 Dysrhythmias
 Shock

25. DIAGNOSTIC EVALUATION
 Arterial or venous blood gas (pH < 7.35 ,HCO3 < 22)
 Basic metabolic panel (a group of blood tests that measure your sodium and
potassium levels, kidney function, and other chemicals and functions)
 Lactic acid test
 ECG

26. MANAGEMENT
 Treatment is directed at correcting the metabolic defect
 If the problem results from excessive intake of chloride, treatment is aimed at
eliminating the source of the chloride
 Bicarbonate is administered if the pH is less than 7.1 and the bicarbonate level is
less than 10
 May need dialysis

27. COMPLICATIONS
 Coma
 Arrhythmias
 Cardiac arrest

28. NURSING INTERVENTIONS
 Keep sodium bicarbonate ampules handy for emergency administration
 Monitor vital signs, laboratory results and level of consciousness frequently
 Record intake and output accurately to monitor renal function
 For management of vomiting (common to metabolic acidosis), position the patient to
prevent aspiration
 Prepare for possible seizures and administer appropriate precautions
 Provide good oral hygiene after incidences of vomiting. Use sodium bicarbonate
washes to neutralize acid in the patient’s mouth

29. METABOLIC ALKALOSIS
Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+
concentration) and a high plasma bicarbonate concentration
Causes :
 Diuresis
 Vomiting
 Excessive gastric suction
 Hyperaldosteronism (retention of Na and excretion of hydrogen and potassium)

30. CLINICAL MANIFESTATION
 Muscle twitching
 Muscle cramps
 Muscle spasms
 Fatigue
 Hypoventilation (shallow respiration)
 Tremor
 Tingling and numbness
 Abnormal heart rhythm (arrhythmia)
 Seizures
 Coma

31. DIAGNOSTIC TESTS
 Physical exam to evaluate symptoms
 Blood tests to measure blood gases, acid-base balance and electrolyte levels
 Electrocardiogram (ECG) to check for arrhythmia
 Urinalysis that may help find the cause of the metabolic alkalosis

32. MANAGEMENT
 Chloride must be supplied for the kidney to absorb sodium with chloride
 Restoring normal fluid volume by administering sodium chloride fluids
 Potassium is administered as KCl to replace both K+ and Cl− losses
 Carbonic anhydrase inhibitors are useful in treating metabolic alkalosis in patients
who cannot tolerate rapid volume expansion (causes an accumulation of carbonic
acid which dissociates to form hydrogen ion and bicarbonate ion)

33. NURSING INTERVENTIONS
 Monitor respiratory rate, rhythm, and depth
 Monitor heart rate and rhythm
 Provide seizures and safety precautions (side rails up, bed in lowest position, protect
airway)
 Encourage intake of foods and fluids high in potassium and possibly calcium
 Monitor laboratory studies as indicated: ABGs/pH, serum electrolytes (especially
potassium)
 Instruct patient to avoid use of excessive amounts of sodium bicarbonate
 Prepare patient for and assist with dialysis as needed

34. CONTD…
 Instruct patient to avoid use of excessive amounts of sodium bicarbonate
 Assess level of consciousness and , strength, tone, movement; note presence of
Chvostek’s or Trousseau’s signs.
 Prepare patient for and assist with
dialysis as needed.

35. RESPIRATORY ACIDOSIS
Respiratory acidosis is a condition that occurs when the lungs cannot remove all of the
carbon dioxide the body produces.
Causes:
 Airway disease, such as asthma and COPD
 Diseases of the lung tissue, such as pulmonary fibrosis
 Diseases affecting the nerves and muscles
 Medicines that suppress breathing, such as narcotics (opioids), and "downers," such
as benzodiazepines, often when combined with alcohol
 Severe obesity, which restricts how much the lungs can expand

36. CLINICAL MANIFESTATIONS
 Breathlessness
 Headache
 Wheezing
 Anxiety
 Blurred vision
 Confusion
 Restlessness
 Lethargy
 Blue tint in the hands and feet
 Delirium

37. DIAGNOSTIC TESTS
 ABGs (pH < 7.35, PaCO2 > 45)
 S/electrolytes
 X ray (to find underlying disease)
 ECG

38. MEDICAL MANAGEMENT
 Bronchodilators
 Antibiotics, to treat infection
 Diuretics, to reduce excess fluid buildup in the heart and lung
 Corticosteroids, to reduce inflammation
 Mechanical ventilation, to assist breathing in people with severe respiratory acidosis

39. NURSE’S ROLE
Remain alert for critical changes in patient’s respiratory, CNS and cardiovascular
functions
 Maintain adequate hydration (to keep mucous membrane moist & to spit out
secretions)
 Maintain patent airway and provide humidification if acidosis requires mechanical
ventilation
 Perform tracheal suctioning frequently and vigorous chest physiotherapy, if ordered.
 Institute safety measures and assist patient with positioning.
 Continuously monitor arterial blood gases.

40. RESPIRATORY ALKALOSIS
Respiratory alkalosis occurs when the levels of carbon dioxide and oxygen in the blood
aren’t balanced
Causes:
 Anxiety
 Hypoxemia
 The early phase of salicylate intoxication
 Gram-negative bacteremia
 Inappropriate ventilator settings

41. CLINICAL MANIFESTATIONS
 Lightheadedness due to vasoconstriction
 Decreased cerebral blood flow
 Inability to concentrate
 Numbness
 Tingling from decreased calcium ionization (increase in pH leads to protein binding
with calcium)
 Tinnitus
 At times loss of consciousness

42. DIAGNOSTIC TESTS
 ABGs
 S/Electrolytes
 ECG
Medical management:
Treatment depends on the underlying cause of respiratory alkalosis.
If the cause is anxiety, the patient is instructed to breathe more slowly to allow CO2 to
accumulate or to breathe into a closed system
A sedative may be required to relieve hyperventilation in very anxious patients

44. ELECTROLYTE IMBALANCES
 Hyponatremia
 Hypernatremia
 Hypokalemia
 Hyperkalemia
 Hypocalcemia
 Hypercalcemia

45. HYPONATREMIA
Hyponatremia occurs when the concentration of sodium in blood is abnormally low
Causes:
 Vomiting
 Drinking a lot of water
 Some medications
 Kidney problems
 SIADH

46. CLINICAL MANIFESTATION
 Decrease skin turgor
 Dry mucus membrane
 Headache (cell swelling causes vessels to compress)
 Confusion
 Postural hypotension
 Loss of energy, drowsiness and fatigue
 Restlessness and irritability
 Muscle weakness, spasms or cramps (The body’s ability to send signals is
interrupted so the brain overcompensates and sends too many electrical impulses
lead to cramps)
 Seizure

47. MANAGEMENT
 Symptomatic treatment for headaches, seizures
 Increase oral intake
 I/V fluids ( 0.9% N/S for slow increase in sodium level)
NURSING MANAGEMENT
 Monitor vital signs and note respiratory rate and depth to identify pulmonary
edema
 Strictly maintain fluid intake and output of patient hourly
 Monitor and observe skin turgor to identify dehydration
 Ensure high sodium-containing food such as milk, meat
 Observe for neuromuscular changes
 Provide safety measures to prevent from fall
 Monitor oral mucosa and manage accordingly

48. HYPERNATREMIA
Hypernatremia is the medical term used to describe having too much sodium in the
blood
Causes:
 Fluid deprivation (in unconscious patients)
 Excessive oral intake of sodium
 Deficiency of ADH
 Watery diarrhea
 Poorly controlled DM
 Burn

49. CLINICAL MANIFESTATION
 Increased thirst
 Lethargy/Fatigue
 Muscle twitching and spasms
 Seizures
 Postural hypotension ( due to fluid shift)
 Increased muscle tone
 Increase deep tendon reflexes

50. MANAGEMENT
 Low sodium diet
 Replacement of water
 0.3% N/S or isotonic non-saline solution (e.g. 5%D/W)
Nursing interventions:
 Monitor intake/output
 Encourage patient to drink water
 Restrict dietary sodium
 Maintain fluid balance with IV isotonic fluid
 Observe for signs of altered mentation, muscle cramps or twitching
 Check deep tendon reflexes (for hyper-reflexia)

51. HYPOKALEMIA
Hypokalemia (below-normal serum potassium concentration) usually indicates an
actual deficit in total potassium stores.
Causes:
 Low dietary potassium intake
 Vomiting
 Diarrhea/Laxative use
 Gastric suctioning
 Intestinal suctioning
 Alteration in acid-base balance
 Hyperaldosteronism
 Diuretics

52. CLINICAL MANIFESTATION
 Fatigue
 Anorexia
 Muscle weakness
 Leg cramps
 Decreased bowel motility leads to constipation
 Paresthesia (numbness and tingling)
 Dysrhythmias
 Polyuria & Polydipsia

53. DIAGNOSTIC EVALUATION
 S/Electrolytes (shows decreased potassium level)
 Urinalysis (show increased potassium)
 ECG (Flat T waves/inverted T waves,
ST depression, presence of U waves)
Management:
 Oral replacement therapy
 Switch diuretics
 IV potassium

54. NURSING INTERVENTION
 Check vital signs especially heart rate
 Monitor changes in ECG
 Monitor blood potassium levels
 Check renal function
 Review the patient’s current medications
 Include potassium in the diet
 Monitor strict intake and output
 Strictly monitor for any change in heart rate if patient in on IV replacement of
potassium
 IV puncture site care

55. HYPERKALEMIA
Hyperkalemia is the medical term that describes a potassium level in your blood that's
higher than normal
Causes:
 High intake of potassium
 Kidney disease
 Medications (e.g. potassium sparing diuretics)

56. CLINICAL MANIFESTATIONS
 Vomiting
 Diarrhea
 Muscle weakness
 Cardiac conduction abnormalities
 Cardiac arrhythmias
 ECG changes (widened QRS complex,
peaked T waves)

57. DIAGNOSTIC TESTS
 S/Electrolytes
 ECG
 ABGs (for metabolic acidosis)
Management:
 Restrict oral intake
 Switch diuretics
 IV calcium gluconate (for stabilizing resting membrane potential, Infusion of
calcium does not reduce the serum potassium concentration)
 IV infusion of NaHCO3 (to reduce acidosis)

58. NURSING INTERVENTION
 Monitor intake/output
 Check serum potassium levels
 Follow ECG closely to look for peaked T waves
 Educate patient on hyperkalemia
 Administer diuretics as ordered
 Administer insulin to lower potassium as ordered (insulin causes intracellular
potassium shift)
 Check blood glucose when administering insulin
 Educate the patient on a low potassium diet
 Encourage the patient to follow closely with the clinician

59. HYPOCALCEMIA
Hypocalcemia is: ‘’lower-than-normal serum concentration of calcium.’’
Causes:
 Hypoparathyroidism
 Diet low in calcium
 Loop diuretics
 Osteoporosis

60. CLINICAL MANIFESTATIONS
 Tetany (involuntary muscle contractions and overly stimulated peripheral nerves)
 Tingling sensation in fingers
 Chvostek’s sign and Trousseau’s sign positive
 Changes in ECG
 Seizures
 Altered mental status may occur

61. DIAGNOSTIC TEST
 S/calcium
 ECG (shows prolonged QT interval)
Management:
 Oral intake of calcium (e.g. milk, green leafy vegs)
 IV administration of calcium gluconate in dilution
 Vitamin D therapy

62. NURSING INTERVENTIONS
 Safety (prevent falls because patient is at risk for bone fractures, seizures
precautions)
 Monitor airway
 Encourage diet high in calcium
 Administer IV calcium as ordered
 Administer oral calcium and vitamin D supplements
 Keep an eye on ECG changes
 Assessment of Musculo-skeletal system

63. HYPERCALCEMIA
Hypercalcemia is: ‘’excess of calcium in the plasma’’
Causes:
 Hyperparathyroidism
 Malignancy
 Immobilization (very rare)
 Thiazide diuretics (increase the action of PTH on kidneys)

64. CLINICAL MANIFESTATIONS
 Muscle weakness
 In-coordination
 Anorexia
 Constipation
 Abdominal pain
 Slurred speech
 Lethargy
 Excessive urination (due to disturbed renal tubular function)

65. DIAGNOSTIC TESTS
 S/calcium
 iPTH level
 ECG
 X Ray (osteoporosis)
Management:
 Restrict dietary/supplemental calcium
 Calcitonin can be given
 Treating the cause
 Chemotherapy for malignancy
 Parathyroidectomy

66. NURSING INTERVENTIONS
 Keep patient hydrated (decrease chance of renal stone formation)
 Keep patient safe from falls or injury
 Monitor cardiac, GI, renal, neuro-muscular status
 Assess for complaints of flank or abdominal pain & strain urine to look for stone
formation
 Decrease calcium rich foods and intake of calcium-preserving drugs like thiazides,
supplements, Vitamin D

67. THANK
YOU !!!